The Boston medical and surgical journal [electronic serial]

This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project
to make the world's books discoverable online.

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject
to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books
are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover.

Marks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the
publisher to a library and finally to you.

Usage guidelines

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to
prevent abuse by commercial parties, including placing technical restrictions on automated querying.

We also ask that you:

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for
personal, non-commercial purposes.

+ Refrain from automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the
use of public domain materials for these purposes and may be able to help.

+ Maintain attribution The Google "watermark" you see on each file is essential for informing people about this project and helping them find
additional materials through Google Book Search. Please do not remove it.

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner
anywhere in the world. Copyright infringement liability can be quite severe.

About Google Book Search

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web

at|http : //books . google . com/

''-■L^ MEDICAL LIBRARY

'■'<AIMCISA. COUNTl/VAY
•■'BRARV OF MEDICINE

Digitized by'

Gc ogle

HARVARD
FRANC

LIBR.

M LIBRARY

■ JNTWAY
DICINE

Digitized by

Google

Digitized by

Google

■l

Digitized by

Google

Digitized by

Google

THE BOSTON

MEDICAL AND SURGICAL

JOURNAL

GEORGE B. SHATTUCK, M.D., Editor

CARROLL EVERETT EDSON, M.D., Assistant Editor

VOLUME CXXX

JANUARY — JUNE, 1894

BOSTON

DAMRELL AND UPHAM

383 Washington Street

1894

Digitized by

Google

PRESS OF S. J. PARKHILL ft OOHPANT,

226 FRANKLIN STREET,

BOSTON.

Digitized by

Google

CONTRIBUTORS TO VOLUME CXXX.

ABBOTT, SAMUEL W., M.D.
ACHORN, J. WAKREN, M.D.
ALLEN, GARDNER W., M.D.
AUGUST, ALBERT, M.D.
BATES, EVERETT A., M.D.
BELL, ROBERT E., M.D.
BILLINGS, JOHN 8., M.D., U. 8. A,
BLAKE, JOHN G., M.D.
BOARDMAN, WILLIAM S., M.D.
BO WEN, JOHN T., M.D.
BRACKETT, E. G., M.D.
BRADFORD, E. H., M.D.
BURRELL, HERBERT L., M.D.
CABOT, RICHARD C, M.D.
CALL, ANNIE PAYSON, M.D.
CHADBOURNE, ARTHUR P., M.D.
CHANDLER, N. F., M.D.
CHEEVER, DAVID W., M.D.
CLENDENIN, PAUL, M.D., U. S. A.
CODMAN, CHARLES R., M.D.
COOLIDGE, ALGERNON, Jr., M.D.
COUNCILMAN, W. T., M.D.
COURTNEY, J. W., M.D.
COVVLES, W. N., M.D.
CROWELL, SAMUEL, M.D.
GUSHING, E. W., M.D.
CUSHING, H. W., M.D.
DAVENPORT. F. H., M.D.
DAWBARN, ROBERT H. M., M.D.
DAY, FRANK L., M.D.
DELAVAN, D. BRYSON, M.D.
DRAPER, PROF. F. W., M.D.
DULLES, CHARLES W., M.D.
DUNBAR, F. A., M.D.
DURELL, THOMAS M., M.D.
DWIGHT. THOMAS, M.D., LL.D.
EASTMAN, JOSEPH, M.D., LL.D.
EDES, ROBERT T., M.D.
EDSON, CARROLL E., M.D.
EGAN, P. RALPH, M.D., U. S. A.
ELLIOTT. J. W., M.D.
EVERKTT, OLIVER H., M.D.,
EWING, CHARLES B., M.D., U. S. A.
FARLOW, JOHN W., M.D.
FAY. WILLIAM E., M.D.
FITZ, REGINALD H., M.D.
FOLSOM, CHARLES F., M.D.
FRANCIS, GEORGE E., M.D.
GAGE, HOMER, A.M., M.D.
GAVIN, M. F., M.D.
GAY, GEORGE W., M.D.
GILBERT, D. D., M.D.
GOSS, FRANCIS VV., M.D.
GRANT, JOHN H., M.D.
GREEN, CHARLES M., M.D.
GREENE, EDWARD M., A.M., M.D.
GREENE, J. S., M.D.
GREENLEAF, R. W., M.D.
HALL, J. N., M.D.
HALL, R. M., M.D.
HARRINGTON. F. B., M.D.
HAVEN, GEORGE, M.D.
HAYES, MARGARET C, M.D.

HILLS, WILLIAM B., M.D.
HOGNER, RICHARD, M.D.
HOUSTON, J. A., M.D.
KURD, E. P., M.D.
INGALS. E. FLETCHER, M.D.
JACK, EDWIN E., M.D.
JACKSON, HENRY, M.D.
JACKSON, HENRY M., M.D.
JOHNSON, F. W., M.D.
JOSLIN, ELLIOTT P., A.B., PH.B.
KEEFE, JOHN W., M.D.
KENYON, C. G., M.D.
KNAPP, PHILIP COOMBS, A.M., M.D.
LOOMIS, ALFRED L., M.D.
MALLORY, F. B., M.D.
MAN LEY, THOMAS H., M.D.
MARCY, H. O., M.D.
MARTIN, F. C, M.D.
MASON, A. LAWRENCE, M.D.
McCOLLOM, J. H., M.D.
MILLARD, PERRY H., M.D.
MINOT, FRANCIS, M.D.
MORRILL, F. GORDON, M.D.
MORRIS, ROBERT L, M.D.
MORSE, JOHN LOVETT, M.D.
MUM FORD, J. G., M.D.
MUNRO, JOHN C, M.D.
PARKKR, W. THORTON, M.D.
PECK HAM, FRANK E., M.D.
PERKINS, JOHN W., M.D.
PLATT, WALTER B., F.S.C.S. (ENG.)
PLUMMKR, R. H., M.D.
POST, ABNER, M.D.
PRESCOTT, WILLIAM H., M.D.
PRICE, JOSEPH, M.D.
PUTNAM, J. J., M.D.
REYNOLDS, EDWARD, M.D.
RICHARDSON, MAURICE H., M.D.
SCUDDER, CHARLES L., M.D.
SEARS, GEORGE G., M.D.
SHATTUCK, F. C, M.D.
SHATTUCK, GEORGE B., M.D.
SINCLAIR, ALEXANDER D., M.D.
8TANDISH, MYLES, M.D.
STEDMAN, HENRY R., M.D.
THORNDIKE, PAUL, M.D.
TOWNSEND, CHARLES W., M.D.
TRACY, EDWARD A., M.D.
TUTTLE, ALBERT H., M.D.
VICKERY, H. F., M.D.
WALCOTT, H. P., M.D.
WANGHOP, P. R., M.D.
WASHBURN, G. H., M.D.
WEBBER, S. G., M.D.
WHEELER, LEONARD, M.D.
WHITE, H. WARREN, M.D.
WHITNEY, W. F., M.D.
WHITTIER, E. N., M.D.
WILLIAMS, FRANCIS H., M.D.
WILLIAMS, JACOB L., M.D.
WITHINGTON, C. F., M.D.
WOOD, EDAVARD S., M.D.
WORCESTER, A., A.M., M.D.

Digitized by

Google

Digitized by

Google

INDEX TO VOLUME CXXX.

Abbott, A. C. Gbemlcal, pbysioal and bacteriological atDdles ol air
over deoompoeing gorfacea, with especial reference to their ap-
plication to the air of aewera, 609.

Abbott, S. IV. National registration a neceulty, 137; recent prog-
ress in public hygiene and prerentire medicine, 3S7.

Abdominal Snrj^ry. Cases of abdominal surgery occurring in
the practice of Dr. J. Collins Warren at the Massachusetts Qeneral
Hospital during the winter of 18u3, Soucider, C. L., I, 28.

Absinthe. The poisonous properties of absinthe and its congeners,
4fi2.

Aobom, J. W. The effect of climate and enTironment on the New
England girl, 68.

Acting AssUtsnt-SarKoons, 226.

Alcohol. The rftle of alcohol In the causation of cirrhosis of the
IWer. 324.

Allen, O.'W. Two oases of litholapaxy, 383, 388.

Allen, H. Morphology as a factor in the study of disease, 867.

American Gont, 273.

Anterlcan Medical Association. BeTiston In the, 6SS; San Fran-
cisco meetings, <36, 667.

AuBBStheala. Mr. Lawson Talt'B use of anaasthesia, 260.

Anarchist. Autopsy on the Qreenwioh anarchist, 326.

Anatomy. Accent progress in anatomy, Dwight, T., 7, 468; mor-
phology as a factor in the study of disease, Allen, H,, 667; Associa-
tion of American Anatomists, 622; the range and the signiticance
of Tarlatious lu the human siieleton, Dwight, T., 626.

Aneariam. A new and distinguishing sign of latent aneurism of
the aorta, Glasgow, W. C, 661.

Animal Experimentation, its influence on medical science,
tioomis, A. fi.. 6''5; resoluiion before Congress of American Physi-
cians and Surgeons, 690.

Appendicitis, with apparent resolution of abscess, relapse, death,
autopsy, Peokham, P. E., 61; specimen of gangrenous and perfo-
rated appendix, Ulchardson, M. H., 67; Infectious appendicitis,
Morris, M. T.,133; recurrent appendicitis, August, A., 186; an ap-
pendix obliterated in the greater part of its length, Kichardison, M.
H., 192; cases of appendicitis presenting unusual features, Rich-
ardson, M. U., 232; twelve consecutive and successful operations
for appendicitis, Keefe, J. W., 282, 306; a case of appendicitis,
Polsom, C. F., 342; the after-treatment ol operations for appendici-
tis, Burrell, H. L., 433, 444; specimen of appendix, Elliot, J. W.,
444; some impressions derivea from an experience of forty-four
cases, Gage, B., 608.

Arm. Amputation of the entire upper extremity (including the
scapula and clavicle) and of the arm at the shoulder-Joint, Keen,
W. W., 565.

Army. The duties of army medical officers, 49; the Army Medical
School at Washington, 100; proposed reduction of the Army Medi-
cal Department, 291; propoeea reduction of the Army Medical
Corps, 351; the proposed reduction in the Army Medical Service,
Parker, W. T., Uawbaru. K. H. M,, 430; scaling the appropriation
for the Library of the Snrgeon-Oeneral's OSioe. 475; infantry foot-
wear, 178; reduction of medical officers in the army, 690.

Araenic Chronic arsenical poisoning from wall-papers and fabrics,
246.

Asepaia. Obstetrical asepsis, Price, J., 32, 40.

Aahnnrat, J.. Jr. The surgical treatment of empyema, 664.

Asthma. Hypnotic suggestion in the core of asthma, 380.

Athletic Sports, Eliot, C- W., 197.

Aneust, A. Kecarrent appendicitis, 186.

Babeoek, B. H. A report of cases of chronic heart disease treated
by the Sehott method of baths and gymnastics, 661.

Bacteriology. The microbe of scarlatina, 73; bacteriological cult-
ures from a cose of puerperal septlca!mia, Morse, ,1. L., 140. 142; a
bacteriological study of four hundred oases of Intlaftimation of the
throat occurring In diphtheria and scarlet fever, with special refer-
ence to pathogenesis, Morse, J. L., 162, 182; the bacteria of perito-
nitis, 271; thel>aoteriology of nephritis, Sternberg, O. M., 673; sun-
shine and microbes, 603; Dr. S. U. Martin's researches on the bac-
teria of vaccinia, Ernst, H. C, 622; modification, temporary and
permanent, of the physiological character of bacteria in mixed
coltarea. Smith, T., 647; the effect of various metals on the growth
of pathogenic bacteria, Bolton, M., 647.

Bag;dad. A sanitary sermon in diagram, Snndberg, J. C, 77.

Bates, E, A. A case of tuberculous pericarditis with enormous
effusion; general tuberculoeis; antopsy, 7.

Beck, C. Laminectomy for tnberenlar disease of the spine, 220.

Bell, R. B. A ease of myx<Bdema, 364.

Beri-Beri, Daland, ,J-, 662.

BlblloKraptay. Adams, W., on ountractlon of the fingers and on
" lutmmer toe," 122; Ashhurst, J., Jr., the principles and practice
of surgery, 396; Baldy, J. M,, an American text-IMWk of gynecol-
ogy, medical and surgical, 653; Bartholow, K., a practical treatise
on materia medtca and therapeutics, 194; ilesrd, U. M., a practical
treatise on nervous exhaustion (neurasthenia), its symptoms,
nature, sequence, treatment, ^21; Berry, G. A., disease of tneeye,
396; boston Board of Health, twenty-tecond annual report, 602;
Boxall, R., the use of antiseptics in midwifery, their value and
practical application, 317; Bramweli, B., alias of clinical medicine.
246; Brodle, C. U., dissections Illustrated, ai graphic hand-book for
students of human anatomy, 345; Buck, A. H., supplement to the
reference hand-book of the niedlciil sciences, 293; Buxton, D. W.,
anffistbetlcs, their uses and administration, 221; Carmichael, J.,
disease In children, 169; Cathcart, G. W., descriptive catalogue of
the anatomical and pathological specimens In the museum of the
Royal College of Surgeons oi Edinburgh, 71; Coplin, W. M. L., and
Bevan, D., a manual of practical hygiene, 169; Corning, J. L.,
treatise on headache and neuralgia, including spinal irritation and
a disquisition on normal and morbid sleep, 631; Crocker, H. R.,
diseases of the skin, 46; Donkin, H. B., diseases of childhood, 293;
Dungllson, K., a dictionary ol medical science, Tl; Eceles, A. S.,
sciatica, a record of clinical observations on the causes, nature
and treatment of sixty-eight cases, 71; Firebaugh, E. M., the
physician's wife, and the things that pertain to Iter life, 369; Gal*
ton, D-, healthy hospitals, observations on some points connected
witn hospital construction, 369; Gray, H., anatomy, descriptive
and surgical, 19: Hart, E., hypnotism, mesmerism and the new
witchcraft, 19; tiewitt, F. W., ancestbetics and their administra-
tion, 646; Hilton. John, rest and pain, 317; Holden's manual of the
dissection of the human body, 369; hospitals, dispensaries and
nursing, 394; Hyde, J. N., practical treatise on diseases of the
skin, 631; Jackson, G. T.. a practical treatise on diseases of the
hair and scalp, 822; Jacobson, W, H. A., the diseases of the male
organs of generation, 19; Jenner, W.. lectures and essays on fevers
and diphtheria, 1849 to 1879, 122; Johns Hopkins Hospital reports,
report in gynecology, ii, 646; Jules, H. K-, a hand-book of ophthal-
mic sciences and practice, 622; Keen, W. W., operation blanks, 346;
Kirchhoff, T., hand-book of Insanity, 293; Landls, H. O., how to
use the forceps, 346; Macready, J. F. G. H., treatise on ruptures,
675; Madden, T. M., clinical gynecology, 71; Massachusetts State
Board of Lunacy and Charity, report for 1893, 72; Manley, T. H.,
hernia. Its palliative and radical treatment in adults, children and
infants, 473; MarlnesanttXtsordnung, 473; Martin, £., essentials of
minor surgery, bandaging and venereal diseases, 122; Mathews, J.
M., a treatise on diseases of the rectum, anus and sigmoid fiexures.
321; Musser, J. H., a practical treatise on medical diagnosis, 396;
Korrls, R C, syllabus of the obstetrical lectures in the medical de-
partment of the University of Pennsylvania, 420; Parkea, L. O^ In-
fectious diseases, notification and prevention, 396; Pepper, W., a
text-book of the theory and practice of medicine, 369; physician's
visiting list for 1894, 71; Pye-Smlth, P. H. an introduction to the
study of diseases of the skin, 20; Sctaenk, S, L., manual of bacteri-
ology. 44; Seun, A^ a syllabus of lectures on the practice of sur-
gery, 71; Surgeon-General's Office, U. S. A., index catalogue, Tol.
xiv, 223; Stearns, H. P., lectures on mental diseases, 317; StllM,
A-, and Maisch, J. M., the national dispensatory, 346; Tebb, W.,
the recrudescence of leprosy and its causation, 20; Thompson, H.,
introduction to the 'catalogue of the collection of calculi of the
bladder, 194; Tuke, 1). H., reform in the treatment of the insane;
early history of the Retreat, York; its object and influence, with a
report of the celebration of its centenary, 19; Von Krafft-Ebing,
R., psycopathla-sexualis, with especial reference to contrary sexual
Instioct, a medico-legal study, 19; Webster, D., eye-strain a cause
of headache, 631 ; Wharton, H. R., minor surgery and bandaging,
663; Whlttaker, J. V., the theory and practice of medicine, 293;
Wimmer, S. J., Wimmer's table and notes on human osteology, 420;
Witthaus, R. A., the medical student's manual of chemistry, 20;
a laboratory guide in urinalysis and toxicology, 473; Witthaus, R.
A., and Becker, T. C, medical jurisprudence, forensic medicine
and toxicology, 395; year-book of treatment for 1891, 473; Zola,
Lourdes, 661.

Bicycle. The pathology of bicycling, 197.

Billings, J. 8. Methmls of teaching surgery, 6.*IS.

Blocntphy. Arnold, J., 48n; Billings, L. F.. .^2; Billroth, T., 176;
Bnggs, C. E., 660, Brown-S^quard, 362, 370; Chrenow, 23; Codnian,
B. S., 2.-8; Conway, W. A., 424; Crary, U., 432; Giesson, C. M., 2»j

Digitized by

Google

TI

INDEX 10 VOLUME CXXX.

Can&lngham, W. F., 636; Dagna, O., 300; Day, A., 4M; OoDovan,
20O, 226, 2fil; Elder, K. 8., 63»; Fogg, W. J. D., 221, 292; Ford.O.
C, 401; Foraalth, F. F., 276; UarcS, V. A., 2;6: Grlergon. G. T..
t2ii; Gattmann, S., 28; Uartnett, M. K., S28; Hawaii, A. H., 4S6;
Hill, H. E., M; Ullson, A. H., 300; Hinch. A., 200; Holmea, H.,
149; Hutchinson. William F., 198: Jacob, Erofst H., 32K; Jamea,
Charlw, M9; Keatiog, W. V., 432; Kundt, A., 636; Lherttler,
S. O., 404; Lacke, A., 276; MHraton, D. E., 404; Metcalf, T., 4S5,
456; Mlohel, M., 636; Nava, J. G., 10«; OUivler, A., 328; Parrlsh,
J., 2a2; FatteraoQ, J. H., 496; Pike, C. U., 12«, B2T: KadBimiDskl, 23;
Kanch, J. H., 328; Roinaiies, G. J., Sfi2; Bobto, F. A., 200; Scheat-
haaer, G., 228; Seaverns, J., 2S2, 327; Smith, G. G., 80; Stanard, A.
C, 6112; Sperk. 636; Van Boueden. F. J., S2; Walker, J. E., 636;
Weld, F. M., 62; Willard, O. A., 82; Workman, J. H.. 404.

Bl«k«, J. O. Keview of a sammer'a work in gynteoolog; at tbe
Boaton City Hospital, 89, 97.

Blank for obstetric casea, Green, C. M., 98.

Bluad. The therapeutic action of blood-aerum, 4B; on the valoe of
the examination of the blood in the insane, Houston, J. A., 53.

Boardman, W. 8. The treatment of pulmonary tuberoolosis by
the sabcataneoos use of tbe chloride of gold and sodium with the
iodide of manganese, 492.

Bolton, M. The etfect of various metals on tbe growth of iMttbo-
genic bacteria, 647.

Bone. A case of myositis ossificans with multiple exoatoses, Qlb-
ney, V. P., 43.

Booth, J. A. A case of ezophtbalmlo goitrv; thyroideetomy, 3>i; a
case of hysteria with peculiar epileptold attacks, 393.

Boaworth, X*. H, Diseased conditions of tbe ethmoidal sinuses,
090.

Bowen, J. T. The prevalence and reoognitioD of wablea, 127; re-
port on dermatology, 241, 263.

Braekett, E. G. Exercise in tbe treatment of lateral cnrTatnre,
329 343.

Bradford, B. H. Flat-foot, 377, 388.

Bradford, E. H., and Braekett, B. O. Recent prograil in or-
thopedic surgery, 9, 38.

Brain. Venous tumor of the diploe, Plloher, L. S., 599.

Brandt Method of pelric massage, 474.

Breast. Large, dilfase fibroma of the breast, with spot of medul-
lary oarcinoma, Ulchardson, M. H., 143; fibroma of the breast, with
large oyst simulating carcinoma, Richardson, M. H., 193; the
change of a malignant tumor into a scirrhous cancer in the breast,
Cabot, A. T., 442; tumors of tbe breast, Warren, J. C, 643.

Brown, C. H. A case of amyotrophic lateral scierosis, 496.

Brown-Sequard'a teachings, 370.

Bryan, J. U. Surgery of tue maxillary slnna, S90.

Bryant, T. The neeessity of a well-paid medical profemlon, 374.

Barrage, W, TL. Three years' experience with electrical treatment
of fibroid tumors of the uterus, with a report of forty-four cates,
289.

Burrell, H. I,. The after-treatment of operations for appeudieitis,
433,444.

Barrel!, H. I», and Cushlnc H. W. Recent progress In surgery,
384, 416.

Batler, G. B. The methods and value of supervised exeroiae In the
prophylaxis of pulmonary phthisis, 630.

Cabot, A. T. The change of a maliguant tumor into a sclrrbous
cancer in tbe breast, 442.

Oabot, Richard C. Tbe diagnostic and prognosHo importance of
leucocytosis, 277, 292.

Call, A. P. Relaxation as a curative agent, 334.

Cancer. The discussion on tbe parasitism of cancer at the Eleventh
International Congress of Medical Sciences, 398; the change of a
lualignant tumor into a scirrhous cancer of the breast, Cabot. A.
T., 442.

Capital Pnnishment. Proposed legislation concerning capital
punishment In Uhio, 146.

Carmalt, W. H. Extirpation of tbe larynx, 600.

Carriages. The conveyance of scarlet fever and diphtheria by
public carriages, 576.

Carshaw, J. The use of antipyretic methods In the treatment of
scarlet fever, 373.

Cash. Pharmacy, Therapeutics and Credulity, GO.

Chadbourne, A. P. The gastric and respiratory symptoms caused
by tbe dust of curled hair, 439, 4S0.

Chandler, N. F. Report of two pregnancies following a laparot-
omy. 93, 9«.

Chaplin, W. S. .St. Ix>uis and its medical schools, 634.

Charles River in its relation to the etiology of intermittent fever,
Greenleaf, R. W., 36;), 367.

Charteris. The treatment of sea-sickness, 434.

Cbeever, D. W. Lectures on surgery, 81, 129.

Chiene, J. The teaching of surgery, 6li5.

Children. The study of pediatrics, Christopher, W. S., 174; feeble-
minded children, 222; cases of acute pneumonia In children, IVtor-
rill, F. G., 841.

China. Self-mutilation In China, 76; the plague In China, 631.

Chloroform. Sir James Simpson's early experiments with chloro-
form, 103.

Cholecyatotomy. Five cases of cholecystotomy, Perkins, J. W., 8T.

Cholera, 102; antl-choleraio inoculation, 198; Hatfklne's method of
inoculation against cholera, .'J23.

Christopher, W. S. The study of pediatrics, 174.

Circulatory System. A case of tuberculous pericarditis with
enormous etrnslon, general tuberculosis, autopsy. Bates, £. A., 7;
a review of ninety-two cases of disease of tbe heart observed In
the out patient department of the Boston City Hospital, (Jackson,
H., Ill; aoaseof malignant endocarditis. Fay, W. E., 189; cases of
fatal hsemorrhage from the Ipft lateral sinus caused by a blow on
the jaw, 201; ligation of both common carotid arteries. Gay, G.
W., 244; the treatment of pregnancy complicated by heart disease.
Sears, G. G., 253, 268; the diagnostic and prognostic importance of
leucocytosis, Cabot, R. C, 277, 292; recent progress in thoracic dis-
ease. Sears, G. G., 286; perforation of the heart, with continuance
of life for thirteen hours, Thompson, 3^; three cases of occlusion
of the superior mesenteric artery. Councilman, W. T., 410; Idio-
pathic hypertrophy of the heart, 421; perforating wound of the

heart. Hall, R. M., 431; peritonitis due to embolism of the mesen-
teric artery, Councilman, W. T., 443; arterio-sclerosis and arteritis,
modem views as to etiology, 547; the obscure origin and indetermi-
nate course of acute infection, as Illustrated by a case of malignant
endocarditis, Greene, J. S., 657, 663; a new and distinguishing sign
of latent aneurism of the aorta, Glasgow, W. C, 661; some patho-
logical conditions of tbe heart and their relation to diabetic coma.
Weber, L., 660; a report of cases of chronic heart disease treated
by tbe Schott method of bathe and gymnastics, Babcock, R. H., 661.

Clark, A. Work as a therapeutic agent, 60; occupation, 176; Mr.
Gladstone's tribute to Sir Andrew Clark and tbe medical profes-
sion, 679.

Clendenln, P. The open incision In uncomplicated cases of hydro-
cele, 440.

Codman, C. R. The Hassachusetts Homoiopathle Hedloal Society
luncheon, 403.

Coley, W. B. The treatment of inoperative malignant tninen by
the toxines of erysipelas and prodigiosus, 698.

Colorado. Some meteorological data of Colorado, Fisk, S. A., <S2.

ContaKlons diseases in tbe public schools, 23.

Coming, J. L. Deafness due to a foot-ball injury^JM.

Coroner. To abolish the office of coroner in New York, 102.

Conncllman, W. T. A case of multiple rupture of internal organs
produced by a fall, 109; three cases of occlusion of tbe superior
mesenteric artery, 410; peritonitis due to embolism of the mesen-
teric artery, 443; specimen of Intestinal obatrnction, 470.

Courtney, J. W. Modem realism and Zolaism in Spanish litera-
ture, 79.

Cowles, W. N. A ease of myxoedema treated by thyroid extract,
167, 168.

Cremation In Paris, 148.

Crime. Surgical treatment ot erlme. 171.

Orompton, D. Operative surgery under dUBcultles, 605,

Crotalas horridns, 3T6.

Crovrell, B. A case ot acute affection simulating scute yellow
atrophy of the liver in a pregnant woman, autopsy, 166, 169.

Cnrtin, B. Q. Creasote, gualacol and benzoyl In phthisis, 630.

Cashing;, B. W. A case of uterine tumor, 37, 42; tbe operative
treatment of uterine fibroids, 301, 316.

Cutaneous System. Tbe prevalence and recognition of scabies,
Bowen, J, '1., 127; r.^port on dermatology, Bowen, J. T.,241; tbe
treatment of chronic ringworm of the scalp. Fox, C, 373.

Daland, J. Beri-beri, 662.

Dana, C. L. Syringe myelia, central glioma of the spinal eord with
spontaneous central biemorrhage, 119.

Daodridge, N. P. Surgical treatment of pulmonary cavities, 402.

Davenport, F. H. Report of progress In gyumcology, 364; the
non-surgical treatment of chronic pelvic inflammations and their
sequels, 407, 420.

Davis, 8. H. The first epidemic of measles in Samoa, 606.

Dawbam, R. H. M. The proposed reduction In the Army Medical
Service, 431.

Day, F. I.. Twenty-six cases of Intubation ot the larynx, 356.

Delavan, D. B. Address before American Ijaryngologlcal Society,
666.

Dercnm, F. X. The therapeutics of inteotlous processes of the
nervous system, 594.

Dermatology. Report on dermatology, Bowen, J. T., 241, 263; tlie
dermatology of to-day, Morris, M., 298.

Diabetes. Pathology of diabetes mellitus, Joslln, E. P., 309, 330;
some pathol<^cal conditions of the heart and their relation to
diabetic coma, Weber, L>., 660.

Dikestive System. A bloodless operation for hemorrhoids, Man-
ley, T. H., 114; infectious appendicitis, Morris, R. T., 133; malig-
nant disease of the rectum. Gay, G. W., 204, 214; the bacteria of
peritonitis, 271; intestinal anastomosis (with Senn's plates) for can-
cerous obstruction, Elliot, J. W., 285; the gastric and reapiratory
symptoms cansiBd by the dust of curled hair, Chadbourne. A. P.
439, 460; digestive paresis, Whlttier, F.. K., 460, 470; specimen of
Intestinal obstruction. Councilman, W. T., 470; a case of amcabio
dysentery, Withington, C. F., 616, 622; strangulation of Heokel's
diverticulum caused by volvulus of tbe Ileum, Elliot, J. W., B86;
snioldal gunshot wound of the abdomen, fn-cal fistula, complete re-
covery without operation, Egan, P. R., 587.

Diphtheria. Blood-pressure In diphtheria, Friedemann, 26; remarks
on diphtheria, 107, 116; dipbtlieritic paralysis, 123; treatment of
diphtheria by frequent small doses of biniodide of mercury, 474;
primary nasal diphtheria, Townsend, G. W., 613, 520; the ooDvey-
ance of scarlet fever and diphtheria by public carriages, 576.

Dispensary, the first, 666.

Dissection in the public schools, 172.

Draper, F. W. A rare form of the hymen. 142; recent progresa in
legal nirdiolne, 313.

Drunkenness In wasps, 49.

Dunbar, F. A. Impure ice. 261.

Durell, T. M. The Leach case, 382, 390.

Dwiicht, T. Recent progress In anatomy, 464; tbe range and the
significance of variations in the human skeleton, 626.

Bar. Deafness due to a foot-ball injury. Corning, J. L., 120.

Bastman, J. Suprapubic bystereciomy, 663.

Bdes, B- T. Ovarioioray for nervous disease, 106.

Editorials. Vaccination and re-vacciiiiition. 21; nailbitine, 22:
contagious diseases In public scliools, 23; the therapeutic aotTon of
blood-serum, 46; report of the .Maspachusotts State Board of
Lunacy and Charity, Ti; the microbe of scarlatina, 73; avoidable
results and essential precautions in vaccination, 99; tlie Army
Medical School at Washington, 100; dlphiheriiic paralysis. Via;
the action of permanganate of potash in rendering morphia inert,
124; the contagium vivuni of vnccine and of sniaTl-pox, 146; pro-
posed legislation concerning capital punishment in Ohio, 146; sani-
tary Insurance, a scheme, 170; surgical treatment of crime, 171;
dissection In the public schools, 172; diseases due to " hard times,"
194; the supervision of the insane in New York, 195; feeble-mlDdod
children, 22^: the Index CaUlogue of the Library of the Surgeon-
General's Office, U. S. A., vol. xiv, 223; chronic arsenical poison-
ing from wall-papers and fabrics, 246; a new bill for the establish-
ment of a national bureau of health, 247; ectopic gestation, 270;
the bacteria of peritonitis, 270; proposed reduction of tbe Army

Digitized by

Google

IJSBEX TO VOLUME CXXX.

VII

Medical Department, 2M; reoeut inveatlgatlons of the British
Government apou the influence of oertAln trades or occupations
apon health, 294; the registration of and preventive measures
•gainst tuberculosis, 322; the n'lle of ftlcohuliii the causation of
cirrhosis of the liver, 32-1; anti-vaccination, 346; the unfavorable
sequelas of certain radical opf rations on the gall-bladder, 347;
Brown-Sequard's teachings, 370; the International Medical Con-
gress, 371; the doctor in fiction, 397; the discussion on the para-
sitism of cancer at the Eleventh International Congress of Medical
Seienoee, 39»; vital statistics of England for 1)>93, 389; idiopatbio
hypertrophy of the heart, 4J1; the Eleventh International Medical
Coosress, 4k3; anemployed medical men, 451; the poisonous prop-
erties of absinthe and its congeners, 452; the Brandt method of
pelvio massage, 474; treatment of diphtheria by frequent small
Ooees of blniodide of mercury, 4^4; scaling the approprintion for
the library of the Surgeou-Qunerars Oftice,476; heart-failure, 409;
the role of the nose in Zola, 300; Uaffkine's method of Inoculation
SJ^alDSt cholera, 523; railway spines and surgeons, 523; compulsory
vaccination, S24; arterio-scierosis and arteritis, modern views as to
etiology, 1H7; annual report of the Massachusetts General Hospi-
tal, 548; Third Triennial Congress of American Physicians and
Surveona, 575; the conveyance of scarlet fever and diphtheria by
poblio carriages, 576; recent sanitary improvements In Hamburg,
S7T; the Twenty-recond Annual Report of the Boston Board of
Health, 602; saDshineandnilorobes, 603; the plague In China, 631;
Zola and Lourdes, 654; revision in the Amerioau Medical Associa-
tion, Ki'i.

Kdncatlan. Another four years' course, 27; " Higher medical
etloeatlon," Ingalls, E. F., 51; the Army Medical School at Wash-
ington, lOO; four years' eottrse at Rush Medical College, ingalls,
E. F., 103; methods nt teaching surgery, Billings, J. S., 535; St.
Loaia and its medical mIiooIs, Cnaplln, \V. s.. 634.

Esan, P. R. Suiclilal gunshot wound of the abdomen, faecal fistula,
eomplete recovery witnout operation, 587.

■Ibow. Excision of the elbnw-joint, Richardson, M. H., 143.

Bkkctoriclty. Electrical reactions and their value In diagnosis and
prognosis, Starr, M. A., 317, 393.

B-lot, C. N. On the regulation of athletic sports, 197.

Klllott, tJ. W. Cases of extra-uterine pregnancy with operations,
260; intestinal anastonioees (with Senn's plates) for cannerous de-
Btructlou. 285; specimen of appendix, 444; strangulation of Meckel's
divertlctilum caused by volvulus of the ileum, 586.

Empyema. The sargical treatment of empyema, Ashhurst, J.,
Jr., S64.

Endocardlti*. A ease of malignant endocarditis, Fay, W. E., 189.

Ernst, H . C. Dr. S. C. Martin's researches on the bacteria of vac-
cinia, 622.

Ethmoidal Slnua«a, diseaseil conditions of, Bosworth, F. H., 690.

Everett, O. H. A case of uulnionary stenosis in an adult, 207.

Ewlnif, C. The action of rattlesnake venom upon the bactericidal
power of the blood-serum, 4m7.

EwIdk, J. Address before American Sargical ABSOciatlon. 664.

Exercise in the treatment of lateral curvature, Braokrtt, £. Q.,
329,343.

Extns-oterlne prM^ianoy, right-sided, followed at an Interval of
two years by left-siaed Fallopian pregnancy, with repeated opera-
tion, Harrington, F. B., 6; six cases of extra-uterine pregnancy,
Johnson, F. W., 266, 265; oases of extri^uterlne pregnancy, Elliot,
J. W.. 260; ectopic gestation, 270.

Eye. Removal of foreign body from the anterior chamber of the
eye, 142; two cases of chancre of the eyelid, with an account of the
manner of infection, Standish, M., 237, 244; thrombosis of the cen-
tral artery of the retina with unusual features, Jack, E. E , 312.

F»rlaw, J. W. Hypertrophy In the post-nasal space, especially
after childhood, 66, 66.

r«y. W. B. A case of malignant endocarditis, 189.

reeble-mlnded children, 222.

F«ii|eer, C. Surgery of the ureters, 696.

risclier, W. The new rational way to sleep, 126.

riaher, K. D. Anomalous cases of general paresis, IS.

Ftok, H. A. A treatment of typhoid fever, 620; some meteorologi-
cal data of Colorado, 632.

Fftchbars. The sewerage system In Fitohburg, 426.

Fits, B. H. The rise and fall of the licensed physician in Massa-
ehasetts, 1781-1860, 629; the legislative control of medical practice,
SMI, 609, 637.

FIsit-Foot, Bradford, E. H., 377.

Folsom, O. F. A case of appendicitis, 342; cases of traumatic
beadache, 821, 641.

Foot. A case of club-hand and club-foot, Sayre, R. H., 42; the
treatment of club-foot by Wolll's nietho<l, Shands, A. B., 43.

Foot-ball rs. insurance. Wells, O. W. 76; deafness due to a foot-
ball injoiT, Corning, J. L., 120.

Forbes, W. S. The removal of stone in the bladder, with the pres-
entation of a new llthotrlte, 6A0.

Fox, C. The treatment of chronic ringworm of the scalp, 373.

Fraetnree. Compound fractures, Mumford, J. G., 46;!, 471; mooted
points as to fracture of the arm, with notice of an Improved splint,
Oaston, J. McF., 699.

Francis, 6. E. Three uterine pregnancies during an extrauterine
pregnancy, 199.

Frank. Tapping of the lateral ventricles, 401.

Frledemann. Blood-pressure in diphtheria, 26.

Oase, H. Appendicitis; some impressions derived from an experi-
ence of forty-four cases, 908.

Oall-bladder. The unfavorable sequelss of certain radical opera-
tions on the gall-bladder, 347.

GastoD, J. McF. Mooted points as to fractures of the arm, with
notice of an improved splint, 699.

Ciavin, H. F. The radical cure of hydrocele, 210, 213.
Gay, G. W. Malignant disease of the rectum, 204, 214; ligation of
both common carotid arterits, 244; letter from Rome, 42K; the
Kedieal Registration Bill, 651.
Generative System. A case of uterine tumor, Cushlng, E. W., 37,
41; the immediate cansatlon of the diseases peculiar to women,
Humdss, T. O., 68; review of a summer's work In gyncecology at
tlie Beaton Ci^ Hospital, Blake, J. G., 89, 97; ovariotomy for ner-
vous disease, Edes, B. T., lOS; a rare form of the hymen. Draper,

F. W. 142; three cases of salpingitis of unusual extent, Richard-
son, M. H., 159, 169; the radical cure of hydrocele, Qavln, M. F.,
40. 213; three years' experience with electrical treatment of fibroid
tumors of the uterus, with a report of forty-fuur cases, Burragc,
W. L., 389; the operative treatment of uterine Hbroids, Cushlng,
E. W.,301, 315; Imperforate hymen with liKmatocolpos, Green, C.
M.. aif, 367; mucous cysts of the vagina. Green, C. M., 368; recto-
vulvar ilstuia. Green, C. M., 358; report of progress In gyna'cology,
IJavenport, K. H., 364; observations in cases of tibroid tumor of tiie
womb, MInot, F., 405, 419; the non-surgical treatment of chronic
l)elviG intlamniations and their scquelif!, l>Hvenport, F. H., 407, 420;
the open Incision In unconitilicatcd cases of hydrocele, Cleiideiiin,
P., 440; strictnre of the urethra, with specimen, Richardson, M.
H., 443; the Brandt method of pelvic massage, 474; suprapubic
hysterectomy, Eastman, J., 653; the conservative surgery of the
female pelvic organs, Polk, W. M., 573; the conservative treatment
of the female pelvio organs, 674; pelvio Intlammations, Wheeler,
L., 615.

Glbney, V. P. A case of myositis ossificans, with multiple exos-
toses, 43; the I,orenz treatment of hip disease, 219; excision of tlie
hip, 219.

Gilbert, D. D. The pro<1uctiou of vaccine virus, 434, 444.

Girl, 'rhe effect of climate and environment on the New England
girl, Achorn, J. W., .18.

Gladstone. Mr. Gladstone's tribute to Sir Andrew Clark and the
medical profession, 679.

Glascow, W. C. A new and distinguishing sign of latent aneurism
of the aorta, 651.

Goodell, W. The conservative treatment of the female pelvic
organs, 674.

Gobs, F. W. Two cases of pulmonary congestion and <edeina oc-
curring during pregnancy, 336, 341.

Goat. American gout, 273.

Grant. J. H. Toxic effects after use of oil male fern (ethereal) for
tapeworm, 337.

Green, C. M. Obstetric case-blank, 98; four unusual cases; Imper-
forate hymen with liii'matocolpos, mucous cysts of the vagina,
recto-vnlvar fistula, salivation of pregnancy, 358, 367.

Greene, E. W Crystalline deposits In the urine, their causation
and relation to renal diseases, 538, 560, 564.

Greene, J. 8. The obscure origin and Indeterminate course of
acute Infection, as Illustrated by a case of malignant endocarditis,
667,663.

Greenhalse. Inaugural address, 49.

Oreenleaf, R. W. The Charles River in Its relation to the etiology
of Intermittent fever, 363, 367.

Gynaecology. Report of progress in gynaecology, Davenport, F. H.,
864.

Haff kine's method of Inoculation against cholera, 623.

Hair. The gastric and respiratory symptoms caused by the dust of
ourle<l hair, Chodbouriie, A. P., 439, 450.

Hall, J. N. " Sending patients away from home," 2T; weight as a
svmptom In phthisis, G07.

Hall, R. M. Perforating wound of the heart, 431.

Hamburg;. Recent sanitary improvements in Hamburg, 677.

Hand. A case of club-hand and club-foot, Sayre, R. H., 42.

Hard Times. IJlseases due to hard times, 194.

Harrington, F. B. Right-sided, followed at an interval of two
years by left-sided Fallopian pregnancy, with repeated operation, 6.

Harrlnicton, M. W. Sensible temperatures, 662.

Haven, G. A cose of puerperal septicojuila. 140, 142.

Bay, G. Removal of foreign body from the anterior chamber of
the eye, 142.

Hayes, M. C. I'he vermiform appendix, 175.

Heart-fallnre, 499.

Benry, F. P. A clinical report of two oases of Raynaud's disease,
621.

Herter, C. A. A critical review of the various theories of uriemla,
based upon original experimental observations, 497.

BIbberd, J. F. Annual address before the American "Medical
Association, 623.

" Higher medical edncatlon," Ingalls, E. F., 61.

Hinsdale, G. The comparative rarity of phthisis In the highlands
of Pennsylvania and the adjacent connties of New York, 6,11.

Hindu system of medicine and the secret of success In practice, 427.

Hip. The Lorenx treatment of hip disease, Glbney, Y. P., 219; ex-
cision of the hip, Glbney, V. P., 219.

Hogner, R. Treatment of small-pox by non-admittance of the
chemical rays of light, 35; on spermatorrboja and Incipient hyper-
trophy of the prostate and a proposed method fur Its treatment, 'iSi),

Honstun, J. A. On the value of examination of the blood of the
insane, 63.

HuKhes, C. H. The nervons system in disease and the practice of
medicine from a neurological standpoint, 624.

Hyde, J. If . The distribution of leprosy in North America, 671.

Hydramnlon. Two cases of hydrainnlun associated with abdominal
distention In the foitus, Townsend, C. W., 139, 142.

Hydrocele. The radical cure of hydrocele. Gavin, M, F., 210, 213;
uie open incision In uncomplicated cases of hydrocele, Clendenln,
P., 440.

Hygiene, Health and Boards of Health. Report of the Massa-
chusetts State Board of Lunacy and Charity, 72; a sanitary sermon
in diagram, Sundberg, ,T. C, 77; sanitary hygiene, a scheme, 17i';
a new Dill for tlie eHtablltihuient of a national bureau of health,
247; recent investigations of the British Government upon the In-
fluence of certain trades or occupations upon health, 294; recent
progress in public hygiene anil preventive medicine, Abbott, 8. W.,
337; the Charles River In its relation to the etiology of intermit-
tent fever, Greenleaf, R. W., 363, 367; the sewage system in
Fitchburg, 425; chemical, physical and bacteriological studies of
air over decomposing surfaces, with especial reference to their a|i-
pllcation to the air of sewem, Abbott, A. C, 569; the effect of
sewer-gas in the production of ilisease, .lacobi. A., 570; sewer-gas
as a cause of throat disease, or the effect of bad drainage on the
throat, Itobinson, B., 570; recent sanitary improvements In Ham-
burg, 577; retrogressive leeiiilalion In regard to Massachusetts
boards of health, 078; annual report of the Boston Board of Health,
602.

Digitized by

Google

Tiii

INDEX TO VOLUME CXXX.

Bymen. A rare form of tbe bymen, Draper, F. W., 142.
Hypnotism. Hypnotic snggefttloii in the cure of asthma, 3fiO.
Icbtbyol. A note on the use of ichthyol, Sinclair, 140, 141.
Immlrraiits. Tbe foreign quarantine of immigrants, 3117.
Infecuoua Dlaeaaea. A olafeitieatlon for Infeetlou* dlseaaef,

Thomson, "W. H., Ml.
Ingalls, E. F. " Higher medical adaeatlon," SI; four years'

coarse at Rush Medical College, 103,
lD*an«. The supervision of the insane in New York, 195.
iDsarance. Foot-ball vs. Insnrauce, Wells, O. W., 76; sanitary in-
surance, a scheme, 170.
Intermittent Fever. The Charles Kiver in Its relation to tbe

etiology of intermittent fever, Oreenleaf , U. W., 363. 367.
Jack, K. E. ThromboBiB of tbe central artery of tbe retina with

unusual features, 312.
Jackson, H. A review of ninety-two cases of diseases of tbe heart
observed in the out-patient department of the Boston City Hos-
pital, ill.
JaoobI, A. Tbe effect of Bewer-gas in tbe production of disease,

870.
Jaooby» O* W. A ease of progressiro muscular atrophy of tbe

perineal tyiM, 392.
Japanese girls In boxes. 656.

Johnson, A. B. A case of neuralgia of tbe great occipital nerve,
with symptoms of a deBlruotive IcBion of tbe cervical Byinpatbetic,
392.
Johnson, F. W. Six oases ot extra-uterine pregnancy, 256, 265.
Joslin, K. P. Patbology of diabetes mellitus, 309, 330; clinical
note-taking, with a list of four hundred and ninety-nine medical
cases shown to the third class of tbe Harvard Medical School, 415.
Keefe, J. W. Iwelve consecutive and successful operations for

appendicitis, 282. 306.
Keen, W. W. Tbe pleasures and pains of a pbystelan's life. 126;
amputation of the entire upper extremity (including tbe scapula
and clavicle) aad < f the arm at tbe sbonlder-joint, 565.
KenyoD, C. U. Annual address before the Medical Society of the

State of Calirornia. 4'<1.
Keyes, K. I.. Nephritis in its surgical aspects, 572.
Knapp, P. C. Keport on diseases of the nervous system, 62, 94.
Knight, F. O. Shall anything be done by legal authority to pre-

Tent tbe spread uf tuberouloBls ? 630.
liane, 1^. O. A reminisoenoe of tbe Nicaraguan fliibusters. 60.
jMtjjkx. Twenty-six cases of intubation of tbe larynx, Day, F. L.,
866; address before American L-iryngoiogicat Society, Delavan, U.
B., 666; extirpation of tbe larynx, Carmalt, W. H., 600.
I.eBch case, 382, 390.
IiCgral Medicine. Recent progress in legal medicine. Draper, P.

W., 313.
LeKlalatlon. Proposed legislation for tbe better protection of the
community against quackery, 478; "The Medical Registration Bill
In the Maaaacbusetts Legislature," 627; the rise and fall of the
licensed physician in MassaabufettB, Fitz, R. H.,629; the Medical
Kegistratioi'i Bill, tiay, O. W., 651: retrogressive legislation in re-
gard to Massachusetts boards of health, 678; the legislative con-
uol of medical practice, Fitz, K. H., 581, 61)9, 637.
leprosy. Tbe dietribation of leprosy in North America, Hyde, J.
N., 671; tbe contagiousness, prophylaxis and control of leprosy,
White, J. C. 671; resolution before tbe Congress ot American
Physicians and Surgeons, 589.
I^ncooytoslR. The diagnostic and prognostic importance of leuoo-

cvtosis, Cabot. K. C, 277, 292.
l.lthoIapaxy. Two cases of litbolapaxy, Allen, G. W., 383, 388.
Llthuliptriat. 69.
Ijiver. Tbe r61e of alcohol In the causation ot cirrhosis of tbe

liver, 324.
Iionicevlty. External Indications of inherited longevity, 126.
Loomls, A. T^. The luHuenee of animal experimentation on medi-
cal science, 685.
I/orenz- treatment of hip<liseaBe, Glbney, V. P., 219.
Male Fern. Toxic effects after use of oil male fern (ethereal) for

tapeworm, Orant, J. H., 337.
Malignant Tumors. The treatment of inoperative malignant
tumors by the toxines of erysipelas and prodiglosus, Coley, W. B.,
698.
Mallury, F. B. Letter from Prague, 77.
Manley, T. H. A bloodless operation for bmmorrbolds, 114.
Martin, F. C. The production of vaccine virus, 479.
Maaon, A. L. Second attacks of typhoid fever in adults, two cases,

180.
Maasaohnaetts. A bill to provide for the registration of physicians

and surgeons In tbe State of Massachuseits, 426.
Materia Medica and Therapeutics. Cbimges iu the Pharma-
copoeia, 25; pharmacy, therapeutics and credulity, Cash, 50; the
action of permanganate of pota^th in rendering morphia inert, 124;
a note on tbe use of Icbtbyol. SlDClair, A. !>., 140, 141 ; remarks on
the therapeutic use of sheep's thyroids Hud of other organic ex-
tracts, Putnam, J. J., 163, 168; relaxHtion as a curative agent. Call,
A. P., 331; toxic effects after use of oil male fern (ethereal) for
tapeworm, Grant, J. H„ 337; saturated solution uf potas-'iuni per-
manganate in tbe treatment of chronic ulcer, Waugliop, P, R., 467;
treatment of diphtheria by frequent small doses of biniodltle of
mercury, 474; the effect of ether and chluroform on the kidneys,
Wunderlicb, 477; the treatment of tiiben'-ulosis by the subcuta-
iioons use of the chloride of gold and sodium with tbe iodide of
manganese. Boardmau, W. 8.. 492; the over-xualous therapeuilcian,
Stokvis, 626; re|iort ou tborapeut'ci, Williams, F. II., 643.
Maxillary Sinus, surgery of the, Bryan, J. H.. 690.
McCoIlum, J. H. Remarks on diphtheria, 107, 115.
Measles. Measles and theology, 427; the first epidemic in Samoa,

Davis. S. H., 605.
" Mental Cure." What " mental cure" Is, Whipple, L. K., 148.
Millard, P. H. Another four years' course, 27.
Mills, C. K. Itelatlon of Infectious processes to mental disease,

692.
Mind. On the value of examination of tbe blood in the insane.
Houston, J. A., 63; report of tbe Massachusetts State Board of
Lunacy and Charity, 72; what *' mental cure " Is, Whipple, L. K.,
]48; tbe supervision of tbe insane In I<ew fork, 196; report on

mental diseases, Stedman, H, B., 494, 617; relation of Infectious
processes to mental disease, Mills, G. K., 592.

MInot, F. Observations on cases of fibroid tumor of the womb, 406,
419.

Morphia. Tbe action of permanganate of potash In rendering mor-
phia Inert, 124.

Morphology as a factor In the study of disease, Allen, H., 667.

Morrill, F. O. Cases of acute pneumonia In children, 641.

Morris, M. The dermalology or to-day, 298.

Morris, R. T. Infections appendicitis, 133.

Morse, J. 1.. Banteriolog cai cultures from a case of puerperal
septicemia, 140, 142; a bacteriological study of four hundred cases
of inflammation of tbe throat occurring in diphtheria and sesriet
fever, with especial reference to pathogenesis. 162, 182.

Momford, J. O. Compound fractures, 463, 471.

Munis collection of skulls, 402.

MyxcBdema. A case of myxiBdema treated by thyroid extract,
Cowles, W. N.. 167; four cases of myxoidema treated by thyroid
extract, Sliattuck, F. C, 177, 191; a case of inyxocdema, Putnam,
J. J., 190; a case of niyxcedema, Bell, U. K., 364.

Nails. Nail-biting, 22.

Megro. Tbe solution of the negro rape problem. 126.

Nephritis in its surgical aspecu, Keyes, E. L., 672; the bacteriology
or nephritis, Sternberg, G. M., 673.

Nervous System. Anomalous cases of general paresis, Fisher, E.
I)., 15; discussion on the relation of syphilis to general paresis,
Peterson, F., and others. 16; report on diseases of the nervous
system, Knapp, P. C, 62, 91; ovariotomy for nervous disease, Edes,
R. T., 105; glio-Barcoma of the basal jnuiglla, 117; sub-acute uni-
lateral bulbar palsy, with autopsy, Wiener, A., 118; tbe pons-
medulla flocculus triangle as a tumor site, with pathological find-
ings, Newton, R. S., 418; syringo-niyeiia, central glioma of tbe
spinal cord, with spontaneous central binmorrhage, Dana. C. L.,
119; a case of Infantile cerebral spastic diplegia, Peterson, F., 120;
deafness due to a foot-ball injury. Corning, J. L., 120; a case of
acromegaly. Parsons, R. L., 120; ergot In the treatment of periodic
neuralgias, Thomson, W. H., 121; diphtheritic paralysis, 123; recent
observations on the functions of the thyroid gland and the rela-
tions of tbe enlargement to Graves's disease, also remarks on the
therapeutic use of sheep's thyroids and of other organic extracts,
Putnam, J. J.. 153, 16H; case of fatal liEemorrbRge from the left
lateral sinus caused by a blow on the jaw, 201; Pott's paraplegia.
Whitman, R., 21f ; electrical reactions and their value In diagnosis
and prognosis, Starr, M. A., 317; a case of progressive muscular

atrophy of the perineal type, Jacoby, G. W., 392; a case of neu-
ilgla of the great occipital t
lesion of tbe cervical sympathetic, Johnson. A. B , 392; a case of

ralgia of the great occipital nerve, with symptoms of a destructive

hysteria with peculiar epileptoid attacks, Booth, J. A., 393; elee-
trjoal reaciions and their value In diagnosis and prognosis, 39:1;
tapping of the lateral ventricles, Frank, 401 ; a case of amyotrophic
lateral sclerosis. Brown, C. H.. 4^6; a case of progressive muscular
dystrophy, Wiener, A., 496; a critical review of the various theo-
ries of urremia, based upon original experimental observations,
Herler, C. A., 497; railway spines and surgeons, 623; tbe influence
of Infectious processes on the nervous system, pathology and eti-
ology, Putnam, J. J., 591; the therapeutics of infectious processes
of the nervous system, Dercum, F. X., 694; cases of tranmatio
headache, Folsom, C. F., 621. 611; the nervous system In disease and
tbe practice of medicine from a neurological standpoint, Hughes,
C. H., 6i4.

Newell, O. K. Tbe iutermittent rapid dilatation of urethral strict-
ure, 389.

Nevrton, K. 8. The pons-meduUa floeeulus triangle as a tumor-
site, with patbological findings, 1 18; a ease of exophthalndc goitre,
thyroidectomy, 392.

New York. To abolish the ofllee of coroner In New York, 102.

Nicaragua, A reminiscence of the Nicaraguan filibusters. Lane,
L. C, BO.

Nose. Tbe riMe of the note in Zola, 600.

Note-taking. Clinical note-taking, with a Hit of four hundred and
ninety-one medical cases shown to the third class of the Harvard
Medical School, .loslin, E. P., 416.

Nurses. What might be done by tbe Obstetrical Society to advance
the training of nurses, Worcester, A., 436, 450.

OI>stetrlcian. A famous country obstetrician two centuries ago, 374.

Obstetrics. Recent progress in obstetrics, Reynolds, E., 210.

Occupation, Clark, A., 175.

Odors. The influence of odors on the voice, 631.

Opium. Permanganate of potash in opium-pu'soning, Pyle, W. L.,
602.

Orthopaxy. Recent progress iu orthopedic surgery, Bradford, E.
H., and Brackelt. K, G., 9, ^^', a oiise of club-band and club-foot,
Sayro, U. H., 42; a case of myositis-ossiticaDs with niultlpin exos-
toses, Gibney, V. P., 43; the treatment of club-foot by Wolff's
method, Shands, A. B., 43; congenital torticollis. Whitman, K.,
218; Pott's paraplegia, W'hitman, R., 218; pcrsist<>nt psoas contrac-
tion, Wbitnjan, R., 219; the Lorenz treatment of hip d soase, Glb-
ney, V. P., 219; excision of the hip, Gibney, V. P., 219; a new
operation for tbe relief or cure of rotary lateral curvature of tbe
spine, Schaffer, 221; exercise in the treatment of lateral curvature,
Brackett, K. G, 329, 343; flat-foot, Bradford, E. H., 377.

Out-Patieiit hospital abuse, 502.

Pancreas. A case of acute ba^morrbaglc pancreatitis, Paul, W. E.,
8; haemorrhage into the imicreas as a cause of sadden death,
Whitney. W. F.. 3711, 390.

Parker, W. T. Tbe proi>osed reduction In tbe Army Medical Ser-
vice, 430.

Parsons, K. I#. A case of acromegaly, 120.

Paul, W. K. A case of acute Inemorrhagic pancreatitis, 8.

Peckhaiu, F. E. Appendicitis, with apparent resolution of abscess,
relapse, death, autopsy, 61; scarlatina with persistent high tem-
perature associated with wild delirium, finally controlled by guaia-
col, 517.

Pediatrics. Tbe study of pediatries, Cbrlstopher, W. S., 174.

Pepper, W. Dr. William Pepper's resignation as Provost of the
University of Pennsylvania, 424.

Peritonitis. Tbe bacteria of peritonitis, 271; peritonitis doe to em-
Imliam of the mesenteric artery, Coanotiman, W. T., 443.

Digitized by

Google

INDEX TO VOLUME CXXX.

iz

Parkin*, J. W. IHre cues of oholeoystotom;, 87.

Petorcon, F. 011o«arooiDa of the basal gauglta, 117; a case of in«
fantlle, cerebral, gpaetlc diplegia, 120.

Petenon, F., and others. Dlsoussioo ou the relatloD of syphilis
to geueral {laresls, 15.

Feaaer, The pathology of bicyolliig, 197.

Fhannaoopoela Changes In the PharniacopGela, 2.9.

Phelpa. A. M. Ezeislon of the tarsus for carles, 220,

Phoaphaturia. Notes on phospbaturla, Tbornilike, P., 134, 144.

PbthUU. Weight as a symptom in phthisis, Hall, J. N., 607; the
comparatiTe rarity of phthisis in tlie highlands of Pennsylraiila
and the adjacent counties of New York, Hinsdale, Q., 651.

Flloher, I.. S. Venous tumor of the diploe, 61)9.

Piatt, W. B. Lamiueoiomy eleven months after injury to the
spine, 412.

PnAamonia. Obserratlons on pneumonia, FrescotL, W. H., 229.

Polk, W. M. Conserrailre surgery of the female pelvic organs, 573.

Praffoe. Letter from Prague, Mallory, P. B., 77.

PregDancy, affections connected with. Klgbt-Bided, followed
at an interval of two years by left-sided Fallopian pregnancy, with
repeated operation, Harrington, F. B.. 6; obstelrioal asepsis, I'rice.
J., 32, 4ii; report of two pregnancies following a iaparotomv.
Chandler, N. F., 93, 98; two eases o( pregnancy associated with ab-
dominal distention In the fotua, Townsrud, C W., 139, 142; a c»Be
of puerperal septicasmia. Haven, O., 140, Hi; bacteriological cult-
ures from a case of puerperal septicsentia, Morse, J. L., 140, 142; a
ease of acute infection simulating acute yellow atrophy of the liver
In a pregnant woman, autopsy, Orowell, N., 166, 16!l; three uterine
pregnanoiefl during an extra-uterine pregnancy, Francis, G. b^,, 190;
the treatment of pregnancy complicated by heart disease, Sears,
6. G., 253, 268; six cases of extra-uterine pregnancy, Juhnfou, F.
W., 256, 285; oases of extra-uterine pregnancy, Elliot, J. W. 260;
eotopio gestation, 270; a case of coueealed accidental hsemorrhsge
during tne first stage of labor, with recovery of mother under cou-
■errauTe treatment, Reynolds, £., 284; two cases of pulmonary
congestion and cedema occurring during pregnancy, Goss, F. W.,
836. 341; salivation of pregnancy, Oreen, C. M., 35ii; the Leach
case, Uureli, T. M., 382, 390.

Prescott, W. H. Observations on pneumonia, 229.

Preaent Oeneration, 198.

Price, J. Ubstetricui asepsis, 32, 40.

Putnam, J. J. Recent observations on the functions of the thyroid
gland and the relation of the enlargement to Graves's disease, also
remarks on the therapeutic use of sheep's thyroids and of other
organic extracts, 153, 168; a case of myxcedemH, 190; theintiuence
of infections processes on the nervous system, pathology and etiol-
ogy, 691.

Pyie, W. L. Permanganate of p >tash in oplnm-potsoning, 502.

Railway Spine* and surgeons, 5 '3.

Rattlesnake. The action of rattlesnake venom upon the bacterici-
dal power of the blood-eeruni, Kwing, C. B.. 487.

Kaynaad'* DUease. A clinical report of two cases of Raynaud's
disease, Henry, F. P., 621.

Recent Prot^re**. Urllinpedio surgery, Bradford, E. H., and
Brackett, E. U., 938; nervuus system, Kuapp, P. C, 62, 94: obste-
trics, Reynolds, E., 210; dermatology, Buwen, J. T., 241, 263;
thoracic disease. Sears, G. G.. 2s5; legal medicine. Draper. P. W.,
313; public hygiene and preventive medicine, Abbott, S. W.,337;
ruascology, I>avenport, F. H., 364; surgery, Burrell, H. L., and
usblng, H. W., 384, 416; anatomy, Dwight, T., 468; mental dis-
eases, stedman, H. R., 494, 517; therapeutics, Williams, F. H., 543.

Rectnin. Malignant disease of the rectum. Gay, G. W., 2U4, 214.

Reed, B. The relation which alimentation should bear to oxygen-
ation in lung diseases, 629.

Registration. National registration a necessity, Abbott, S. W.,
137; a bill to provide for the registration of physicians and sur-
geons in the State of Massachusetts, 4'/6; " reserving the claim of
exemption from registration," 679; a qualified signature to the
Registration Law, 635: the Medical Registration Law, 625.

Relaxation as a curative agent. Call, A. P., 334.

Reapiratory System. Hypertrophy In the post-nasal space, espe-
cially after childhood, Parlow, J. W., 56, 65; a case of pulmonary
stenosis in an adult, Everett, U. H., 207: observations on pneu-
monia, Prescott, W. H., 229; recent progress in thoracic disease.
Sears, Q. G., 285; two cases of pulmonary congestion and cedema
occurring during pregnancy, Goss, F. W., 336. 341; twenty-six
cases of intubation of the larynx, Day, F. L., 356; surgical treat-
ment of pulmonary cavities, Dandridge, N. P., 402: the gastric and
respiratory symptoms caused by the dust of curled hair, Chad-
bourne, A. P., 439, 460; the surgical treatment of empyema. Ash-
hurst, J., Jr., 664; cases of acute pneumonia in children, Morrill,
F. G., 541; weight as a symptom in phthisis, Hall, .J. N., 607; the
treatment of certain symptoms of croupous pneumonia, particu-
larly in adults, Robinson, B.,618; alimentation In pulmonary dis-
ease, Smith, A. H., 629; the relation which alimentation should
bear to oxygenation in lung diseases, Reed, B., 629; tlie methods
and value of supervised exercise in the prophylaxis of pulmonary
phthisis, Butler, O. R., 630; creasote, guaiacol and benzoyl in
phthisis, Curtin, R. G., 630; shall anything bo done by legal au-
thority to prerent the spread of tubercuiosii? Knight, F. G., 630;
the comparative rarity of phthisis in the highlands of Pennsyl-
Tanla and the adjacent counties of New York, Hinsdale, (i., 661;
some meteorological data of Colorado, Fisk, S. A., 652.

Reynold*, E. A case of concealed accidental hiemorrhago during
tne first stage of labor, with recovery of mother under conservative
treatment, in.

Riohardaon, M. R. Specimen of gangrenous and perforated ap-

fiendix, 67; large dlH'use fibroma of the breast, with spot of medul-
ary carcinoma, 143; excision of the elbow-joint, 143; three cases of
salpingitis of unusual extent, 159, 169; an appendix obliterated In
the greater part of its length, 192; fibroma of breast with large
cyst simulating carcinoma, 193; cases of appendicitis presenting
nnusuikl features, 232; stricture of the urethra, with specimen, 443.

Roblneon, B. Sewer-gas a cause of throat disease, or the etfect of
bad drainage on the throat, 570; the treatment of certain symp-
toms of croupous pneumonia, particularly in adults, 618.

Rome. Letters from Rome, Gay, G, W., 428; a few notes on Rome
and the late International Medical Congress, 429,

Cut

Rush Medical College. " Higher medical edncatlon," Ingalls, E,
F.. 61; four years' course at Rush Medical College, Ingalls, ■!!. P.,
103.

Russell, W. Pathology and the scii'nt flc mind, 77.

Salplneitls. Three cases of salpingitis of unu>ual extent, Uicbard-
son, M. H., 169, 169.

Samoa, 'fhe first epidemic of measles in Samoa, Davis, S. H., 605.

San Francisco. Letters from San Francisco, 685, 667.

Sanitary Insnrance, a scheme, 170.

Sayre, K. U. A case of clul>-hand and club-foot, 42.

Scabies. The prevalence and recognition of scabies, Bowen, J.
T., 127.

Scarlatina. The microbe of scarlatina, 73; scarlatina with persist-
ent high temperature associated with wild delirium, fliialiy oon-
troiled by guaiacol, Peckbam, F. E,, 517.

Scarlet Fever. The use of antipyretic methods in the treatment
of scarlet fever, Caralaw, John, 373; the conveyance of scarlet
fever and diphttieria by public carriages, 676.

Schools. Contagious diseases in the public schools, 23.

Sehott Method. A report of cases nf chronic heart disease treated
by the Scbott method of baths and gymnastics, Babcock, K. H.,
651.

Si^udder, O. L. Cases of abdominal surgery occurring in the prac-
tice of Dr. J. Collins Warren at the Massachusetts General Hos-
pital during the winter of 1893, 1, 29; surgical oases, 646.

Sears, G. O. The treatment of pregnancy complicated by heart
disease, 253, 268: recent progress in thoracic disease, 285.

Sea-Sickurss. 'rhe treatment of sea-sickuess, Cliarterls, 464.

Self-mutllation in China, 76.

" Sending patients away from home," Hall, J. N., 37.

Sewage system in Fitcbburg, 426.

Sewers. Chemical, physical and bacteriological studies of air over
decomposing surfaces, with especial reference to their application
to the air of sewers, Abbott, A. C, 569; the etfect of sewer gas in
the production of disease, .lacobi. A., 570: sewer -gas as a cause of
throat disea^, or the etfect of bad drainage on the throat, Rol>in-
son. B.,570.

Shaffer. A new operation for the relief or cure of rotary lateral
curvature of the spine, 221.

Shand*, A. B. The treatment of club-foot by Wollf's method, 43.

Shattuck. F. O. Four ca^es of myxoMlema treated by thyroid ex-
tract, 177, 191; the frequency of renal albuminuria, ss shown by
albumin and casts, apart from Brlgbt's disease, fever or obvious
cause of renal irritation, 613.

Shoes. Infantry footwear, 478.

Simpson. Sir James Simpson's early experiments with chloroform,
103.

Sinclair, A. I). A note on the use of Ichthyol, 141, 142.

Skulls. Mufiiz collection of Fkulls, 41)2.

Steep. The new rational way to sleep, Fischer, W., 126.

l^mall-Pox. The treatment of small-pox by non-admittance of the
chemical rays of light, Hogner, R,, 35; a personal experience wltb
small-pox. White, H. W., 91; the contagium vivum of vaccine and
of small-pox, 145; the experience of two women physicians with
smallpox, 148; the diagnosis of small-pox, 276; variola, Webber,
8. Q., 467, 490.

Smith, A. H. Alimentation In pulmonary disease, 629.

Smith, T. Modification, temporary and permanent, of the physio-
logical character of bacteria In mixed cultures, 647.

Societies. American Cllmatological Association, 629, 660; American
Medical Association, 276. .'!2T, 5<J3, 563, 623, 636, 667; American Sur-
gical Association, 564, 695; American Laryngologlcal Society, 656;
Association of American Anatomists, 622; Association of American
Physicians, 618, 647: Boston Society for Medical Improvement, 142,
190, 244. 341, 442, 470. 520; California SUte Medical Society, 481;
Cambridge Society for Medical Improvement, 367; Congress of
American Physicians and Surgeons, 567, 675, 589; International
Medical Congress, 76, 371. 422, 428, 429; International Sanitary Cun-
ference, 274; Massachusetts Medical Society, 217, 625, 628; Massa-
chusetts Medico Legal Society, 390; New York Academy of Madl
cine, 42, 218; New York County Medical Association, 68: New
York Neurological Society, 16, 117, 317, 391, 496: Obstetrical Society
of Boston, 97, 142, 169, 265, 289, 419, 436, 4.V); Pennsylvania, the Medi-
cal society of the State of, 227, 600; Suffolk District Medical So-
ciety, 11, 40, 108, 268, 2:42, 315, 388, 447.

SpermatorrboQa. On spermatorrhoea and incipient hypertrophy
of the prostate and a proposed method for its treatment Hosner,
H , 239.

Spine. laminectomy for tuberculous disease of the spine. Beck.
C, 220; a new operation for the relief or cure of rotary lateral
curvature of the spine. Shall' .'r, 221; laminectomy eleven months
after injury to the spine, Piatt, W. K., 412.

Splints. Remarks on surgical cplinting, Tracy, E. A., 361.

Standlsh, M. Two ca^es of chancre of the eyelid, with an account
of the manner of infection, '237, 244.

Starr, M, A. Electrical reactions and their value in diagnosis and
prognosis, 317.

Stedman, H. R. Report on mental diseases, 494, 617.

Sternberg, O. M . The bacteriology of nephritis, 673.

St. lAials and it« medical schools, Chaplin, W. S., 6?4.

StokTls. llie over-zealous therapeutician, 526.

Stricture. The intermittent rapid dilatation of urethral stricture.
Newell, O. K., 389.

Suicide in New York, 224.

Snndberg, J. V. A sanitary sermon in diagram (Bagdad), 77.

Sanslilne and microbes, 603.

Surgeon*. Acting assistant surgeons, 226.

Surgery, lectures on surgery. Gheevar, C W., 81, 129; recent
progress in surgery, Burrell, H. L., and Cushing, H. W., 384, 415;
methods of teaching surgery. Billings, J. S., 535; the teaching of
surgery, Chlene, J., 595; surgical cases. Scudder, G, L., 646.

Swift. Cancer of the cervix, 367.

Symptomalio treatment of disease. West, S., 661,

Syphilis. Discussion on the relation of syphilis to general paresis,
Peterson, F., and others, 15.

Talt, li. Mr. Lawson Tait's use of anesthetic*. 250.

Tarsus. Excision of the tarsus for caries, Phelps, A. M., 220.

Temperstore. Sensible temperatures, Harrington, M, W„ 652,

Digitized by

Google

INDEX TO VOLUME CXXX.

Thomas, T. 6. The Immediate causation of the diseases peculiar
to womeo, 68.

Thompson. Perforation of tlie heart, with ooutinuance of life for
thtrteCD hours, 360.

Tbumpson, W. G. Notes on the obserratlon of iiialarisl organisms
In oounectioii with enteric fever, Thonipeon, W. U., 648.

Thomsou, W. H. Ergot hi the treatment of periodic neuralgias,
121; A clHSslHcation for infectious diseiLHes, 051.

Thorndifce, C. W. Two cHses of hydrHmniou ussocluled with nb-
domlTial distention in the fcetus, 139, \i2.

Tliorndlke, P. Notes on iiliosphataria, 134, 144.

Thyroid. Itecent observations on the functions of t e thyroid
gland and the relation of the eulareement to Graves's disease, also
remarks on the therapeutic use of sheep's thyroids and of other
organic extracts, Putnam, fl. J., 153. 168; a case of niyxoedema
treated by thyroid extract, Gowles, W. N., 167, 1C8; four cases of
niyxcsdema treated by thjrroid extract, Shiittucli, ¥. C, 177, 191 ; a
case of exophtbalniic goitre, thyroidectomy, Uooth, J. A., 391;
a case of exophthalmic goitre, thyroldectoniy, Newton, U. S-, 392.

Tiffany, J. McL,. The surgery of the kidney, 595.

Towneend, C. Vf. Primary nasal diphtheria. 613, S20.

Truer, <j. A. Kemarks on surgical splinting, 361.

Tuberoulosla. The prevention of tuberculosis, Vlckerr, H. F., 6,
11; a oasH of tuberculous [lericarditis with enormous effusion,
general tuberculosis, autopsy. Bates, K. A., 7; the registration and
preventive nieasu'es against tuberculosis, 322; the treatment of
pulmonsry tuberculosis by the sutwutaneous use of the chloride of

fold and sodium with the iodide of manganese, Boardnian, W. S.,
9i.

Tyndall, J. Professor Tyndall and Boston resources, 260.

Tyndall. rrofessor, 427.

Typhoid Fever. Second attacks of typhoid fever in adults, two
cases. Mason, A. L., IW; two attacks of typhoid fever in the same
person, 4ii2; a treatment of typhoid fever, risk, S. A., 620; notes on
tlie observation of malarlsl organisms in connection with enteric
fever, Thompson, W, G., 648. »

Unemployed medical men. 451.

Urinary System. Notes on phospbatnrla, Thorndike, P., 134, 144;
two eases of lithola|iaxy, Allen, O. W., S>A, 38i<; the Intermittent
rapid dilatation of urethral stricture, Newell, O. K., 3K9; strictare
of the urethra, with specimen, Richardson, M. H.,443; the etfeet
of ether and chloroform on the kidneys, Wunderlich, 477; urinary
difwnosis. Wood, K. S., 4X4,605; crystalline det>oaiis In the urine,
their causation and relation to renal diseases, Greene, K. M., S3&,
666, 661; nephritis in its surgical aspects, Keyes, E. L., 672; the
bacterio1o)ry of nephritis, Sternberg, G. M., 673; the surgery of the
kidney, Titfany. J. McL., 695; the surgical treatment of surgical
kidney. Weir, It. F.. 696; surKcry of the ureters, Fenger. C, 696;
discussion on renal and ureteral surgery. 537; the renioral of stone
in the bladder, with the presentation of a new llthotrlte, Forbes,
W. S., 600; the frequency of renal albuminuria, as shown by albu-
min and easts, apart from Bright's disease, fever or obvious cause
of renal Irritation, Shattuck, F. C, 613.

Vaeolnatlon. Vaccination and re-vaociuation, 21; some vaccina-

tion statistics, 26; vaoeination In ancient times, 60: avoidable re-

a suits and essential precautions In vaccination, 99; the coiitaglnm
vivum of vaccine and of sniall-pox, 14.'>: a bill relative to vaccina-
tion, 226; anti-vaccination, 346; vaccina ion in the Japanese navy,
401; compulsory vaccination, 624.

Vaccine Virus. The produatiou of viuscine virus, Gilbert, D. !>.,
434, 447; Martin, F. G., 479.

Vaccl nia, l>r. S. C Martin's researches on the baoleria of vaeclnla,
Krnst, H. C, 622.

Variola, Webber, S. G., 4.17, 490.

Vermiform Appendix, Hayes, M. C, 175.

VIckery, H. F, The prevention of tuberculosis, 6, II.

Virus. The production of vaccine virus, Gilbert, D, D., 434, 447;
Martin, F. (J., 479.

VIUl MiHtlstles of Kngland for 1893, 399.

Warren, J. C. Cases of abdoininal surgery occurring in the prac-
tice of Dr. ,1. Collins Warren at the Massachusetts General Hos-
pital daring the winter of IxOi, Scudder, U. 1/., 1, 29; tumors of the
breast, 643.

Wasps. Drunkenness in wasps, 49.

WauKhop, P. R. Saturated solution of potassium permanganate
In the treatment of chronic ulcer, 467.

Webber, H. G. Variola. 457, 490.

Weber, L. Some pathological conditions of the heart and their
relation to diabetic coma. 650.

Welicht as a symptom In phthisis. Hall. J. N., 647.

Weir, R. F. The surgical treatment of surgical kidney, 696.

Wells, O. W. Foot^ball vt. insurance, 76.

West, 8. The symptomatie treatment of disease, S51.

Wheeler, I^. Pelvic inflammations, 616.

Whipple, L. K. What " mental cure " Is, 148.

White, H. W. A personal experience with small-pox, 91.

White, J. C. The contagiousness, prophylaxis and control of lep-
rosy, 671.

Whitman, R. Congenital torticollis, 21*; Pott's paraplegia, 218;
persistent psoas contraction, 219.

Whitney, W. P. Hwinorrhage into the pancreas ss a cause of
sudden death, 379, 390,

Whittler, B. N. Digestive paresis, 460. 470.

Wiener^ A. Subacute unilateral bulbar palsy, with autopsy, 118; a
case of progreHvivA muscular dystrophy, 496.

Williams, P. H. Kepurt on therapeutics, 643.

Wlthlngrton. V. ¥ A case of ammbic dvsentery. 616, 622.

Wolff's Mrthud of treating ciub-Ioot, Shands, A. B.,4S.

Wonaen. The immediate causation of the diseases peculiar to
women, Thomas, T. G., 68.

Wood, E. H. Urinary diagnosis, 484, 605.

Worcester, A. What might be done by the Obstetrical Society to
advance the training of nurses, 436, 450.

Work as a therapeutic agent, Clark, A., 60.

Wnnderlloh. The effect o( ether and chloroform on the kidneys,
477.

Zakharln. An eccentric Russian physician, 299.

Zola. The role of the nose In Zola, 600; Lourdes, 6S4.

Digitized by

Google

I

Digitized by

Google

Digitized by

Google

Vol. CXXX, No. 1.] BOSTON MEDICAL AND SUBGIOAL JOURNAL.

CASES OF ABDOMINAL SURGERY OCCURRING
IN THE PRACTICE OF DR. J. COLLINS WAR-
REN AT THE MASSACHUSETTS GENERAL
HOSPITAL DURING THE WINTER OF 1893.

BEPOBTKD BT CHABLSS L. gOUDDSX, K.I>.

The following cases are reported in order to show
the miscellaneous character of abdominal cases which
come to a general hospital for treatment, and in order
to illustrate the general method of dealing with cases
of this class.

Case I. Solid tumor of the ovary; laparotomy;
recovery.

A domestic, single, forty-three years of age, entered
the hospital November 2, 1892. For the last twelve
years she has suffered from epileptic seizures, which
she describes as "giving warning," and affecting the
right side mainly. Her general health has otherwise
been good. The catamenia have been regular, but
ceased two months ago. She noticed some soreness of
the abdomen upon bending over about two months
ago, and not until that time did she notice any enlarge-
ment. She has had no pain, but has experienced a
feeling of weight and dragging when walking about.
The patient is poorly nourished, and there is a slight
suggestion of cancerous cachexia. On examination,
the abdomen was found to be somewhat distended with
ascitic fluid, and a large, very hard and nodular tumor
was felt, extending three inches above the umbilicus'
and down to the pubes. It was quite movable, and
could be easily pushed from side to side of the abdo-
men. On vaginal examination, the uterus was found
small, movable and not connected with the growth.
The lungs and kidneys were normal. The tumor was
regarded as probably malignant, and attached to the
omentum. It was thought advisable to perform an
exploratory operation.

An incision, four inches in length, was made below
the umbilicus, which disclosed a hard, nodular mass of
a whitish color floating in ascitic fluid. The incision
was enlarged to two inches above the umbilicus, and
the tumor was delivered, and found to be attached to
the left broad ligament. The pedicle was long and
thin, and easily tied with a Staffordshire knot. The
tumor, on removal, was found to be about the size of
a child's head, and to weigh eight and one-half pounds.

Examination of the other ovary showed it to be
about twice its normal size, hard and nodular, resem-
bling somewhat in this respect the dise&sed ovary.

Patient made a good recovery, temperature not ris-
ing above 100° F., although the evening of the opera-
tion she sat op in bed, and had several epileptic seiz-
ures during her convalescence. The stitches were
removed on the thirteenth day, union being perfect.
The catamenia appeared on November 28th, immedi-
ately after one of the seizures.

She was discharged from the hospital four weeks
and four days after the operation.

The following is the report of the microscopical
examination of the tumor by Dr. W. F. Whitney: "A
large globular growth, the size of the head, firm, not
covered by peritoneum, and united to a fragment of
the Fallopian tube. Microscopic examination showed
it to be made up of fibrous tissue, with here and there a
few bundles of unstriped muscular fibre. Fibro-myoma.
There were no cysts in any part of the tumor."

Case II. Cyst of the ovary ; laparotomy ; recovery.

Age forty, unmarried. Catamenia regular, painless.
For four years the abdomen has been enlarging.
There has been constant pain in the right side. Upon
examination, a symmetrical abdominal tumor was
found, which was dull on percussion and not tender.
Vaginal examination found the uterus drawn well up.

Operation, by a median abdominal incision, disclosed
a cyst of the right ovary. There were no adhesions
present, and the cyst was easily delivered, and its
pedicle clamped and tied with a Staffordshire knot.
A small cyst was found upon the left ovary about the
size of a small cherry, which was touched with the actual
cautery ; the left ovary, however, was not removed.
The abdominal wound was closed without drainage.

The patient made a good recovery.

Dr. W. F. Whitney's microscopical diagnosis was
a mnltilocular cysto-adenoma.

Case III. Salpingitis, circumscribed serous peri-
tonitis ; laparotomy ; recovery.

A woman thirty-two years old, married. Fairly
well developed and nourished. Rather anaemic, with
a feeble pulse. Catamenia irregular and excessive.
Miscarriage five years previous to the operation. Pa-
tient has had pain in the left iliac region for a year
and a half, which has been continuous, and during the
past two months accompanied by* vomiting and fever.

Examination discovers a marked fulness in the left
iliac region. Dulness and tenderness exist over this
area of fulness. Vaginal examination fipds the cervix
drawn up and fixed under the symphisis pubis, the
vaginal vault hard and firm everywhere, the uterus
not differentiated ; no fluctuation made out.

Operation by a median abdominal incision in the
Trendelenberg position.

The tumor was found adherent to the anterior ab-
dominal wall for about six inches. Upon freeing the
tumor, the left iliac fossa was found to contain a thin-
walled cyst, which was easily ruptured, giving escape
to one pint of thin, serous fluid. Below and behind
this cyst was a tumor the size of the fist, adherent to
the uterus and posteriorly to the sacrum. Several
large glands were felt at the sacral promontory. This
deeper tumor was aspirated, and eight ounces of creamy
pus evacuated. The sac of the tumor was opened ; its
interior thoroughly cleansed and drained by glass
drainage surrounded by gauze. Incision partially
closed. Recovery uneventful.

Case IV. Congenital hernia of the liver; reduc-
tion of the hernia ; recovery.

The paternal grandparents, as well as the father of
the little patient, are living and in good health. The
mother is well, but not robust. Her mother is living,
but her father died of consumption. The mother of
the patient was married five years ago. Her first child
was born three years ago, but died at the age of four
months of cholera infantum. It had no deformity,
and was in previous good health.

The second child was born November 14, 1892.
Labor began at 6 p. m. of the ISth, and was completed
at 10 A. M., and was normal in every respect. Dr.
G. W. Nickerson, of Stoneham, Mass., who was her
physician, states that he was surprised to see, after
birth of the head and shoulders, a tense, bladder-like
tumor come popping out, after which followed the
lower extremities. He states: "I was puzzled at first
to make out what it was, but, seeing that it was covered
by an expansion of the umbilical cord, concluded that

Digitized by

Google

BOSION MEDICAL ASD SURGICAL JOUBNAL. [January 4, 1894.

it most be a hernia." The child was sent that after-
noon to the hospital, and was operated upon by me
the next morning, when it was aboat twenty-four
hours old. On inspection, the child was otherwise
well formed, but thiu and with a somewhat wrinkled
face. It did not look strong. At the umbilicus was
seen the cord, which was greatly distended at its point
of insertion into the abdomen, forming a tumor about
six and one-half centimetres in diameter. The cover-
ings of the cord were inserted into a raised rim of
skin, and were opaque, so that the contents of the
hernia could not be determined (Fig. 1).

There was also a moderate-sized right inguinal
hernia.

Fig. 1.

The child was etherized, and a hasty attempt hav-
ing been made to render the field of operation aseptic,
the sac was opened, and was found to contain the
liver, which seemed to be situated wholly external to
the abdominal cavity. It was with some difficulty
that the myxomatous tissue of the cord was separated
from the surface of the liver, as it appeared to be ad-
herent in several places. The umbilical vein and the
two hypogastric arteries having been tied and cut, the
cord was removed. The umbilical ring was slightly
enlarged by an incision, and, with some manipulation,
the liver was finally pushed through the opening into
the abdominal cavity. A small amount of ascitic fluid
escaped when the sac was first opened. The separa-
tion of adhesions from the liver caused a slight haemor-
rhage, which was checked by pressure. The wound
was brought together by four or five strong silk
stitches. The infant Buffered somewhat from shock.
There was, however, no sign of peritonitis after the

operation, and it took its nourishment well duriug
convalescence. The food consisted of a mixture of
cream and water.

The stitches ulcerated somewhat, and were removed
during the first week, in consequence of which the
edges of the wound separated at one point, and the
liver could be seen. The edges were, however, ap-
proximated by crepe eCliue and collodion, and the
wound bad healed at the end of two weeks, when the
baby was taken home to be nursed by its mother.

The child has done well since, and at the time
the second photograph was taken it was about four
months old (Fig. 2).

There is no umbilical hernia at present — one yeaj

Fia. 2.

after the operation. The child was a sufferer from
eczema, but now enjoys excellent health, and has de-
veloped rapidly.

Case V. Ruptured cyst of the broad ligament;
contents evacuated ; treated openly ; recovery.

A woman was admitted to the medical side of the
hospital in 1889 with tubercular peritonitis. Her
general health had improved since her former visit to
the hospital, and ten days ago she complained of pain
in the left side of the abdomen. At no time has there
been any vomiting, and a normal movement of the
bowels resulted after the use of salts. The abdomen
was slightly distended ; and in the left lumbar and iliac
regions was a tumor the size of two fists, over which
there was dulness and slight seusitiveDess. The uterus
by vaginal examination was low down, the posterior
and left lateral cul-de-sacs being filled by a soft mass
which seemed to surround the cervix which moved
with the tumor. The urine was normal.

Digitized by

Google

Vol. CXXX, No. 1.] BOSTON MEDICAL AJSD SURGICAL JOURNAL.

Operation. — The Trendelenberg position. A median
abdominal incision. Some ascites present. The in-
testine and omen tarn were found adherent to a ruptured,
thin- walled cyst having its origin in the left broad
ligament. The cyst was farther opened and its in-
terior rendered dry. It being impossible to enucleate
the cyst, it was left tn ritu, being sutured to the ab-
dominal wall. In the left lateral cnl-de-sac was fonnd
a second smaller cyst, which was likevrise ruptured
and drained by means of a glass drainage-tube.

The patient made a good recovery and was dis-
charged from the hospital about three weeks after the
operation, a small sinus remaining.

Case YI. Abscess following appendicitis ; opera-
tion on the fourth day ; recovery.

A man who had always been well was attacked
suddenly after breakfast by pain in the right iliac
fossa. Through that day there was some nausea.
Two days later there was a slight rise of temperature,
and vomiting was present. Four days later the teiA-
perature rose to 101.4°, the pulse to 140. A tumor
presented in the right iliac fossa, a half inch below
McBurney's point, about the size of a lemoni dull on
percussion and sensitive.

Operation. — An incision parallel to Poupart's liga-
ment opened a circumscribed abscess cavity, in which
was found the appendix twisted under the caecnm.
This was removed, the abscess cavity thoroughly
cleansed with boiled water, a rubber drainage-tube sur-
rounded by iodoform gauze placed in the abscess
cavity, and the wound partly closed.

The patient made a good recovery. Two months
after the operation there was a slight tendency to
hernia at the seat of the operation. The patient had
gained ten pounds in weight and complained of no
pain or any other trouble.

Case YII. Abscess following appendicitis ; opera-
tion on the seventh day ; removal of appendix ; recovery.

A man who bad had each year for several years two
or three attacks of vomiting attended by slight con-
stipation, and who had never had with any of these
attacks pain, was suddenly seized with pain in the
right iliac fossa. The temperature rose to 99.5°.
There was some vomiting. There was a movement of
the bowels after calomel and a rectal enema. The
temperature rose to 103.2°, the pulse to 120 upon the
fifth day. Upon entering the hospital on the seventh
day of the disease, it was stated that from the sixth
day vomiting was constant. The abdomen was not
distended, but the abdominal muscles were rigid. The
most tender point upon the abdomen was one and a
half inches above the anterior superior spine, but there
was general tenderness through the whole right loin.
A slight bulging was detected upon rectal examination
upon the right side.

Operation. — An incision parallel to Poupart's liga-
ment fonnd the subperitoneal tissues not cedematous.
A circumscribed abscess cavity was opened, the ap-
pendix found and removed, the cavity irrigated with
boiled water, and two tubes for drainage (surrounded
by iodoform gauze) were inserted.

The patient made a good recovery. Six weeks after
the operation he was reported as in excellent condi-
tion.

Case YIII. Appendicitis ; operation ; recovery.

This patient was a boy who was sent to the hospi-
tal with a history of several days' illness, all the symp-
toms of which pointed to an appendicitis. Although

the patient presented slight dnlness on percussion in
the region of the right iliac fossa, there was no well-
marked cake. He was seen repeatedly by the surgeons
of the hospital in consultation. All the symptoms
present led to a delay of the operation, and it was
supposed up to the fourth day of his presence in the
hospital that he would recover without operation, but
upon this day there was a sudden rise of temperature
and operation was decided upon. The usual incision
parallel to Poupart's ligament was made. CEdematous
tissue was seen before opening the peritoneum. The
appendix was found under the inferior edge of the
caecum, perforated at its middle and lying in a very
small abscess cavity, which contained beside purulent
and faecal material, a concretion. The omentum and
mesentery near by were gangrenous. The appendix
was ligated one-third of an inch from the cmcum and
removed. The abscess cavity, being circumscribed,
was thoroughly irrigated with boiled water. It was
fonnd that the pus lay between coils of intestine some
distance from what appeared to be the only abscess
cavity. A large tube was placed in the bottom of the
abscess cavity and two smaller tubes extending in
opposite directions, all the tubes being surrounded by
iodoform gauze.

Six weeks from the operation the boy was discharged
well.

These three cases were the only cases of appendicitis
occurring during a winter service. It is perhaps
worth mentioning that in the spring service of a similar
length. Dr. Beach had under his immediate care a
large nnmber of cases of appendicitis. This fact raises
the question of the possibility of the period of the year
being a factor in the etiology of this disease.

Case IX. Double tubercular salpingitis and peri-
tonitis ; laparotomy ; relieved.

A woman who had had pleurisy one year previous
to her entrance into the hospital gave a history of profuse
flowing for two months. She presented upon examina-
tion a resistant mass in the region of the right tube.
The uterus was in fairly good position and movable.
The cervix was slightly lacerated and hyperplastic.
Posteriorly to the uterus was a mass the size of the
closed fist. This corresponded with the mass felt
upon external examination. The urine was 1,013,
acid, high in color, contained a trace of albumen, some
red blood cells and a few epithelial cells.

Operation. — Trendelenberg position. An incision
four inches long in the median line. Some ascites
present. The uterus was very large. The broad lig-
aments and tubes were found studded with miliary
tubercles. The tabes themselves were enlarged and
thickened. Upon the left side there were no adhe-
sions and the tube was removed without difficulty.
Upon the right side the tube was the size of a fist, and
was adherent to the bowel above. Upon separating
these adhesions both tube and ovary were removed.
A small amount of puriform fluid escaped into the ab-
dominal cavity upon the removal of the tube. The
abdomen was thoroughly flushed with boiled water,
dried and drained by a glass drainage-tube in the pos-
terior cnl-de-sac. The abdominal wound was closed,
leaving the glass tnbe projecting at the lower end of
the incision. This patient made a long and slow re-
covery, having a hectic temperature and some stoma-
titis. By careful nursing, and upon warm days by
being taken into the open air, she eventually recov-
ered so as to leave the hospital in a fairly good condi-

Digitized by

Google

BOSTON MEDICAL AND SURGICAL JOURNAL, [Jantjiht 4, 1894.

tion, feeling that she had been improved by the oper-
ation, her stay in the hospital having been some three
months.

It seems that in a great many cases the careful nars-
ing and the out-of-door exposure contributes much to
the recovery of these cases.

Case X. Probable carcinoma nteri ; rapture into
the abdominal cavity ; laparotomy ; drainage ; death
from shock.

A woman, married, having three children, had
passed the climacteric three years ago. She had a
foul leacorrhoea, and at times a bloody serons discharge
from the vagina. She suffered from pain over the
pubes and difficult micturition. Upon examination,
the uterine canal measured five inches. A small greeu-
ish-brown mass was found projecting from the cervix.
This was removed some six months previous to the
present entry into the hospital, since which removal
she has grown weak, has lost flesh, and has occasional
chills accompanied by nausea. Her feet and hands
were cold, and she presented a general cachectic ap-
pearance. The pulse was 112. The temperature at
night ranged from 160° to 101°. The uterus was cu-
retted and thoroughly cleansed with corrosive sublimate.

Finding the patient was losing ground, it was de-
cided to do a median abdominal section in order to
determine the extent of the disease, and if possible to
remove it. Accordingly, in the Trendelenberg posi-
tion, the operation was done. The omentum was found
adherent to the bladder, and the intestines adherent to
the fundus of the uterus. On breaking up these adhe-
sions, a cavity containing six ounces of pus was opened
a little to the left of the fundus which communicated
directly with the cavity of the uterus. The bottom of
this cavity was filled with greenish sloughing tissue.
The cavity was irrigated and packed with iodoform
gauze. A suprapubic glass drainage-tube was placed
in position. A strip of gauze was passed through the
cervix to secure more thorough drainage.

The patient died of shock some hours after the op-
eration.

Case XI. Double ovarian cyst ; laparotomy ; re-
covery.

A woman thirty-six years old, always well, had been
married for fourteen years. She has had no children.
The catamenia have always been regular and painless.
An enlargement of the abdomen was first noticed seven
years ago. Never at any time has there been pain.
Her general health has been good.

Physical examination showed general abdominal en-
largement. No enlarged veins were seen upon the
abdominal wall. Circumference of abdomen at the um-
bilicus was forty-five inches. Vaginal examination
found the cervix high and crowded forward. A bard
and resistant mass was felt in the posterior cul-de-sac.

Operation A median abdominal incision. The

omentum was found adherent to the anterior abdomi-
sal wall. A pearly-white cyst wall presented, was as-
pirated, discharging a coffee-colored fiuid. The weight
of the fluid was twenty-eight pounds. The cyst, after
the evacuation of the fluid, was found to originate from
the right ovary. The tumor was removed by Staf-
fordshire knot and cautery. No drainage.

Eight days after the operation phlegmasia alba do-
lens of the left leg appeared. One month later the
swelling had entirely disappeared from the left leg and
she was discharged from the hospital, seven weeks
after the operation.

Pathological report by Dr. W. F. Whitney : " Mul-
tilocular cystoma, to which a small piece of the ovary
was attached."

Bemarkt, —The phlebitis which occurred in this
case did not have any apparent septic origin. The
patient was kept still in -bed for the time mentioned
above, in order to avoid the danger of embolism, which
occasionally occurs with such inflammatory distur-
bances.

Case XII. Intra-ligamentous ovarian cyst ; lapa-
rotomy; recovery.

Two months ago a woman first noticed an enlarge-
ment in the lower abdomen, extending over to the left
side. This tumor gradually and painlessly increased
in size. The tumor was dull upon percussion, and.
fluctuating. The vaginal examination found the ute-
rus pushed backward and to the right.

Operation by median abdominal incision discovered
a cyst in the broad ligament containing about a quart
'Of brown fluid. The intestines were adherent pos-
teriorly. After freeing these adhesions, an attempt
was made to enucleate the sac of the cyst, which
proved futile on account of the dense adhesions to the
sacrum posteriorly. The right ovary was removed.
The cyst sac was stitched to the anterior abdominal
wall, drained by glass drainage and gauze. A sinus
formed, and was packed with iodoform gauze, gradu-
ally closing without untoward symptoms. The patient
was discharged from the hospital with a very small
sinus properly healing.

Case XIII. Ovarian cysto-adeuoma ; laparotomy ;
recovery.

A woman of good family history and good previous
personal history one year ago noticed an enlargement
of the abdomen, which daring the past two months had
rapidly but painlessly increased. Daring the past six
weeks there had been considerable flowing. The pa-
tient was well developed and well nourished, and the
examination disclosed a swelling of the abdomen ex-
tending above the umbilicns, dull upon percussion,
fluctuating and not tender. Vaginal examination found
the uterus immovable and small. The posterior cul-
de-sac was distended with an olMCurely fluctuating
mass, which was not tender. The os was rather soft
and patulous.

Operation by median incision found a glistening cyst
wall, which contained a chocolate-colored fluid, nine
quarts by measure. Small cysts were found anteriorly
attached to the anterior wall of the larger cyst. The
tumor rose from the right ovary, which, with the cyst
wall, was removed by clamp and cautery. The left
ovary was found enlarged and moderately cystic, and
was not disturbed. The uterus was heavy and ante-
flexed. The wound was closed in the usual fashion by
interrupted sutures without drainage.

Pathological report by Dr. W. F. Whitney: "A
large cyst, smooth-walled, with but few adhesions, to
which a very much elongated Fallopian tube was at-
tached. The fluid was ropy, dark reddish in color,
speciflc gravity 1,026, and contained abundant blood-
corpuscles, and also enlarged epithelial cells (manjr
with numerous grannies). Diagnosis, cysto-adenomct

of the ovary."

ITobe conOmted.)

The Richmond City Hospital has been purchased
by the College of Physicians and Surgeons of that
city for $18,489.39.

Digitized by

Google

Vol. CXXX, No. 1.] BOSTON MEDICAL AND SURGICAL JOUSNAL.

THE PREVENTION OF TUBERCULOSIS.*

BV HIBMAH T. VIOKEBY, H.D,,

Pkyieiah to Out-Patienit, MatiaaJuuetU Oeneral Botfital ; Itutmo-
tor in CliniocU Medicine, Sarvard nniverttty.

The ofBcial statiBtica of the State of MassachuBetts
for the five years, 1886-1890, set the total namber of
deaths from typhoid fever for that period at 4,891 ;
from diphtheria and croup, at 8,855 ; from pneumonia,
at 17,378 ; and from phthisis, at 28,868. With regard
to relative fatality, diphtheria held the sixth rank in
1881, but in 1890 the eleventh. Likewise typhoid
fever, which waa fourth in bad pre-eminence twenty
years before, was surpassed in 1890 by no less than
fifteen rivals. The encouraging results which have
thus attended efforts at purification and isolation in
these two infectious diseases reflect credit upon the
medical profession, and they stimulate the expectation
that similar efforts with regard to another infections
and contagions disease will prove equally advanta-
geous. As yet no advance seems to have been made.
Phthisis remains the most deadly of all diseases. In
the number of victims it claims, it was the first in
1881 ; and in 1890 it remained still the first. There
bad, indeed, been some improvement, taking the State
as a whole ; for in 1890, the ratio of deaths from
phthisis to the total mortality was 13.30 per cent, the
least of any year recorded up to that time, while in
1881, the ratio was 16.14 per cent. But Suffolk
County showed no such change, its ratios being 16.39
per cent, in 1881, and 15.59 per cent, in 1890.

Lawrence F. Flick' finds that Philadelphia has
been more fortunate. From 1881 to 1891 the percent-
age of the whole mortality in the city due to phthisis
sank from 14 down to 11. Hence it will hardly be
proper for us to try wholly to explain the slow im-
provement in Boston by a reference to the overcrowd-
ing and foreign immigration which are presumably
common to both cities.

" Theoretically, with our present knowledge," says
Dr. Baker, Secretary of the Michigan State Board of
Health, "consumption, which still is the most impor-
tant cause of mortality, is now, next to small-pdx, one
of the most easily preventable diseases. The next
quarter of a centary should see it lessen in importance
as a cause of deaths, until it takes its place alongside
small-pox." •

In the five years 1886-1890, while the above-men-
tioned 28,868 persons died of phthisis in Massachusetts,
small-pox killed 19.

It is the object of this paper briefly to review the
etiology of phthisis, and to contribute in some degree
to a more general and united effort on the part of our
Society in the prevention of the disease.

With regard to its causation, it is not improbable
that Koch's demonstration in 1882 of the power of
pure cultures of tubercle bacilli to cause tuberculosis
diverted the attention of the profession for a time too
far from the important factor of hereditary and acquired
predisposition to the disease. Even weeds must have
soil to grow in. This constitutional side of the ques-
tion has been newly asserted by Aviragnet,* Koster,*
and Wolff;* while Giirtner^ believes that the results

> Bead before the Seotion for CUnioal Medicine, Pathology and
HTglene of the Soffolk Dletriot MedloaJ Sootetv, November IS, 18*3.

• Philadelphia Medloal News, May 14. 1892.

> Hare't System of Therapeatlos, 1, 672, 1891.

• Qaz. Hebd., zzxtz, SS, 1892.

• Inaus. IbtM-. Leyden, 1883.

• MUnch. Med. Wooh., zxzlz, 39.

' Zeitsohr. f. Uyglen. n. InfeoUouakr, zUl, 3, 1893.

of his experiments justify him in asserting that the
disease itself is hereditary, that hnman mothers may
directly give a foetus tubercle bacilli.

We cannot forget the influence of climate on the
development of the disease, powerful for good or ill.
Solly's experience is impressive.

" In Colorado," ' he says, " to which my personal
observations upon the influence of the altitude have
been mostly confined, the native population is too small
and youthful to gather any statistics ; but living as I
have done for the past sixteen years among a people
of whom perhaps thirty per cent, came to the country
with tuberculosis, and not a few of whom live under
unhygienic conditions in crowded lodgings, and where
free expectoration is carelessly practised, I know of
only four cases of phthisis which could be fairly as-
sumed to have originated in Colorado."

Granting, however, the influence of both climate
and personal constitution upon the production of the
disease, the bacillus tuberculosis is an essential factor ;
and probably no one doubts that its complete des^ruo-
tion would exterminate tuberculosis.

The ways in which the bacillus enters the human
body are fairly well agreed upon. The raw ' milk of
tuberculous cows may occasionally convey it into the
stomach,** but not very often.** The flesh of tuber-
cnlous animals if inspected (Jeffries, Nocard) is not
very dangerous.*' The tuberculous discharges of ani-
mals or human beings may infect others by direct in-
ocalation into wounds or by contact with mucous mem-
branes (dissection-wonnds, coitus).**

The main source of danger, however, lies in tuber-
culous sputa or in the pus of scrofulous sores. The
latter might conceivably be indirectly conveyed into
the system because of lack of cleanliness. Sputum
likewise may be deposited on the lips, hands, cloth-
ing and utensils of patients and thence carried to some
healthy person ; or the act of coughing may directly
spray it into the mouth of a bystander. Any tubei^
culous material if thoroughly dried may be inhaled in
the form of dost. This last is probably by far the
most frequent way in which the infection is distributed.
The number of bacilli in the sputa is enormous,**
and as Cornet and others have shown, even the walls
of the room where a consumptive lives may become
sources of infection.

The way, therefore, to prevent the spread of tuber-
culosis is evident enough ; and it has been repeatedly
enunciated by medical men.** Behreua, for example,
sums the matter np as follows : (1) the public should
be enlightened; (2) sputum in public places should be
minimized or rendered inocuous ; (3) the streets
should not be allowed to be dusty ; (4) clothing, etc.,
and houses should be disinfected ; (5) there should be
public hospitals for the taberculous ; (6) tuberculous
patients should not pursue vocations in which they
might endanger others; (7) tuberculosis in cattle
should be under governmental inspection and control.
A corollary to these regulations is the compulsory re-
port of cases of tuberculosis to the boards of health,

• Hare's Therapeatlos, 1, 424.
> Nooard : Ann. d'. Hygiene, xxviii, 6, U92.
>° Ernst : CEarre sur la Taberoo, 1890.

" Jeffries : Boston Mediosl and Sargioal Journal, ozzt. 10, 1891.
» FhlladelphU Medical News, April 1. 1893.
" Qiirtner : supra oit.

u NnttaU : Ztschr. f. kUn. Med., zzl, 3 anJ 4. 1893.
u Behrens : Hilderheim, 1891.

FUok: PhUadelphU Medical News, Ixiii. 17. 1893.

Porteons : Boston Hedleal and Sargioal Journal, ozziz, 19, 1893.

Boohester : Philadelphia Medical News, Si iitember 2, i893.

Baker : Hare's System of Iherapentics, i, Diu.

Digitized by

Google

6

BOSTON MEDICAL AMD SUROIOAL JOURSAL. [Januabt 4, 1894

jost as in diphtheria or small-pox. Flick add* that
interstate and international migration of oongamptirea
shoold be restricted and regulated.

If all, or even the most important of these so^es-
tions were persistently carried oat, there can be no
doubt that tuberculosis woald be vastly less freqnent
than it now is. The benefit would be an increasing
one, for many individuals who to-day are apparently
well really carry in their bodies the seeds of tnbercu-
losis, ready to germinate whenever the constitution
becomes from any cause undermined. Pizzini ** and
Spengler " have recently shown how often the lym-
phatic glands — particularly the bronchial — contun
tubercular bacilli in persons who have shown no symp-
toms of tuberculosis. This is in accord with the
opinion expressed by Yolland of Davos (Hamburg,
1891) that for adults the chief means of avoiding tu-
berculosis lies in care of the constitution.

In the long run, however, general, persevering,
hygienic efforts must overcome this deadliestof diseases.

In concluding, I seek justification for rehearsing facts
which are already so familiar to the members of this
Society, in the apparent lack among us of systematic
and united effort along the lines indicated. With few
if any exceptions, we have doubtless all of us for years
given advice to the victims of tuberculosis and their
friends with a view to lessen the dangers of contagion ;
but why should not we as a Society engage more
earnestly in this good work ? Pennsylvania has a
Society for the Prevention of Tuberculosis. " The
society is formed for the purpose of preventing tuber-
culosis (consumption) : (1) by promulgating the doc-
trine of the contagiousness of the disease ; (2) by
instructing the public in practical methods of avoidance
and prevention ; (t<) by visiting the consumptive poor
and supplying them with the necessary materials with
which to protect themselves against the disease, and
instructing them in their use ; (4) by furnishing the
•consumptive poor with hospital treatment ; (5) by co-
operating with boards of health in such measures as
they may adopt for the prevention of the disease ; (6)
by advocating the enactment of appropriate laws for
the prevention of the disease ; (7) by such other
methods as the society may from time to time adopt."

This society is a noble one and I am proud to be ^
member of it. Yet with us here, it seems as if any
increase in the number of societies were to be depre-
cated, and that our present society by exercising its
proper functions might do beneficent work in this very
line. Matters that suggest themselves as needing first
to be done are :

(1) The drawing up, by a committee, of a tract
suitable to leave in families where tuberculosis has
entered. Properly worded, such a leaflet would add
nothing to the sufferings of the sick, while it might be
beneficial to them (hygiene, re-infection) and of price-
less value to their friends.

(2) Cooperation with the Board of Health in ap-
propriate measures.

(3) Agitation for the establishment of a public
hospital for the consumptive poor.

Landouzt has been made Professor of Clinical
Medicine and Therapeutics at Paris in succession to
Hay em.

<" Zeltacbr. f. klin. Med., xxi, 3 and 4, 1882.

" Z«iuclir. f. Hyglen. n. Infectloaakr, xlii, 3, 1893.

Clinical Z>q^actnieitt.

RIGHT-SIDED FOLLOWED AT AN INTERVAL
OF TWO YEARS, BY LEFT-SIDED FALLO-
PIAN PREGNANCY, WITH REPEATED OPER-
ATION.

BT rBAXCIS B. HABBIIfSTOH, K.D.,

Smrgtan to Out-Patit»ti at tke MattachiuelH Oeneral Btmital:
AMnttoMt ia Surgay m the Medical Department of Harvara Oui-
vertity.

Mb8. M. J., thirty-two years of age, had been mar-
ried for three years. Until two years ago had been
well. She then became somewhat debilitated, and
suffered from pelvic pains. Menstruation was slightly
painful, and occurred every three weeks. She bad
never been pregnant.

In January, 1891, the menstrual period was delayed
two weeks, when flowing came on with severe pain.
The loss of blood was slight, but continuous.

This condition had existed, with increasing pelvic
pain, for three weeks, when I first saw the patient.
The abdomen was slightly distended and painful to
the touch. Vaginal examination disclosed a mass on
the right side of the pelvis as large as a lemon. This
mass felt like a dilated Fallopian tube. The patient
went to bed, was given opiates and vaginal douches.
The flow of blood and pain gradually diminished, but
returned on slight exertion. In six weeks' time from
its first appearance the bleeding ceased. The pain,
however, continued, and the tumor increased slightly
in size. The continued abdominal tenderness and pain
seemed to demand surgical treatment.

Laparotomy was performed May 15, 1891. The
dilated right Fallopian tube was removed, together
with a considerable amount of bloody fluid. The pa-
tient made a quick recovery.

Dr. Whitney makes the following report as a result
of his examination of the specimen :

" The specimen consisted of about twelve centime-
tres of a Fallopian tnbe with an ovary close to the
uterine end. The tube at the point of removal was
increased in size, chiefly from thickening of the walls,
which were very vascular. Close to this point a
sudden dilatation began, forming an ovoid mass about
eight centimetres in the direction of the tube, and nine
centimetres in circumference, and beyond this it con-
tracted somewhat to the fimbriated end, which was
closed by adhesions and contained a few small cysts.
The outer surface of the tube was rough and shaggy
from adhesions.

"On opening the dilated portion it was found to
contain a thin membranous-looking sac, loosely at-
tached to the villouB-looking inner surface of the tube,
beneath which on one side were extensive infiltrations
of blood separated by narrow fibrous portions. Within
the sac lay a small reddish mass the size of a cherry-
stone, on which was a curved differentiated portion re-
calling a very early embryo, the whole attached by a
sort of string to the sac.

" Microscopic examination of this showed an amor-
phous granular mass, at one end of which was an accu-
mulation of black pigment.

" The ovary was small, contained a few retention
cysts, no evident corpus lutenm.

" The diagnosis is a tubal pregnancy with early death
of the fcBtus (three to six weeks), haemorrhage into
the walls of the tube, but without rupture."

The process probably remained at a atandstill from

Digitized by

Google

Vol.. CXXX, No. 1.] BOSTON MSDIOAL AND SURGICAL JOUBNAL.

the death of the fcBtns until the time of the removal,
and the pain is to be referred to the peritonitis.

Two years later the patient had removed to the
country, where she came under the care of Dr. £. S.
Jack, of Melrose, who has kindly sent me the follow-
ing notes :

"On March 24, 1893, the patient consulted me at
my office, complaining of ancomfortable sensations over
the lower abdomen. She was flowing.

" She feared that she bad same trouble on the left
side, which had been found on the right side two years
before, as she felt very much as she did then.

" Tbe examination was negative as far as determin-
ing the existence of extra-uterine pregnancy on the
left side, although some tenderness was found.

" J next saw the patient on March 30, 1893. She
was lying upon the sofa and complained of colicky
pains, and a feeling of discomfort. There was con-
siderable tenderness over the lower portion of the ab-
domen. The pulse was 80 and the temperature 99.4.°

'' The patient was ordered to bed, and was given hot
applications, hot douches and salines.

" Friday, tbe pulse was 76 and the temperature was
99°. More comfortable.

" Saturday, the pulse was 76 and the temperature
was 99.6°. More comfortable, though flowing some.

"On Monday, April 3, 1893, there was more pain
and tenderness, particularly on tbe left side. Vaginal
examination showed considerable resistance on the left
side.

" On Tuesday, the condition was the same. I de-
manded a consultation and advised operation.

" On Wednesday morning the patient felt decidedly
better, but about 11 a. u. I was suddenly called. The
patient had more colicky pain, and was faint, and suf-
fered from blurring of vision. 1 advised immediate
operation, to which the patient consented."

I saw Mrs. M. J. in consultation with Dr. Jack on
April 5, 1893. There was a tumor in the posterior
cul-de-sac toward tbe left side. The patient's condi-
tion was not bad, there was pain and some flowing.

I agreed with Dr. Jack in the diagnosis of probable
extra-uterine pregnancy. As the immediate condition
was not threatening, it was decided that we should de-
lay operation until the first reappearance of severe
pain or other urgent symptoms. On the following
day there were signs of internal bssmorrbage.

It seemed unsafe to defer operation longer. An
opening was made through the old line of incision.
The abdominal cavity was reached with some difficulty,
owing to the adhesions of the omentum. It was found
to be full of dark blood and blood-clots. The dilated
tube and the ovary on that side were excised. The
blood and clots which lay among the intestines as high
up as the diaphragm, were removed. The abdomen
was closed without drainage. The patient made a
good recovery, and now is quite well.

The patient's condition before the last operation did
not seem especially bad. There bad been some quite
severe pain accompanied by giddiness. Neither the
countenance nor the pulse gave a true indication of
the large amount of the concealed hemorrhage.

This case affords strong argument against delay.
Waiting for extreme symptoms in extra-uterine preg-
nancy should be discouraged as ii should be in case of
appendioitis.

The question must arise whether the manipulation
of the preceding day did not assist in producing the

haemorrhage. Such a result is, of course, quite possi-
ble.

The liability to rupture of the mass by handling
should always be borne in mind. An examination
must try the strength of the tissue much more than
any movements or acts of the patient.

Dr. Whitney makes the following report of the
specimen removed at the second operation :

" The specimen was a pear-shaped dilatation of the
Fallopian tube, which measured about eight centime-
tres in length, and about four centimetres at its great-
est diameter at the fimbriated end, which was widely
opened when received. The inner surface of this dila-
tation was quite smooth except in one or two places
where there was a little roughness and a hsemorrhagic
mass. The walls were thin and fibrous.

" With this was a rounded mass of blood-clot (which
had come from the interior of the sac, probably),
rough on its surface and containing in its centre a very
thin, fibrous sac. There was also an embryo about
four and one-half centimetres long (about the eighth
week). The ovary was small, and contained a corpus
luteum one and one-half centimetres in diameter.

"The diagnosis is a tubal pregnancy, with rupture
through the fimbriated end of the tube at about the
eighth week."

A CASE OF TUBERCULOUS PERICAKDITIS
WITH ENORMOUS EFFUSION; GENERAL
TUBERCULOSIS; AUTOPSY."

Br KVBBETT A. BATK8, H.D,, BFKINOFIELD, MASS.

W. J. J. P. was a marble-carver, fifty-eight years of
age. His father bad died at thirty years of " dropsy " ;
the mother at* forty years of "consumption of the
bowels," with cough as a persistent symptom in her
illness ; and a sister at twenty-eight years of the same
trouble as the mother.

Mr. P.'s army experience resulted in a bullet-wound
through right flank, followed by necrosis of the crest
of ilium, with complete recovery in fourteen months.

Four years later than this, when thirty-three years
of age, and coming on after exposure, he had an ill-
ness characterized by fever, loss of strength and flesh,
cough and ezpectoratiou, lasting ten weeks, called
" quick consumption," and terminating in a rapid con-
valescence and recovery.

There is a history of intermittent fever for four
consecutive springs some twelve years since ; but apart '
from the above, and a tendency to " lung colds " and
temporary cough, the subject of this report had con-
sidered himself well and robust until three years ago
the past spring, when he had a sickness, called by him-
self "grippe," associated with fever, debility, and
cough without expectoration. He considered himself
well in a month, after taking tonics, including cod-
liver oil.

Again, eight months later, and a year before bis last
illness, similar attacks, all termed "grippe." But
during these three years — noticeably the past year —
there has been slight but gradual loss of flesh and
physical vigor ; and during tbe last five months there
again developed cough, slight at first, but later hard
and useless. He began to feel conscious of an after-
noon temperature, and finally, from increasing weak-
ness, gave up work February 8, 1893. During the

>Bead at the meeting of tbe Hampden District Medleal Society,
September U, IMS.

Digitized by

Google

8

BOSTON MEDICAL AND SURGICAL JOURNAL. [Jahdakt 4, 1894

next ten days, slight dyspnoea and palpitation on exer-
tion developed, with vague prsecardial uneasiness, lead-
ing him to consnlt Dr. G. P. Hooker, with whom I
saw the case March 18tb, and bj whose courtesy I am
enabled to make this report.

The patient was a large, well-developed man, at this
time fairly nourished. 8kin sallow and dry ; lips and
nails a little dusky; very slight oedema of legs and
ankles and of trunk, especially noticeable in the pree-
cardial area ; slight pafiBness of eyelids. The jugulars
pulsated and the veins of forehead were distended.
Right semi-ventral decnbitas was invariably assumed.
The temperature varied from 100.5° to 102° in the
afternoon, with a morning remission to normal. Pulse
was 120, irregular and of fair strength. Bespira-
tion 26.

Inspection of chest showed prsecardial fulness, with
obliteration of intercostal spaces in this area. There
was absence of cardiac pulsation or apex-beat. The
prsecardial dulness had for its upper boundary a line
extending from the lower margin of the fifth rib, eight
and oue-half centimetres to the right of median line,
to the junction of the right third rib with sternnm,
and thence in a gradual curve across sternum to
second left interspace, downward through left nipple
to fifth rib at a point thirteen and one-half centimetres
from median line. With the patient sitting, this curve
flattened perceptibly.

The heart-sounds ■ — not abnormal in character —
could be heard only, and faintly, in the second inter-
spaces and the fifth and sixth interspaces left axillary
line.

Dulness in the back was found below the eighth
interspace scapular line on right, and eighth rib corre-
spondingly on left. A few medium, moilt rales above ;
lungs negative elsewhere. The liver was palpable
below the costal border, with its lower line of flatness
extending directly across abdomen.

The abdomen was full, not distended, with moderate
dulness in flanks.

The urine was high-colored, loaded with urates,
specific gravity 1026, no albumen, and no casts de-
tected. No sputum could be obtained. The etiology
of this affection was considered as, probably, tubercu-
lous.

During the remaining six weeks of life the patient
was comfortable; there was gradual loss of strength
and moderate increase of plural and abdominal elfn-
■sious, without apparent increase in pericardial.

Aspiration of the pericardium was considered, bat
not done, owing to the remarkable absence of distress-
ing symptoms in spite of the enormity of the effusion.

During the last week delirium and anginal attacks
at night developed ; and the patient died suddenly on
the morning of May Ist, while attempting to get oat
of bed.

The autopsy was performed eight hours after death.
Rigor mortis present. Sternum prominent, slight
general oedema, and subcutaneous tissues of trunk
very watery. Head not opened. A considerable
amount of clear serum escaped on opening the ab-
dominal cavity. On removing the sternum, the peri-
cardium presented as a large, distended bag, tense and
nowhere adherent. The lungs were collapsed, and
both pleural cavities contained a considerable amount
of clear serum.

The outer surface of the pericardium showed numer-
ous whitish elevations, some confluent and others dis-

crete. On incising the sac this pericardial layer was
found to be greatly thickened, in portions as mach as
six or seven millimetres ; the sac contained two litres
of turbid, bloody semm. The cardiac layer of peri-
cardium was everywhere thickened, and resembled so-
called honey-comb tripe, and on section presented
numerous opaque and yellowish points, and some yel-
lowish masses scattered here and there. The heart
itself, apart from a moderate degree of hypertrophy,
was normal ; its cavities were empty.

The pleurte were nowhere adherent ; the palmonary
layer was everywhere studded with grayish, opaqae
points up to a pin-bead in size; the costal and dia-
phragmatic layers were free of these. The lungs, at
the apices of the npper and lower lobes, showed old
fibrous scars, and in other portions — as a rale, jast
beneath the pleura — many scattered and conglomerate
tubercles. The air-passages contained reddish, frothy
fluid. The bronchial glands and those in the anterior
mediastrium were enlarged, caseous, and several per-
ceptibly softened. The kidneys and spleen contained
a few scattered tubercles. The pericardial flaid was
not examined.

A CASE OF ACUTE HEMORRHAGIC PAN-
CREATITIS.

BT W. B. PAOL, M.D., BOSTON.

The following case is reported as having some bear-
ing on the subject of appendicitis. At the same time
it illustrates the difficulty not infrequently presenting
itself in making an ante-mortem diagnosis in abdom-
inal affections. Moreover, cases of acute haemorrhage
into the pancreas are sufficiently unusual to warrant
the report of an undoubted case however incomplete
the data.

E. C, a robust farmer, aged sixty-two, suflTered
thirty years ago from severe intestinal symptoms. For
five days death was expected, when something seemed
suddenly to turn over in his stomach, and an intense
epigastric distress, with vomiting, was relieved. The
vomitus was black, but did not suggest blood.

Nine years later he suffered from symptoms similar
in character but of less severity. A sense of discom-
fort was described as centering in the lower chest
front and epigastrium. Every few days during the
more recent years the distress has recurred, and dar-
ing the past year its intensity has increased. For the
past six years the patient has been confined to the
house sit weeks at a time. In the last summer of
his life the attacks recurred daily, and required the
patient to lie down.

Tuesday, October 3d, the patient felt more misera-
ble, and at 11 A. u., Wednesday, had a decided pain
in his epigastrium and under the lower half of the
sternum, extending to each side perhaps as far as
the nipples. He was looking forward eagerly to his
dinner, feeling that the meal of pork and onions would
relieve the distress and pain. He eat heartily, but im-
mediately after finishing his meat was forced to leave
the table and vomit the meal. Considerable retching
followed, and the pain increased.

After about four hours the patient was visited, and
was found pale, with a cold perspiration on the tem-
ples and hands ; and suffering severely from most
acute pain referred to the epigastrium and snbstemal
region. The pulse was 70, of good strength, and
the temperature was normal. Sulphate of morphia

Digitized by

Google

Vol. CXXX, No. 1.] BOSTON MEDIOAL AND 8UR610AL JOURNAL.

9

(gr.^), with sulphate of atropia (gr. ^), was given
sabcDtaneouBly, and a few whiffs of chloroform added
before the pain was at all relieved. The abdomen was
moderately distended and tympanitic, bat there was
no tamor or special tenderness in the coeliac region.
The bowels had moved daily, and operated twice
freely on Wednesday morning. No gas had been
passed since the pain set in. An enema was given,
but nothing came away. Foar hoars later another
enema was given without effect, though Epsom salts
were added. The p&in continued; and sulphate of
morphia (gr. ^), with sulphate of atropia (gr. ^iv))
was administered.

At 11 A. M., of Thursday, the pain was most severe.
The pulse was 120, and the temparature subnormal.
The feet were cold. Some dark f»cal matter had
been passed without gas. Occasional vomiting through
the night had ceased about fourteen hours before death.
The abdomen was now considerably distended and tym-
panitic. A diagnosis of appendicitis with perforation,
was made. The question of ulceration from gall-stone,
duodenal ulcer, internal obscure strangulated hernia,
volvulus, and invagination was considered.

Dr. W. 6. Beed, of Southbridge, was caUed in con-
saltation, and the possible help of an operation caused
a summons to be sent to Dr. Homer Gage, of Worces-
ter. In the mean time, the patient failed rapidly, and
at six o'clock Dr. (^ge decided an operation was not
warranted. The diagnosis he considered obscure, but
inclined to the belief that there was an obstruction
of the bowel, with perforation. The patient failed
steadily, the abdomen swelled more and more, the
breath becoming shorter and shorter, but he remained
perfectly conscious. The death, thirty hoars after the
beginning of the attack, was apparently typical of acute
peritonitis.

A partial post-mortem examination was granted.
The abdomen was opened, and the omentum was
found adherent from old peritonitis. The appendix
was normal. The intestines were everywhere free,
and showed no sign of peritonitis. Several stones were
present in the gall-bladder. A soggy, heavy, enlarged
pancreas was discovered, of a dark-red color: the
organ was apparently loaded with blood.

RECENT PROGRESS IN ORTHOPEDIC SUR-
GERT.

BT K. H. BBADFORD, K.D., AMD B. O. BBACKBTT, M.D.

ARTBRODISI8 OF THE TIBIO-TAB8AL JOINT FOB PAB-
ALTTIC CLOB-FOOT.

Dbs. Edwabd Sohwabtz and H. Bieffel report
three cases of this operation with successful results.

The three cases were of adults, twenty-two, twenty-
five and eighteen years of age, of paralytic equino-
varus, all of whom had had previous operation or had
worn apparatus, and in whom one lower extremity
alone was paralyzed. The operation was by section
of a tendo-Achillis, and in one case incision over the
internal, and in the other two over the external surface
of the ankle-joint, with section of the ligaments, erasion
of the cartilages, and the bony parts being brought
into apposition. In all the cases there was a firm bony
anchylosis, and in all there was much improvement
in walking.

The three methods of procedure are described by
the authors, and consist of (1) by the anterior incision,
as advocated by Albert, and later by his pupil Zins-
meister ; (2) by incision above the internal malleolus,
as recommended by Kirmisson ; and (8) by the exter-
nal incision, which is used by most surgeons. The
relative value of these different procedures are care-
fully considered, as is also the method of the bone
suture and the indications and contraindications for
the operation. He gives the following conclusions :

(1) The operation is best done by external incision,
as it is easier and does less injury to the important
structures, without the necessity for osteotomy of the
fibular ; and also, if the bones of the tarsus are found
to be the seat of extensive change, it gives the chance
of changing the procedure at any part of the operation.

(2) It should be done in individuals having a flail
foot, with whom walking is painful, and in whom
apparatus has been found for any reason to be imprac-
ticable.

(3) It is also indicated in those irreducible paralytic
club-feet which have resisted the use of tenotomy or
of apparatus.

TREATMENT OF JOINT TCBERCnLOSIS.'

KSnig calls attention to the three methods of treat-
ment of this condition: (1) local treatment without
the apparatus or an operation, (2) local treatment
with medication by subcutaneous injection, (3) treat-
ment by mechanical means. He inclines strongly to
the mechanical and conservative methods, referring to
a number of cases of spontaneous cure, and* considers
it wiser in a way to return to the old method of treat-
ment, rather than to advocate too strongly active and
early operative interference. He advises the use of
continued extension and compression during the whole
period of sensitiveness, the deformity to be overcome
by extension, and later immobilization to be employed.
When this is not snfBcient he advises the use of injection
of iodoform.

He reports 410 cases, 150 of which were treated by
extension, and later by plaster for immobilization. In
50 there was an injection of glycerine and iodoform.
Of 250 resections there was a mortality of 1 9 per cent.
In 100 cases of resection of the knee in adults ranging
in age from twenty to sixty-six, six died from the re-
sults of the operation and six soon after, four of these
from septicaemia and two from tuberculosis. In 64
there was a complete cure ; in 16 there was a sinus
remaining ; in eight amputation was performed.

He recommends a complete extirpation of the capsule
in this joint, but does not advocate the resection of
the hip-joint for coxitis, as recommended by Barden-
beuer and Schmid, on account of the greater difficulty of
removing all of these tubercular products. In suitable
cases, when seen early, he recommends the removal of
interosseous tubercular focus, bat unfortunately it is
not often possible, as they have usually broken into
the joint when they first came under observation. In
these cases he recommends, besides the erasion of this
focus, the distension of the capsule with the mixture
of glycerine and iodoform.

DIFFERENTIAL DIAGNOSIS OF NEW OROWTH8 AND
INFLAHHATORT ENLAQREKENTS OF BONE.'

Mr. Howard Marsh gives several examples of cases
presenting enlargement of bone with the appearance

> ArchiT. fUr Kiln. Chlrnr., Band 44, Heft 3, p. 6S2.

• St. Bartholomew'! Hoapital K^iorta, 1892, TOl. zxTlii, p. 7.

Digitized by

Google

10

BOSTON MEDICAL AND SURGICAL JOURNAL. [Jantabt 4, 1894

of new growtfag, particalariy maligDant disease, all of
which were found to be of an inflammatory character
and contained pus. He cautions against the hasty
diagnosis of malignant disease in these cases, and ad-
vises exploratory incision in all, and, if necessary, the
microscopic examination with staining. As an aid to
the diagnosis, he gives the following points to be ob-
served : (1) age (all nnder twenty are asnally inflam-
matory), (2) distinct history of injury, (3) the shape
of the swelling, (4) the persistency of the swelling,
(5) the rate of growth, (6) the condition of the skin
and deeper soft parts over the swelling, (7) pain,
(8) body temperature.

OSTKOMALACIA DURING FEKaNANCT."

Seligman reports a case of this condition occurring
in a woman of thirty-seven, beginning daring the
seventh pregnancy. At the time the condition was
very bad, and there was considerable complaint of
pain in the pelvis. In the following seven years there
were fonr pregnancies ; and in the last the delivery
was by version. At this time the patient was going
about with the aid of crutches. Between the tenth
and eleventh the patient fell, fracturing the thigh.
When seen in the thirty-fourth week of the twelfth,
the general condition was extremely bad. The right
leg was two inches shorter than the left ; the abdomen
unusually prominent ; there was a right kyphoscoliosis
in the dorsal region, and left in the lumbar. The
child was delivered by Csesarean section, the pelvis
showing, osteomalatic changes. After delivery the
general condition was bad, and the patient was put to
bed with the whole trunk placed on extension ; and
after eight weeks the condition was very much im-
proved. The length of the body had increased seven
inches. The right leg was nearly the same length as
the left, and the patient soon was able to get about
and attend to her household duties.

SUTURE OF TKMDOM8.

In the Revue tT Orlhopedie, Dr. A. Dupureil reports
a case of injury of the hand in which the deep and
superficial tendons were cut, and in which operation
was done later in the attempt at reunion. There was
possible flexion of the phalanx on the metacarpus, prob-
ably due to the interoBsei, but none of one phalanx on the
other. The operation was decided upon to attempt to
rejoin the cut ends of the tendon. The incision was
made over the site of the tendon of the iudex-finger ;
and in this, the distal end was found, but a long search
failed to reveal the other end of the divided tendon.
Therefore, the portion which was found was sutured
to the tendon of the middle finger, and the wound
closed. For a time there was no power of flexion
over the finger, but this soon begun to appear, and
later the use of the finger became almost as perfect as
before the injury.

UALLET FINGEB.*

Dr. Bobert T. Mann reports two cases of this condi-
tion, which is described as being found after a blow on
the end of the finger while extended, and in which
some of the fibres of the extensor tendon are ruptured,
resulting in a flexion of the terminal phalanx on the
first and second. As a rule, the deformity is permanent,
the tendon having little or no power over this phalanx.
The treatment is by long incision over the site of the

> Centmlblatt fUr GyoeoolOKla, 1893, No. 28, p. 949.
< Medlesl News, Sqttember 9, 1893, p. 287.

injury, separating the tendon into the two natural fasi-
culi, and dividing the tendon transversely, advancing
each point along its own side, and securing it to the
skin at the base of the nail by a suture, tying on the
outside. This is done rather than suturing through
the periosteum, as it affords better hold. The nail is
often lost temporarily ; and after operation there is
sometimes an over-extension, which disappears in time.

LAHIHECTOUT FOB FOTT'S FAHAPLEOIA.*

Dr. Samuel Lloyd gives a comprehensive view of
the condition of this subject at present, and the follow-
ing deductions :

The operation is oontr»>indicated (1) in cases where
there are other complicating tubercular lesions ; (2) in
cases where mechanical treatment has not been ap-
plied.

It is indicated (1) in cases where the posterior spinal
disease is made out as the cause of the paraplegia; (2)
in cases where the lesion seems to indicate the failure
of mechanical treatment, that is, where dislocation has
occurred or where a sequestrum is causing compression ;
(H) in cases where during the employment of intelli-
gently applied apparatus the symptoms continue to in-
crease in severity ; (4) in cases where after a period of
careful mechanical treatment, say eighteen months,
the condition has remained stationary ; (5) in cases
where, pressure myelitis threatens the integrity of the
cord.

LATER BK8ULT8 OF LAHINBCTOUT FOR PARAPLEGIA
DUE TO ANGULAR CURVATURE OF THE SPINE.*

Mr. W. Arbuthnot Lane gives the ultimate results of
eleven cases previously reported by him. In two of
the cases death occurred, but only one could be attri-
buted to the operation ; and of the other nine, two de-
rived but temporary benefit. In the other seven the
relief was permanent, both as regards the paraplegia
and the local condition. He considers the operation
one of not great severity, and one that should be at-
tempted in all oases presenting these symptoms.

LATERAL DEFORHITT OF THE SPINE IN POTX's DIS-
EASE.^

KirmisBon reviews the literature of the past few
years on this subject, and takes a neutral ground in
reference to the etiology of this deformity. He de-
scribes the two forms which are met with : * the one, in
which the lateral deviation accompanies the angular
deformity ; and the other, in which the lateral deform-
ity exists alone. The question of differential diagno-
sis is considered, but little new light is thrown on the
subject. The presence of tenderness over the spinous
or transverse processes is regarded as of value, existing
only in the cases of caries. He calls attention to the
fact that where the lateral deviation accompanies the
kyphosis it may be either postural purely, or due to
the bone change ; but when existing alone, that it is
due to muscular contraction. In the former, althonsh
under recumbency, the deformity may nearly or quite
disappear, under suspension it is more marked by the
increased muscular contraction. He coneidera the ex-
istence of .the lateral deformity in Pott's disease as an
indication for prolonged rest in bed.

Marlier * adds a contribution to this subject, and re-

• Annals af Snrgerr, lt92, vol, xtI, p. S89.

• Brittib HwUosl Joarnal, Deoembsr 31, 1892, p. 142.
' Barae d'Orthopedie, 1892. No. 6, p. 440.

• Loo. Olt., 1893, No. 3, p. ITS.

Digitized by

Google

Vol.. CXXX, No. 1.]

BOSTON MEDWAL AUfi SURGICAL JOURNAL.

11

ports a caae in which there was a typical scoliotic carve
in which there was pain in the side and leg, bnt the
back showed no rigidity or mnscnlar spasms, and also
the child was able to walk aboat freely. A treatment
of gymnastic exercises was given, bnt in the course of
a few months a knuckle appeared and later au abscess.
In this case there was not present the tenderness of
pressure over the transverse process which is men>
tioned by Phocas, who reports a case with this symp-
tom in a boy of fourteen.' This case showed a slight
projection at the point of deviation at the first Inmbar
vertebra. There were no subjective symptoms, an4
the motions of the back were entirely free. The case
developed later with a kyphosis and abscess.

Dr. Bidlon ^'' gives cases in which this deformity is
present, but in which the diagnosis was doubtful, and
in which the lateral deformity was marked while the
symptoms were light He thinks the diagnosis should
be based rather from the absence of muscular spasm
than that of pain or of the character of the deformity,
and that when the deformity is high when spasm is
doubtful, the d^ee of rigidity should determine the
diagnosis.

FORCIBLE CORRECTION OF ANOULAB DEFORMITY OF
THE KNEE.

Dr. J. £. Groldthwait" reports altogether eleven
cases which have been operated on within a period of
from five years to one year ago. The contractions
were from various causes, chiefly from tumor albus ; a
few from rheumatism, and one from gonorrhoea. In
one the trouble appeared at the age of thirteen months
and had existed until the time of operation, which was
at the age of sixteen, at which time the leg was flexed
at a right angle and markedly subluxated. At present
the patient has a useful joint with free motion in an
arc of ninety degrees.

In all of the cases the results were good, giving use-
ful joints, cratches having been discarded. It is inter-
esting to note that in all of the cases, the operation was
followed by very little reaction or pain, and each case
was up in two weeks.

For the employment of force in those operations the
author had modified the apparatus devised several
years ago by Dr. Bradford for the correction of the
angular contractions of the knee, in which the deform-
ity is maintained by fibrous adhesions. As modified,
the apparatus is adjustable, and can be used upon any
patient regardless of size. The arch on which the
power is applied is movable on the uprights, and can
be secured at any distance from the fulcrum. The
counter-pressure comes upon a single leather pad, and
is so placed that the force is always directed against
the strongest part of the femur, no pressure coming
along the epiphyseal line.

OPEN INCISION IN OONTRAOTBD KNEE.

Wahncan " reports from Schede's Clinic eight cases
of open incision in contraction of the knee and hip,
with healing by blood-clot. The same method is used
successfully by Lorenz and HoSa.

ETIOLOOT OF FES CALCANEUS.

Bayer " refers to the grouping by Nicholodani, in
whicli all the cases of these were divided into two

• ReTve d'OrtboMdle, 1898, No. I, p. 14.
» New Tork Medieal Beeord, SeptemlMr 17, 1898.
" BottOD Medical and Surgical Jonrnal, September 7, 1883.
» Hambnix Hoapttal Beporto, 1890.
» Frager med. Woob., 1893, No. IS.

groups, the congenital and the paralytic acquired, and
reports two cases which be considers show that there
should be added another classification to these two. In<
one there was a phlegmonous inflammation of the
plantar region, and in the other an injury to the sole
of the foot by a piece of broken glass. In both of
these there was contraction resulting in this deformity
of the foot. He considers that the condition is due to
the position of the foot during walking, and that by
the permanency of this the contraction occurs. In
both of these cases the muscles of the calf were atro-
phied, and there was a secondary retraction of the
muscles which resulted in the pathological condition of

the foot

(3V>ieeoii(<niie<i.)

lEUiiort^ of jfeoctetiejer«

MASSACHUSETTS MEDICAL SOCIETY.
SUFFOLK DISTRICT.
SECTION FOE CLINICAL MEDICINE, PATHOL-
OGY AND HYGIENE.

HBHBT M. JAOKSOn, H.D., SXCaBT.lJiT.

Beoolab meeting, Wednesday, November 15, 1893,
the President, Dr. F. C. Shattdck in the chair.
Dr. H. F. Vickebt read a paper on

THE PREVENTION OF TDBEBCDL08I8.'

Dr. V. T. BowDiTCH : I am very glad to have the
privilege of listeniog to Dr. Vickery's paper. I am
sure it will bear good fruit I think that no experi-
ments that I have seen recorded thus far can compare
in beauty of result with those of Dr. Trudeau made in
1886 or 1887,' in which he speaks of environment for
the cure or prevention of tuberculosis. He made ex-
periments upon rabbits and I should like briefly to
review them. He took fifteen rabbits and divided
them into three sets, five of which he inoculated with
tubercular virus, and placed them in the best possible
hygienic position, that is, putting them on an island in
the middle of a lake and feeding them with vegetables
every day. Another set he inoculated keeping them
in a damp, dark place. The other five were not inocu-
lated, but lived in a damp, dark place. After two or
three months those on the island were caught and
killed. In only one was there any symptoms of tuber-
cular infection having been carried through the body,
the others all being fat and remarkably healthy. In
the five inoculated and put in the damp, dark place,
four died in a few weeks and all were filled more or
less with tubercular disease. The remaining one was
tuberculous also. The others were simply kept in a
damp, dark place without being in jected with tubercular
virns, and they were simply t£in and miserable, but no ■
tubercular disease was found upon examination after
killing them a few months later. From this I think
we can argue that among human beings environment
can act in the same way. I hope very much that the
Society will take some action upon this question. It
seems to me that by combined effort we can accomplish
very much more than by oi\b man single-handed. I
hope that some day we can see in Boston, as well as
elsewhere, laws made by which no such buildings should
be erected like certain apartment houses which I have

* See page S of tbe Jonrnal.

> Iransaotloni of tbe American CUmatologloal Anooistion, liar.
1887.

Digitized by

Google

12

BOSTON MBDIOAL .AlTD SUBGWAL JOUBNAL.

[Jakcart 4, 1894.

seen upon the Back Bay and in other places, where the
only means of ventilation from the bed-room was by a
'door leading to the parlor or diniDg-room and one
window opening into the well, three feet sqaare, into
which all the water-closets were ventilated. I wish
also that we coald do in Boston what they are doing
in some places where in the public schools boys and
girls are taught to avoid the disgusting habit of spitting
in houses and in the streets. I wish also that the ef-
fort to stop smoking on the rear of the open cars had
been successful, not for the smoking itself, but because
of the filthy conditions of the back seats when ladies
and others are obliged to get in them, for no one knows
what sort of tubercular material may be there to be
carried on their skirts. In regard to the action of
boards of health in declaring tuberculosis an infectious
disease in the same rank with diphtheria and small-poz
and scarlet fever, I feel that we must be cautious. It
is an infectious disease according to our present knowl-
edge but not in the same degree as the others and the
conditions are very difierent. It seems to me that
with patients who are just beginning to show signs of
pulmonary disease it wonld have a most depressing
and deleterious effect to have such action taken as is
now done for the acute infections diseases. The great-
est care, however, should be taken among the friends.
They should be informed of the state of the patient and
steps taken to prevent the spread of that disease as far
as possible and within reasonable limits. I always
direct my patients never to use handkerchiefs or any
article of clothing, simply to have cloths or paper cups
that can be burned immediately, or china sputa cups,
the contents of which can be destroyed.

I think Dr. Vickery deserves the thanks of the
Society for his paper.

Dr. J. G. White : From the title of this paper I
hoped that some allusion might be made to tuberculo-
sis of other parts of tlie body as well as of the lungs,
because the communication of other forms from person
to person as shown in skin clinics is no small evil.
For example, I treated last year at the Massachusetts
General Hospital thirty-five new cases of tuberculosis
of the integument, in a condition to have extended the
disease again in more serious forms possibly to other
persons. For a lung time, you know, the identity of
Inpus and other forms of tuberculosis was not recog-
nized. Now it is known that a large proportion of pa-
tients with lupus eventually die of consumption. Such
patients are generally members of families, and no
means are taken to prevent contagion. We see many
oases where, from the sputum undoubtedly, tuberculo-
sis of the hands and lungs occurs in the same person.
We observe the former especially in attendants upon
consumptive patients and in those who have charge of
children with scrofulous sores in the neck : scrofulo-
derma. Again, it is possible that a person with tuber-
culosis of the bands, or other forms of tuberculosis of
the skin, may introduce the bacilli through the mouth
to more dangerous tissues and thus produce more seri-
ous and rapidly fatal forms of the disease. I want to
say also that I think it is a mistake to consider tuber-
culosis in any way on the same level of danger as scar-
let fever and small-poz, so far as any attempt to con-
trol it by boards of health is concerned. It should be
considered rather like leprosy, as it is communicated in
the same way. Leprosy occurs still in some commu-
nities as frequently as consumption does in others, and
if consumption were accompanied by such frightful ex-

ternal appearances and disfigurement as leprosy, no
doubt the same methods of restraint might long ago
have been used against it, and it might have been
crushed out from civilised communities exactly as
leprosy has been crushed ont by exclusion, and although
it would seem a cruel thing that we should treat patients
with phthisis as lepers were formerly treated, there
can be no doubt that if those measures were exercised,
that we should exterminate tuberculosis from our
midst. The lazarettoes iu Europe several centuries
ago were numbered by hundreds and it was only be-
cause such active means were taken that that disease
was crushed out. I hope that this subject may be
made the subject of more serious consideration on the
part of this Society.

Dr. £ O. Otis : With very great interest in the
general subject of pulmonary tuberculosis, Dr. Vickery's
paper upon its prevention has especially appealed to
me and I feel indebted to him for its presentation. I
am, as he is, a member of the Pennsylvania Society
for the Prevention of Tuberculosis, and I wish we had
some similar society in this community. It seems well
nigh an hopeless undertaking to prevent contagion
when yon consider the innumerable ways and avenues
by which the disease may be disseminated. Consider
how constantly we are exposed to the contagion almost
everywhere we go — in the various vehicles which
transport us — steam and street cars, carriages ; in the
various buildings we enter, halls, hotels, theatres.
How many thousand people are constantly expectorat-
ing bacilli in-doors and out. The physician himself —
so familiar is he with the disease 1 suppose — in so
many instances does not seem to realize the danger of
contagion or the importance of guarding against it in
every possible way. Consider the waiting-rooms in
our out-patient departments where there is generally a
not inconsiderable number of tuberculous patients,
waiting anywhere from a half-hour to an hour and a
half and who expectorate about to their own and the
risk of others. Then consider the matter of vocation :
poor ]>eople are obliged to keep at their work so long
as they are possibly able to do so, and so we have
many tubercular cases working with others and expos-
ing them constantly to the dangers of the disease ; for
example, I had last winter at the dispensary a baker
with quite advanced pulmonary tuberculosis ; often he
was unable to work, being without means he slept
every night in a bake-house through the kindness of
one of his friends ; what an opportunity for the dis-
semination of the contagion. It seems to me one of the
great needs of the present day are hospitals. State, City
or National for the care and seclusion of poor tuberca-
louB patients. As it is now, no adequate provision is
made for them in any of the charitable institutions and
they wander about often ending their lives in the poor-
house.

One other point I wish to refer to, and that is the
matter of proper respiration. I have had the opportu-
nity of examining a good many so-called well people
in regard to this and it seems to me that we do not
give sufficient consideration to it. We mast Uaeh
people to breathe properly. We must remember that
the city life is for the most part a sedentary one, and
unless we give especial attention to it we rarely fully
inflate our lungs. It has got to be a matter of conscious
exertion. Each day, and several times a day, I be-
lieve, full lung inflation should be practised. It is one
of my standing rules, in advising men as to exercise in

Digitized by

Google

Vol. CXXX, No. 1.] BOSTON MEDICAL AND 8VROIOAL JOURNAL.

13

tbe gymDasium, that they should take deep full breaths
several times a day. After this is practised a while
they establish a custom of breathing more deeply aud
folly all the time.

Dr. Gbrenleaf : I regret that I was unable to
hear Dr. Vickery's paper. The subject is one in which
we are all especially interested. While we may no
doubt accomplish much towards the prevention of
tuberculosis through the efforts of boards of health and
by other general measures, there is a way of prevent-
ing its spread, which we may carry out as individuals.
The idea for this was suggested to me largely through
the investigations of Dr. Stone, who found that the
dried sputa of consumptives contained living bacilli
after a considerable length of time. I think his ob-
servations showed that the bacilli were alive and cap-
able of caosing tuberculosis in animals after at least
three years. Such facts show tbe very great necessity
for having some means of disinfecting the sputa as
soon as passed. In hospitals we have the sputa cups,
but they do not meet the difficulty we find with pa-
tients when outside, whether in the streets, the cars, the
hotels or in their own homes. It occurred to me that
if we could have something in a convenient shape and
of such material that patients would use it whenever
they expectorate that we should accomplish a good
part of tbe battle, and these samples which I take
pleasure in presenting to the Society this evening de-
monstrate one way of meeting the problem. My first
thought was to have a small bit of thin paper of par-
affine or other impervious material and place on it a
small wad of absorbent cotton, then to have the patient
use one every time he expectorated, roll it up and put
it in his pocket or a convenient receptacle and then
burn all the wads immediately on reaching home. I
advised such for a while. An improvement on this
plan appeared to be to have the bit on which each
sputum was to be passed made of absorbent material
only, and then to wad these up and store them in a
bag of impervious material, and then burn bag and all
on reaching home. I am endeavoring to have a manu-
facturer make up such napkins for me by the whole-
sale, so that they will be as inexpensive as possible
and yet sufBciently neat in jippearanoe so that patients
of every condition may be induced to use them. In the
meantime I am advising my patients to buy the form
of absorbent cotton, known as lintine, which comes in
a convenient thickness, or sometimes thick enough for
two or three napkins. I have them cut the rolls into
small squares, say three by three inches as in these
samples, then I have them use simple brown paper
bags to pat them in.

I have used these especially in the Boston Dispen-
sary and have found no difficulty in getting the patients
to adopt them on explaining to them the possibility
that they may have taken their disease by having in-
haled particles of dried sputa carelessly or ignorantly
expectorated by other consumptives in places where
they have slept or have otherwise been exposed ; more-
over I carefully explain to them that unless they adopt
some such device they are likely to similarly infect
their relatives and friends.

I would add that I do not confine the use of these
napkins to consumptives. I endeavor to encourage
their use in every disease accompanied by expectoration,
partly with the idea of making it a little easier for
the consumptives, so that they may be relieved of the
possible odium of being the only users of such napkins,

and -partly to be especially on the safe side regarding
all forms of the offensive and dangerous habit of ex-
pectoration.

Dr. 0. K. Newell : I am very glad to have heard
this interesting paper. I think that I have sent fully
a half-dozen cases to Professor White's clinic recently
where there has not been any doubt at all that there
was a direct auto-infection producing tuberculous dis-
ease in children who were living in families where
there was consumption. Dr. Otis says there are a
great many sources of infection, but I think the two
real sources of evil are in the first place the sputa,
especially in this country where we are reputed to be
a nation 6f expectorators, and in the next place the
overcrowding. I think that Dr. Vickery's statement
that as far as overcrowding is concerned the same con-
ditions were to be found in Philadelphia as here is
incorrect. In Philadelphia the question of overcrowd-
ing is practically eliminated because it does not exist.
There are square miles of small houses and it is a well-
known fact that in that city there are more single
homes than in any other city in the world ; there being
60,000 to 70,000 more buildings in Philadelphia than
in New York City. Although they may not have per-
fect drainage in Philadelphia, there is not overcrowd-
ing. In reference to the advisability of boards of
health taking the same attitude towards taberculosis
as towards scarlet fever, etc., I think that the fairest
way to consider that subject is to remember that scar-
let fever aud diphtheria and such diseases are rare
diseases comparatively. They are acute and rapid in
their coarse and rapidly dangerous, whereas tuberculo-
sis is an extremely common disease, one that is only
inoculable with difficulty. The seriousness of the dis-
ease depends upon where the inoculation is made. If
dried sputum is inhaled into the lungs it is in a place
where it is impossible to get at it. If the eye is in-
oculated of course it is easy to reach it. I think that
tuberculosis of tbe skin is not very dangerous ; it is
only when it involves the lungs that it is such a serious
danger.

Dr. E. O. Otis: I neglected to mention a case
which came to my attention a few days ago, and was
of interest to me on account of the possible source of
infection. It was this : A young man apparently well
had been shooting, and while returning fell with bis
gun, wonnding his thumb ; he had on a pair of woollen
gloves at tbe time, which he continued to wear after
the wound was received. He went directly from
Norfolk, where the wound was inflicted, to Washing-
ton and there visited the Army Medical Museum.
The wound did not heal kindly, the finger was ampu-
tated, but still healing did not ensue and local tuber-
culosis was discovered at the seat of the wound. Later
he developed pulmonary tuberculosis for which he is
now at a health resort. Was it from the woollen gloves
or at the Medical Museum that the bacilli gained en-
trance into the wound ? It is an interesting conjecture.

Dr. White : I should like to mention the fact that
I once counted the number of sputa in crossing the
Common from Park Square to the West Street gate.
It was early in the morning after two or three trains
had come in on the Providence railroad. The tem-
perature was below freezing. I was attracted by the
great number of fresh sputa on the sidewalk and
counted many hundreds before I got to the West
Street gate. Very likely many of them came from
persons with consnmption. They were safe at the

Digitized by

Google

14

BOSTON MBDIOAL AUD SVSGJCJl JOVJSJfJL.

[Jancabt 4, 1894.

moment because frozen, but the same number of epnta
on that path in the sammer would rapidly dry and be
taken up by the wind and pass into the atmoBphere.
So, I think, we are in the constant presence of bacilli
in the air from sources which are not apparent. I was
going to the hospital a few days ago and passed a house
in which a woman was engaged in shaking rugs out of
the window. A few weeks previously the red card of
scarlet fever was on that house. Very likely those
rugs had been in the chamber with the patient. Chil-
dren passing might readily have taken the disease.

Dk. F. C. Shattcck : I was very glad to hear Dr.
Vickery speak of the soil. I think that in the ardor
of our enthusiasm at having discovered the cause of
tuberculosis, as is very natural, we have at first been
inclined to attribute too little importance to the ques-
tion of soil ; and those experiments of Dr. Trndeau,
which Dr. Bowditch quoted, are certainly very im-
portant and should not be lost sight of for a moment.
Jt is not a very easy matter to determine the relative
importance of contagion and susceptibility. Within a
fortnight 1 have seen two ladies with pulmonary tu-
berculosis following the death of sisters from pulmonary
consumption, — ladies who had nothing to do with each
other whatever, in two entirely different families.
There you may say there was family predisposition.
The sisters who survive were about those who were
ill a good deal of the time, and it has been noted be-
fore that cases of contagion from husband to wife are
more frequent than from wife to husband, the women
naturally staying in the house a great deal more. But
I recall a case of another kind. Some years ago I was
asked to take charge of a kept woman who had pulmo-
nary consumption and afterwards developed tubercular
disease of the bladder. The young man who kept her
behaved in a way different from some men, and stuck
to her through thick and thin, and as far as his means
would allow provided her with everything which would
contribute to her comfort. He continued to go to see
her. She died ; and not long afterwards he came to
my office feverish and with a sharp stitch in the side.
I found that he bad pleurisy, and sent him home to
another city in the State. He pretty rapidly developed
consumption, and some years later died at Saranac.
He probably got his trouble from his mistress, and not
through coitus. Then we have on the other side the
statistics of the Brompton Hospital for Consumptives
in London ; the very small number of cases which
have developed among attendants or physicians. And
the physicians to out-patients sit three or four hours
in small consulting-rooms in the most intimate contact
with consumptive patients. So very common, so omni-
present we may say, is the contagion of tuberculosis
that it seems almost a wonder that any of us survive.
I am perfectly convinced, although it is very difficult
to prove that many people are tuberculous and never
know it ; have pulmonary tuberculosis and get well of
it. If one-seventh of all deaths from all causes at all
ages are due to consumption of the Inogs, I should like
to know how large a contingent of the population is
tuberculous somewhere or other and does not die of it.
I do not dwell upon this with a view of discouraging
any attempt to limit the spread of the disease which
undoubtedly occurs through the sputum. It is only
that I think we are apt to look too strongly on one
side, and the side which presents itself to us now is
the side of contagion naturally springing from the dis-
covery of that in which the contagion resides.

Db. Vickrrt : I should like to express my satisfac-
tion in having the opportunity of hearing the opinions
of other members of the Society and to say that that
was one of the objects which I had in mind in writing
the paper. What Dr. Otis said about respiration is
confirmed by such writers on climate as Solly. As to
the effect of notification in shocking early cases : I
have thought of that too, and it is a valid objection,
but still I find that after a while it seems wiser to me
for my patients to know what they have, although
perhaps if they were told the first day it might do
them a great deal of harm. I have in mind some to
whom the knowledge has come very gradually, but
still while they have been in the early stages, and with-
out any apparent detriment ; and I have been told by
a patient lately that at Saranac Lake they know what
they have got and it is intended they should, so that
they will take the best care of themselves. There are
two sides to the matter. I think there is no doubt
that the disease is contagions. I remember one case
that struck me very much ; a perfectly healthy mother
of middle age had a married daughter come home to
die of consumption. She nursed her with great assidu-
ity and buried her. In about a year after I was called
to her to see her die in the same way. It seemed to
me a very plain case. Of course, we have all met simi-
lar ones. If I am going to be poisoned and killed by
a disease it is not much comfort to me to know that it
may not happen next week, that it is going to hang
over me and kill me gradually. About cases of un-
conscious tuberculosis, there have been interesting
pathological reports in that regard, and a good many
cases are found in adults who present healed scars and
who die of other diseases.

Db. Bowditch : I wish to emphasize one thing I
said. It is in reference to cases of tuberculosis being
reported to boards of health. Now while I agree with
Dr. Vickery that sooner or later it is usually best that
a patient should know that he has tuberculosis (I refer
now to the pulmonary form) yet I maintain that for
many reasons in some cases it may be wisest not to let
him know at the outset, although the family or friends
should know the true facts. If then, we were to fol-
low the same rules as apply to scarlet fever, diphtheria,
etc., and under the penalty of a fine for neglect, were
compelled to notify the board of health the instant we
detect the disease what would be the result ? I need
not picture the disastrous results to the patient were
such active steps taken. I do not yet know the exact
course the Michigan State Board of Health takes in
this matter, but 1 must confess to having been startled
by their announcement that they class tuberculosis
with the acute infectious diseases, a position which I
think now unjustifiable. With caution and with ra-
tional methods I believe an immense deal of good can
be done by boards of health in this matter, but let na
keep within bounds.

Db. Nbwell : It seems to me the boards of health
can cover these two points and they do to-day practic-
ally in what relates to overcrowding. They could
educate the people in regard to spitting and regulate
the overcrowding without taking the same action that
they do towards cases of acute contagion.

Db. Vickebt : I remember that Flick suggests that
cases should be reported when the tissue begins to
break down. I think that would be very difficult to
carry out. I am sure many cases would not be re-
ported. Perhaps if we started by enlightening the

Digitized by

Google

Voh. CXXX, No. 1.] BOSTON MBDIOAL AND 8UB6I0AL JOUBNAL.

16

public, after a time they would thank us to know it.
I would thank any man, if I had beginning tuberculo-
sis, to let me know it right away. That is from my
point of view, and I think that the public may be
brought to the same position.

Db. J. J. MiNOT : I move that such a committee be
appointed by the Chair as Dr. Yickery suggests in his
paper, the committee to make a report on the best
means of preventing the development of tuberculosis.
Seconded. Carried.

The Pkbsident : I will announce the committee at
the next meeting.

■ •

THE NEW YORK NEUROLOGICAL SOCIETY.

Stated Meeting, held at the New York Academy
of Medicine Tuesday evening, November 7, 1893,
Dr. B. Sachs in the chair.

Db. Edwabd D. Fisbeb read a paper on

ANOMALOn^ CASES OF OENESAL PARESIS.

He stated that a general definition of general paresis
may be given as a disease of the nervous system, espe-
cially of the brain, in which, pathologically, we find a
diffuse inflammation of the membranes and cortex of
the brain, and also of the membrane and systemic
tracts of the cord. Typical cases follow a more or
less well-defined course, the somatic and psychical
symptoms going on haud-in-band, and finally terminat-
ing in two or three years iu death. Of late years
many cases have been reported which differ largely
from the ordinary clinical picture. Savage refers to a
type of case in which all the physical signs of the
disease are present, but none of the mental or psychi-
cal, or, again, when only dementia of a simple charac-
ter is present. He found that the course of the
disease may often in these cases be protracted, extend-
ing over many years. Dr. Fisher said it is not an in-
frequent experience to have our diagnosis disputed,
both by the friends and by the physician iu attendance,
in this form of the disease, especially as under proper
care improvement takes place, and because the disease
is so long protracted. There may in the future be
subdivisions made of the general disease as the symp-
tomatology and pathology are better understood. It
has suggested itself to him that when either alcohol or
syphilis seems to be a prominent exciting or etiologi-
cal factor the so-called somatic symptoms are usually
the most marked. Another explanation of these cases
may be that the prodromal stage is protracted. In
fact, the disease, as a rule, long antedates its first
recognition by friends and physician. In mental dis-
eases, the emotions are probably the first to show evi-
dence of change. This may express itself by undue
exhilaration over a slight thing in itself, by depression,
by outbursts of irritability, by a disregard for the feel-
ings of others', etc. ; or the patient may become care-
less, or show a lack of proper concern in regard to his
health or business. On the somatic side we may have
evidence of slight motor disturbance, perhaps slight
tremor, slowness or clumsiness in speech, or a slightly
ataxic or spastic gait. In other cases, again, the early
symptoms may indicate hypochondriasis, only later on
to develop with rapid strides into a welMefined case
of' general paresis.

Dr. Fisher then gave the histories of a few cases of
general paresis coming under his observation which
pursued an anomalous course. In the first case the

disease extended over a period of at least nine years,
and in all probability much longer. The second case
was that of a man aged thirty-eight years ; excepting
that he is rather forgetful and has lost interest in his
personal affairs to a large extent, no mental symptoms
are present. The man has the peculiar fatuous ex-
pression common to the disease ; there is some tremor
of the tongue and slight tremor of the face ; speech
clumsy ; he has had two or three attacks of aphasia of
short duration, lasting from several hoars to a day.
At times there appears to be great improvement in his
condition. This will probably prove to be one of the
prolonged type of cases. The man is still under obser-
vation.

Dr. Fisher said that considering these cases and
many others to which he could refer, in which the
course of the disease seems to be almost arrested, or
even does not commence in the usual manner, it must
be seen that general paresis, at least in some cases,
may be much altered in its course — to such an extent,
indeed, as to make the diagnosis a question of doubt.
Some dementia, however, he thought always exists in
these cases. Even in the early stages of a classical
case, with exaggerated ideas of wealth and ability, we
recognize the inconsequence of ideas and responsibility
so essentially characteristic of dementia. This latter
condition becomes more apparent if these cases are
allowed to engage in their ordinary avocations. It
will often be seen that when they are removed from
hospital care, and permitted to resume their business
when improvement takes place physically and men-
tally, that the course of the disease becomes a rapid
one towards physical exhaustion and dementia.

DISCUSSION ON THE RELATION OF STPHILIS TO

OENEBAL FARE8IS.

Dr. Frederick Peterson opened the discussion
by reading a paper on this subject. He stated that
the question of the position taken by syphilis in the
etiology of dementia paralytica is one that has been
attracting great attention among syphilologists and
alienists of late years. No fewer than seventy authors
have contributed to the elucidation of this problem.
The majority of these contributions treat of the subject
from a statistical standpoint, and it would seem that
sufficient data have been collected to fully satisfy all
inquiries regarding that particular. Naturally, the
first point upon which precise information was needed
'was as to the percentage of cases of general paralysis
with a history of syphilis, and we are now in a posi-
tion to supply it fully. Although these statistics differ
very materially at times, yet the results in the main
agree. The figures range from as low as 13 per cent,
to as high as 88 per cent. Ejellberg has taken the
stand that all cases of general paralysis are of syphilitic
origin ; that the cases are affected either congenitally
or through acquisition. This author stands quite alone
in his assertion, which is not justified by observation
or facts.

Dr. Peterson said his own statistics on this point
are rather questionable, as are all obtained from large
public asylums to which patients are taken in stages
of the disease too tax advanced for them to give trust-
worthy information regarding themselves, and whither
they are generally brought by relatives or officers un-
acquainted with such an etiological factor in their
histories. There were admitted to the Hudson Biver
State Hospital for the Insane 287 cases of general

Digitized by

Google

16

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Jahuart 4, 1894.

paresis. In 55 of these syphilis was definitely ascer-
tained to have preceded the disorder. In the remain-
ing 232 it was either absent or unascertainable.
Actually, then, only 19 per cent, were found to be
syphilitic ; but, assuming that one-half the others were
affected, the total ratio would be in the neighborhood
of 60 per cent, of the cases. At public dispensaries
we see these cases in the earliest stages, when histories
may be more exactly obtained. At the Vanderbilt
Clinic, 40 cases of general paresis were observed;
definitely syphilitic, 10; definitely not syphilitic, 12;
unascertained, 18 ; taking the 22 cases in which the
exact facts were obtained, we have 45.4 per cent, cer-
tainly syphilitic, and 54.5 certainly not syphilitic.
From an examination of all the figures collected above
from various sources, it would, perhaps, be fair to
assume that about 60 to 70 per cent, of all cases of
general paralysis have a syphilitic history. The fact
is thus established that syphilis is a striking etiological
factor in general paresis, but that 30 to 40 per cent, of
the cases are not syphilitic. A much more di£Bcult
problem is to determine the exact relationship between
syphilis and general paresis. Is it a direct cause, or
merely a contributing agent ? Is it in syphilitic cases
a post-syphilitic a£Fection, or is foregone syphilis merely
a predisposing factor ? This problem may be examined
from several standpoints. In the first place, we have
the rather remarkable statistics of Lewiu, of 20,0U0
cases of syphilis, one per cent, of which became insane,
and in which not a single case of general paresis de-
veloped. Then we have the further fact that among
the native Egyptians, where syphilis is one of the
most widespread of disorders, no case of general paresis
has as yet been reported. It is significant, by the
way, that alcoholism is seldom or never observed
among them. Again, from the pathological stand-
point, it is well known that the direct invasion of the
brain by syphilis is characterized by changes in the
blood-vessels, by the formation of gummata, or by dif-
fuse meningeal iufiltration. The first and third of
these processes is most frequent in and about the base
of the brain ; the second is more common in cortical
regions. On the other hand, in general paresis we
have a chronic meningitis of the convexity, with
atrophy of the cortex, and the processes in this disease
and in syphilis are quite distinct, although there are
cases in which a syphilitic meniugo-encephalitis may
closely simulate, symptomatically, dementia paralytica.
There are some who argue that tabes and generaT
paresis are frequently associated, and that tabes being
a form of syphilitic disease, general paresis in conse-
quence must owe its origin to syphilis. If the two
diseases have the same etiological imprint, there ought
to be a close correspondence in the percentages of
syphilis in relation to each ; but the consensus of opin-
ion seems to be that a history of syphilis is found in
only 60 to 70 per cent, of general paresis, whereas in
tabes the percentage ranges, according to different
authorities, from 80 to 98 per cent. At the Vander-
bilt Clinic, in 83 cases of locomotor ataxia, 51 were
syphilitic, 20 not syphilitic and 12 unascertained. Of
the 71 cases of tabes of whose specific history we have
exact data, over 71 per cent, were syphilitic and over
28 per cent, not syphilitic. That is, then, among
cases equally well studied and from the same sources,
45.4 per cent, of general paralytics were syphilitic, and
71 per cent of tabetics. Dr. Peterson said he did not
agree with the statement made by Dr. Sachs in a re-

cent article, that there is a very frequent development
of tabes after dementia paralytica, and of dementia
paralytica after tabes. In cases of paralytic dementia
with tabetic symptoms the nerve fibres of the posterior
columns are often little if at all implicated. One of
the facts which has been employed against the opinion
that general paresis is a late form of specific disease is
the absolute futility of anti-syphilitic treatnaent. In
every form of cerebral syphilis proper we are often
enabled to accomplish a great deal of good by vigorous
and systematic treatment, whereas in general paresis,
even if the history of syphilis is clear, no appreciable
effect is produced by anti-syphilitic remedies.

In concluding his paper. Dr. Peterson said that in
his opinion dementia paralytica has no immediate or
late relations to syphilis as a direct cause. Syphilis
is a common etiological factor, but only in the sense of
its being a predisposing cause. It prepares the soil in
more than half of the cases for the development of
dementia paralytica, this disorder having its direct
causes in alcoholism, sexual excesses and over-strain of
the mental functions. The higher nervous elements
are rendered prone to degeneration by the fore-running
specific disease, which, as is well-known, gives rise to
a cachexia with changes in the constitution of the
blood.

Dr. Granger said that the question of a change in
the character of the mental symptoms of paresis from
the standard type of the disease is one that has been
very much debated and studied ; and it looks as though
the outcome of it might be that the disease known as
general paralysis of the insane would be found to em-
brace more than one disease — possibly more than two
— the distinction being based upon the clinical aspect
and the pathological conditions present. The varia-
tions from the ordinary type of the disease, as he has
observed them, have not been so marked in this coun-
try as abroad. Two or three per cent, would probably
cover the melancholic form of paresis in this country ;
while in England, in some of the largest asylums, the
number has risen as high as 15 or 20 per cent, of the
cases admitted. He has seen two forms of the melan-
cholic type of paresis : in one of these the delusions of
the patient, although they were those of depression in
one sense, were of grand depression. For instance, a
patient was very much depressed with the idea that he
was the devil ; he would constantly cover his face and
head in order to hide his horns, and carry a newspaper
behind him in order to prevent his tail from growing.
But he was the biggest devil, the greatest and the
wickedest devil that could be imagined. On the other
hand, there are cases of general paresis in which there
is simply melancholia with no grand delusions. An-
other anomalous type of paresis is that in which no
special symptoms are present, excepting that of pro-
gressive dementia and a feeling of satisfaction ; this
type is becoming more and more common. The ques-
tion whether the disease is lengthening or shortening
in its course is very much discussed ; many think that
its course is being shortened, while on the other hand,
according to some of the English asylum reports, it is
being lengthened. In this country we still commonly
see the typical form of general paresis, and death takes
place about thirty months after the full development
of the disease.

In regard to the relation of syphilis to general
paresis, Dr. Granger said he agreed very closely with
the views expressed by Dr. Peterson. Syphilis itself

Digitized by

Google

Vol,. CXXX, No. 1.] BOSTON MEDICAL AND 8UBGI0AL JOUBNAL.

17

does not cause the disease, and it is very difficult to tell
«hat does cause it. That syphilis is very common in
Egypt, and that venereal excess is also very common
there is acknowledged by all, and that general paresis
is very uncommon there is also true, but other condi-
tions exist there which the world over are favorable to
the non-development of paresis. These natives possess
neither energy nor ambition, and spend most of their
time basking in the sun. In the coal regions in Eng-
land, general paresis is quite common, the percentage
in the asylums being from 30 to 40 per cent. ; in the
adjoining agricultural districts the pemntage falls as
low as two or three per cent., and yet probably syphilis
and intemperance are very common in both of these
communities. In this country, general paresis rises as
high as 15 to 20 per cent, in the Eastern States, while
in the Western and Southwestern States the percentage
is very low indeed. Yet syphilis is undoubtedly very
common in the latter localities; so is drunkenness;
Still, general paresis is very infrequent there. It takes
something besides syphilis or intemperance to produce
the disease. In the cities we call it the strain due to
high civilisation. In the coaling regions we call it
their laborious and peculiar life. Syphilis, while it
does not cause paresis, is undoubtedly a strong factor
in its production. As regards the value of statistics
in this connection, the speaker thought it extremely
difficult to get accurate statements from the patients
who are sent to asylums, and upon these we are uaually
dependent for our statistics. The history of syphilis
often dates back many years and is extremely untrust-
worthy.

Dr. Lton said he has often been struck by the fact
that when a history of syphilis is obtained in a case of
general paresis, the former disease usually existed a
long time ago. Most of the patients state that they
were treated for the disease and cured, and that they
have had no manifestation of it for many years. Dur-
ing the current year seventeen cases of general paresis
were admitted into the Bloomingdale Asylum; of
these, twelve have a pretty clear history of syphilis.
In only one of these was the syphilis as recent as four
years previous to the development of the general
paresis. In almost all the cases the patients had prob-
ably received the modern treatment for syphilis, that
is, mercury and the iodides.

Dr. Lyon said he agreed with the previous speakers,
that while syphilis is not the immediate cause of gen-
eral paresis, it is one of its provoking causes ; it pro-
duces instability of the brain, which then yields to other
more immediate causes. These same patients who
give a history of syphilis have for many years led
liberal lives. The course of the paresis in these cases
seems to he more rapid than in those uncomplicated by
syphilis. The speaker said that cases of paresis of
long duration are not unknown — indeed, not very in-
frequent. He has met with one case in which the dis-
ease lasted over ten years. Its duration depends on
the patient's constitution.

Dr. FiKLD referred to the unreliability of statistics
obtained from patients affected with general paresis.
He has never seen a paretic in whom active syphilitic
symptoms existed. The history of syphilis obtained is
usually an old one. It is generally combined with a
history of alcoholic and venereal excesses. He has
made inquiries among those engaged in the treatment
of venereal diseases, and who have followed up their
syphilitic patients for many years ; and they have in-

formed him that general paresis is not common among
such patients, although it does occur. Dr. Field said
he regarded syphilis as a predisposing rather than a
precipitating cause of general paresis. This is also
true of alcohol. Magnin says that chronic alcoholism
always terminates in dementia or general paresis. The
Chinese are well known to be syphilitic — at least,
those in this country ; still, he has only observed one
case of paresis among them. That case was a typical
one : the patient imagined he had thousands of acres
of land, thousands of dollars and thousands of wives
— all white. The reports of the asylums in California
show many cases of insanity among the Chinamen, but
no form of paresis. In conclusion. Dr. Field referred
to the change of type that seems to be occurring in
dementia paralytica.

Dr. Joseph Collins inquired on what grounds Dr.
Fisher based the statement that in general paresis due
to alcoholism or syphilis the somatic symptoms were
supposed to be in the ascendency over the mental?
If such a statement be well founded, it is in contra-
diction to the other diseases due to these poisons,
wherein mental symptoms are well marked. At the
Medical Congress in Washington some years ago. Dr.
Savage referred to a variety of paresis wherein the
motor and somatic symptoms were apparently the only
symptoms of the disease for quite a long time. Such
a case, Dr. Collins said, is now under his observation.
As regards the statement made by Dr. Peterson that
cases of paresis are unknown in Egypt, Otto has re-
cently reported fifteen cases of the disease in that coun-
try. So far as the relationship between syphilis and
general paresis is concerned. Dr. Collins said he was
very much in accord with the statements made by Dr.
Peterson. His statistics correspond very closely with
those of Jacobson, taken from the St. Hans Asylum
in Denmark ; and it appeared to him that such statis-
tics could be relied upon. The patients in that institu-
tion came from within the narrow confines of the State ;
and Jacobson, in making up the statistics, ferreted out
every possible etiological factor by inquiry regarding
the patient's antecedents, friends, etc. The statement
made by the French syphilographers, and also by
Sternberg, of St. Hans Asylum, that there can be no
general paresis without a history of syphilis is no
longer worthy of credence. We have statistics galore
at our command, and it is now time to draw such con-
clusions as can be drawn from figures. Dr. Peterson's
statistics, taken from the Vanderbilt Clinic, are very
valuable. The cases were seen early ; they were ap-
parently carefully studied, and are sufficient in number
to draw conclusions from. We all admit that in about
60 per cent, of all cases of general paresis a history of
syphilis, dating back from one to twenty years can be
olitained. What we want to know is the way in which
syphilis causes general paresis. In one of the speci-
mens presented by Dr. Van Giesen this evening, a
section taken from the brain of a general paretic, the
microscope shows a large number of cells collected
around a blood-vessel, with some of their protoplasmic
prolongations destroyed or atrophied. In the early
stages of general paresis there is vaso-motor disturb-
ance, not only in the cortex of the brain, but through-
out the whole body. Syphilis may act through its
sinister manifestaUons on the blood-vessels. It causes
a pathological condition that is favorable to the develop-
ment of general paresis. If there are other attribut-
ing fitctors — and in nearly all cases there are — they

Digitized by

Google,

18

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Januabt 4, 1894.

act as the torch to the pile that has already been
prepared.

Dk. Parsons, id referring to the possible relation-
ship between syphilis and general paresis, stated that
so far as his observation and reading went, the tissue
changes that occur in general paresis do not correspond
with those that are produced by syphilis. Further-
more, we know that general paresis occurs in a certain
number of cases in which there is no history of syphilis.
His own studies of dementia paralytica have led him
to think that the more immediate causes of the disease
depend upon emotional conditions, or one might say
coDgestioD of the capillaries of the cortex due to over-
exertion or over-stimulation of the nerve cells of the
cortex. Syphilis sometimes causes a degeneration of
the nerve tissue, but in opposition to this we observe
that general paresis occurs usually during the most
vigorous period of life. Dr. Parsons said that while
he felt unwilling to make the statement that there is
no possible relationship between syphilis and paresis,
as cause and effect, such causative relation has not yet
been proven.

Dr. William M. Lesztnskt said that in those
patients who have died from general paresis, it seemed
to him that the pathological changes found in the brain
were very much the same in those who gave a history
of syphilis, and those in whom a specific history could
be positively excluded. Dr. Hinckley, of the Essex
County Asylum, at Newark, N. J., recently sent him
some statistics in conuectiou with this subject. The
asylum has about 500 inmates. During the past eight
or ten years, 15 cases of general paresis were received
there. Of these, 18 were males, two females. In
only two of these cases was a history of syphilis ob-
tained, and in those there were no somatic manifesta-
tions of the disease. The causes given in the remain-
ing 13 cases were alcoholism, overwork, anxiety, etc.
Id conclusion, Dr. Leszynsky raid he agreed with Dr.
Peterson in considering syphilis only as a predisposing
factor in the production of general paresis.

Dr. a. D. Rockwkll referred to certain cases of
general paresis that have come under his observation,
in which the patients for temporary periods were ex-
tremely wretched, utterly disregarding all rules of tidi-
ness and decency ; these manifestations, after a number
of weeks, passed away, and the patients became quite
reasonable again.

Dr. C. H. Brown said he regarded general paresis
as a disease of evolution; syphilis, alcoholism, sexual
excesses, etc., were merely complications or predispos-
ing factors. He also referred to the difficulty of get-
ting a reliable history of syphilis in these casest

Dr. £. D. FiSHBR, in reply to Dr. Collins's question
as to the ascendency of the somatic over the mental
symptoms in certain cases of general paresis, said he
referred to those cases where we have extreme alcohol-
ism or a recent history of syphilis. In such oases,
too, we frequently have a more rapid response to treat-
ment ; however, they do not, as a rule, go on to com-
plete recovery. While the old typical cases of general
paresis are still the ones usually met with, yet anomal-
ous cases are not infrequent. These, perhaps, in the
past would not have been classed as general paresis.
He agreed with Dr. Peterson in regarding syphilis
simply as a predisposing factor. In cerebral syphilis
we may have many symptoms similar to those of gen-
eral paresis, but the disease does not run a similar
course. Asylum reports on this subject must always

be regarded with more or less suspicion. In concla-
sion. Dr. Fisher referred to the futility of specific
treatment in dementia paralytica.

Dr. J. F. Terriberrt referred to the diflSculty of
properly classifying certain cases in which there is
dementia and other symptoms of cortical degeneration.

Dr. Sacbb said that too much reliance should not
be placed upon the value of statistics in connection
with this subject. A few years ago the number of
cases of tabes with a syphilitic history was placed at
87 per cent., and much lower than this by some au-
thorities ; now every one is agreed that the figures
should have been as high as 92 per cent. We all
admit the frequency of syphilis in general paresis, but
the majority of the speakers have laid too little stress
upon it as a predisposing cause ; they refer to it as the
lesser cause. The speaker said he did not agree with
them in this. In other mental diseases in which hered-
ity plays an important part, that factor is regarded aa
a priedisposiog cause, while an emotional element is re-
garded as the exciting cause, but the hereditary taint is
certainly one hundred fold more important than the
latter element. He is of the opinion that syphilis playa
a more important rdle in general paresis than any
other etiological factor. Other facts go to prove that
syphilis plays a very important part in dementia para-
lytica. In probably every case of general paresis that
has occurred in early life, that is, between the ages of
fifteen and twenty-five years, there is a history of
syphilis. The general impression seems to be that the
specific history is one of long standing. While this is
true in the majority of cases, it is not so always. A
striking instance of this recently came nnder his ob-
servation. A young man of 22, while a student at
Heidelberg, contracted syphilis : six months after infec-
tion be developed a typical general paresis, from which
he is still suffering.

As regards the possible relationship between tabes
and general paresis, Dr. Sachs said be has seen a num-
ber of cases in which the development of the two dis-
eases rapidly followed each other. In one case the
tabes developed nine months previous to the general
paresis ; in that case there was an undoubted history
of syphilis. In one class of paretic patients the knee-
jerks are much exaggerated, while in another they are
below the normal or entirely absent. In these latter
cases the probability is that changes in the posterior
columns have occurred closely related to the changes
that are fouud there in posterior spinal sclerosis.

Dr. Peterson then closed the discussion. As re-
gards the statement made by Dr. Collins about the
cases of general paresis found in Egypt, Dr. Peterson
said he has not seen the article by Oito referred to.
Dr. Sand worth, the physician in charge of the asylum
at Cairo, informed him that he had never seen a case
of general paresis in a native Egyptian, nor bad his
predecessor, who was there for many years. The dis-
ease does occur among the Turkish oflicials in Egypt,
but not among the natives.

With regard to Dr. Sachs's statement as to the rela-
tionship between tabes and general paresis, it is of
course true that there are often tabetic symptoms in
general paresis, and that the knee-jerks may be absent.
In the majority of cases, however, in which the knee-
jerks are absent in the early stage of the disease, they
subsequently return and become exaggerated. Further-
more, no changes are found in the posterior columns
after death from general paresis.

Digitized by

Google

Vol. CXXX, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL.

19

Xtecent Siteratute.

Rtform in the Treatment of the Insane — Early His-

tory of the Retreat, York : lit Olgect and Influence,
With a Report of the t'elebrations of itt Centenary.

By D. Hack Tokb, M.D., LL.D. Pp. 96. Londou :

J. and A. Churchill.

The Tolome before us contains an interesting bat
* short account of the rise and growth of the now fa-
mous York Retreat and the worlt done there by several
generations of the Tukes, from the pen of one of their
number, himself an eminent alienist and writer on in-
sanity and kindred subjects. The achievements of
Samuel Tuke in England and Pinel in France form
an epoqb in history ; and the reforms in the care and
treatment of the insane by them instituted will rank
with the highest efforts for the alleviation of human
suffering. This small volume commemorative of the
centennial of the York Retreat, may therefore properly
stand as a fitting memorial of the inception of a great
work for the amelioration of the insane, and thereby
the good of mankind.

Ptychopathia Sexualis, with etpecial reference to Con-
trary Sexual Inttinct : A Medico-Legal Study. By
Db. R. ton Kbafft-Ebino. Authorized Trans-
lation by Cbables G. Cbaddook, M.D. Pp. 436.
Philadelphia and London. 1893.
The alienist is often in much doubt regarding the
status of certain distasteful cases which come to his
notice in whom the sexual element is the chief, per-
haps the only, feature. It is here that this work will
be a decided help, for in it not only are the unmistak-
ble cases of contrary sexual instinct given a practical
classification, based upon an apparently sound patho-
logy, but other less pronounced manifestations and
syndromes of similar nature, generally held to be
simply the expression of vice in its most revolting
form, are here taken from their criminal setting and
placed in the proper category of mental degeneration.
At the same time the boundary line between sexual
depravity and disease is kept well defined.

In the matter of treatment there is little advice given
that is of practical value. The cases in which the author
tried hypnotism do not seem to have been particularly
suocesslni, and his encouragement of marriage for such
patients strikes us as reckless in the extreme and not
warranted by the results.

It is unfortunate that such a book should be needed,
albeit it is a masterly production and one that is thor-
oughly scientific in tone and method ; for its circulation
cannot, of course, be confined to medical readers. On
the contrary, by translation the seven editions of the
original are likely to be speedily duplicated and given
a greater notoriety, owing to the pornographic interest
on the part of the public.

Bypnotitm, Metmeritm and the New WUchcrafl. By
Krnest Uabt, formerly Surgeon to West London
Hospital, etc. Pp. 182. New York: D. Appleton &
Co. 1893.

The publication in book form of the papers on this
subject by Mr. Hart which have appeared recently in
the British MediealJoumal and the Nineteenth Century
is most welcome. They will do a good service in
making easy of access a remarkably clear, concise and
forcible exposition of much of the folly and humbug

connected with hypnotism, mesmerism, "animal mag-
netism," objects of psychical research, and "the
occult" generally ; although the author, in his impa-
tience with credulity and imposture, is often unnecessa-
rily severe in his strictures, and at times far too sweep-
ing in his statements. It is refreshing to read such a
fearless attack upon the hypnotic craze of to-day — we
had almost said, yesterday. The subjection of research
into psychical phenomena of all sorts to rigid control
tests is not only here insisted upon, but has been prac-
tised also by the author to some purpose, notably in his
exposure at great pains of the theatrical " hypnotic "
performances in the wards of Dr. Lays at the Udpital
de la Cbarite. The " psychological researchers " are
also not spared, and telepathy is shown to have " no
more substantial foundation than mesmeric trance or
clairvoyance, although the name sounds better to
modern ears." The abuse and evil effects of hypnotism
are graphically and convincingly set forth, and his
estimate of its therapeutic value placed none too high.
In fact, the limit he puts to its use is somewhat too
restricted, but the author's experience and the extent
of the folly will explain and excuse all.

Anatomy, Deteriptive and Surgical. By Henrt
Grat, F.R.S. A new American, from the thir-
, teenth English edition. Edited by T. Pickering
Pick, Surgeon to St. George Hospital, etc. Phil-
adelphia : Lea Brothers & Co. 1893.
This new edition is a decided improvement over all
preceding ones. Gray's Anatomy has always been a
favorite with students, and deservedly so, though
(trecise anatomists have at times found a good deal to
criticise. It has held itself rather aloof from modern
methods of instruction of Continental origin. It has
been very English. A change has been manifest in
recent editions. The present one shows it more than
ever. The book has become more comprehensive, but
without the sacrifice of its characteristic merits. Of
late American editions have had as an appendix
Holden's " Landmarks," edited by Dr. Keen. This
is now done away with. Its place is more than taken
by the sections on surface form and on surgical anat-
omy scattered throughout the book. Many new and
excellent illustrations have been added. t. d.

The Diteatet of the Mode Organs of Generation. By

W. H. A. Jacobson, M.Cb., Oxon., F.R.C.S.

Philadelphia : P. Blakiston, Son & Co. 1893.

In this work the author maintains the deservedly
high place which he has won in medical literature.

The volume covers satisfactorily and thoroughly the
ground indicated by its title — with the exception of
some conditions of the prostate — to which short-
coming the writer himself draws attention in his preface.

The subject is divided into five parts, which treat
respectively of the diseases of the testicle, of the cord,
of the scrotum, of the vesicular seminales and of the
penis.

In the first division, that part which relates to mis-
placements of the testis and the complications in con-
nection therewith, presents in a concise and interesting
manuer, much useful knowledge of a kind hitherto not
readily accessible.

Chapter VI (of Part I), which relates to tubercular
disease of the testis and its appendages, is perhaps the
most important contribution this volume contains. In
it the author discusses the theories regarding the

Digitized by

Google

20

BOSTON MEDICAL AND SVBGJCAL JOURNAL.

[Janpart 4, 1894.

chanuels by which infection of the epididymis and
testis occurg ; also the vexed question as to whether
the disease is primary in these organs or secondary to
tuberculoBis in some other portion of the genito-arinary
tract — his conclusion, with which we are in accord,
being, that the epididymis is the most frequent primary
seat of the disease. He also considers that the bacilli
are carried principally by the blood-vessels, and in a
less degree through the lymph-channels.

A short rStume is given of the evidence with respect
to the occurrence of tuberculous infection by means of
sexual contact.

The rare manifestation of the disease in the form of
" galloping testicular tuberculosis " is well described.

in regard to the surgical treatment of the disease in
these organs, the author strongly advocates incision —
thorough curetting and antiseptic cleansing of all tu-
bercular swellings of epididymis and testis — at any
rate, and leans toward the side of the more radical
operations by early excision of the affected parts,
while recognizing that this is still an open question.

While writing of "Atonic Impotence," the author
indorses the view of Professor Gross, to the effect that
urethral stricture is a frequent result of masturbation.
In this conclusion we do not concur, never having been
able to satisfy ourselves of its truth during a long period
of careful investigation with reference to this point.

We are unable to give a more extended account of
the many excellent and valuable matters to be found
in this book, but must be content to add, in concluding
this notice, a word of praise for the admirable manner
in which the work is illustrated as well as written, and
to the fair-minded way in which the author has set
forth the various theories bearing upon the more im-
portant parts of the subjects presented, while at the
same time he has avoided ihat error into which the
judicial mind sometimes falls, namely, that of lack of
perspection, or of proportion with relation to their
importance, of the matters presented.

The publishers have produced the book in a con-
venient size. The type is excellent, as are the other
details for which they are responsible.

The work has the useful quality of not being beyond
the reach of uoder-graduate students, while, at the
same time, it meets the needs of the practising physi-
cian, and we take pleasure in cordially recommending
it to the attention of both.

The Reerudetcenee of Leprotff, and its Cautation. A
popular treatise. By Wm. Tebb. London, 1893.
In this book of 412 pages, the writer, a well-known
lay opponent of the practice of vaccination, attempts
to show that the spread of leprosy is owing, to a great
and unrecognized degree, to compulsory arm-to-arm
vaccination as a preventive of small-pox. It is simply
an amplification, after much travel and considerable
study, of a previous brochure on the same subject that
has already been noticed in these columns. Mr. Tebb
has visited the West Indies, British Guiana, Vene-
zuela, Norway, California, the Sandwich Islands, Cey-
lon, Egypt, New Zealand, Cape Colony and Natal^
together with most of the colonies in Australia; and
his book is mainly composed of quotations from jonr-
nals and medical writings, together with an account of
some conversations with superintendents of asylums
and other people whom he met in his travels. The
mass of evidence and oases collected is very large, and,
if carefully sifted, may prove of value to the student

of this disease; but it cannot be said that the writer
has gone very far towards proving his case. It is not
for an instant to be doubted that both syphilis and
leprosy have been inoculated by vaccination, and that
the greatest care should always be taken to avoid im-
purity of lymph ; but that this procedure is in great
measure responsible for the existence of leprosy no
sufficient proof is given. Many of the cases cited in
favor of this view are loosely reported, and are utterly
inadmissible as evidence on either side. Some few of •
the cases point to vaccination as a probable cause.
The mass of statistics and material is introduced witb-
.ont order or critical comment, and little attempt is
made to discriminate between skilled and ignorant ob-
servers. The book bears the mark of one little versed
in scientific research, and is colored throughout by the
writer's obstinate antagonism to one of the greatest
boons ever conferred upon humanity. The writer's
honesty and zeal, however, are certainly to be re-
spected, and the amount of time spent in travelling in
search of information must have been very great.
The book will not have been written in vain if it
causes a greater degree of caution to be taken in com-
munities (as the Sandwich Islands, for instance) where
it seems probable that careless and improper vaccina-
tion has been the source of disseminating disease ; but
the attainment of the writer's aim, namely, the utter
suppression of vaccination and the abolition of all at-
tempts at experimental therapeutics in leprosy, can
only be regarded in the light of a great calamity.

An Introduction to the Stud]/ of Diuasea of the Skin.
By P. H. Pie-Smith, M.D., F.B.S. Philadel-
phia : Lea Brothers. 1893.

This book has been compiled from the chapters on
diseases of the skin which were written in 1886 to
complete the late Dr. Hilton Fagge's work on medi-
cine, together with several papers that have appeared
in "Guy's Hospital Reports" and the "Pathological
or Clinical Transactions." The author has had abun-
dant opportunities for observing skin diseases, having
been in charge of the department for cutaneous dis-
eases iu Guy's Hospital for a series of years, and has
" tried to make his description an epitome of what he
has himself observed." The book is interesting, as
setting forth the views and experience of a leading
London practitioner who has devoted considerable
time to the study of dermatology.

The Medical Student' t Manual of Ohetnittty. By B.
A. WiTTHADS, A.M., M.D., Professor of Chemistry
and Physics in the University of the City of New
York, etc. Fourth edition. New York : William
Wood & Co. 1893.

A book which is so favorably known as this one is
does not need extended comment. In the present edi-
tion no important changes have been made in that part
of the work which is devoted to inorganic chemistry.
The part treating of the chemistry of the carbon com-
pounds has been extended by about twenty pages, and
the text iu great part rewritten. The organic com-
pounds are classified, as in previous editions, according
to their constitution so far as is known, and those alka-
loids whose molecular structure has been completely or
partially determined, occupy in the present edition
their proper places in the classification. We consider
the book one of the best text-books on chemistry for
students of medicine.

Digitized by

Google

Vol. CZXX No. 1.]

BOSTON MEDICAL AUD SURGICAL JOVRSAL.

21

THE BOSTON

laeOical ano Surgical Sjoumal*

Thursday. January 4, 1894.

A Jttumml <tftl»dMme, Bwrterii,and AUied Soienea.publiihed <U
Botton, weeklji, by tht u»der$ig*«d.

SuBBCsiPTioH TxRM g : 95.00 per year, in advanee, poetage paid,
for the United State; Canada and Mexico ; 90.66 per year for all for-
ng* oovntrie* ttUmging to the Pottal Uruon.

Alt coiammieation* for the Editor, and all bookt for revievi, ihotUd
be addretied to the Jtditoro/the Boeton Medical and Surgical Journal,
S83 fTaehington Street, Boeton.

All letteri eoniaining buiineti conammicatiom, or referring to the
publication, eubieriplion, or advertiting department (tf tMe Journal,
ehould be addreeted to the undereigned.

Bemittanaee should be made by money-order, draft or regietered
letter, pay able to

DAMKELL A UPHAH,
283 WASHmoTOiT Stkkbt, Bostok, Mxbb.

VACCINATION AND REVACCINATION.

The rarity of small-pox in Massachusetts daring the
past dozen years or more has been such that scarcely
one in ten of the physicians now in active practice has
ever seen a case of the disease. Hence the difSculty
of diagnosis which very frequently happens when cases
do occur, or when other diseases simulating small-pox
are met with in the practice of young physicians
who have entered upon the duties of their profession
since the epidemic of 187^78. There is no reason to
suppose that the remarkable immunity which our pop-
ulation has had the good fortune to enjoy for several
years will be indefinitely prolonged, since an unvacci-
nated population, consisting both of immigrants and of
nnvaccinated infants born since the last epidemic, is
likely to furnish the combustible material for a future
epidemic, whenever the disease gains a foothold among
us.

Fortunately, we have a sure preventive, in vaccina-
tion and revaccination, when thoroughly and properly
performed under the supervision of an intelligent phy-
sician or sanitary officer. With abundant resources in
the shape of plentiful supplies of lymph, obtained by
calf-vaccination, there can be no excuse on the part of
local sanitary authorities for negl^ting this important
preventive measure.

The present outbreak is by no means confined to
Boston. Emigrant ships arriving at United Slates
sea-ports have brought small-pox to this country many
times during 1893, from crowded cities where this dis-
ease is almost constantly occurring in Europe. Out-
breaks have occurred in many Western cities during
the year ; and with the presen't facilities of intercourse
by rail and by steamer, the spread of small-pox is ren-
dered much more certain than' it was in earlier times.
A recent summary of the deaths from small-pox in
Massachusetts daring the past twenty years, shows
that, out of the 161 towns in which these deaths oc-
curred (mostly in 1872-7S) only eight were not directly
on some line of railway communication at the time
when the death ooonrred.

During the year just closed, there have been 678
cases of small-pox in the city of Reading, Pa., a city
having scarcely one-eighth as many inhabitants as
Boston.

While it is true that single cases are liable to occur
anywhere, as in the case of nnvaccinated immigrants,
it is also trae that extensive and widespread outbreaks
following such first cases, can only occur in places
where the preventive measures of vaccination, notifica-
tion, isolation and disinfection are neglected.

The importance of revaccination is also apt to be
underestimated ; but the history of those countries
where revaccination has been thoroughly enforced
places the value of this measure beyond a doubt. An
illustration of the value of revaccination is shown in
the case of Germany since the law of 1874 went into
operation. By the provisions of this law every infant
must be vaccinated, and in addition every scholar in
public and in private schools must be revaccinated at
the age of twelve years. The provisions of this law
have been so thoroughly carried out that, as a conse-
quence, Germany has enjoyed an immunity from small-
pox far exceeding that of any of the contiguous coun-
tries, particularly Austria, Russia and France.

In support of this statement the following figures
are presented from Dr. Sykes's " Public Health Prob-
lems," London :

MOBTALITV FBOJI SXALL-POX PKK 100,000 LiVXSO.

Pruas'n
Army.

Aiutri'D
Arinj.

AustriK.

Prunia.

BerllD.

London.

Viaona.

1S70

33.32

17.28

35.18

17.52

22.37

30.ao

46.71

l»7t

27.67

40.1

30.30

243.21

63-J.56

242.16

74.90

1872

5.65

101.4

189.09

2B2.37

182.61

&3.K0

636.98

1873

2.68

108.0

»^2.1.36

35.66

11.21

3.55

228.60

1874

0J3

67.0

178.18

9.52

2.47

1.66

136.86

ReriuMi

1 nation

oompii

Isory.

1875

0.0

21 Jl

87.73

3.60

6.19

1..12

IISJSO

1*7«

0.0

1U.4

39.28

3.44

l.«t

20.80

167.80

187T

00

•aji

16.9t

0.34

0.40

70.98

84.01

1878

0.0

15.4

6.57

0.71

0.78

88.81

75.91

1879

0.0

22.T

50.88

1.26

0.75

12.13

46.91

IK8U

0.0

64.27

2.60

0.81

12.50

TS.52

1881

0.0

78.t0

3.62

4.74

61.91

123.86

I 82

0.0

3.64

0.13

11.07

10<.2>

I8<<3

0.0

4.00

0.33

3.00

9.6

These figures show that Prussia, although exposed
to constant danger from small-pox, upon its Russian
and Austrian borders, has been enabled to reduce its
8mall-pox mortality to exceedingly low terms by means
of vaccination and revaccination ; and the Prussian
army, which constitutes a very large portion of the
population, has, with the exception of a single death
in 1885, been absolutely exempt from deaths from
small-pox.

The effects of vaccination and revaccination upon
the attack-rate, and the death-rate from small-pox,
during an epidemic in a large city, are well illustrated
by the admirable report of Dr. Barry upon the epi-
demic of 1887-88 in the city of Sheffield, England.
The following were the attack- and death-rates per
1,000 of the population at each of the two age periods,
children under ten years and persons over ten years of
agei

Digitized by

Google

22

BOSTON MEDICAL A2fD SVSGICAL JVlJiiAl.

[Jaucabt a, 1894.

OnM Twice

^ UiiTaoolnated. Vsootuated. Tfteclnated.

' Under ten, 101 S.

Over ten, M 1>.

Under ten,
Oyer ten

44
61

0.09
I.

]

Attaek-Bate.

0.08

Death-Rate.

These dgares may be sammarized as follows : " The
children. Taccioated had, as compared with the unvac-
cinated, a 20-fold immanity from attack, and a 480-
fold secaritj against death from small-pox; the per-
sons over ten years of age, once vaccinated, had a
5-fold immunity against attack, and a 51-foId secnrity
against death; and the twice vaccinated, a 31-fold im-
manity from attack, and a 640-fold secnrity against
death."

In commenting further upon the significance of these
figures, which are the result of a most careful house-to-
house canvass in a city of about 200,000 inhabitants.
Dr. Sykes says :

"We may conclude, therefore, that natural insus-
ceptibility to small-pox practically does not exist, that
the contagion is so far-reaching, so readily attacks in-
discriminately the unprotected, and is so fatal, that in
a community, entirely unprotected, either by previous
small-pox, inoculation or vaccination, an epidemic
causes an enormous mortality ; that the disease leaves
the survivors disfigured, maimed or weakly, but pro-
tected more or less against future attacks, so that the
disease continues to fall only upon the unprotected,
namely, the newly born and infant population, the few
survivors of which remain protected for a number of
years.

" Vaccination protects the infant and the young pop-
ulation in proportion to the number vaccinated, aud
the quality and quantity of the vaccination marks ; but
the protective influence of vaccination fades sooner
than that of an attack of the disease, so that in later
years susceptibility to small-pox returns. Revaccina-
Uon compensates for the less duration of immunity, and
practically brings artificial immunity to a protective
level equal to a previous attack of the disease, so that
periodical revaccination almost entirely averts small-
pox."

The first law in Massachusetts in regard to small-
pox was enacted in 1809, and provided for the inocula-
tion of the inhabitants with the cow-pox, under the
direction of the town boards of health, or of a committee
chosen for the purpose. The present law provides
that parents and guardians shall cause their children
and wards to be vaccinated before they attain the age
of two years, and revaccinated whenever the town au-
thorities shall, after five years from the last vacci-
nation, require it. The town authorities shall also re-
quire and enforce the vaccination and revaccination of
all inhabitants when the public health requires it The
penalty for neglecting to comply with these provisions
is five dollars. Towns shall furnish means for vacci-
nation to those who cannot pay for it. Incorporated
manufacturing companies, and superintendents of public
institutions, are required to see that the inmates of
such institutions are vaccinated. Towns may make
further provisions for vaccination, under the direction

of the board of health or of a committee chosen for
the purpose. School committees are required to ex-
clude unvaccinated children from the public schools.

Practically much of this law is a dead letter. The
last clause is the most efficient part of the law. As a
matter of fact, there is to-day a large unprotected
population in Massachusetts, made up partly of unvac-
cinated immigrants and partly of unvaccinated native-
born Americans. The same conditions obtain prob-
ably to a greater extent in other States.

The degree of protection afforded by a primary and
secondary vaccination may be estimated in some meas-
ure by the size and character of the scars. It is im-
possible to formulate a positive rule as to the period of
protection acquired by any given individual. Revac-
cination, if properly done upon a subject neither very
old nor very feeble, is a small penalty to pay for im-
munity. If it does not take, the individual has the
assurance of probable immunity and no harm u done ;
\i it does take, there is at once the evidence of its ne-
cessity and the assurance of reacquired safety. Al-
though there is now no epidemic of small-pox in any
part of New England, the present conditions are
such and so widespread as to indicate to thoughtful
aud intelligent people the desirability of vaccination
and revaccination.

NAIL BITING.

A French scientist and surgeon, Berillon, has just
issued a brochure on "Finger-Nail Biting" (onyco-
phagie), containing the results of a series of observa-
tions in the public aud private schools of France and
extending through a period of more than seven years.

His observations lead him to pronounce the habit
far more widespread and pernicious than would be
imagined, and force him to conclude that, if not a dis-
ease itself, it is an unfailing mark of incipient degener-
ation of the nervous system, which, if unrecognized,
may be productive of the most evil results.

In a mixed school of the Department of I'Yonne,
the report showed the following results :

TveWe to fourteen ;eara.
Thirteen to fifteen years.
Fifteen to seventeen jean, .

From twelve to fourteen seems from this to be the
age most susceptible to the habit. A like experiment
with girls shows them to be even more susoeptible at
this age.

Number

Nail

Biten.

. 13

T

. 18

«

. 18

8

Number
Examined.

Ten to thirteen jrears 80

Twelve to fifteen years 7B

Fifteen to sixteen ;ean, . . . . B2
Sixteen to serenteen years, ... 10

Nail
Bttars.
27
21
18
S

In all the schools where the children have been the
objects of careful and attentive observation, the reports
have agreed in pronouncing that pupils observed to
have the habit are universally the poorest students;
that if boys, they are inclined to effeminacy, and if
girls, to slackness. In many, there are marked defects
of character and less sustained attention.

Digitized by

Google

Vol. CXXX, No. 1.]

BOSTOy MEDICAL AND SURGICAL JOURNAL.

23

Berillon's careful ioquiriea elicit the fact that nail
biting is not to be looked at merely as a child's habit,
nnpleasant and punishable, but as a direct and positive
indication of hereditary physical degeneration. So
naarked is this, that he has found no families in which
nail biting has been olwerved to be general whosb head
has not been either ao alcoholic, an unbridled gambler,
a conrulsive, a feeble-minded person, a lunatic, a
criminal or a consumptive.

In such families the hereditary degeneration is to be
observed, anhappily, in more than nail biting. Often
the heads of such children present species of deforma-
tion, snch as microcephalus, bony crests and protuber-
ances on different parts of the head, while the face re-
veals crossed eyes, near-sightedness, irregular teeth or
displacement of the features. At this point, reversing
the inquiry, Berillon gave his attention to a large class
of nervous patients in the Paris hospitals and found
that a considerable proportion of the children of these
show the habit of nail biting, with other signs of physi-
cal degeneration.

Berillon thinks his experiments prove that nail biting
as a habit in children has its source deeper than mere
imitation or childish idiosyncrasy. He regards it as
no wilful habit to be cured by ordinary petty punish-
ment, but an indication of an incipient degeneration of
the nervous system, which, once observed, may be
treated understandingly at its very beginning. The
outward habit, if it does not disappear when the cause
is removed, will yield to ordinary treatment.

While M. Berillon's statistics are interesting, we do
not feel that such unhappy conclusions are wholly
warranted from his cases. School-children, especially
girls, eat chalk and slate-pencils, and pass at a certain
age through a condition which might be called " philo-
pickle-lime-phagia"; and we think that a child may
bite its nails without danger of passing to a state of
idiocy. On the other hand, we can recall A>me nail
biters who had been blessed with very intelligent and

estimable progenitors.

♦

CONTAGIOUS DISEASES IN PUBLIC SCHOOLS.

Db. Mokkau Mobbis has made a report to the
Board of Health of the City of New York in regard
to the spread of diphtheria and other contagions dis-
eases among the children in the public schools. He
found that it was the custom in all the schools that he
▼isited for the scholars to use slates and pencils in
common, these articles being kept in baskets from
which they help themselves indiscriminately. The habit
children have of putting their pencils in their mouths
and of cleaning their slates with saliva is well-known,
and the reporter suggests, as has been before suggested,
that disease is frequently conveyed by this agency. It
is therefore recommended that the ule of slates be dis-
continned altogether, that all books which have been
used by sick children should be destroyed, and that
school-books shonid be covered with hard paper instead
of muslin, as is now done, on account of the liability of
the latter to retain disease germs.

MEDICAL NOTES.

A Phtsician in thb Italian Cabinet. — Dr.
Baccelli, Professor of Clinical Medicine at the Uni>
versity in Rome, and President of the Royal Academy
of Medicine, has been made Minister of Public In-
struction in the new Italian Cabinet.

Death at an Advanced Age. — James Morris,
a negro, died at Lyons, N. Y., last week at the age of
one hundred and twenty-one years. He was born in
slavery in Delaware, and his age was authenticated
by the family records. It is not stated whether he
ever saw Greorge Washington.

A Vindication of Darwinism. — A man was re-
cently arrested in Central Park, New York, for assault-
ing a monkey in one of the cages because it made up
faces at him.

An Oppobtonitt for a Pbtsician. — The Mtdi-
eai New$ prints the following advertisement, which
appeared in the Philadelphia Prtu of December 11,
1893, "as another illustration of the mercantile de-
mands for and uses of physicians " :

Wantbd. — A PhTSioIan to travel with medicine company to
lecture ; experience not necessary : prefer one who can play or-
gan; a steady, pleasant and lacrative position offered. Ad-
dress, etc.

Tas Iowa Board of Medical Exahinerb. —
This board has ordered that on and after July 4, 1898,
no medical school shall be considered as of " good
standing," for the purposes of registration of its alumni
within the State, unless it has a four-course curriculum.
Each course of attendance upon medical lectures must
be not less than six months long, but two courses in
the same year will not be counted for two full courses.

A Peasant's Idea of the Cholera. — Two
Russian peasants in Tomsk were recently sentenced
to imprisonment for the murder of a woman whom
they had " taken for the cholera." A quarantine had
been established id their town against the cholera in
the neighborhood. On the morning of the murder the
peasant woman had come to town, but was turned
back at the outpost. Soon afterwards the two men
left the village ; and in a short time gaushota were
heard near by. One of the men on trial said later in
the day to his neighbors : " Pray to God. We have
killed the cholera: It is dressed like a woman above the
waist and like a man below." The men were convicted,
and sent to jail for three years.

Medical Mabttbs. — Commenting on the deaths
of medical men from diphtheria recently recorded in
the BritUh Medical Joumcd, the St. P«ter$burger metU-
cinische Wochtntchrift says such occurrences are by
no means rare in Russia. Within the last few weeks
two practitioners of Sengilei iu the Simbirsk Govern-
ment, MM. Raddiminski and Chrenow, have died of
diphtheria contracted from patients under their care.
Two young Parisian physicians have died this autumn
from diphtheria taken from a patient.

Lookino after Babbkbs and Hairdressers.
— The Government of the Republic of Colombia in

Digitized by

Google

24

BOSTON MEDICAL ASD SVB610AL JOVBSAL. [Jahcast 4, 1894.

▼lev of the possibility of oontagiona diseaaes, such as
ringworm, favns and syphilis, being transmitted by
combs, brashes, etc., has passed an enactment making
it compulsory for all barbers and hairdressers to keep
the instruments of their art clean, and to disinfect
them every time they have been used.

BOSTON AND NEW ENGLAND.

Small-Pox in Boston. — Only one new case of
small-pox has occurred the last week. The patient is
a man living in the same tenement-bouse in which the
first group of cases occurred at the South End. There
are now fifteen patients in the hospitaL

A New Emkroenot Hospital in Boston. — A
new Emergency Hospital, to cost about a hundred
thousand dollars, is to be built by the friends and trns
tees of Tufta College; and the clinical advantages
are to be given wholly and exclasively to the students
of the TufU Medical School.

Illegal Use of Pbabhact Certificates. — The
first cases under the new law of last June by which the
State Board of Registration has power to suspend any
person's registration as a pharmacist, and his certificate,
for such term as may be deemed fitting, and in flagrant
cases to revoke the certificate, occurred last week. All
three holders were charged with letting out their cer-
tificates to unqualified persons. The charges were
proven, and one certificate was revoked and the other
two suspended.

Report of the Children's Hospital. — The
report of the managers of the Children's Hospital in
Boston for the year 1893 says : " The year, just closed,
' has been an unusually busy one in all the departments
and the results have been most successful and satisfac-
tory. At the beginning of the year there were in the
wards 41 patients; treated during the year, 295 boys
and 287 girla. In addition, 2,071 new cases have been
cared for in the out-patient department. Most of the
patients admitted to the wards have been free patients."
The Board of Officers elected is the aame as laat -year
with the exception of Mr. Oliver Ames 2d, who suc-
ceeds to his father's place.

The School fob the Blind. — The aixty-aecond
aoDual report of the truatees of the Perkins Institute
and Massachusetts School for the Blind shows that
there are now 237 blind persons connected with the
establishment. The financial record shows a balance
of $3,248.

Free Vaccination in Boston. — The appropria-
tion of $5,000 for free vaccination has been exhausted ;
but the Mayor, in view of the satisfactory working of
the public inoculation, has authorized the continuance
of the work, and has told the Board of Health that the
money expended will be granted when the work is
completed. The number of persons vaccinated in-
creased each day laat week from 1,000 on the first
Monday to over 4,000 on Saturday, a total of over
S0,000 for the ve«ki

SxALL-Pox Precautions in CAMBBioaB.— The
Board of Health of Cambridge has opened public sta-
tions for free vaccination, and has secured from the
City Council the sum of $5,000 with which to build a
hospital for contagious diseases. During the cholera
scare a year ago the Board petitioned the City Council
for $4,500 for thia purpoae, but the appropriation waa
not given.

Influenza at Sea. — One of the steamera from
Boston to New York reports that on her last voyage
ahe was signalled from the Vineyard Sound Lightship,
that most of the crew were sick with the grip, and in
need of medical attendance. A steamer was sent from
New Bedford with a physician.

NEW TORE.

Influenza. — On December 18th it was reported
that there were more than five hundred cases of grip
at Dunkirk, N. Y., and three deaths had occurred.

Soft Coal. — For some time past complaints have
been made of the increasing use of soft coal by various
manufacturing establishments in the city, by reason of
which the atmosphere is contaminated by bituminous
smoke; and the Board of Health has now issued
peremptory orders that the nuisance shall be abated.

A Bullet in the Skull for Sixteen Months.

— A case of unusual interest has recently occurred at
St. Luke'a Hospital. Oo November 2lBt a male pa-
tient, thirty-one years of age, was admitted suffering
from severe spinal trouble, who stated that fifteen
mouths before he had shot himself in the back of the
neck with a piatol. On December 20th be died, and
the bullet was found imbedded in the base of the akall.
The cause of death was found to be preaaare on the
spinal-cord from vertebral dislocation, together with
spinal meningitis, which were produced by the ball,
which had remained in the body for sixteen months.

A Lion on an Opebatino-Tablb. — At the New
York College of Veterinary Surgeons, on December
29th, the operation of setting and dressing the fract-
ured femur of a lion from one of the down-town
museums waa aucceasfnlly accomplished. The lion
waa kept quiet by a hypodermic injection of morphine.

Death fboic a Spider's Bite. — While engaged
in helping to put up the Christmas decorations in the
Episcopal Church at Sparkhill, on the Hudson, a
young woman was bitten on the cheek by a spider which
had been brought in on the greens, and in a few days
death reaulted from septicaemia.

Appointments to the State Board of Health.

— Governor Flower has appointed as members of the
State Board of Health Dr. John Edwards, of Glovers-
ville, to succeedcDr. Dawes, of Saugerties, and Dr.
Murray M. Adams, of Watertown, in the place of
Professor Perkins.

Mortalitt. — During the week ending Decenaber
23d, the number of deaths reported in the city waa
818, whieh is an in«reasa of 43 over the mortality of

Digitized by

Google

Vol. CXXX, No. 1.] BOSTON MBDIOAL AND SUSGIOAL JOVSNAL.

25

tbe previous week, and 11 above the average for tbe
corresponding weeks of tlie past five years, and which
represents an annual death-rate of 22.19 per thousand
of the estimated population. During the week there
were 166 deaths from pneumonia, an increase of 38,
and six deaths from influenza, against three during the
week ending December 16th. During the week end-
ing December SOth the number of deaths from in-
fluenza increased to 14, but the deaths from pneumonia
showed a decrease of 22. The total number of deaths
for the week was 824, which is 21 less than the
average of the corresponding weeks during the past
five years. This represents an annual death-rate of
22.34, against 22.91 for the same week since 1886.
There were 637 cases and 88 deaths reported from
contagious diseases, against 599 cases and 78 deaths in
the week ending December 23d.

The Vital Statispios fob 1893. — During the
year 1883 there were reported 51,516 births, 16,144
marriages and 44,370 deaths in the city. In 1892
the figures were, respectively, 49,447, 16,001 and 44,-
329. The death-rate for 1893, estimated on a popu-
lation of 1,827,396, was 23.46, which is the smallest
ever recorded ; the lowest previous death-rate having
been 23.65, in the year 1877. The number of deaths
from some of the principal diseases in 1893 were as
follows : influenza, 220 (495 in 1892) ; small-pox,
100; measles, 887; scarlet fever, 531; diphtheria,'
1,962; whooping-cough, 340; typhoid fever, 380;
typhus fever, 201 ; diarrhoea! diseases, 8,314; cardiac
disease, 2,376; bronchitis, 1,569; pneumonia, 6,476
(635 more than in 1892); consumption, 5,101 (5,033
in 1892) ; sun-stroke, 43 (against 820 in 1892).

Appropriation fob Charities and Correction.

— For the year 1894, the Board of Estimate and
Apportionment has allowed $2,295,675 and $425,080
for the expenses of the Departments of Charities and
Correction, For 1893, the appropriations were, re-
spectively, $2,223,425 and $470,23e.

Hospital Satdbdat and Sunday Association.

— As December SOth and 31st were both snowy days,
it is to be feared that the annual collection of the Hos-
pital Saturday and Sunday Association will prove
smaller than usual this year. In its appeal to the
public for liberal contributions for the hospitals the
Association states that it has been found that, through
the obliteration of old methods of individual competi-
tion by the establishment of large corporations and
trusts in modern times, the income of rich charitable
institutions as are supported by the individual gifts of
tbe benevolent has been seriously affected.

Report of the State Board or Health. —
The bulletin of the State Board of Health for tbe
mouth of November, issued December SOth, siiows
that the reported mortality has further decreased from
the low daily average of 290 in October to one of 281,
which is the same as that of November, 1892. Tliin
is nuiformly the healthiest month in the State of New
Torki the number of deaths per day being less during

November by 25 than the daily average for the past
eight years. Compared with November, 1892, the
zymotic mortality, and also the infant mortality, is
lower ; both are also lower than during the month of
October. Typhoid fever caused the same number of
deaths as in November, 1892, and 75 fewer deaths
than in October. Scarlet fever continues, with little
change, to be less prevalent than last year. There is
an increase in measles since October, chiefly in New
York City. Diphtheria caused about the same num-
ber of deaths as in last November. Tbe death-rate
for the month from all causes is 15.35, against 15.83
in October.

THE CHANGES IN THE PHARMACOPEIA.

The new pharmacopoeia of 1890 became official
this week. For the convenience of our readers we
give a list of tbe new remedies which are now official
as well as of those which are no longer recognized.
Certain changes in official nomenclature are important
for correct usage in the future. There are eighty-
eight new articles, and ninety have been omitted.

The newly-adopted articles are the following :

Ac«taDiUduni, acidam hypophospborosam dilutam, aoidam
stearicum, adeps lanae hydrosus, alcohol absolatam, alcohol
deodoratam, aloe barbadensis, alolnum, aqua anrantli florum
(dilated), aqua chloroformi, aqua hydrogenii diozidi, aqua rose
(diluted), aapidoaperma, barii dioxidum, caffeina citrata, cat-
leioa citrata e£Ferve8ceo8, calcii sulphas exsiccatua, clnnamomaiu
saigooicum, cocainee hydrocbloraa, convallaria, elastica, elixir
aromaticum, elixir phosphor!, eriodictyon, eucalyptol, eztractum
apocyni fiuidum, extractum asclepiadis fluidum, extractum
aspidosperraatis fluidum, extractum cimicifuges, extractum con-
vallarise flaidnm, extractum eriodictyl fluidum, extractum
jalapiB, extractum lappse fluidum, extractum menispermi
fluidum, bxtractum phytolaccte fluidum, extractum rhamni
purshiaiiEB fluidum, extractum scopurii fluidum, extractum nvas
arsi, extractum viburn! opuli fluidum, ferri et quiniDce citras
solubllis, glyceritum acidi carbolici, glyceritum acidl taunici,
glyceritum Tmroglyceriui, glyceritum hydrastis, hydrastininie
hydrochloras, hyoscinffi hydrobromas, hyoscyamiiiie bydro-
bromas, lithii citras efferveacens, meuthol, methyl galicylas,
□aphtalinum, napbthol, oleatum zinci, oleam betuln yolatile,
oleum cadinum, oleum terebiothinffi rectificatum, pancreatinam,
paraldebydum, pepslnum, petrolatum liquidom, petrolatum
spissum, pfiysoatigminaa sulphas, pilule catbarticse vegetabileii,
pilulte ferri carbonatis, potaasii citras eServesceus, pryogallol,
resorcinum, rhamnus purshiana, salol, sodii aitrls, sparteiDEB
sulphas, spiritus am^gdalee amarse.gpiritusauraQtii compositus,
spiritus gloDoini, spiritus phosphori, stroutii bromidum, strontii
iodidum, strontii lactas, stropbanthus, suppositoria glycerini,
terebenum, terpini hydras, tinctur.i lactncarii, tincturaquillajaB,
tinctura stropbanthi, trochisci sautoalui, Tiburnum opulus, zea.

The articles dismissed are :

Abstractum aconiti, abstracfum belladonna, abstractum
conil, abstractum digitalis, abstractum hyoscyami, abstractum
ignatisB, abstractum jalapie, abstractum nucis vomicse, abstrac-
tum podophylli, abstractum seneg», abstractum valerinnte,
acetum lobeliie, acetuni sanguinariie, aether, ammonii phosphas,
ammonii sulphas, amylum ioiatum, aurantii flores, azederacb,
cannabis Americana, ceratum extraoti cantharidis, ceratum
sabinns, charta cantharidis, chinoidiiium, chloroformum venate,
cbincona flava, cornus, cupri acetas. cydonium, elixir aurantii,
emplastrum ammoniaci, emplastrum afuifoelidai, emplastrum
galbani, emphistrnm picis canadensis, extractum cornus fluidum,
extractum lactncarii fluidum, extractnm maltl, extractum
mezerei. fel bovig inspisgatuni, ferri oxalas, galbanum, gaul-
tlieria, gutta-percba, hydrargyri sulphidum rubruni, ignatia,
iiifusum brayern, juniperus, lavandula, linimentum canthar-
idis, linlmentum plumbi subacetatis, liquor ferri et quiniDSe
citratis, liquor gatta-perchse, liquor pepsini, magnesii sulpbls,
magnolia, maltum, mistura m^nesffi et asafoetidn. mistura
potassii citratis, mucilago cydonii, oleum lavandula, oleum
rutai olsnni saoeloii olsttm rslsrlanisi orlgabnm, plllnlis terrl

Digitized by

Google

26

BOSTON MEDWAL AND SURGWAL JOURNAL.

fjAKiTABr 4, 1894.

oomposUse, pillalse galbani oompositte, piz canadensis, potaisil
snlpbis, potassii tartras, prinos, rosmarlnns, saliz, sodii blcar-
bonas venalis, sodii santoninas, spiritus odoratag, synipos ferri
bromidi, syrupus limonis, thaja, tinctara conii, tinctara ferri
acetatis, tinctara ignatise, trocliisci maf^eslte, trocliisci sodii
■antoninatis, anguentum acidi gallici, anguentam mezerei, nn-
gaentam salpliuris aUcalinom, ustilago, vinam album fortras,
rlDam aloes, Tinum aromaticum, Tinam rbel, yiola tricolor.

CHANQKS IN OrFICIAL LATIN TITLES.
Pbabmacopceia, 1880. Phabmacopoiia, 1890.

Aoldam anenioram

Ather (ortlor

Aloe

Alumlnll hydras

Aluminll tulpliaa

Aqoa aurantii florum

Aqua creasotl

AqnarosB

Arsenil iodidam

Brayera

Chloroformam pnrlfloatam

CluDamomum

CoUodlam eom eantharide

Creasotum

Erythrozylon

Emplastrnm pteii oum oantharlde

Kztraetnm aloes aquosum

Extraotum belladonnae alcohol-

team
Extractum belladonius flaldam

Extractom brayene floldnm
Eztraotnm oonii aloohoUcam
Eztractnm byosoyami alcohol!-

cam
Extractum sarsaparilliB eompoel-

tnm fluldnm
Extractttin stramonil
Eztraetum stramonll flaldam

Extractum Tlboraiauidom

Ferri phoaphas

Ferri pyrophoephas

Ferri sapbas prieelpltatas

Ooasyptom

Hydrargyri lodldnm vlride

Iiiqaor aeldl arsenlost

Liquor araenti et hydrargyri iodldi

Liquor sodii arsenlatls

Magnesil citras grnnulatas

Maoganl oxidun nlgura

Mlstnra ammonlaol

Mistura amygdalie

Mlstura a^afcBtid^e

Mistura chloroforml

MIstara ferri et ammonll aeetatls

Olenm bergamli

Oieam theobromse

Opium denarcotlsatum

Petrolatum

Phytolaocse baoca

Plperina

Qalliaia

Sapo Tirldis

Sodii arsenlas

Tinctara belladonnse

Tinetbra oolohlci

Tinctara opli deodorata

Tinctara saponis Tirldis

Tinctara stramonll

Ttbumum

Acldom arsenceam

jElher

Aloe soeotrina

Aiumlni hydras

Alnminl sulphas

Aquie aurantii floram fortlor

Aqoa creosotl

Aqua roa<e fortlor

Arseni lodidum

Cosso

Chloroformam
I Clnnamomum cassia
\ CinnHmomam zeylanicnm

Collodium cantharldatum

Creosotum

(.'oca

Emplastrnm picis oantharidatnm

Kztraetnm alors

Eztractam belladonnn foUorum
aleobolicnm

Eztraetum beIIsdonc» radicis
flaidum

Extractum eusso fluidum

Extractum oonIi

Eztraetum hyoseyaml

Extractum sarsaparillie flnidam

compositam
Eztracium stramonll seminis
Eztraetum stramonll seminis

fluidum
EztrsciDm Tibnml pranlfolll

fluidum
Ferri pbosphas solnbllis
Ferri pyrophosphas solubllls
Ferri sulphas granulatns
Oossypium puriiioatam
Hydrargyri lodidum flavum
Liquor aeldl arsenosi
Liquor arseni et hydrargrrl
Liquor sodii arsenatis iMldl
Magnesii citras rtferrescens
MaDgaiil dioxidum
Emulsnm ammoniacl
Emnisom amygdalte
Emaisum asar<BtidR<
Emulsum chloroform^
Liquor ferri et ammonll acetatis
Oleum bergamotts
Oleum theobroraatis
Opium deodoratom
( Petrolatum moWe
\ Petrolatum sptssum
PhytolacciB fructus
PIperinam
Quillaja
Sapo mollis
Sodii arsenas

Tinctara belladonnte foliorum
Tinctara eolchld seminis
Tinctara opli deodoratl
Tinctara saponis mollis
Tinctara stramonll seminis
Tibumum prunlfollum

SOME VACCINATION STATISTICS.

Tbe present outbreak of small-pox in Boston would
nndoubtedly cause bat little alarm were it not for the
fstct that the complete freedom from tbe disease for
the last twenty years has resulted in a widespread care-
lessness regarding vaccination. Nearly a whole gen-
eration has grown up since tbe last epidemic, and a
surprisingly large number of these young people have
not been vaccinated. The increase in foreign immi-
gration has been large, and comparatively few of this
class of people seek vaccination under less stimulus
than fear.

Some statistics of vaccination of 5,866 cases recently
published by Mr. Franeis Cadell in the Edinburgh
Medical Journal are of especial interest at this time.

The figures are taken from the reoorda of the Edia-
burgh Dispensary from July, 1886, to December, 1891.
" Iiuuiceptibilittf. — No case occurred in which so
infant was found insusceptible to vaccination by th«
arm-to-arm method. Jtepetition$. — Si sty -one caiei
required the vaccination to be repeated, owing to want
of success on the first occasion. Erytipelat. — Seven
cases of this dangerous accident occurred, and io al-
most every case the dwelling-honse of tbe family was
found to be damp or otherwise unhealthy. SuppMn-
Hon of Lymphatic GUmdt. — This complication of vac-
cination also occurred seven times out of 5,866 cases.
J^hili$. — There was no case of syphilitic infectioD.
Deaths. — Two deaths resulted from the compHcatiou
of vaccination — one from erysipelas, the other from
blood poisoning following the suppuration of a lym-
phatic gland in the axilla. Both deaths took place
about three weeks after the operation. Sevaeeina-
tiotu. — Only 45 revaccinations were performed. Tbe
large proportion of these were on boys between tbe
ages of twelve and fourteen, employed at tbe Greneral
Post-office. Among the laboring classes few came to
the dispensary to be revaccinated, and these only when
compelled by their employers. It would be much to
the advantage of the commanity were revaocination
made compulsory."

BLOOD PRESSURE IN DIPHTHERIA.

The appalling rapidity with which death may folloir
the first clinical evidence of heart paralysis in diphthe-
ria has led Friedemann ' to experiment upon a series
of cases to determine whether sphygmomanometric
measuring of the blood pressure could give the phyai
cian an earlier warning of the cardiac poisoning, espe-
cially in children. Sixty-three cases were studied, in
all the measurements were taken upon tbe radial
artery and when the child was in a recumbent position
and, if possible, during sleep. His results were as
follows: The most favorable prognosis was for such
cases as showed at no time any variation in the press-
ure, more than the slight rise and fall which was noted
in nearly every case, and which, when not over five or
ten millimetres of mercury, was of no moment. Tbe
second class of cases, which, though they ended in re-
covery after a longer or shorter time, gave the physi-
cian much anxiety, were those in which there was a
continued fall of pressure. So long as tbe manometer
did not fall below seventy-five to ninety millimetres of
mercury (according to the t^e and size of the child),
the prognosis was still fair. A lower pressure than
seventy-five millimetres was considered serious and a
pressure of less than sixty-five was almost invariably
cause for a fatal prognosis. Twenty-six cases at one
time or another showed an abnormally low pressure,
seventy millimetres or less, Hg. Fifteen of these
showed a sudden dangerous fall within the first week,
and of these fifteen only two recovered, death in tbe
other cases occurring within seven days. In tbe
remaining twelve cases which first showed a fall of
blood pressure after the first week of illness, five re-
covered and seven died within eight days afterwards.
The general result of the observations was that a regu-
larly-recorded measure of the blood pressure gave the
earliest warning of approaching danger, which often
was not shown by clinical signs until later.

> Jahrbtich. f. KInderhellkande, zzztI, p. SO; CentralUatt f.
med, Wissensebafteo, l8ta, p. iS.

Digitized by

Google

Foi. crxx, No. 1.] sosros medical and surgical journal.

27

"SENDING PATIENTS AWAY FROM HOME."

1517. Stout St., Denver, Col.,
December 27, 189S.
Mb. Editor : — Tn connection with Dr. Knight's paper
la a recent issue (December 21, 1893), I wish to call atten-
tion once more to a matter which needs to be mentioned
freqaentl^. I refer to a habit that some physicians, no
doubt actuated by a mistaken liindness to the patient, have
of stating to the patient about starting for Colorado, that
be bad " a little trouble in his bronchial tubes," or " a little
cbronic bronchitis," or merely "that be is a little run
down." JMany such patients come here, and we all see
them occasionally, with the idea that otiier persons who
come are consumptive, but that in their own cases there is
nothing of serions import. Hence they are likely to rebel
at suggestions that they conform to such rules as are com-
monly given to phthisical patients. Some even refuse to
believe that they have any serions disease, because they
■ay, if such were the case, "my own physician at home
would have told me so, and he said notning of the kind."
Thus I have under my care at this time a young lady with
all the usual signs of phthisis at the right apex, who utterly
refuses to believe that there is anything of sufficient import
in her case to make it necessary for her to stay more than
a few months in Colorado, because her physician in the
East UAA her that she bad only " a little bronchial diffi-
culty," and a visit there for a few months would be all
that was necessary. She has been here for five months,
and is making preparations to return to the Atlantic coast
in April, as sue has gained thirteen pounds and her cough
has nearly ceased. The great probability is that she will
be compelled to return here within a short time after her
retoro.

I have seen many illustrations of this same error during
the past eleven years. Most of the cases from the larger
medical centres, and nearly all from the hospitals and
clinics, which we see in dispensary and hospital work here
are quite aware of the gravity of the disease for which
they have left home, and are prepared to stay here per-
manently if necessary. Certainly private patients should
sot be deceived in a matter of so serious import through
any motives of false delicacy or desire to avoid telling an
unpleasant truth upon the part of the family physician.
It is almost needless to state that it is much easier to treat
those patients who have a full knowledge of the gravity of
the rituation than others. I think the physician, in send-
ing a patient here, should speak plainly of the necessity of
remaining for some time, or even, possibly, permanently.
J have known several consumptives to regain health to
soch a de^ee as to lead them to believe that they could
safely reside in the ii^ast, who, breaking down again, have
returned to Colorado too late to again check the tubercu-
lons process, so that the outcome has been a fatal one.
With proper advice from the family physician in tlie East,
many such patients would see the desirability of remaining
here permanently rather than incur such risks by a return
borne.

A wider dissemination of the points so well treated in
tbe paper of Dr. Knight would certainly be of inestimable
Tiloe to the profession, and, through them, to the public.
I am yours very truly,

J. N. Hall, M.D.

*

ANOTHER FOUR-rEARS' COURSE.

Ukiveiisitt or Minnesota,
Minneapolis, December 80, 1893.
Hs. Editor: — The Board of Regents of the Univei^
Bty of Minnesota have extended the course of study in the
Coil^ of Medicine and Surgery from three to four years,
of el^t and one-half months' duration for each course.
The new schedule of requirements becomes operative in
18»5. Fkrrt H. Millard, M.D.,

Dean of the College of Medicine and Surgery.

METEOROLOGICAL RECORD,

For the week ending December 23, in Boston, acoordineto ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corps:—

Baro-

niermom-

Belatlv*

Direction

Veloelw
of wind.

We'th'r.

1

meter

eter.

humldltT.

ol wind.

•

Date.

i

f

i

5

i

i

S

i

n

i

>i

i

a

«

a

'S

k.

y

a

4

S

•i

«i

'4

a

U

a

S

«

eg

e

t£

00

ao

«o

^

to

n

3..I7

29.67

36

41

.10

77

84

80

s.w.

w.

12

9

o

0.

JM

M..I8

29.96

22 28

IS

74

68

71

N.W.

8.W.

6

8

0.

p.

T..19

29.76

31 45

24

97

H2

90

SW.

w.

4

16

N.

o.

W.20

30.24

24 29

lf>

61

M

52

W.

w.

24

;6

0.

0.

.01

T..21

30.16

30 44

17

M

62

ra

a.w.

S.W.

18

22

F.

0.

P.. 22

30 38

38 42

.13

71

90

80

w.

B.

10

13

F.

N.

S..23

30.14

44 56

32

90

79

84

s.w.

W.

10

9

O.

0.

.03

or

*0.,eload7) C, clean F., fmln G., foci H.^huji B-tUnokyi B.,mn( T.,thmt-
sBlnict N..tDOw. t IndicatMtrancof niuifBU. WST Mwn for week.

RECORD OF MORTALrrr
For thb Wbbk bhding Satuhdat, Dkckubsr 23, 1893.

1.

J

Percentage of deaths from

-O K

0 e.

Oltles.

P

sl

^1

¥

M

II

r

New York . ,

1,891,806

818

294

12.60

24.60

.72

ZM

.96

Obioago . . .
PUladelpUa .

1.438,000
1,U6,B«2

"~

"~

I

—

—

—

Brooklyn . .

978,394

368

loe

10J»

24.67

.81

4.32

1.08

St. Lonls . . .

eeo.goo

—

—

^

_

—

Boston . . .

487,397

264

66

14.06

27.74

.38

7.22

2.66

Baltimore . .

600.000

—

_

_

—

Washington .

308,431

131

?*

6.8t

16.72

4.56

3.80

_

Clnolnnatl . .

sus.uoo

130

36

14.63

10.78

3.85

3.8S

_

Clereland . .

290,000

140

46

13.49

22.01

3.56

4.Z6

1.42

Pittsburg . .

263,709

108

37

11.96

24.84

1.84

1.84

6.44

Milwaukee . .

260,0110

96

W)

18.52

20.80

1.U4

6.24

1.04

NashTllle . .

87,764

31

7

3.23

16.16

—

Charleston . .

6S,lt>9

44

15

_

4.51

._

_

. ,

Portland. . .

40,000

18

1

6.56

33.33

—

_

0.66

Woroester . .

96,217

26

lu

19.26

13.40

3.«6

3.M

Fall River . .

87,411

33

13

12.12

33.39

3.U3

3.C3

8.03

Lowell . . .

87,191

36

12

8.34

8.31

2.78

2.78

77.100

35

16

IT. 18

20.00

—

8.58

3.86

Lynn ....

62,606

20

—

10.00

10.00

—

6.00

Springfield . .

48.684

21

5

4.76

33.22

—

_

Lavrenoe . .

48,366

—

—

—

—

...

_

_

New Bedford .

43,886

86

U

8.34

27.60

^

2.78

Holyoke . . .

41,278

—

—

—

.

—

_

Salem ....

32,233

13

2

7.69

7.6ft

7.69

_

_

brookton . .

82.140

7

—

14.28

14.28

14.28

^

_

HaverUn . ,

31.396

5

0

40.00

—

_

,.

Chelsea . . .

30,264

16

2

13.33

13.33

6.66

6.66

_

Maiden . . .

29,394

10

2

—

20.00

__

Newton . . .

27,666

—

—

^

—

._

^

FItchbnrg . .

27,146

8

8

12.60

37.60

_

_

Taunton . . .

26,972

13

1

—

30.76

—

_

_

Olouoester . .

26,688

5

3

—

—

—

_

^

Waltbam . .

22.068

9

2

—

2S.22

..

__

QainoT . . .
Pittsfleld . .

19,642

11

4 9.09

36.16

9.09

_

18.X02

10

3

10.00

30.00

10.00

„

Everett . , .

16.586

4

1

25.00

50.00

■~

26.00

.^

Northampton ,

16,331

13

0

7.69

15.38

7.69

,

Newbtiryport .

14,073

4

2

26.00

—

25.00

— .

Amesbnry . .

10,920

6

3

60.00

20.00

».

—

60.00

Deaths reported 2,6S0: under five years of age 785; principal
Infectious diseases (small-pox, measles, diphtheria and croup,
diarrhcaai diseases, whooping-cough, erysipelas and fever) 2S7,
acute lung diseases S7S, consumption 273, diphtheria and croup
121, typhoid fever 37, scarlet fever 37, diarrhosal diseases 32,
measles 20, whoopiug-coagh 17, cerebro-spinal meningitis 16,
erysipelas and malarial fever 6 each, small-pox 4.

From diarrbosal diseases New York 12, Cincinnati 6, Cleveland
6, Brooklyn, Boston and Cambridge 2each. From measles New
York 9, Brooklyn and Milwaukee i each, Worcester 2, Boston 1.
From whooping-cough New York 6, Brooklyn i, Cincinnati 3,
Boston 2, Cleveland and Pittsburg 1 each. From cerebro-spinal
meningitis New York 6, Brooklyn 3, Cleveland, Worcester,
Lowell, Lynn, Somerville and Fitchburg 1 eacta. From erysipelas
Boston 2, New York, Cleveland, Pittsburgh and New Bedford 1
each. From malarial fever Brooklyn 3, New York, Nashville

Digitized by

Google

2S

BOSTON MSDtOAL AlTD SUBGIOAL JOURSAL. [Jamoabt 4. 1894

and Brockton 1 each. From small-poz New York and Boston 2
each.

In the thirty-three greater towns o{ England and Wales with
an estimated population of 10,322,429, for the week ending
December 16th, the death-rate was 26.6. Deaths reported 6,27fi:
aoote diseases of the respiratory organs (liopdon) 711, whooping-
oongh 172, diphtheria 122, measles 71, scarlet fever 6tf, fever B2,
diarrhoea 17.

The death-rates ranged from 16.0 In Norwich to 36.4 in Bristol ;
Birmingham 21.2, Bradford 22.1, Cardiff 21.2, Croydon 24.9,
Leeds 23.H, Leicester 29.4, Liverpool 31.8, London 31.8, Manches-
ter 27.6, Mewcastle-on-Tyne 21.2, Nottingham 31.9, Portomouth
20.3, Salford 19.7, Sheffield 27.0, Sunderland 19.0, West Ham
26.5, Wolverhampton 19.2.

OFFICIAL U8T OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE HEUICAL
DEPARTMENT. U. 8. ARMY, FROM DECEMBER 23, 1893,
TO DECEMBER 29, 1893.

By direction of the Secretary of War, leave of absence for
two months, to take effect on or about January IS, 1894, with
permission to apply for an extension of one month, is granted
Majob John D. Hall, surgeon.

LiECT. John S. Kulp, assistant surgeon, U. 8. A., is relieved
from further duty at Jackson Park, Chicago, 111., from Decem-
ber 23, 1893.

OFFICIAL LIST OP CHANGES OF STATIONS AND DUTIES
OF MEDICAL OFFICERS OF THE UNITED STATES
MARINE-HOSPITAL SERVICE FOB THE FOUR WEEKS
ENDING DECEMBER 16. 1893.

Bailhachb, p. H., surgeon. Granted leave of absence for
five days. November 28, 1893. To inspect quarantine ports.
December 7, 1893.

PuBviANCB, Qeosgs, surgeou. To inspect quarantine ports.
December 7, 1893.

Sawtellb, H. W. surgeon. To Inspect quarantine ports.
December 7, 1893. Granted leave of absence for three days.
December 4, 1893.

Austin, H. W., surgeon. Detailed as chairman, Board to
amend and revise the Quarantine Regulations. December 9,
1893.

Gassawat, J. H., surgeon. To proceed to Mobile, Ala., as
inspector. November 22, 1893. To inspect quarantine ports.
December 7, 1893.

Mbas, F. W., surgeon. Detailed as chairman, Board to ex-
amine candidates, Revenue Marine Service. December 9, 1893.

Cakteb, H. R., surgeon. To proceed to Brunswick, Ga., for
temporary duty. November 29, 18U3. To inspect quarantine
ports. December 7, 1893. Detailed as member, Board to revise
and amend the Quarantine Regulations. December 9, 1893.

Wbbklbb, W. a., surgeon. Detailed as member. Board to
revise and amend Quarantine Regulations. December 9, 1893,

Banks, C. E , passed assistant surgeon. Granted leave of
absence for seven days. November 32, 1893.

Cabxicbaki., D. a., passed nssistant snrgeon. To inspect
quarantine ports. December 9, 1893.

Wbitb, J. H., passed assistant surgeon. To proceed to
Savannah, Ga., for duty. December 4, 1893. Detailed as mem-
ber. Board to revise and amend the Quarantine Regulations.
December 9, 1893.

Cabbinoton, P. M., passed assistant snrgeon. To proceed to
Baltimore, Md., for duty. December 9, 1893.

Williams, L. L., passed assistant surgeon. To proceed to
Charleston, 8. C, for duty. December 4, 1893.

Pbtths, W. J., passed assistant surgeon. Granted leave of
absence for eleven days. To proceed to Buffalo, N. Y., for
dnty. December 1, 1893.

KiNYOCN, J. J., passed assistant snrgeon. To rejoin station
Washington, D. C. November 24, 1893. Granted leave of ab-
sence for three days. December 4, 1893. Detailed as recorder,
Board to revise and amend Quarantine Regulations. December
9, 1893.

Woodward, R. M., passed tusistant snrgeon. Granted leave
of absence for seven days. To proceed to Cairo, BI., for duty.
December 4, 1893.

Vavohan, G. T., passed assistant surgeon. Detailed as re-
corder. Board for physical examination of candidates. Revenue
Marine Service. December H, 1893.

Cobb, J. O. , passed assistant surgeon. To inspect quarantine
ports. December 7, 1893.

OviTBBAS, G. H., passed assistant snrgeon. To report at
Bureau for temporary duty. December 6, 1893.

Okddinos, B. D., passed assistant snrgeon. To proceed to
New York, N. Y., for duty. December 2, 1893.

YouNO, O. B., assistant snrgeon. To procesd to New York,
N. Y., for duty. December 4, 1893.

Stimpsoh, W. G , assistant surgeon. To proceed to Detroit,
Mich. December 4, 1893.

BuBHs, B. W., assistant snrgeon. Granted leave of absence
for seven days. To proceed to Washington, D. C. December
4, 1893.

HouoHTON, E. R., assistant snrgeon. To proceed to Vise-
yard Haven, Mass., forduty. December 4, 1893.

RosBNAu, H. J., assistant snrgeon. To proceed to St. Lonis,
Mo., for duty. December 4, 1893.

Ntdboobb, J. A., assistant surgeon. Granted leave of ab-
sence for seven days. To rejoin station Plttsbnrgh, Pa. De-
cember 7, 1893.

Stbwabt, W. J., assistant snrgeon. Granted leave of ab-
sence for fourteen days. November 27, 1893.

Stbaybb, Edqab, assistant surgeon. Granted leave of ab-
sence for seven days. November 2(, 1893.

Oaklbt, J. H., assistant snrgeon. To proceed to Halifax, N.
S., for temporary dnty. November 24, 1893. To proceed to
New York, N. Y., for temporary dnty. December 14, VHH. To
proceed to San Francisco, Cal , for duty. December lit, 1893.

SOCIETY NOTICE.

Boston Socibtt fob Medical Impbovbhbnt. - The annual
meeting of the Society will be held at the Medical Library, Ko.
19 Boylston Place, on Monday, Jannarr 8, 1894,at8o'clock,p. x.

Election of officers. Report of the Treasurer.

Dr. W. J. Otis will read a paper on, " External Piles and their
Relation to the External Hemorrhoidal Veins." Discussion by
Dr. C. B. Porter, Dr. H. L. Burrel) and others.

Dr. Myles Standish will read a paper on, "Two Cases of
Chancre of the Eyelid." Discussion by Dr. A. Poet, Dr. E.
Wigglesworth and others.

Dr. C. B. Porter will show patienta illustrating results of some
exceptional operations for exceptional surgical lesions.

Members are kindly requested to show Interestiag case* and
pathological specimens.

John T. Bowbm, M.D., Sterttary.

HARVARD MEDICAL SCHOOL.

EVBNINO LzCTUBXS.

The next lecture will be given on Wednesday evening, Janii>
ary 10th, at 8 o'clock, by Assistant Professor Ernst. Subject,
" Advances in Bacteriology." Physicians are cordially InTlted.

RECENT DEATHS.

Cbablbs H. Cbbsson, M.D., a well-known chemist of Phila-
delphia, died December 27tb, aged sixty-five years.

Db. S. Guttmann, of Berlin, the editor of Dfatstlxt Medt-
cinUche Wocheruchrift, died of inflnenxa, December 22d.

BOOKS AND PAMPHLETS BBCEIVED.

Epileptic Insanity. By James H. McBride, M.D. Reprint.
1893.

Fourteenth Annual Report of the Associated Charities of Boe-
ton, November, 1893. Boston. 1893.

Bacteriology in its Relations to Chemical Science. By Percy
Frankland, Ph.D., B.Sc. (Lond.), F.K.S. Reprint. 1893.

Transactions of the Medical and Chlmrgical Faculty of the
State of Maryland, Ninety-fifth Annual Session held at Balti-
more, April, 1893; also Semi-annual Session held at Easton,
March, 1892.

8p.istic Senile Entropion cured by Canthotomy. The Treat-
ment of Blennorrhoea Neonatorum. The Relation between the
Eyes and Disease of the Female Genital Organs. By Boerne
Bettman, M.D., of Chicago, 111. Reprints. 1893.

The Measured Effects of Certain Therapeutic Agents, among
which especially are Lavage, HCl, and Intragastric Eleotridtyt
upon the Secretory and Motor Functions of the Stomatdi In
Cases of Chronic Catarrh (Glandular Gastritis). By D. D.
Stewart, M.D. Reprint. 1893.

Chimrgie des Malades du Byst^me Nerveuz. M. le Professenr
Charcot, Lefons du Professenr, U^moires, Notes et Observa-
tions Parus pendant les ann^es 1889-90 et 1890-91 et publics sons
la directiore de Georges Guinon, chef de clinique avec la collabo-
ration de MM. Blocq; Souques, et J. B. Charcot, internes de la
clinique. Tome IL Paris: Anx Bureaux du Progrte M^ical.
1893.

Digitized by

Google

Voi,. CiXX, No. 2.] BOSTON MEDIO AL AND SUSOIOAL JOUBNAL.

29

Original %ttit\t^*

CASES OF ABDOMINAL SURGERY OCCURRING
IN THE PRACTICE OF DR. J. COLLINS WAR-
REN AT THE MASSACHUSETTS GENERAL
HOSPITAL DURING THE WINTER OF 1893.

BXPOSTU) BT CBASLEB I» SCUDDBS, K.I>.

(Conelnded trom No. 1, pace 5.)

Case XIY. Exploratory laparotomy for tamor in
the region of the kidney ; recovery.

A negro, forty-two years old, single, always well
with the exception of some rheumatism, six weeks ago
complained of pain in the back and the left side of the
abdomen. This pain has gradaally increased, accom-
panied by nausea. Decubitus on the left side. The
chest and spine, upon examination, were negative.
There was a tumor in the left loin extending under
the ribs, which moved slightly with respiration. The
edge of the tumor was rounded, rather ill-defined, and
not movable. The colon passed in front of the tamor.

Operation. — A carved incision was made from the
eighth rib on the left, with the convexity down, as
far as the left anterior superior spinous process.
The colon presented. The patient having been
tipped over on one side, the intestines were dis-
placed so as to uncover the region of the left kidney.
Irregular nodular masses (not connected with the
spleen, bat retro-peritoneal) were found adherent to
the inferior vena cava and to the left iliac vessels and
to the brim of the pelvis, these being enlarged lymphatic
glands. Large and tortuous veins covered the mass
in the region of the left kidney. An incision was
made through the posterior wall of the peritoneam.
The abdominal contents were displaced from over the
tumor as far as the spinal column, clearly exposing
this region. Owing to the presence of infected glands,
it was found impossible to remove the mass without
incurring too great risk, and further interference was
advised against by those seeing the patient in consulta-
tion. Consequently, the abdominal wound was closed,
and the patient made an uninterrupted recovery from
the exploratory operation. He was heard from several
months after he left the hospital, and was in fairly
good health, the mass in the side still being present.

Case XV. Pyo-salpinx ; operation ; recovery.

A woman, married, twenty-three years old. The
catamenia have always been regular and painless until
within the last two years, when there has been some
irregularity. 8he has two children, the youngest being
three years old. For two years there has been some
swelling in the left side of the pelvis, which has
caused a certain amount of pain. She entered the
hospital on the medical side a few months ago, and
was treated for a left salpingitis, and apparently im-
proved while under treatment. Symptoms of pain in
the left groin returned shortly after her discharge
from the hospital. Examination upon re-entering
found tenderness in the left groin upon deep pressure,
and by the vagina the left cul-de-sac filled with a
doughy mass which was tender.

Operation. — Trendelenberg position. A median
incision found the omentum slightly adherent to the
uterus and to a tnmor in the left side. While freeing
the adhesions the sac of the tumor was ruptured and a
puriform fluid escaped, some of it into the abdominal
cavity. The sac was removed, the abdomen washed
with boiled water and drained by glass drainage in the

posterior cul-de-sac together with iodoform gauze. The
tube was removed in two days, when the temperature
was normal. She was discharged four weeks from the
time of the operation, well.

Case XVI. Exploratory laparotomy; carcinoma
of stomach ; recovery.

A man fifty years old, single, had always been well,
although not very strong. Two months ago he had
the feeling of weight in the left side, especially on ris-
ing in the morning ; had lost some weight during this
time, and had a dull, dragging feeling in the left abdo-
men. At no time has there been vomiting or distress
after eating. His bowels have been fairly regular.
He was pale, but not cachectic. In the abdomen, a
hard, ovoid mass was felt in the epigastric region,
which was movable, slightly irregular on the surface,
seen to move with respiration, and was not adherent
to the aI)dominal wall.

Operation by an incision parallel to the left costal
margin. The stomach presented in the wound very
much enlarged, with a tumor at the greater curvature
reaching nearly to the pylorus. The tumor involved
the inferior, posterior and some of the inferior and
anterior walls of the stomach. It was nodular poste-
riorly and adherent to the transverse colon. No sec-
ondary nodules were detected in the liver. On account
of the extent of the growth, which previous to the
operation could not be accurately determined, farther
interference was advised against. The wound was
closed with interrupted sutures.

The man made a good recovery from the laparotomy,
and died about six months later from the disease.

Case XVII. Double pyosalpinx; operation; re-
covery.

A woman thirty-one years old, married. Catamenia
regular until the past few months. No children or
miscarriages. Two weeks ago pain and soreness de-
veloped in the right ovarian region accompanied by
tenderness in the right side of the abdomen ; and upon
vaginal examination bulging of the right vaginal vault,
with fluctuation, was detected.

Operation. — Trendelenberg position. A median
incision disclosed a tumor on the right side, the size of
a small orange, adherent to the omentum and small
intestine posteriorly. The tip of the vermiform ap-
pendix was adherent to the tumor. Half an ounce of
foul pus and cheesy material escaped posteriorly upon
an attempt to unroll the tube, which had become
twisted backward. Upon removal of the tube, the
pelvis was thoroughly irrigated with boiled water, a
glass drainage-tube placed in the posterior cul-de-sac,
and the abdominal wound partially closed. The drain-
age-tube was removed in one week. Two days later
there was a sudden rise of temperature, and a phlebitis
developed on one side. This gradually subsided, and
the patient was discharged a few weeks later, the
wound entirely closed. Shortly after the removal of
the glass drainage the discharge became fscal, but re-
mained so for only a day or two. Evidently a fistula
formed, which rapidly closed without interference.

Case XVIII. Abdominal hysterectomy for cancer
of the nteras ; death.

A woman fifty-one- years old, married. Her grand-
mother died of " cancer of the womb." The patient
passed the climateric six years ago. For the past six
months she has complained of pain in the left ovarian
region, which has extended into the groin and left
thigh. Vaginal examination found present an os uteri

Digitized by

Google

30

B0810S MEDICAL AND SURGICAL JOURNAL. [Januast 11, 1894

three or four times the normal size, oloerated, and the
vaginal wall adjacent to the external os likewise alcer-
ated. An extension of the disease beyond the regions
above named was not detected. Twenty-four hours
previous to the operation the cervix was cauterized with
the Pacquelin cautery and packed with iodoform ganze,
the vagina being likewue packed. At the time of
operation the vagina was irrigated with corrosive sub-
limate (1 to 3,000). The cervix was again cauterized,
and an iodoform gauze tampon placed in the cervix.
In the Trendelenberg position by median abdominal
incision the nterus was exposed. The right and left
broad ligaments were clamped and divided, the ovarian
arteries being separately ligatured. The peritoneum
was separated anteriorly from the bladder and poste-
riorly from the rectum. The vaginal wall was found,
excepting in the area felt by previous examination, to
be free from new growth. The vagina was packed
with ganze up to the vaginal wound. A^lass drain-
age-tube was placed through the abdominal incision
down to the vaginal wound, and surrounded by gauze
so that there was continuous gauze drainage from the
abdominal wound to the vaginal wound externally.
The infiltration of the vaginal wall below the cervix
made the attempt to remove the disease through the
abdominal wound exceedingly slow, and prolonged the
operation so that the shock was necessarily very severe,
and in her weak condition proved to be too great.
The patient died twenty-foar hours after her recovery
from ether.

Case XIX. Secondary laparotomy in presence of
a suppurating sinus ; death.

A woman, four months ago, complained of pain in
the left ovarian region. There was some swelling in
this region later. She remained in bed for ten weeks';
and some ten weeks ago the doctor in attendance aspi-
rated the swelling, getting no fluid. Two weeks later
a parulent discharge appeared from the vagina and the
rectum. A laparotomy was done soon after this. The
left ovary and a pus-tube were removed. Several
months later she returned to the hospital with a dis-
charging sinus in the abdominal wound, and complained
of great pain and tenderness just posteriorly to the
anus. Under ether, an abscess in the region of tender-
ness posterior to the anus was opened, curetted and
packed with iodoform gauze. It was found that there
was a communication between the anal sinus and the
abdominal siuns. The faecal discharge contained pus.
Various attempts were made to close the abdominal
sinus by means of curetting, cauterization and various
careful dressings.

With the hope of excising the abdominal sinus, and
because of the presence of an encysted tumor of the
right broad ligament and ovary which had developed
since the left ovariotomy, a second laparotomy was
performed. At the time of this operation very great
precaution was taken to prevent infection of the fresh
abdominal wound by the old sinus. To prevent this,
the sinus was, previous to the operation, thoroughly
cauterized, and the fresh wound very carefully pro-
tected. The left ovary and cyst were removed; the
sinus was excised; and a glass drainage-tube was
placed in the posterior col-de-sac. The upper part of
the wound was sutured. Three days later, after gradu-
ally increasing symptoms of peritonitis, the patient
died.

Cask XX. A male deaf mute, thirty-six years
old and married, entered the hospital with the history

of having been several times janndioed; otherwise, he
had always been well. A little over two months ago
he was said to have had typhoid fever. The symp-
toms at that time were right iliac pain, vomiting, con-
stipation followed by diarrhoea. Four weiks ago he
had a similar attack, but less severe, since which time
he has not been very well. A week ago a painfol
tumor was noticed in the epigastrium, tender upon
pressure. The man was fairly well developed. Hit
skin was slightly yellow. The sclerotic of the eye wsi
white. The pulse was 110 and was of fair strength.
The heart and lungs were negative. The epigastric
swelling was about the size of a small orange. The
movements from the bowels were of natural appear-
ance. He slept fairly well. The temperature at mid-
night was 103.4°, and was normal in the morning.

Operation by an incision parallel to the right costal
border. A cavity the size of the end of the thumb
was opened and a small amount of puriform fluid
evacuated. Several blind pus cavities were opened
and curetted it not being possible to determine their
exact anatomical boundaries. The bowel appeared to
be healthy in the immediate neighborhood. The pas
cavity seemed to be sitnated in a mass of inflammatory
exudation. Grause drainage was inserted and an ab-
sorbent dressing applied. In the right iliac fossa st
the time of this operation there was very alight dul-
ness. Three days after the operation this dnlness in
the right iliac fossa became more marked and pain in
that region developed. One week after the first op-
eration the patient was again etherized and an incision
was made parallel to Poupart's ligament, over the dull
and tender area in the right iliac fossa. A bile-stained
fluid with light green flakes was evacuated, indicating
a fsecal fistula. The vermiform appendix was not
found in connection with the cavity from which the
fluid came. An opening was made in the colon during
the operation, and this fsecal fistula gradually closed,
and the wound of the first operation closed rapidly ;
and the patient was discharged about five months after
entering the hospital gaining in flesh and strength,
apparently well, having had a normal temperature for
four weeks previous to his discharge.

Case XXI. General suppurative peritonitis fol-
lowing the reduction of an inguinal hernia by -taxis ;
laparotomy ; washing and drainage of the afaidomissl
cavity ; recovery.

For a year, the patient, who was a thin and yet
fairly well developed man, had had a left ingainal
tumor. Two days before entrance tenderness developed
in the region of this tumor and an attempt was made
by the attending physician to reduce it, which was
supposed to be an inguinal hernia, by taxis. The
tumor was reduced in size, and there was no impulse
upon coughing. Because the symptoms of strangula-
tion and intestinal obstruction remained, he was sent
to the hospital, and it was decided to lay open the
hernial sac, and a very peculiar condition of things
was discovered. On laying open the sac, which had
thick and rigid walls, it was found to be uninhabited,
containing serum and flakes of fibrin only. A finger
being passed through the neck of the sac into the sb-
dominal cavity was, upon removal, followed by a gnih
of thick creamy pus. The first incision was enlarged
nearly to the anterior superior spinous process of the
ilinm. Coils of intestine were thus exposed, which
were found injected and covered with flakes of fibrin
and pus. A finger introduced into the opening passed

Digitized by

Google

Vol. CXXX, No. 2.] BOSTON MEDIOAL AND SUBGIOAL JOURNAL.

31

to the hollow of the sacram freely among the ooils of
intestine.

An abdominal inoiaion through the nmbilicus, half-
way to the pnbes, was now made for purposes of drain-
age of the entire abdominal cavity. Pus gashed from
the median incision. The entire abdominal cavity
was flashed with warm water through the median in-
cision, the wash-water passing out of the left inguinal
opening. Glass drainage-tubes were inserted through
both incisions to the hollow of the sacrum. A counter-
opening was made in the left loin, through which two
large rubber drainage-tubes were passed from the
median incision. The wounds were packed about the
tubes with iodoform gauze. The operation relieved
the general peritonitis, but the symptoms of obstruc-
tion remained ; consequently after six days the pre-
senting coil of bowel, which proved to be small in-
testine, was opened in the left inguinal region with
great relief to the distention. A discharge of faeces
by both rectum and fistula followed. The median ab-
dominal wound healed kindly, but considerable diffi-
culty was found in preventing the digestion of the
skin about the opening of the feecal fistula in the left
groin. The skin immediately surrounding the fistulous
opening was protected by means of absorbent cotton
and oxide of zinc ointment, which was allowed to dry,
forming a firm crater-like opening around the fistula.
A special nurse was in constant attendance, and re-
moved the discharge from the fistula as fast as it ap-
peared at the bottom of the crater. Gradually under
this very careful attention the fistula healed. Dr.
Warren decided not to attempt closure of the fistula
by suture, but to trust to healing by granulation, as
the fistnlous opening was situated at the bottom of a
deep wound, the conditions differing materially from
those present in cases in which the bowel presents
close to the abdominal wall in artificial anus. The
man left the hospital in splendid physical condition,
with the fistula healed, about three months after the
operation.

Rtmark*. — This case may be very well regarded
as one of most desperate character. A suppurative
peritonitis was probably caused by an inflammation of
the strangulated loop of intestine which had been re-
duced out of an old and rigid sac. It illustrates too,
the value of efforts to relieve general suppurative
peritonitis by operative procedure.

Case XXII. Chronic appendicitis ; recovery.

A man, thirty-five years old, married, had always
been well previous to his present illness, four months
previous to the entrance to the hospital, when he had
a sharp attack of pain across the middle of the abdo-
men, was constipated, bat did not vomit. This attack
lasted for a few days, and he went away as a sailor
to sea, since which time he has had one other similar
attack. At the time of entrance some resistance was
felt to the right of the epigastrium. He had consider-
able pain in the right iliac region and fulness in the
right flank, where there was dulness and increased re-
sistance. There was very great tenderness present.

Operation, — An incision was made parallel to
Poupart's ligament upon the right side. The muscles,
as divided, appeared cedematons. An abscess cavity
was opened, containing a small amount of puriform
material. The wall of the abscess cavity presented
the appearance of sarmomatous tissue. The wound
was thoroughly washed and packed with iodoform
gauze. Six weeks later a tender spot, with some

swelling, was felt jost below the right false ribs.
Under ether, an incision here evacuated eight ounces
of foul pus. One day later a second fluctuating area
developed just above the last incision, and was opened,
giving exit to four ounces of pus. The exploring finger
entered an abscess cavity behind the liver. Three
weeks later, having a continuous pus temperature and
growing weaker, another operation was done, laying
open the previous incisions, which had not yet entirely
healed. The patient is still in the hospital, the old
sinus discharging.

Case XXIII. Movable kidney ; nephrorrhaphy ;
recovery.

A woman, married, in good health, has had since
her last child was born, sixteen months ago, distress in
her abdomen in the region of the stomach, accompanied
by a dragging feeling. Has lost some fiesh of late.
Examination found a rounded movable tumor in the
right hypochondrium, pressure upon which caused pain
in the epigastrium. The tumor is easily moved. The
knee-chest position permits more ready access to the
tumor, which resembles the kidney in shape. An
operation for the fixation of the kidney to the posterior
abdominal wall was advised, as offering the bestohanoe
of relief from the symptoms. The operation of neph-
rorrhaphy was done by an incision four and one-half
inches long in the right flank, starting two and three-
quarter inches from the spine, one-half inch below the
twelfth rib, and extending outwards towards the iliac
crest. The muscles were divided in the full length of
the incision. The edge of the latissimus dorsi slightly
encroached on the wound. The perinephritic fat was
found. All bleeding points were tied, and the fat
tissue incised. Pressure over the abdomen cansed the
surface of the kidney to present in the wound. Five
silk sutures were taken through the fibrous capsule
and a little of the kidney substance, and then through
the lumbar fascia and erector spins muscles. Two of
the sutures were slightly above the middle of the kid-
ney. The wound in the abdominal muscles was closed
with three silk sutures, leaving some of the perinephri-
tic fat bulging between them. The skin was sewed
with interrupted silk sutures ; baked gauze dressing ;
swathe. The condition of the patient at the end of
the operation was good. The recovery was unevent-
ful. The patient, after four weeks' recumbency, was
allowed to walk about, wearing an abdominal binder
of flannel.

Case XXIV. A man, sixty-five years old ; carci-
noma of rectum ; Litre's operation ; recovery ; condi-
tion six months after operation.

. The patient was smajl, always well and strong till a
year ago, when he noticed pain in the rectum on defe-
cation. He has been troubled with frequent micturi-
tion for the last six months. Examination showed the
patient to be well developed, but thin and somewhat
cachetic. The radial and temporal arteries were ather-
omatous. By rectum, the prostate was found to be
somewhat larger than normal and tender. Internal
sphincter was rigid. Just above it was a tender spot ;
no induration was felt. The rectum was ballooned.
Externally, in the left iliac region, a hard band was
felt; it was tender, and corresponded to the site of
the sigmoid flexure. Kectal tube passed readily eight
inches up the bowel. Small movements resulteid from
high injections of glycerine and suds.

On the 24th of the month the operation was done.
An incision three inches long was made in the left in-

Digitized by

Google

32

BOSTON MEDICAL AND SUROIOAL JOURNAL. [Jambabt 11, 1894.

gninal region, two inches above Ponpurt's ligament,
starting just inside the line of the anterior superior
spine. On opening the peritonenm, the sigmond flex-
ure presented, much distended with gas, and was sewed
to the margins of the wound with three fine silk stitches
on each side for a distance of one and one-half inches
above and below the loop of bowel ; the lips of the
incision were united with three deep silk sutures.

On the 25th he had a good night; little pain or
nausea. The gauze was slightly stained. Some three
or four feet of small intestine were found protruding
from the wound. Under ether the escaped bowel was
cleansed with boiled water and replaced.

The man made a good recovery. The artificial
anus was a success. Daily formed movements OC'
curred. He had much less pain and ate well. After
six weeks he was discharged from the hospital, greatly
relieved.

Six months after the operation, December, 1898, he
was examined, and the general condition was found to
be much improved. Said he could walk a mile with
ease. He had formed movements through the artificial
anus, and some liquid always passed per rectum. He had
very little pain, mostly in the left lumbar region. He
had no pain in the leg. There was a tendency for super-
ficial abscesses to form around the fistula, which dis-
charged slightly and then dried up.

The foregoing cases serve to illustrate the variety
of abdominal surgery occurring in a single service at
the Massachusetts General Hospital, and are suggestive
of the methods of procedure in certain obscure and
difficult cases.

In every instance great care was exercised in the
preparation of the field of operation, the instruments
used, the ligatures, suture and dressing material. The
hands and arms of the operator and his assistants
were first scrupulously cleansed with soap and nail-
brush, then with a saturated solution of permanganate
of potash, decolorized with oxalic acid and peroxide of
hydrogen and soaked in a solution of corrosive sub-
limate of the strength of one to two thousand. In
spite of the great care exercised in the counting of
sponges, one was left in the abdominal cavity of one
of the fatal cases.

There were in all twenty-four cases, as follows:

Solid tumor of the ovary 1

Haltilocalar cyst of the ovary, single ... 2

SalpinidtiB S

Congenital liver hernia 1

Cyst of the broad ligament 1

Appendicitis, acute 3

Appendicitis, chronic 1

Salpingitis, doable, tubercular 1

Carcinoma uteri 1

Carcinoma uteri (hysterectomy) .... 1

Cysto-adenoma of the ovary 1

Intra-IigamentouB ovarian cyst
Exploratory laparotomy .
Sinus of abdominal wall .
General guppurative peritonitis
Movable kidney (nephrorrhaphy) .
Carcinoma recti (Litre's operation) .
Obscure abdominal abscess

There were three deaths, making a mortality of
,twelve and one-half per cent.

A Novel Christmas Entertainment. — A daily
paper relating the events at the annual Christmas party
at the poor-house of a neighboring city, says : " An ex-
cellent entertainment by local talent was given. Among
the features was the treating of several of the inmates
who have rheumatism by a magnetic healer."

OBSTETRICAL ASBPSI8.»

BT JOSEPH raiCI, H.D., OV THB PBSBTOS BETBE^T, PHILADBI.-
PHIA.

It is customary to come to Boston to listen. The
one who comes here to talk should be sure he has some-
thing to say. This fact gives me embarrassment. I
do not bring to you those graces of classic coltare
attained in old Harvard's college halls. . I have no
surprises in the shape of new facts ; and my only logic
will be that with which my experiences, observations
and reading supply me. The same may be yours, and
in giving mine I only strengthen and confirm yours.
Within myself I represent but little ; yet with yon I
enjoy the proud privilege of sharing in the common
triumphs of our profession. A distinguished novelist,
one who gives us in our brief leisure delightful enter-
tainment, sitting talking with a Boston friend on a
public occasion in one of your great halls, remarked,
on the entrance of one of your illustrious citizens,
orators and statesmen — a man he did not know, had
never seen before; "There goes one of God's noble-
men." It is with such men I would be in touch for
what they are to me, for what they have for me, for
the strength such contacts and associations renew in
me. If there be a human calling, service or profes-
sion that commands only the best, all the forces of in-
nate and cultured manhood, all that distinctively makes
up the nobleman, it is that of medicine and surgery.

It may impress the profession that I urge with a
relentless persistency the importance of cleanliness iu
maternity work, and in all surgery, special and general.
For this urging there is no need of apology. It is one
of the lines in which our efforts rnn no risk of extrava-
gance. From time immemorial there has been mnch
discussion of dietary precautions, drink, climatic influ-
ences, dress, exercise, morals. Mnch that is wise has
been said, and much that is otherwise. Yet the sub-
ject of cleanliness has never been given that consider-
ation in all its many bearings its importance to the
general health demands, and that is yet more imper-
atively demanded in all cases where medical and sur-
gical treatment is involved. No matter how scrupu-
lous our purely personal precautions may be to render
the patient less liable or susceptible to infectious, if
the influence of environments are against us, our suc-
cess cannot be complete. But science is going on
correcting our mistakes and evolving for us new truthp.
It is not my purpose to deal with the abstruse qaes-
tions of the science of obstetrics. Our increased
knowledge of anatomy and of the phenomena of labor
has cleared away many of our diflSculties.

A high mortality in a maternity or in private ob-
stetrical practice is simply evidence of bad management.
Success in our maternities and in private obstetrical
practice requires scrupulous attention to cleanliness.
This cleanliness should begin with the physician, with
his person, his clothing ; his hands should not be in
mourning. There should be no room for the applica-
tion of the witticism of Charles Lamb to his companion
in the game of cards : " If dirt were trumps you would
hold a full hand." This cleanliness should extend to
the nurse and with equal scrupulousness to the patient.
In considering what cleanliness has done for maternities,
it is interesting to note the views of some of the men
who have filled important positions in our great schools
as teachers.

s Bead before the Ubstetrioal Seetion of the Soflolk Diatrlot Medi-
cal Soolety.

Digitized by

Google

Vol. GXXX, No. 2.] BOSTON MEDICAL AND SVBOIOAL JOUJtNAL.

88

Professor Hodge says : " The resalt of the whole
discassion will, I trost, serve, not only to exalt your
views of the valoe and dignity of our profession, bat
divest your minds of the overpowering dread that yoa
can ever become, especially to woman, under the ex-
tremely interesting circumstances of gestation and
parturition, the minister of evil; that you can ever
e<m»e!f, in any possible manner, a horrible virus, so de-
structive in its effects, and so mysterious in its oper-
ations as that attributed to puerperal fever."

Professor Meigs says : "I prefer to attribute them to
accident, or Providence, of which I can form a concep-
tion, rather than to a contagion of which I cannot form
any clear idea, at least as to this particular malady."

That is a pitiable, professional courage which makes
Providence responsible for these calamities, when
they are the result of unskilful work, neglect of im-
portant details of treatment, of the common-sense les-
sons of practical obstetrics, and of sleepy, lazy, slovenly,
sloppy nursing. If you should tell one of that class
of gentlemen who shift their bad work off on Provi-
dence, that their results were caused by filth, by inat-
tention, bad nursing, unskilful treatment, their reply
would probably be that of Emerson's school boy to the
teacher : "That letter is A," said the teacher. '< A,"
drawled the boy. "That is B," said the teacher.
« B," d rawled the boy. " That is W," said the teacher.
" The devil it is," exclaimed the boy, " I thought it was
something else."

Bat listen to the good sense of one of your New
England teachers, Oliver Wendell Holmes : " The dis-
ease known as puerperal fever is so far contagions as
to be frequently carried from patient to patient by
physicians and nurses."

Gordon, as far back as 1795, wrote : " I arrived at
that certainty in the matter, that I could venture to
foretell what women would be affected by the disease,
upon hearing by what midwife tbey were to be de-
livered, or by what nurse they were to be attended,
during their lying-in; and almost in every instance,
my prediction was verified."

Since Gordon has made mention of the midwife, I
will say that I am not so sure that she is a boon to the
physician. She may serve to prevent his sleep from
being disturbed, but I am uncertain as to her success
in saving the lives of mothers and children. They
rarely come from the more cleanly, refined and edu-
cated ranks of society. As a rule, they are without
pretension to training for such responsibility ; and the
risks are those that come of ignorance and all that fol-
lows in its train. The nurse attending in lying-in
cases should be scrupulously clean by habit in every-
thing that pertains to her person, be of some refine-
ment and culture, have had a prolonged period of
pupilage. In the service of every obstetrican there
should be the trained nurse.

I am not stating a modern medical experience when
I state that we cannot expect good results in a stink-
ing atmosphere, by breathing air filled with the volatile
refuse of the human body, the effluvia of sewers. It
is the stealthy, lurking poisons, those in ambush, our
cleanliness must reach. It would be interesting as
well as valuable to us if we had reliable statistics of
the many cases of septicssmia caused in young and
healthy women by the impurity of the air of the room
in which they are confined, by the septic influence of
chronic pyssmia and malignant disease. Cancer of the
stomach, all discharging malignant sores are a source

of danger when in close proximity to a lying-in woman.
We have passed beyond questioning drain and sewer-
gas poisoning. And in this connection we must get
beyond simply interrogating tables of mortality. The
inquiry should be extended as to how many women
barely escape with their lives, and thus escaping live
out miserable lives, useless as wives and mothers, a
burden to their families or the community.

There can be no restricting the broad meaning of
the term " cleanliness." It applies with strong force
to person, to clothing, to hands, to finger-nails, and
with yet stronger force to personal morals. As physi-
cians we are the supremely trusted of society ; we are
the mifisionaries of a humanly saving Gospel, the one
supreme command of which is, " Be clean." When
we have clean men — clean morally ; men with high
self-control, the energy and intensity of whose moral
lives diffuses itself through — permeates — their very
clientile; then we shall have less syphilitic complica-
tions. Improved morals and healthful physical condi-
tions go together. And there is no form of cleanliness
more strongly and devoutly to be hoped for. We have
much to do with the underlying, the better life-prin-
ciples of our social fabric. We communicate what we
are ; we dominate in proportion as our own cleanness
is beyond reproach. The alliance of clean morals with
the forces of our science, with our improved arts and
methods, will greatly aid in reducing the sum of hu-
man suffering, and relieve us of much of that severe
tension, that weighty, wearing burden of anxiety in-
separable from much of our work. That general prac-
titioner or surgeon who lightly takes a case into his
hands for treatment, no matter what its nature or char-
acter, who does not realize that it appeals to the best
genius of his science and art, who does not feel the
motor force of solicitude as to issue, is unworthy of a
place in our profession. There should be done with
him that which your heroic — though, from the Briton's
standpoint — naughty forefathers did with the tea :
he should be thrown overboard.

I have been speaking of cleanliness in obstetrics,
not as to its wider possibilities in the matter of general
health. In obstetrics it is local undeanness and not
so much with general that we are concerned. Since
health is one of the conditions of human happiness,
there is nothing in which we should have so much and
so enlightened and active an interest as in the health
of our communities. Suppose you take note of the
dumping-grounds within your municipality or its en-
virons, of the particular localities where there are
cesspools or putrescent collections of solid and liquid
matter, and reckon the percentage of the sick and en-
feebled, and the mortality within the same and iu con-
tiguous neighborhoods, and compare these with other
localities where there is a rigid observance and prac-
tice of wise, scientific, healthful sanitary conditions.
The result would be startling. It is not possible though
to so analyze the statistics of mortality as to give due
credit to tilth.

Science and experience confirm the fact that under
filthy conditions we run great risks and have deaths,
and that under opposite conditions we have good results.
We know that cases of zymotic disease are much more
frequent and numerous within certain filthy localities
or areas than they should be, than they are in others
where sanitary conditions are as nearly perfect as it
is possible to make them, where there is a more strict
observance of the plain, conservative laws of hygiene.

Digitized by

Google

34

BOSTOar MEDICAL AND SURGICAL JOUBNAL. [Jancabt 11, 1894

An important question with physicianB should be,
How many diseases are preventable by absolute cleanli-
ness, by rigidly enforced sanitary regulations, by rules
that are the very transcripts from nature, those ap-
proved by the best science? We know that many
diseases have their birthplace exterior to the human
body. Many sad, horrifying experiences convince us
that many diseases have their origin amid controllable
conditions. The fact that many diseases go on more
actively in summer than during any other season of
the year can be credited to no other fact than that
organic decomposition goes on more rapidly then than
in other seasons.

The general public has not yet grown to a full ap-
preciation of the beneficence of sanitary science and
the necessity of the scrupulous practice of all its lessons.
Such an appreciation will only be reached through en-
lightened, wisely directed and energetic efforts on the
part of the medical profession. The extent of the
responsibility of the profession in this matter cannot
be overestimated or too strongly pressed home. We
claim to be a self-governing people, to make our own
laws, to have incorporated in them our own wills :
their wisdom must be taken as the reflex of our wis-
dom. If they are inadequate or faulty in their provi-
sions or they fail of execution, it is not diflScuh for us
to trace a large share of the responsibility. The gen-
eral public should be educated up to the understanding
that thete is no politics in disease, and that our sanitary
authorities should be representative of the highest in-
telligence and scientific culture and research. They
should be above the reproach of having any politics in
their motives or their methods ; tbey should be typical
representatives of the best morals, intelligence, public
spirit and enterprise to be found in the community,
irrespective and regardless of party affiliation. They
should not be appointed simply because they are the
Grovernor's, the Mayor's or some City Father's
friends, but for their clean morals and their brains.
If disease only affected the small district or ward politi-
cian, no matter of what " kith and kin," we would
say. Let the filth pile up, dump the garbage at the
doors, dam up the sewerage, and be cheerful while the
funerals pass. But these tough men live on while filth-
diseases destroy the worthy and good.

The condensing of populations into close neighbor-
hoods renders cleanliness and perfect sanitary admin-
istration difiicult. This fact renders it the more im-
portant that the responsible work should be placed in
intelligent hands.

My experiences and observations have not been
confined to maternity hospitals, bnt have extended into
the homes of the well-to-do, the refined and educated.
They bad their beginning in alleys and courts densely
crowded with the poor; our best lessons, those of
most practical value, we gain there. These unfortu-
nates in their dire, distress ask no questions, imply no
doubts, but trust ; and we put to severest test our re-
sources, our best skill. The lessons we learn there,
we carry into the sick-chambers of the more fortunate.
My experiences and observations, therefore, have not
been entirely drawn from or confined within the limits
of a maternity hospital. I speak for maternities for
the reason Chat I believe that there should be more of
them, and that tbey should be better sustained. They
should be established, and put under the best of man-
agement, in every manufacturing and mining town, in
every centre of any considerable population.

It has not been long since the propriety of clodng
maternity hospitals in some of the cities of Europe
was seriously discussed ; by reason of their mortality
they were condemned. This was very prominently s
fact in Dublin not many years since, and was aimed
specially at the great Dublin Hospital. The beoefi-
cience of the maternity hospital prevailed over igno-
rance and prejudice. They are a great source of edo-
cation in one of the most important departments of
medical education ; but they have grown to be recog-
nised CO be something more than educational, as hu-
mane institutions and the most Christian of charities.

It will always be difficult to obtain full and accurate
statistics in private obstetrical practice, such ttatistici
usually being derived entirely from memory, no care-
ful record ^ing kept. It is alio difficult to always
obtain truthful and reliable statistics from many hos-
pitals. In the matter of the data bearing upon this
subject, we cannot do better than quote so eminent as
authority as Dr. Matthews Duncan, of England.

" To judge the hospitals aright, the proper course it,
evidently, to take the best as an example. We cannot
justly condemn all hospitals because in that of Leipzig
the mortality is one iu seven. We do not condemn
ovariotomy because in the hands of some surgeons the
mortality of it is nearly cent, per cent. We take the
practice of the best ovariotomists to judge by. To
judge of hospitals, let us take the Dublin Hospital
as managed by Collins. In seven years he had 16,-
654 births under his care. The mortality of mothen
was one in one hundred. When I take this example,
I must add that I regard it as not the best, but as s
itir, handy and well-known example. If all hospitali
are to be condemned, then this one must be condemned
(1 in 100). And I ask any obstetrican to oome for-
ward and cast the first stone. Several have already
come ; but, in future, if any one is bold enough to
come, he must tell us what is the mortality in his owo
practice, and he must consider whether or not his own
practice is comparable with that of a hospital which
receives the poorest, having among them drunkards,
the diseased, the seduced, and also cases of difficult;
in higher relative proportion than in ordinary practice.
The great Dublin Hospital, then, can show a mortality
of 1 in 100. Sir James Simpson has published the
mortality of two years of his practice ; it is 1 in 45, at
least. Dr. Cross had iu his practice a mortality of 1
in 98. I have had a mortality in* mine (Duncan's) of,
at least, 1 in 105. Dr. McClintock's is 1 in 108. Dr.
T. E. Beathy's is 1 in 121."

When we get really trustworthy and comparable
figures, how does hospital practice look ? I, at least,
cannot condemn it. I see no reason to doubt that it
may be, and has been good enough to compare with
any kind of practice. I know no good, large and un-
exceptional data of deliveries, which show results that
are better than those of Dr. Collins in the Dublin
HoBpit»l.

I would here acknowledge an individual profes-
sional debt, one shared in by the profession at large —
to that grand old man, the " Professor and Autocrat
of the Breakfast Table," Dr. Oliver Wendell Holmes.
We honor and love him for the delights we find in all
the pages of bis books ; for his many witticisms pointed
with great common-seuse ; for tbe elegant diction,
clothing the great thoughts, veiniug every page he has
written. We honor and love him the more for the
great truth* he has taught us, truths vital and guiding

Digitized by

Google

Vol. CXXX, No. 2.] BOSTOIT MBDIOAL AND SUBOIOAL JOURNAL.

35

in the practice of oor profession. When all that was
ever done, uttered or written, by a Hodge or a Meigs
has passed oat of human memory, ceases to be even
honored by traditional mention, that described by
Meigs as the "jejune and fizenless dreaming of the
sophomore writer " will live on. The grand old
" sophomore writer " lives to-day in a bright, cheerful
old age, filled with the sense of a useful and nobly
spent life, that his fellow-beings are the better for his
having lived ; honored of two worlds, and looking with
assured trust and confidence into the next. What a
depth of truth, what a deep touch of pathos in the fol-
lowing words of your loved New England Professor !
They are words that should be deep graven iu the
memory of every obstetrician : " No man makes a
qnarrel with me over the counterpane that covers a
' mother, with her new-born infant at her breast' "

TREATMENT OF SMALL-POX BY NON-AD-
MITTANCE OP THE CHEMICAL RAYS OF
LIGHT.

BT KIOH. ROOKBB, X.D., BO8T0H, MASS.

Am article in the Swedish medical journal Eira,

November 30, 1893, over the signature " F " sums

up what is at present known about the medico-practi-
cal significance of the ultra violet rays of light and be-
gins with a mention of Prof. J. E. Widmark's article
on " The Influence of Light on the Skin," published
in Hygiea (Stockholm, Sweden), 1889, in which Wid-
mark demonstrates that ecsema (erythema) solare is
caused by the ultra violet (chemical) rays of light
from the sun, and in which he, at the same time, ad-
vances the opinion that this eczema mast not be con-
fused with eczema caloricum, which is caused by the
influence of great heat. The latter usually develops
instantly and hastily, and traces of it disappear with
comparative rapidity ; whereas the sun-erythema, on
the contrary, first develops several hours, or even a
day after exposure, is of longer duration, disappears
after several days by scaling, and leaves a pigmenta-
tion.

In 1858, Charcot observed that the electric arc-light
could cause a skin disease which greatly resembled
sun-eczema. In the meantime it was reserved for
Widmark to strengthen, through a series of ^act ex-
periments, the observations of .Charcot, and to prove
that the ultra violet rays of light played the chief part
in the cause of eczema electricnm. Finally Widmark
quotes from Yeiel the history of a woman who suffered
from sun-eczema for a long time, which reappeared as
soon as she came into the open air, even if the sky was
clouded. She was not troubled by heat from a stove
or intense lamplight and Veiel concluded, therefore,
that the chemical rays were the cause. After Veiel had
learned from a photographer that he succeeded best in
excluding chemical rays of light by the use of dark
red paper, he allowed his patient to go out in full sun-
shine when wearing a red veil. The experiment suc-
ceeded and she could remain out-of-doors for forty
minutes at a time without inconvenience.

Through his experiments Widmark arrived at the
conclusion that the ultra violet rays (whose caloric
energy may be so little that it can scarcely be meas-
ured by the most sensitive instrument, and whose
power, of irritating the retina is so weak that it is only
perceived by our eyes when the rays of light are en-

tirely shut out), do develop pathological processes on
the surface of the body, in case they are of sufficient
strength.

In the JBospital* Tidende, No. 27 (published in
Copenhagen), appears an article concerning " The In-
fluence of Light on the Skin," by Prosector N. R.
Fiusen. After relating Widmark's experiments and
proofs that the ultra violet rays of sunlight produce
eczema solare in an acute form, some observations of
Unna are related, which show that pigmentation in
such a case is the result of a chronic influence from
the same light, and forms a protection for the skin.
It is further shown from a paper in the Lancet for
1867, by C. Black, that the latter has employed non-
admittance of daylight with remarkable success during
a small-pox epidemic, and that Black's observations
were endorsed by Barlow and Waters (Lancet, 1871).

On the strength of the foregoing and our present
knowledge of light as an irritant of the skin, Finsen
advanced the opinion that in place of complete ex-
clusion of daylight from the small-pox patients, a
closely-drawn red curtain or a window of red glass
may be used.

"rhe proposition was soon put into execution ; for
only one month later. Dr. Lindholm, of Bergen (Nor-
way), wrote to Finsen as follows : " I am pleased to
be able to tell you that the proposed treatment of
small-pox seems to have a remarkable effect, inasmuch
as the cedema disappears rapidly, and the suppurative
fever does not appear at all." This applied to ten un-
vaccinated cases.

In No. 44 of the same journal we find a further
statement of the small-pox epidemic in Bergen, re-
lated by Dr. Svendsen, where the following occurs :
The clinical diagram of the cases treated in this way
shows the following deviations: "The stage of sup-
puration was avoided ; there was no increase of tem-
perature, no oedema, etc The patients went from the
vesicnlar stages, which seemed to me somewhat pro-
tracted, immediately to convalescence and were spared
disfiguring scars." Although the material is indeed
small, from which to prove the efiicacy of this mode
of treatment in all cases. Dr. Svendsen considers that
the results call for further trials of this simple and
harmless method. .But it must be strictly employed
and before the suppuration stage begins ; later its use
would be of no avail. A couple of test cases where
the patients were exposed to daylight, after exsiccation
began everywhere except on the hands, showed that
the vesicles there began to suppurate and left small '
scars.

In the same number of the JBbspitaU Tidende, Pro-
sector Finsen writes — in a new and longer treatise, —
" Concerning the Injurious Influence of Chemical Rays
on the Animal Organism," after having briefly recalled
the contents of the preceding article : " The so-called
chemical rays which have their place principally in
the blue and violet, but especially in the ultra violet
portion of the spectrum, are the most frangible raya
of light ; in them the chemical influence is strongest,
but the caloric influence at a minimum. The condi-
tion at the other end of the spectrum is just the re-
verse ; there the red and ultra red rays are the least
frangible, there the caloric influence is strongest and
the chemical influence at a minimum."

These two kinds of rays, the red and the violet, be-
ing representatives of the two extreme ends of the
spectrum, seem also to exert very dissimilar physiologi-

Digitized by

Google

36

BO SI ON MEDICAL AND SURGICAL JOURNAL. [Jamuakt 11, 1894.

cal influences. The violet seem to act with more in-
tensity, at least their inflaence is more obvious to the
eye; and nben ooe collects observations on the in-
fluence of monochromatic light on different organisms
and combines them, one finds that there seems to be a
common quality in all living organisms (perhaps with
the exception of vegetable growths), so that they are
affected disagreeably, even injuriously, by chemical
rays whenever these exist in snfiicient intensity.

As proof of this assumption, reference is made to
the power of light in destroying bacteria, in doing
which the chemical rays are most active. On the light-
shunning dew-worm red light acts as darkness, violet
as daylight. The same is the case with the protons.

The shiftings of color on the chameleon under the
influence of light depend on the fact that those cells of
the skin which are rich in pigments lie near the sur-
face when in light, but deeper when in darkness.
Paul Bert has also found that neither red nor yellow
light works upon these cells, but that both the blue and
violet light act so much the stronger. It has even been
shown that horses and horned cattle get erythema from
the chemical rays dn such portions of the body as lack
pigment — a fact which Widmark bad previously
proved concerning rabbits. The injurious effect of
the chemical rays on human beings has already been
stated.

The acnto effect (which is discernible macroscopi-
cally) presents all stages from slight irritation and
redness to strong inflammation with blisters which con-
tain liquid, and desquamation of the epidermis. The
stages depend on intensity, light and the quality of the
chemical rays ; and in this connection it is noticed that
of the artiflcial lights, lamplight contains relatively
fewer, but electric-light relatively more chemical rays
than sunlight. The stage further depends on the dura-
tion of the influence and on the greater or less pig-
mentation of the skin. Unlike every other inflamma-
tion which lasts the same length of time it leaves
pigmentation after it. It is distinguished from in-
flammation resulting from beat by its not appearing
immediately after exposure to that which causes it,
and that it reaches its climax a half or a whole day
later.

That the skin is most easily affected in spring de-
pends, says Finsen, on the fact that during winter time
the pigment wears away with the epidermis, and the
skin is left less protected in consequence. The bridge
of the nose and the cheeks are most affected. But
with glacier tourists who are subjected to reflected
light, the rays coming from below, the skin under the
nose and chin is most affected. Boat-racers get a
typical sun-erythema on their bared arms during the
spring, and the militia on their faces at the same
season.

The Bassian physician Maklakoff brought on a
severe erythema like that of the laborers when he wit-
nessed a smelting of metal by means of five hundred
accumulators. This erythema could not be ascribed
to development of heat, which was relatively slight,
which proves what Professor Widmark said of the
effect of the chemical rays on the skin (as previously
stated) to be true; that is, that it is not the caloric
rays, but principally the ultra-violet ones, that cause
the well-known effects of light on the skin.

Following this, Finsen attempts to search out the
histological processes of the inflammation in question.
To this end, he has made use of tadpoles, whose tails

he examined under a microscope after exposing them
to sunlight from which the caloric rays were excladed ;
thereupon the usual signs appeared in and around the
capillary vessels, but, besides this, the blood-corpnscles
changed from oval to round. It is well known that
light acts as a contractor on living protoplasms. Fin-
sen thinks the influence of light on the capillary ve»-
sels should be taken as explanation of the inflamma-
tory process in the skin. He bases this assumption
first and foremost on the fact that the pigment which
forms a means of protection from the chemical rayi
lies alongside the capillary cells, and, further on, the
fact that no living tissue absorbs so much light, and at
the same time such a mass of violet rays, as the blood.

" Now that we have seen," says Finsen, " what
strongly acute affections the chemical rays can pro-
duce, we can easily understand that even several
chronic skin troubles stand in relation, both as to eti-
ology and its subsequent course, to these rays. Of
such diseases, we already know pellagra, xeroderout
pigmentosum and Hutohinson's summer prurigo. Bat
as the chemical rays have been so recently recognized
as irritants of the skin, it is possible that the list of
such diseases will be extended.

'' In another category may be placed such diseases
as, without being etiologically dependent on the chemi-
cal rays, are unfavorably affected by them, and among
these we should place small-pox. It is impossible to
say at present whether in time we shall come to reckon
with the latter other exanthematic diseases or skin dis-
eases, but it seems not impossible when the chemical
rays can act so injuriously upon a healthy skin. At
to small-pox, we see by concurring reports, and most
recently that of Dr. Svendsen, that when the chemical
rays are shut out the vesicles dry up without becom-
ing purulent, and thus suppurative fever is avoided, in
consequence of which the disease is less dangerous, of
shorter duration, and, when ulceration is eluded, lest
painful. By this means scarring is obviated."

It seems to be nndisputable that on the exclusion
of the chemical rays depends the non-purulent charac-
ter of the vesicles and the changed character of the
disease. Still the author declares that a complete
explanation cannot at present be given. But while
awaiting further examination of the process, he thinks
it may be stated thus: the power of chemical rsyi
to prodflce irritation acts as a plus quantity, it in-
creases already existing skin inflammation and pro-
longs it, so that the conditions become more favorable
for the development of micro-organisms.

As the proposed treatment for small-pox is not, so-
cording to the author, a special thing for this disease,
but a new therapeutic principle, he recommends physi-
cians, especially those treating epidemic diseases, to
try its effect on other exanthematic diseases, sncb as
measles, scarlet fever and erysipelas.

As a last addition to this subject of treatment of
small-pox, an article appeared in Ho$pitatt Tidmde
for November 8th, written by the well-known medical
historian. Prof. Julius Petersen. "The interesting
communications," he writes, " of Prosector Finsen and
Dr. Svendsen have strengthened for me, as medical
historian, the old rule, which I often advanced, of the
constant working in a circle in medicine — a circular
movement which consists of the reappearance of the
old permanent principles, though newly applied and
fortified through the more exact investigations of the
present." Then he tells how it was customary, even

Digitized by

Google

Vol. CXXX, No. 2.J

BOSION MEDIO AL AND SUR610AL JOURNAL.

87

in the Middle Ages, to make use of red curtains and
cloths in the treatment of small-pox. For example,
in the "Rosa anglica" (abont 1300) of the English
royal physician Gaddesden, we read that when the
king's son had small-pox " everything ased around his
bed was of red, and that it is a good cure. I cured
him without pock-marks (sine vestigiis)."

When small-pox was rife in Denmark in the seven-
teenth century, Thomas Bartholin spoke of this recog-
nized method of treatment; and in the eighteenth
century Fouquet wrote from Montpelier that in his
childhood, *'on vetaissait les petits v^rol^s de trap
ecarlate et que Ton les tenait dans les lits formds des
rideaux de la mfime ^toffe." Further on, in the " en-
lightened period," the method was denounced as super-
stition, and was forgotten pntirely by historians of
medical practice. And there was no rational foanda-
tiou for its use. " It is," says Professor Petersen, in
closing, " investigators of the present day who have
the whole honor of having found an undeniably more
satisfactory and exact scientific foundation for the old
empiric fact."

»

€Itttical aDepactmetit.

A CASE OF UTERINE TUMOR.»

Br Da. E. W. CC8HIHO, BOSTOir.

Miss £., of New Hampshire, forty years old, came
under my care this winter with the following history :

Was well until six years ago, when a small tumor
was noticed, which increased gradually. There never
was any menorrhagia. She consulted various physi-
cians, both at home and in this city ; but from all she
received advice to wait and see if the tumor would not
disappear at the menopause. It has grown steadily
and rapidly, however, until now her condition is very
serious — health broken, heart rather feeble, digestion
impaired, respiration impeded. She realizes that she
cannot live much longer without surgical relief.

At present the patient is slight in figure and much
emaciated. The abdomen is occupied by a large tumor,
which is so soft as to give an indistinct sensation of
fluctuation. The pelvis is filled with the lower por-
tion of the tumor, which is smooth and not very hard,
and continuous with the uterus.

Diagnosis, probably a soft myoma.'

On opening the abdomen the tumor was exposed,
and as it seemed too soft for a myoma it was punctured
with a trocar, but no fluid escaped. Incision was pro-
longed, and the upper part of the tumor was delivered
through the opening. It was seen that the growth
had lifted the layer of peritoneum from the posterior
abdominal wall, and had separated the folds of the
broad ligament; so that the large intestine appeared
to be adherent to the tumor high on its posterior sur-
face. The apparent adhesions, however, were really
the insertion of the mesentery, as is often seen in such
cases, but not always understood at once.

The outer part of each broad ligament, with the
ovarian arteries, was tied off; but it was impossible at
this stage to tie the uterine arteries, as the tumor
could not be lifted from the pelvis. On each side were
several great veins, each larger than a lead-pencil.

To free the tumor, the thin capsule of peritoneum
and uterine tissue was divided by a circular incision,

• Bead before the Obetetrlcal Section of the 8li0ol)c Ptotrlet Medl-
ailSoeietf,

some four inches above the brim of the pelvis and well
clear of the mesenteric insertion. On the left side a
little spurt of clear fluid, from what appeared to be a
large vein, was noticed.

By enucleation of the tumor and clamping of vessels
the growth was lifted from the pelvis, and an attempt
was made to secure the uterine arteries for iotra-peri-
toneal treatment of the stump ; but, owing to the bulk
of the tumor and the size and variety of the vessels,
this method was abandoned, and a rubber tube was
used as a constrictor, the tumoi cut away, and the
stump treated extra-peritoneally, as usual.

When the tumor was removed a deep cavity re-
mained bare of peritoneum on each side, so thut at the
bottom of each side of the pelvis the iliac vessels were
visible. On the right was a large, tortuous tube, di-
lated in some places more than others. This had been
carefully avoided in tying off the vessels and separat-
ing the tumor ; and it waswell that it had been spared,
for its relation with the iliac vessels and with the
broad ligament in the region of the bladder showed
that it was the ureter.

On the left, near the iliac- vessels, 'where the ureter
should be situated, was found the cut extremity of a
large vessel which had already been ligated. This
was close to the ligature which had tied the ovarian
artery, but it was also close to the iliac vessels, the
peritoneum, which before had been pulled up, now
having retracted. Convinced that this vessel was the
ureter, I took off the ligature, and after some search
found the corresponding end ; and then came the ques-
tion what to do. I knew of no instance where a ureter
had been severed and united. Simon, on cutting a
ureter, had gone on and extirpated the kidney ; and
Greigg Smith advises this procedure. The patient's
condition, however, would not permit of such a course
at that time; and the choice offered was between
bringing the upper end of the ureter out through the
wound, leaving the extirpation of the kidney as a
future operation, or suturing the two ends of the ureter
together, hoping for union if possible, but providing
for leakage if it should occur. The latter course
seemed preferable, for I saw no reason why a ureter
should not unite as well as an intestine if properly
brought together, and I had had some experience
which led me to believe that the ureter had more ca-
pacity for closing a partial defect than is commonly
supposed. I therefore sewed the two ends of the
ureter together with two silk and one catgut sutures.
I was afraid to put in more, not being absolutely sure
that the distal cut end was really ureter, and also fear-
ing that more stitches would obstruct the lumen. I
therefore used the catgut, to hold if possible, and give
way if necessary.

AH this seems long to describe; but the decision
had to be made in a minute or less, and the suturing
did not take long. After thorough irrigation of the
abdominal cavity, I laid the ureter where I thought it
belonged, and pressed it against the floor of the pelvis
on the left with the middle of a square of iodoform
gauze, into which I packed strips of the same material
after the manner of Miculicz. The cavity in the right
side of the pelvis was similarly packed with gauze,
and a glass tube carried to the bottom of the pouch of
Douglas. The stump was fastened in the angle of the
abdominal incision as usual, and the tube and gauze
were brought out of an opening separated from the
stuqip by two sutures.

Digitized by

Google

38

BOSTON MEDICAL AND SURGICAL JOURNAL. [Janvabt 11, 1894

I now felt Bare that if the severed ureter should leak
I could lead the urine to the surface without danger to
the abdominal cavity ; and my plan, if all the urine
from that ureter came through the wound, was to torn
the current through the lumen of the cervical canal
into the vagina, and then later turn the extremity of
the cervix uteri into the bladder, and so finally lead
the urine where it belonged. Happily, this it not
likely to be necessary.

The patient did very well after the operation ; but
on the fourth day thtf discharge from the gauze on the
left side smelled ammoniacal. The gauze on the right
side and the glass drain had meanwhile been removed.
By the next day it was clear that some urine was
escaping from the abdominal wound. The amount
passed from the bladder had from the beginning been
normal in quantity. The last of the iodoform gauze
was now removed from the wound, and a rubber tube
carried down to the site of the ureter. By care and
some ingenuity the stump had been kept dry, and on
the tenth day it was cut away. The quantity of urine
escaping from the tube, which was never more than
three ounces during twenty-four hours, now diminished ;
and the tube, which had been shortened, was taken out
about the fourteenth day, the whole wound treated
with balsam of Peru and covered with gause and ab-
sorbent cotton.

The patient is now sitting up, and wets one napkin

over the wound during the day and one during the

night. I have taken care to preserve the patency of

the cervical canal, and have closed in the skin so that

the opening of the urethral fistula is close to the upper

end of the cervical canal. The discharge is slight,

however, and I hope it will finally cease without

further operation.

NoTB. — November, 1893, tbe patient wrote that the fistula
had closed entirely, that she was in perfect health and able to
take active exercise of all kinds.

RECENT PROGRESS IN ORTHOPEDIC SUR-
GERY.

BT E. H. BBA.DFOBD, H.D., AND B. O. BBACKETT, M.D.

(Concluded from No. 1, page II.)
SPASMODIC TOBTICOLL18."

HoFFA has collected the recent literature on this
subject, and reports the opinions of the different writers.
Paralysis of the sterno-cleldo mastoid follows tbe
Ofieration of section of tbe spinal accessory nerve.
Cure of the spasm does not usually follow immediately
after the operation, as slight spasm of the other
muscles follows, but these secondary spasms gradually
diminish and in time entirely disappear. If this is not
the case. Keen advises the section of the posterior
branch of the cervical nerves. A bead support is
needed for several months after the operation, and
the employment of massage is advised.

SCIATIC SCOLIOSIS."

Fischer and Schonwald give observations on seven-
teen cases, and describe the two forms which occur ;
the one, tbe homologous form in which the concavity,
and the other, the heterologous, in which the convex-
ity is toward the affected side. The former is caused

" Zeltxchrirt for Orthopedic Sarger^, 1«92, p. 316,
'Vieaer med. Woob., 1803, No*. 16 and 21.

by a condition of irritation produced through the short
anterior branches of the lumbar plexus, and when
there is no implication of the lutnbo-sacral miucle.
The second type is caused by a weakness of the sacro-
lambar muscle which is due to affection of the posterior
branches of the plexus supplying it. When both
groups of nerves are affected, either variety u assumed,
the one or the other predominating according to whether
the disease affects one or the other to a greater or lesi
degree. The second form may develop rapidly in
those cases where the anterior branches either are not
affected or only to a light degree, and it may also de-
velop when the pain becomes located in this region,
in those cases which appear early as tbe first variety,
When both sets of nerves are affected to the same
degree, the patient attempts to assume whichever ttti-
tuae gives most ease, and the form may not then be well
marked, but if improvement occurs in one or the other
groups, the variety then becomes well defined.

In general, it can be said that the irritation of the
anterior branches causes the homologous variety when
the Inmbo-sacro muscle is not affected. The hetero-
logous variety occurs when this muscle is weak.

The following differential diagnosis is given : In the
second, the patient complains of fatigue in the back,
before the onset of the disease, during extension of the
spine, while this symptom is wanting in the homologooi
form. Also the heterologous form is prolonged be-
yond the period of pain, on account of the weakness of
the saoro-lumbar muscles, whereas the homologoni
disappears with the pain. The heterologous form
never changes to the homologous, while the reverse
often occurs suddenly. Both varieties have, however,
one symptom in common, namely, that of the forward
inclination of the trunk. In the second variety it ii
due to the action of the sacro-lumbar muscles ; in the
former, to a relaxed condition of the muscles supplied
by the anterior branches of the lumbar plexus.

Other references to this subject may be found, by
Higiea and by Bemak."

hoffa's operation fob conob.vital dislocatioi

OF TUB hip-joint."

Denuce, of Bordeaux, reports a case in a child of
six, operated upon by him. The child entered the
hospital September, 1891, with characteristic deformity
of the hip. The left trochanter major was three
centimetres above the Melaton line, while the right
was upon that line. According to the statement of
the parents, the shortening had increased.

An incision was made seven centimetres long, parallel
to the axis of the femur, reaching four centimetres
above the top and three centimetres below. Tbe
muscles were divided in the course of the fibres of
the glutaeus maximus, tbe capsule laid bare and in-
cised The insertion of the muscles on the great
trochanter was then divided with scissors. Tbe bead
of the femur was found to be slightly flattened and
oval in shape ; some granulations were present at tbe
point of the insertion of the round ligament, which
was entirely wanting.

If traction was made upon the foot the head could
be pulled down somewhat, but not sufiicieutly to place
it in the cotyloid cavity. The muscular insertion of the
pyramidalis, the obturator internus and the gemelK
were pushed backwards, and a portion of the cartilage

" Deotsch. med. Wooh , 1892, 27.
" Berne d'Orthopedle, p. 108, 1S93.

Digitized by

Google

Vol. CXXi, No. 2.] BOS f ON MEDWAL AND SURGICAL JOURNAL.

d9

of the great trochanter was cat at the point of mutcn-
lar insertions. After this, the head of the femur could,
under traction, be palled downward. The cotyloid
cavity was found to be small and of a triangular shape.
The loose tissue in the cotyloid cavity was incised to
the bone, and a flap detached with the periosteal ele-
vator (curved on the flat), leaving the upper portion
undivided and attached. This flap was raised by means
of a silk suture passed through the edge, and the head
of the femur was reduced underneath this cartilaginous
flap into the cavity. The cavity was deepened by
means of a gouge, and after the operation it was found
that the bead did not have any tendency to slip out of
its new position. The capsules and flaps were sewn
together. A traction by weight of four pounds was
applied. The muscles, cartilages and the capsules
were sewed with catgut, and a slight orifice left for
drainage. The skin was sutured by silk. Iodoform
gauze dressing. Plaster-of-Paris bandage was applied.

The temperature was raised the night following the
operation and on the following day, but afterwards
dropped. The patient was allowed to walk on the
30th of October, and it was found that the lordosis had
entirely disappeared. The 15th of November the pa-
tient was again seen, and was found to walk well.
The patient was allowed to walk without crutches on
the 10th of November, and when seen a year after the
operation, the patient was in good condition. There
was no lordosis, and but little scoliosis ; the muscular
atrophy had diminished ; the head of the great tro-
chanter was not above the Nelaton line. The differ-
ence in the length of the legs was about two centi-
metres, having been five centimetres before.

Lorenz *' reports an operation on a child of seven,
and does not agree with Hoffa in thinking that the
contraction of the muscles is the chief binderance to
the reduction of the dislocated head, but the muscles
which arise from the tuberosity of the ischium ; that
is the adductive group. He considers that the reduc-
tion can be facilitated by myotomy of these muscles,
and that the joint should be opened from th.e front,
and reports four cases operated upon in this way. In
one, a child of about five years of age, the reposition
took place without opening the joint. One of these
patients was flfteeu years of age.

Karewski " disagrees with both Hoffa and Lorenz,
and ihiuks the difficulty in reduction lies chiefly in the
head of the femur and in the improper shape of
the acetabulum. He reports five cases. In most of
the cases the head remained after operation in the new
socket. An equality of length of both limbs was not
gained, through the faulty formation of the neck.
The good results were obtained by the use of appliances
carried out for a long time. In two cases, where the
apparatus was worn only three months, the head was
dislocated upward again. In two, where the treat-
ment was thoroughly carried out, the gait was almost
normal.

Karewski enlarges the acetabulum by means of a
chisel, dividing the cartilaginous tissue over it to make
a place for the head. In a few instances he has driven
a nail into the ridge of the acetabulum, keeping it
there for six or eight days.

Hoffa, in the same publication, replies to both these
surgeons, and states that he has operated in 24 cases,
and that the definite results will be published. He

<• Centralblstt fttr Cblrargle, ISSS. No. SI.

» ZaltMhritt tor OrthojHBdisobe CUrorgle, 18(2, Bd. 11, Heft 8.

prefers an early operation, and claims satisfactory
results. He does not think that the resistance of the
adductor muscles is of importance, or that in all cases
there is a faulty shape of the head of the femur to an
extent of preventing reduction.

Nota," of Turin, has operated by the method of
Paci upon 12 oases, of which five were doable and
seven were single ; that is, he has operated eighteen
times, eleven with good, one with partial, four with
negative, and two with doubtful results. He thinks
that a cause of the difficulty of a permanent cure of
the deformity sometimes lies in the faulty shape of the
pelvis, which is either too flat or too oblique, and that,
combined with a shallow acetabulum aud a rudimen-
tary edge, promotes dislocation after reduction of the
deformity. Nota regards an apparatus as necessary
after the operation, and thinks that good results are
largely due to this. He regards it necessary to retain
the limb after the forcible redaction (the method of
Paci) in a position of extreme forcible rotation out-
wards.

Panzeri is not convinced of the value of the method
of Paci, as he does not see how the development of a
new joint can be brought about simply by violent re-
duction.

Oliva is of the same opinion, and mentions a case in
a girl of twelve operated on by him according to
Hoffa's method without positive benefit, though he
favors this operation in young children.

Panzeri prefers the operation of Hoffa in children
from three to fourteen ; in old cases the results are
not good. Under three, he would advise the method
of Paci and mechanical treatment.

SCOLIOSIS.

Wisser*^ has investigated the deviations of the
spinal column in 515 school-children. These children
were from seven to eleven years of age : 292 boys and
293 girls. Tables are given to illustrate the observa-
tipns. At the beginning of the school-year a large
percentage of habitual curvatures were discovered ;
some of them of the typical form, others of various
curves. He also found that a larger percentage of
carves was found in the boys thau in the girls at the
age of seven. The percentage of curves he found to
be 41 per cent, of the boys at the end of the first
school-year, and 33 per cent, of the girls. The second
and third year the number had increased from 40 to
49 per cent. The increase in pathological cases was
not in proportion to the longer course of study, and
for that reason he concludes that the school is only
one of the factors in the development of scoliosis.

Redard ^' calls attention to the connection between
scoliosis and flat-foot. He finds this common in pri-
mary lumbar scoliosis on the side of the convexity
where the lumbar curve exists.

Heusner '* considers that there is a definite relation-
ship between flat-foot and deformity of the lower ex-
tremities and the existence of scoliosis, and farther
claims that the element of rickets is an active one, not
in children alone, but during the period of adolescence.
He gives a series of observations from which his deduc-
tions are made, having examined 1,000 patients at
Barmen, of whom 835 had scoliosis; 283 of these

» Zeltnbrlft f. Orthop. Ohlr., 1893, p. 273, Bd. It, Heft 3.
" Ceniralblatt Zeltsebrlft fUr Ortbopndirche Cblrnrgie, p. 398,
Bd. II, Heft 3.
» Quette Medical de Paris, Angiut 8, 188?.
■■ Compte renda da 21 Oongrta de Ohlrorgte Allemand, 1892.

Digitized by

Google

40

BOSTON MEDlCAl ASJ> StJROtOAL JOUMSAL. [Januast 11, 1894.

showed a flat-foot Of 663 men, 288 had scoliosis ; of
8S7 women, 147. Of the 283 patients hariog flat-
foot, 167 bad scoliosis ; and of 717 patients without
flat-foot, only one-fifth showed deformity of the back.
He also examined 250 infants at .the orphanage, and
found among these 64 with the back deformity, and 65
with flat-feet. Of the 65 cases of flat-foot, there were
24 which showed back deformity ; and of 185 children
without flat-foot, there were only 40 who showed a
lateral curvature. Of 143 boys, 26, and of 107 girls,
28, showed a lateral curvature.

He considers that the treatment by muscular exer-
cise to be of paramount importance, and useful in all
cases ; but, in addition to this, he employs the t^ea^
ment of correction by mechanical force, and for this
uses an apparatus which he describes and pictures in
his book. This consists of an inclined plane, on which
the patient rests, at the same time having head-suspen-
sion, and by means of broad leather straps weighted
by sand-bags, pressure is made on the curves in the
direction of correction, and this carried out for an
hour or two every day. While in the apparatus ef-
forts are made at forcible inspiration.

Schede " describes his apparatus for forcible correc-
tion. Schulthess comments upon this, and states that
he has seen better correction by means of this appliance
than by that of Lorenz. Schede reports excellent re-
sults, and mentions the almost entire disappearance of
projection of the ribs in a sixteeu-year-old child under
the use of this appliance.

Messner ** reports in the case of a twelve-year-old
child a year after infantile paralysis the development
of a paralytic curve, although the muscular paralysis
had apparently passed away. The appearance was
exactly as if the right side of the thorax had been im-
perfectly developed, and this seems to be proved by
measurement. The difference between this and the
ordinary scoliosis lay in the less amount of rotation.
The treatment consisted in massage and electricity.

Xleportjtf of j6ociettejtf*

SUFFOLK DISTRICT MEDICAL SOCIETY.
OBSTEl'RICAL SECTION.

O. H. WASHBUBN, M.D., SECBBTABV.

Rboular meeting Wednesday, February 22, 1893,
De. F. H. Davenport in the chair.

Dr. Joseph Price, of Philadelphia, read a paper
on

OBSTETRICAL ASEPSIS.'

Dr. Euha L. Call : The lying-in department of
the New England Hospital was established in Novem-
ber, 1862, and from that time till October 1, 1892,
8,259 patients have been delivered there.

In order to mark the progress of modern methods,
in its effects on the health of maternity patients, it will
be convenient to divide the work done into three
periods of ten years each.

During the first ten years, namely, from 1862 to
1872, the hospital consisted of three small houses on
Pleasant Street. The wards were necessarily crowded
and inconvenient and the general surroundings not of

> See page 32 of tbe Joamal.

X Dentaohe Med. d'Oftbopedie. No. 12.
» Ceutralbl. Obirargie, 1SU2, Mo. 44, p. 9T.

the best. At this time the hospital was the only lying-
in hospital in Boston, and consequently receiveid in
emergencies many patients brought by the police from
the worst parts of the city. The use of the clinical
thermometer was quite unknown, so that we did not
have the aid of that valuable danger-signal, while the
employment of antiseptics in the modern sense of tbe
word was not understood.

During this period 1,009 women were delivered,
with a mortality from septic diseases of twenty, or
about one case in fifty. These fatal cases occurred
chiefly in two epidemics, one in 1867, the other in
1872. Id addition to the twenty fatal cases there were,
of course, a still larger number of septic cases, which
after varied periods of illness, escaped with their lives.

In 1872 the hospital was removed to Roxbury, and
a new cottage was built especially for the maternity
cases. Temperature records were kept, and very
early in this period, the use of carbolic acid for hands
and in douches was begun. During the latter part of
the period, frequent douches with carbolic acid, per-
manganate of potash, phenol, etc., were a part of the
routine treatment of every case.

From 1872 to 1882 the number of cases was 1,026,
with nine deaths, the mortality being reduced to one
in 114. Nevertheless the records give us nearly every
year cases of sepsis that were only pulled through with
anxious care. There was no decided epidemic during
this period, which was probably due largely to tbe fact
that in 1879, an annex cottage was added, to which
septic cases were at once removed and cared for by
separate doctors and nurses.

In 1882 the maternity cottage was closed and thor-
oughly repaired and replumbed, since which time the
records have been much more satisfactory.

From October, 1882 to October, 1892, among 1,224
cases (200 more than the other periods) we have lost
but two patients from septic diseases, reducing our
mortality to one in 612. These two deaths occurred
in 1884, since which time we have had 897 cases with-
out a death.

In the latter part of 1886 the use of antiseptic pads
and of bichloride solutions for personal disinfection
was established, and has been continued, with slight
modifications, ever since. Patients receive an anti-
septic vaginal douche at the beginning and end of
every labor, and an intra-uterine douche after compli-
cated labor. After labor the antiseptic pads, with
irrigation of the external genitals before ftnd after
each urination, and rigid disinfection of the hands of
the attendants before and after touching each case, is
practised. If fetid lochia appear, bichloride vaginal
douches are ordered ; if this is accompanied by chill
or decided rise of temperature, an intra-uterine douche
is given. If the symptoms do not quickly subside,
cnrettement of the internal surface of the uterus is em-
ployed.

Since this method of treatment has been followed,
the number of cases which we have been obliged to
isolate has steadily diminished. Most of these cases
have occurred among patients who have come to us in
depressed conditions of health, and their removal to
the annex has stopped the trouble. Thus, during the
last three years, we have had one case of septic peri-
tonitis, and two of extensive diphtheritic deposit, oc-
curring in different years. Not the slightest trouble
among the other cases resulted from these.

In the spring of 1892 we again removed to oar new

Digitized by

Google

Vol. CXXX, No. 2.] BOSTON MSDIOAL AND SVSGIOAL JOURNAL.

41

** Sewall Maternity," which has been fitted up with all
the latest sanitary appliances, and where we hope the
next ten years will give os still better records, than
those of the past.

Dr. J. G. Blake : I have listened with pleasure to
Dr. Price's paper. Daring the twenty years preced-
ing the last ten I had a large number of cases of labor,
and during that time there was but little attention paid
to antisepsis. I must say that I was singularly fortu-
nate, however, and had but a small mortality. The
great benefit resulting from it has been conclusively
demonstrated by the results in the Lying-in Hospital.
I think that favorable as they have been in the New
England Hospital those of the Boston Lying-in Hospi-
tal are even better. We all remember the paper of
Dr. Richardson in which he showed that in one thou-
sand births they had had no death ; and that, in fact,
any rise of temperature more than one or two degrees
was of rare occurrence. Unfortunately, in private
practice the necessity foe antisepsis does not seem to be
recognized. This was brought forcibly to my atten-
tion in the uterine ward of the City Hospital, where
during the last summer term of service I was called
upon to curette eight or nine cases where patients had
bad chill, and offensive lochia and all the conditions
pointing to septic poisoning. Under the treatment
which we all recognize now, and which it is not neces-
sary to speak of in detail, I believe we had no death.
One woman came in in a condition which precluded
recovery. If it could be made a legal obligation that
doctors and midwives should be compelled to fully
carry out antiseptic precautions, I think a great many
lives would be saved to the community. Of course,
amongst a certain class of physicians such measures
are taken, and the mortality has steadily diminished ;
but unfortunately a large number do not fully appreci-
ate the necessity. I believe I took that side of the
question myself in the Obstetrical Society some years
ago. I argued that you had susceptibilities on the
part of patients, and you could not avoid septic poison-
ing. Dr. Richardson's paper cleared my mind of that
cant ; and I am a strong and earnest believer in the
absolute safety attending' it. If I had my way, I
should make it a criminal offence if complete antiseptic
precautions were not always taken.

I want to thank Dr. Price for myself and for those
who were present at the operation at St. Elizabeth's
Hospital this morning, for the careful, painstaking,
minute carrying out of all the details of what to me
was the most perfect operation I ever saw.

Db. Price : Bostou has done more, perhaps, than
any educational centre in our country for saving
women. The work of Dr. Richardson and a few
others cannot be estimated. It would be difficult also
to estimate that great contribution of Dr. Homans.
Hundreds and thousands of lives have been saved by
it. I want to suggest that you read more papers. 1
fiud the profession ignorant regarding the simple pre-
cautions of cleanliness. In saying this I am not criti-
cising Boston or Massachusetts in particular.

I am glad to hear the results in the New England
Hospital. Two deaths in twelve hundred cases is
hard to beat. If that means two deaths from septic
cases it probably can be beaten.

The history of maternity hospitals, mixed and spe-
cial, is exceedingly interesting. The mortality has
varied from one to forty per cent. Several maternity
hospitals have been closed. A satisfactory solution

of the shocking mortality in some hospitals can be
reached when we look into matters a little. For in-
stance, in one hospital a large sponge was used for
months and years sponging patients off after delivery.
This indicates that gross carelessness aud reprehensible
filth existed in many maternity hospitals. Some of
the old nurses washed their hands superficially once a
day. The towel was washed perhaps once a week.
In the mixed hospitals the resident physician attended
to a patient with erysipelas, and went without washing
the hands to attend to a woman in labor.

I have always felt, and still feel, that maternity
hospitals should be used wisely for educational pur-
poses. The rich have to take care of the poor, and I
feel that the pauper element of society should be
wisely and humanely used for educational purposes,
that we may have more finished physiciiiDS and more
good work, and we will not attain that acme of perfec-
tion in any specialty until we have that condition of
affairs, until directors and trustees realize the impor-
tance of practical education in every public institution,
and until all material of chat class be used wisely and
humanely for educational purposes.

Dr. Price then spoke of the details of the work in
the out-patient department of the maternity hospital
with which he was connected. Out of eight hundred
cases a year attended by the students among the poor
of the city, there were sometimes one or two genuine
cases of child-bed fever. Usually these cases could be
traced to some neglect of cleanliness on the part of
the student. In some instances scrupulously clean
men had attended women in labor after caring for
surgical cases, and without mischief. He had himself
attended women in labor after treating all sorts of con-
tagious diseases, and had never seen any harm arise
from it. He saw no danger in this, provided a man
kept himself scrupulously clean.

At the Retreat in Philadelphia patients were ad-
mitted two weeks before labor, and remained four
weeks after. This he considered very important. The
plumbing was entirely out of the building, which was
also a very important matter, and the effect of which
could be seen in the temperature charts. Patients,
upon being admitted, received a thorough bath, were
given a laxative, and, if there was a suspicion of renal
trouble, the urine was examined. The patients receive
two soap-baths weekly ; the bowels are kept opeA ;
and they improve wonderfully in general health. The
patients admitted two weeks before labor always do
better than those admitted in labor. When a patient
complains of labor pains, she receives a bath and a
vaginal douche of corrosive (1 to i!,000), and goes into
the clean delivery room. The toilet is made by a
nurse who has nothing to do with puerperal wards.
Both nurse and physician bathe before entering the
room, and scrub again after entering. But one exami-
nation is made, if everything is favorable, until the
head is ready to clear the perineum, when the physi-
cian sits down and superintends the delivery. After
the delivery a vaginal douche is given, aud the patient
receives the occlusion dressing of Dr. Richardson.
Nothing short of extravagance in maternity work will
give a nil mortality. In the Retreat, out of 1,200
cases, there has been no death from any cause.

" I regard vaginal douches important, particularly in
women with a relaxed vaginal outlet, iu order to pro-
tect the child's eyes against acrid and irritating dis-
charges; and if specific viras lurks there, it is the

Digitized by

Google

42

BOSTON MBDIOAL AND SURGICAL JOURNAL.

[Jancart 11, 1894

more important that we shoald protect the eyes of the
infant. If every woman in Massachusetts should re-
ceive in the next ten years the antepartum douche,
and receive the same toilet as at the Retreat, you
would reduce your blind asylums from five to one in
the next ten years. All dirty instruments, and the old
dirty bag which has been carried ten or fifteen years,
shoald be discarded."

Dr. £. W. CcsHiNO described °

A CASE OP DTERIME TUMOR.*

Dk. Pri'ce: This subject of hysterectomy I have
been much interested in. I almost feel like apologiz-
ing now for a big tumor. This operation has been
criticised considerably lately, and I want to say in all
fairness to the operation that I know none giving me
at least better results. I consider the early removal
of the appendages in disease one of the most valuable
operations in surgery. After the tnmor grows large
it becomes a very formidable operation. The size of
the tumor impairs the health of the patient by inter-
fering with breathing and by producing pressure symp-
toms. These growths seem to be on the increase.
More of them grow now after the menopause than
years ago. I have two or three patients now who have
waited for the menopause, and have had the benefit of
well-directed palliative treatment; and these growths
have continued to grow, notwithstanding the menses
ceased four or six years ago. I have removed a good
number of these tumors between the ages of fifty and
sixty ; and the cedematous form, the muscular form
and the multinodular form seem to grow more after
the menopause than they did years ago. That has
been the observation of a good number of operators at
home and abroad. A few years ago but little was
said about the soft variety of myomas. At present
about every operator has something to say about the
(edematous forms. They grow rapidly, they are quite
symmetrical, and, as a rule, very easy to deal with.
It is a quick operation.

Dr. Gushing has alluded to injuries of the ureter.
I believe Keith severed one or both in one case. Mr.
Tait opened the bladder in a hysterectomy he did in
Albany. The bladder injuries, if the patient lives,
always close; but the ureters do not close so kindly,
and they are hard to manage. I have had injuries of
the ureters in two cases out of 101 supravaginal hy-
sterectomies. Dr. Gushing has called attention to the
method of dealing with these capsules. Uutil one
learns how to make a pedicle, he had better keep his
bauds oS of them. It is of vital importance first to
learn how to make a pedicle; and if you cannot make
pedicles, you cannot deal with them succpssfully ; you
are apt to include bladder or something in the pedicle.
I am satisfied from my own experience that you should
never use a temporary clamp, that you should simply
use a large, long-bladed, heemostatic forceps, and never
a constrictor before severing this great capsule. I am
satisfied that many of the early operators included one
or both ureters in the pedicle, and that to that may be
attributed some of the deaths from so-called suppres-
sion, etc.

Dr. H. W. Gcshing showed two tubes and ovaries
removed on account of inflammatory trouble. The
tube on the left side was largely dilated, and there was
an abscess situated apparently in the left ovary. This
communicated with the vagina and with the rectum.
> S«e page 3T of the Joomal.

It was removed by enucleation, breaking up adhesions,
ligatiug and cutting oS. Two small fibroids were
also taken from the uterus of the same patient.

Dr. £. W.GcSHiMO showed specimens of pus tubes.

Dr. Price : Our present idea of the pathology of
pelvic inflammatory troubles baa been slow in gaining
ground. In New York I do not believe they have as
yet accepted it. It would seem from what they are
doing at present that every woman suffers from endo-
metritis, that every patient must be curetted. Now,
in the presence of those huge abscesses, of course, the
woman has a discharge. lu this case the woman did
discharge from the bladder and bowel. Why not
curette the bladder ? The indications are as clear as
for curetting the uterus, and yet that goes on for this
condition of affairs in New York. There is but one
treatment in these cases. As yet I have never found
a pelvic abscess wholly independent of ovarian disease
except in traumatism or criminal abortion. A good
number of these cases are treated for typhoid fever,
appendicitis, dysentery, etc. They are not examined.
There has been of late a good deal of conservative talk
and writing; but as this conservative talk goes on,
the complications increase and our cases are getting
worse. They are neglected. All this talk means a
higher mortality for all of us.

THE NEW YORK ACADEMY OF MEDICINE.
SECTION ON ORTHOP^SDIC SURGERY.

Stated Meeting, October 20, 1893, W. B. Towm-
8END, M.D., Ghairman.

A CASE OF CLUB-HAND AND CLUB-FOOT.

Dr. Reginald H. Satre presented a little boy
with a congenital club-hand. There was an absence
of the thumb, radius, and certain of the carpal bones,
and also a marked curve in the ulna. This last was
corrected by subcutaneous osteotomy. Some weeks
later, an open incision was made, and it was found that
the ulna did not articulate with the carpus, and that
there were some ligamentoas bands which bound down
the baud at right-angles to the forearm. These bands
were divided, and an attempt made to bring the hand
down, but the flexor tendons, particularly the flexor
carpi radialis, were so short that it was not practicable
to bring the styloid process clear of the carpus. He
then removed the os magnum and the unciform, cut off
the styloid process of the ulna, and put the bone into
the cavity thus formed. Another time he would not
destroy the ligaments on the posterior part of the car-
pus, on account of the difficulty experienced in keep-
ing the bone in place. . There is still a noticeable ten-
dency for the hand to turn to one side, as there is a
very small surface on the ulna out of which to make a
wrist-joint.

He bad seen a picture of a similar case where the
carpus articulated with a facet on the side of the ulna,
making a good joint. Under such circumstances, one
might cut the ulna just above the articular surface, and
torn it at right-angles to itself, thus bringing the joint
surface in its normal position.

His patient also had a congenital club-foot, which
was operated upon before the hand was treated,
by the use of subcutaneous incisions and Bradford's
instrument. This boy also had a curvature of the
spine, and the right upper and lower extremities

Digitized by

Google

Vol. CXXX, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL.

48

seemed to be more developed than those on the other
side. Since the deformity of the foot bad been cor-
rected, there had been a notable improvement in the
lateral curvature.

The speaker said he had only seen five cases of club-
hand. In one case under treatment at present, an in-
fant of three or four months, plaster-of-Paris dressings
are applied, and changed at short intervals ; and be
expected a fair result. In the other cases there were
simply contractions of the tendons, bat the skeleton
was apparently normal.

▲ CASE OF MYOSITIS OSSIFICANS, WITH MULTIPLE
EXOSTOSES.

Dr. v. p. Gibnet presented a boy, ten years of
age, who was admitted to the Hospital for Ruptured
and Crippled for the first time when five years old.
At that time a diagnosis was made of myositis ossificans
affecting the levator anguli scapulss. He was taken
into the hospital with the idea of severing the strip of
ossified muscle, but the parents would not consent to
the operation, and removed the child. He did not re-
turn until last spring, when he was seen by Dr. Town-
send. He stands with his head tilted a little to the
right ; the upper extremities are bowed so that the
thumbs touch, and the elbows are separated some dis-
tance from the sides. There is a bony enlargement
springing from the middle of the jaw, about the size
of a split pea. He is able to bring his neck up to a
vertical bearing, but his head soon falls down into the
position already noted. The rotation of the head is
limited to a very small arc, about ten degrees. The
right clavicle has an extra curve at its outer half, the
greatest convexity being toward the spinal column.
The outer end presents an appreciable enlargement,
while the sternal end is subluxated forward and seems
to be ankylosed. The left clavicle presents an unus-
ual curve throughout its whole extent, the convexity
being towards the neck. Springing from the middle
is a bony, irregular mass, elevated half an inch. The
base of the tumor spreads out into the clavicular por-
tion of the pectoralis major, and continues into the
pectoral portion, terminating in an irregular mass in
the anterior wall of the axillary space, deepening this
space very much. Over the articular surface of the
second rib with the sternum is a small exostosis, which
shades off into the mass just mentioned. There are
similar exostoses over the sternal end of the third and
fifth ribs. There are no such bony musses on the right
side. The respiratory movements of the thorax are
limited. Beginning about the middle of the fifth rib,
just in front of the axilla, is a bony enlargement,
triangular in shape, which extends backward and down-
ward, taking in the whole area of the latissimus dorsi
and the serratus magnus. He was re-admitted to the
hospiul on March 9, 1893. With the idea of freeing
the shoulder, the bony tendon of the latissimus dorsi
on the right side was divided, and a piece of bone
about one inch wide and very dense and hard was ex-
cised, but new bone was thrown out very soon, and the
mass became if anything more unyielding than before.
There was also a peculiar osseous tumor over the
right tendo-Acbillis, about the size of a peanut, which
interfered with his wearing a shoe. This was dissected
out at the time of the other operation, and has not re-
curred.

About the time of this operation an old case returned
which he presented to the Pathological Society many

years ago. An account of it was published in the
New Tork Medical Record, 1875, Vol. X, page 747.
She was at that time ten years of age, and first came
under his care on September 14, 1875. She bad been
perfectly well up to December, 1874, when she had an
attack of diphtheria, followed by paralysis of the vocal
cords. The muscles involved in her case were the
latissimus dorsi, the scaleiii, and the erector spinas.
Her right arm was held down by the tendon of the
latissimus dorsi, and she suffered more or less pain in
her back. There was also a lateral curvature from
lack of muscular tone. At the suggestion of some
members of the Pathological Society, she was put on
lactic acid ; and though no real improvement was noted,
it was observed that after a year and a half there had
been no further increase in the disease. Since 1884
she has been working at millinery, and the disease has
made no further progress.

The boy just presented has been taking lactic acid
for the past six months. He has had very little pain.

The speaker said that so far as he had been able to
ascertain, the first American case of this kind was
published by Dr. Byers in the New Orleans Journal of
Medicine in 1870. The first reference to the subject
which he had found in literature was by Bulhak, who
published a dissertation on the subject in 1860. Kum-
mell has reported a case where the ossification probably
began in intra-uteriue life, since it was noticed as early
as fourteeu days after birth. When the child was two
years of age, there were numerous fluctuating tumors
over the back, which ultimately became as hard as
bone. Nothing is known of the etiology. There is
no traumatic element in the case presented by him.

Db. N. M. Shaffer said that such cases must be
very rare, as this was the first of the kind he had ever
seen. He would suggest that the electrical reactions
of all the muscles be determined, also the condition of
the reflexes, and that a critical examination be made
of all the organs. He would classify it as a nervous
disease, the changes in the muscles being the result of
pathological changes in the central nervous spinal
system.

the treatment of club-foot BTWOLPF'S METHOD.

Db. a. B. Shands read a paper on this subject, ex-
hibited a number of illustrative cases, and gave a de-
monstration of the manner of carrying out the treat-
ment.

Dr. Shaffer asked how many of the patients had
been operated upon prior to the adoptiou of Wolff's
treatment.

Dr. Shanos replied that most of them had been
operated on previously, but in one of the cases ex-
hibited no operative treatment had been employed.

Dr. Shaffer said that the principle embodied in
this treatment was one which he had taught for a long
time. By this method one accomplishes with plaster-
of- Paris what he had long done, and he thought in a
more thorough manner, with his lateral traction shoe.
With lateral traction a certain amount of force is ap-
plied at frequent intervals. His success bad been such
as to entirely warrant him in saying that the method
just presented is perfectly competent to bring about a
cure, and hence, it would be found very useful where
more elaborate apparatus is not obtainable. He pre-
ferred to make changes in the position of the foot
every three or four hours instead of at intervals of a
few days, as in the method described in the paper.

Digitized by

Google

44

BOSTON MEDICAL AND SVBGICAL JOVRSAL. [Janoabt 11, 1894.

The great majority of cases of club-foot under ten
Tears of age can be cured without operative interference.

Dr. Henrt Lino Tatlob said he had been much
interested in Dr. Freiberg's account of Wolff's method
when published in the Medical Newt, for the method
seemed very reasonable, and presented certain analogies
to one which he himself employed. The method de-
scribed iu the paper was simple and efficient, and placed
the proper mechanical treatment of club-foot within
the reach of any country practitioner who possessed a
clear notion of just what he wished to accomplish.

Last summer while away from the city, he had seen,
at the request of a surgical friend, an easily curable
case of club-fool in a child two years old. Nothing
bad been doue because the snrgeon was " waiUng un-
til the child was old enough for an operation." This
was a great mistake ; if the surgeon cannot construct
a proper splint out of metal or wood, he should correct
the deformity by means of plaster-of-Faris dressing,
according to the method shown this evening. There
was not much difference between this method with
plaster and that which he had called " the method of
continuous leverage." In the former, moderate cor-
rection is made, and the foot retained in this position.
The correction goes on while the splint is applied, be-
cause the foot continuesto yield ; when it has yielded
sufficiently, another correction is made in the splint.
This is not very different from applying his leverage
apparatus, aud following up improvement in the posi-
tion of the foot by adjusting the straps or bending the
side-bar from time to time. The foot is being continu-
ously impelled in the right direction, and is at all times
prevented from failing back into a wrong position.
This method of Wolff is essentially the same in principle.

Db. a. B. Judson said that in children as young as
these, the deformity easily yields to persistent and ap-
propriate treatment. Plaster-of-Faris used in this way
embodies a lever with points of pressure and counter-
pressure ; but he preferred to use steel, adhesive plaster
and webbing, by which more gradual steps are made
toward correction, taking more time, giving no pain,
and taking advantage of tl^e weight of the body
properly directed on the foot, the same apparatus being
used for the after-treatmeut as long as may be required.
He was reminded by Wolff's method of having seen
Dr. Gibney many years ago using plaster-of-Faris and
a wedge in the reduction of flexion of the knee. He
was surprised that there are so many young children
whose club-feet are neglected till large calluses form
on the outer borders of the feet. Our duty is to ex-
tend a knowledge of what may be done with little
trouble on the part of the family physician towards
correcting this deformity in young children.

Vittent literature.

Manual of Bacteriology for Practitioners and Students,
with especial reference to practical methods. By
Dr. S. L. Schknk, Professor Extraordinary in the
University of Vienna. Translated from the Ger-
man (by the author's permission) with an appendix
by W. R. Dawson, B.A., M.D., Univ. Dubl., Late
University Travelling Prizeman in Medicine. With
100 illustrations, partly colored ; 302 pp. with an
index. Loudon and New York : Longsmans, Green
&Co.ii.l893.

The book appropriately begins with an introdactory
chapter on the general morphology of micro-organisins,
after which bacteriological technique is considered.
Then follow chapters on the bacteriological analysis
of air, water, foods, putrefying substances and pus.
In the remaining chapters the organs and cavities of
the body and their contents are discussed from the
point of view of bacteriology. Under these varioas
heads, descriptions of the bacteria met with are given,
an arrangemeutof the subject which is quite satisfactory.

The bacteriological methods are, ou the whole, well
described, though there is much that is disappointing.

A great many staining methods are included, some
of wJiich are certainly rarely used and are of no import,
ance. It would seem that iu a book of the scope of this
one a much smaller number of well-approved methodi,
selected with the discrimination of a trained bacteriolo-
gist, would better suit the needs of those for whom the
author writes. We note with pleasure that the use of
the double glass dishes of Petrie is recommended for
obtaining discrete colonies, though the antiquated and
cumbersome apparatus of Koch is still described with
great detail and illustrated by figures, some of which
have grown familiar in other books on bacteriology.

In the chapter on air we find no mention of the ex-
cellent method of Sedgwick. The description of the
biology of the various species of bacteria is, in gen-
eral, unsatisfactory. Numerous saprophytes which are
to be found in all of the tex^book.1 on systematic bac-
teriology here also appear, but the customary descrip-
tions of most of them, useless and inadequate as they
are for purposes of their identification, have been still
further abbreviated by the author, so that 'it would
probably be just as well if he had limited himself to
a simple catalogue of their names. Iu the treatment
of the pathogenic aud better studied bacteria, similar
defects are observed. A conspicuous instance of this
is seen in the case of the typhoid organism, the differ-
entiation of which from the bacillus coli communis, is
very imperfectly given ; some of the most important
and trustworthy distinguishing characteristics being
altogether omitted. The statement is also made that
the typhoid bacillus forms spores aud the same is said
of the bacillus prodigiosus. This teaching is not now
accepted. The account of the relations of various
bacteria to pathological conditions of the organs and
tissues of the body is also defective. Thus little or no
importance is assigned to the part played by the
streptococcus in pseudo-membranous inflammation of
the throat

The translation is done in a very readable manner,
but here and there an apparent ignorance of the techni-
cal English equivalents betrays itself by the use of the
terms " islets " for " colonies," " thrust " for " stale"
culture, Fetrie's " capsules " for Petrie's " dishes " or
" plates," " second " for " secondary " infection,
" heat " for " temperature." At times also there are
indications of a too close adherence to Grerman idiom.

In an appendix by the translator there are retumit
on the subjects of pathogenic protozoa, cholera vac-
cination, and action of light on bacteria, together with
some additional technique.

The publishers' part has been well done in Messrs.
Longmans' well-known style. Some of the illustrations
are new and excellent, especially those of gelatine cul-
tures which constitute the most valuable part of the
book. Many, however, are taken from the usual
stock in common use. Misprints are few.

Digitized by

Google

Vol. CXXX, No. 2.] SOS f OS MSDWaL AUTD SUttGlCAL JOVAKAL.

46

JXteeuet of tM» SUn. By H. Radoliffb Cbockbb,
M.D., (Lond.). Second edition, revised and en-
larged. Philadelphia: P. Blakiston, Son & Co.
1898.

We are somewhat late in taking notice of the second
edition of Dr. Crocker's work for the reason that a
hasty examination convinced us that the large amount
of new matter that had been added, together with the
maay alterations, demanded careful reading and study,
and it is with great pleasure that we are able to say,
that the, time has been most profitably spent. As a
proof that dermatology is not standing still, we may
point to the fact that one of the foremost dermatologists
of Great Britain, a writer who has shown much critical
discernment in his attitude towards innovations, has
felt justified in adding to the list of aSeclions that ap-
peared in the edition of 1888, twelve titles of more
important affections of the skin, and thirteen subjects
of minor interest. Too much praise cannot be accorded
for the carefal and systematic manner in which these
new sabjects have been presented, so that this book
will be gladly turned to by the expert, as well as by
the general practitioner, when a short, accurate account
of the modern contributions to dermatology it de-
manded. Much weight and dignity is added to the
book, by the impartial and scientific spirit shown to-
wards the so-called " schools " of dermatology, and to
this much of the book's value must be attributed.
The writings of German, French and English speak-
ing people have been impartially and carefully studied,
and the result, as we view it, shows that no one school
can to-day afford to slight the contributions of the
others, without danger of retrograding.

As is natural, we are not always able to agree with
the writer, but that is mostly in matters of minor
details. We should have liked to see lupus vulgaris
inclnded together with scrofuloderma, and verrucous
tuberculosis, under the heading of tuberculosis of the
skin, and cannot but think that an abundance of ma-
terial was at hand for an amplification and broader treat-
ment of this whole subject. Dermatitis herpetiformis
is treated under the heading hydroa herpetiforme. It
is better and fairer, we think, to retain the name given
it by Duhriug, who was the first to call attention lo the
polymorphism of this disease, until its pathology and
etiology have been more clearly defined. It is gratify-
ing to see impetigo contagiosa, ecthyma, furuuculus
and carbunculus grouped together under diseases due
to pus cocci, and these affections are considered tersely
in the light of modern pathology.

The paragraphs ou pathology are well and critically
written and receive added value from the author's ex-
perience in histological iuvestigatiou. The treatment
is more concise and emphasizes the writer's own preter-
ences more strongly than is the rule in text-books, and
this is also a went, as a prosaic rehearsal of the differ-
ent drugs that have at any time been used, is apt to
prove an embarrassment rather than a help, to the
seeker for aid in therapeutics.

Altogether this second edition of Crocker stands, in
our opinion, as the best modern exposition of the sub-
ject ol dermatology that has been offered by an English-
speaking writer.

THE BOSTON

f&.thital atiD Surgical ^jounml*

Thursday. January li, 1894.

A Journal o/Medieine, 8mrg»ni,<md AUitd SeieHca, publiihed at
Bo$Um, taeekly,bt the under$ign*4.

guBSCBiPTioN Xkrhb: 96.00 jmt y<ar,i« advcmee, poBtagepaid,
for the United Stalei, Canada and Mexico, ■ 98.66 per year for all for-
tign eomitriei beUmgimg to the Poetal Union.

All oommttnioationt for the Xdttor, and all booke for reviev), ekonld
be addreeied to the Xditorqfthe BoetcnMedieal and Swgioal Journal,
288 Woihington Street, Botton.

All lettere containing tmeinete eommmnieaUom, or referring to the
pnblioation, nbeoription, or advertieing department qf thit Jotmial,
ehonld be addreteed to the undereigned.

Semittanea ehonld be made by money-order, draft or regietertd
tetterfpayable to

DAHBELL ft UPHAM,
388 WASHnnStTon StbeIt, Bobtob, Uass.

The total income of the London Hospital Sunday
collections for lliUS was £;}i),OOU as against £41,0u'u
for 1892.

THE THERAPEUTIC ACTION OF BLOOD-
SERUM.

At the present time when reference is so often
made to the action of blood-seram in producing immu-
nity, another brief riiumi of the leading facts in con-
nection with it, and what has been established is timely,
and will be of aid in understanding the value of future
experiments in the same line. Such an analysis has
been recently made by Gunther, and it is from his
article that the chief points in our present review of
(his subject are taken.^

The principle rests ou the discovery of Behring, that
the serum from an animal, which has been rendered
artificially immune to a disease, if introduced into the
body of another animal, cures him of the disease or
renders him immune. Thus the mouse, which is es-
pecially susceptible to tetanus, is cured after the out-
break of the disease throngh the injection of the serum
from a horse that has been made artificially immune.

But before sketching the development of the blood-
serum therapy, the chief points of the theory of immu-
nity must be touched upon.

It is well-known that one species of animal is very
refractory to a certain infectious disease, while another
is very susceptible. Among the susceptible individuals
there are those which have a greater or less degree of
immunity. This rests on unknown factors. These
can, however, be acquired, accidentally or otherwise,
through exposure to which the individual is subjected.
A child which has passed through scarlet fever, is
generally immune for the rest of its life, through acci-
dental exposure to the disease. On the other hand, a
sheep, very susceptible to anthrax, can acquire immu-
nity against this through an intentional artificial vacci-
nation.

From the time of Jenner to 1880 there was no ad-
vance made in the direction of protective inoculation.
In that year Pasteur found that if the bacterium' of
hen cholera was exposed to the air for mouths it«

> Carl. Qlknther : Die Blatserauitherapie. Uice geMhialttUohe
EDlvriekliuig and Ibr gagenewkntger Stauid.
UeoMoli. Med. Woch., Moreiuber 1«. VM.

Digitized by

Google

46

BOSTON MSblCAt Aifb StlttGICAl JOtJMSAL. [Jahuaet ll, 1894.

viruleDce was greatly lessened. If a ben was inocalated
with one of these weakened cultures, there was set
up only a local transitory affection, and after this
bad passed off the bird was not susceptible to the
virnlent form of the disease. The same line was fol-
lowed in the artificial immunity given to animals
through the injection of weakened cultures from an-
thrax, swine plagu>!, and hog cholera. Various methods
to attain this weakening of the virulence were em-
ployed. For some the action of oxygen was sufficient,
to others chemical substances had to be added. Others
had to be grown at a high temperature, while others
had to be passed through the body of some other ani-
mal. In general, it was found that in order to be
weakened, the bacteria must be placed under conditions
which are unfavorable to them. As to the real cause
of this, little can be said to be known. Many show no
change of form or method of growth, while with
others a partial degeneration goes hand-in-hand with
the decline in virulence.

Several hypotheses have been advanced to explain
the action of these less virulent forms and the changes
in the body of their recipient.

The first, which may be called the hypothesis of
"exhaustion," was supported by Klebs and Pasteur.
This supposes that to produce immunity some peculiar
nutritive material of the body necessary for the bacte-
ria was used up, so that bacteria that came after-
wards could not thrive. This hypothesis is to-day
given up. Another which comes nearer the truth is
that of " retention," advanced by Chauveau. He be-
lieves that for immunity certain products of the bacte-
ria must be kept back in the body, and that these pre-
vent further growth. A third is that of Metschnikoff,
grounded on his theory of phagocytosis. He has
shown that certain of the body-cells, especially the
white corpuscles of the blood and the larger cells of
the organs, have the power to seize upon and destroy
bacteria. For the act of immunity it is necessary that
the phagocytes should first destroy the weaker forms,
and in this way they acquired the power to make way
with the virulent ones.

A further advance was made by Salmon and Smith
in 1887, who discovered that immunity was possible
through pure chemical means. Thus the products of
a culture of hog cholera, freed from all bacteria, could
render pigeons immune to the disease. By this it was
surely proved that it is a chemical change of the juices
of the body in the act of immunity, which makes the
body resistant to the attacks of the virulent bacterial
material.

At about the same time Fodor showed that the
juices of the normal living body, especially the blood,
possessed qualities destructive to bacteria. Blood
freshly drawn from a vein was found to kill large num-
bers of the bacteria placed in it. This property was lost
after a few hours, however, and then all kinds of bac-
teria grow abundantly in it. Serum was found to
work in the same way. And Buchner in 1889 an-
nounced that the albuminoids in blood-serum freed

from all cells were the possessors of this peculiarity.
At the same time it was discovered that aU sernm did
not work in exactly the same way. While these facts
might be used in the explanation of immunity, they
were found to fail in so many cases, that they had to
be set aside, and the conclnsions formulated as follows :
" The bactericide properties of the blood or its serum
cannot be used in general to account for the condition
of immunity."

Further studies made in this field by Behring .brought
oat, however, a perfectly regular peculiarity of the
blood-serum of an individual rendered artificially im-
mune. He stated this as follows, and it is called Behr-
ing's law: "If an individual is rendered artificially
immune against a certain infectious disease, then his
blood or its serum has acquired the property of trans-
mitting immunity against the same infectious disease
to a susceptible individual (no matter of what species)
into whose organism it can be brought in sufficient
quantities."

The first communication was made in regard to
tetanus by Behring and Eitasato in 1890. They were
able to render rabbits immune against tetanus. The
blood-serum of these rabbits, when introduced into the
bodies of mice (extremely susceptible to this disease
by nature), protected these little animals completely.

It must be mentioned here that the tetanus bacilli
belong to that group of bacteria which are called
"toxic" in contradistinction to the "infectious" in
the narrowest sense. These last work harmfully by
their enormous increase in the body, while, on the
other hand, the toxic work by the production of a
specific poison. If the tetanus spores enter into a sus-
ceptible body they develop in the spot of introduction,
and it is here that the active poison of tetanus is pro-
duced, which is taken up into the body, and then de-
velops its general deleterous working. The poison
can be produced outside of the body in artificial cul-
tures as well. If such a culture is freed from its liv-
ing bacteria (by filtration), then this filtrate, introduced .
in proper doses into the body of an animal, causes an
outbreak of tetanus just as surely as if the bacteria are
used. In the first case it is a tetanus infection. The
bacteria penetrate the body and increase. From this
there is developed an intoxication, which is absorbed
from the poison produced by the developing bacteria.
In the second case we have at once, and primarily, an
intoxication. The ready-formed tetanus poison pene-
trates the body as a soluble chemical, and acta thus.

Behring and Kitasato have shown in the above
work that the introduction of the serum of animals
made immune against tetanus protects the aasceptible
animals not only against the infection of tetanus, but
also against the primary intoxication. These authors
have thus added a new point to our knowledge of im-
manity, and have drawn the following conclusion from
their experiments: "The immunity of the experi-
mented animals depends upon the capability of the
blood-serum freed from cells to render harmless the
toxic substances which the tetanus bacillus produces.

Digitized by

Google

Vol. CXXX, No. 2.] BOSTON MBDIOAL AND SUBGIOAL JOUBNAL.

47

-A. iorther proof is that the blood-«ernm of animal*
made artificially immnne acts in the same way against
the tetanns poison in the test-tubes. Further, it was
found that animals suffering from tetanns could be
cared by the inoculation of the serum of immune
animals. This acquired resistance rests, therefore, on
the antitoxic peculiarities of the blood-serum."

This epoch-marking discovery in the case of tetanus
has been the point of departure for a great number of
experiments to see to what extent the blood-serum of
artificially immune individuals can be used for the
purpose of healing in the infectious diseases. As
would be supposed, investigation has been carried on
with the blood-serum of individuals immune by nature,
and the result has been that in their blood-serum there
is no substance which can render other individuals re-
sistant. These substances are therefore never present
naturally in an individual, biit must be first formed;
and this happens only by artificial means. For the
understanding of natural immunity, every point fails
us at the present time.

Diphtheria was the next disease to tetanns to be in-
vestigated (1892). We have to deal here with one
which is also produced by toxic bacteria. Here all
the general symptoms are to be referred to an intoxi-
cation ; and the blood-serum of artificially immune in-
dividuals was proved to be active through its antitoxic
properties. This process of immunization against teta-
nus and diphtheria can be regarded, from the nature
of those diseases, in the light of a seizure of the virus
(Giftfestignng). Ehrlich, too, has shown that Behring's
law holds also for the seizure of other poisons than
those produced by bacteria. He was able to render
mice immune against ricin (an extremely poisonous
albumen obtained from the seeds of the ricinus com-
munis), as well as against abrim (the toxic albumen
from the jequirity beans), by feeding them with gradu-
ally increasing doses of these poisons.

The serum of these animals was capable of transfer-
ring its property of seizing these poisons to healthy
animals. It also rendered the poison harmless when
they were brought together in the reagent glass.

In all infectious diseases Behring's law has turned
out to be true, even where one cannot speak of the
seizure of the virus. For example, in all cases of sep-
ticemia which have been investigated in this regard.
Even in those where as yet the .poison has not been
isolated — for example, rabies — it holds good that
the blood-serum of artificially immnne individuals can
trausmit immunity to normal individuals.

The above investigations have also thrown light
upon the -spontaneous healing of infectious diseases.
This appears, in general, to come about when there
have been formed in the body, especially in the blood,
substances which paralyze the harmful agents. If the
disease has been overcome, these "anti-agents" in
the blood are found afterwards. In men who have
lived through a pneumonia, typhus, cholera or diph-
theria, the blood-serum has been found to act in ren-
dering animals immnne.

It has been stated above that the protective serum
can also heal diseases that have already broken oat
(therapeutic action of blood-serum). But it has been
generally found that very mjich more serum is neces-
sary for healing than to produce immunity ; and still
more is needed the further advanced the disease. And,
furthermore, the necessary amount stands in direct
relation to the body-weight of the individual.

It will at once be realized that there are practical
difficulties in the way of obtaining a large quantity of
very active serum for treatment in the care of man.
In the two diseases in which it has been tried, diph-
theria and tetanus, the sheep and horse are the animals
from which the immunizing serum has been obtained.
The results from this treatment, however, will have to
be subjected to the severest scrutiny before all that is
claimed for them can be allowed. Certainly the work
is a great contribution to our understanding of these
obscure processes, and while that can at once be ac-
cepted, the practical outcome must still be regarded as
under judgment.

Of the chemical nature of the active substance in
the serum there is little known. In the case of the
anti-tetanus, it has been found to be very resistant
against physical, chemical and atmospheric influences.
It passes through the dialyser, and by this the charac-
teristic reactions for albumens are lost.

It has been shown by Ehrlich that the immunizing
substance of the blood can pass into the milk, and
through nursing immunity can be obtained. At the
same time, it has been shown that immunity (through
seizure of the poison) can be transmitted through the
mother, but not the father. In the inheritance of
artificial immunity two factors come into play : first,
the supply of the fcetus with immunizing substances
from the maternal blood, and, second, the continued
accretion to this by the offspring through the milk.

In regard to the length of time and the persistence
of the artificial immunity, the two ways in which it
can be acquired are to be kept sharply separated. If
the immunization is " active " — that is, if the body
itself helps prepare the substance which overcomes
the disease — then the resulting immunity is relatively
strong, and exists a long time. If, on the other hand,
it is " passive " — that is, if immunity is given to the
organism by the iutroductiou of serum, blood or milk
in which the agent is already prepared, then the im-
munity is a relatively short one, probably not extend-
ing over more than a few weeks.

MEDICAL NOTES.

The Congbess fob Hygiene and Dbmoobapht.
— At the eighth International Congress for Hygiene
and Demography, to be held this year at Budapest,
an entirely new section is to be organized for the study
of the hygiene and etiology of diseases of the tropics.
Dysentery, malaria, yellow fever, elephantiasis, beri-
beri, the influence of tropical climates upon Europeans,
tropical f**—'!"""! of the liver, and the effects of the

Digitized by

Google

48

BOSTON MEDICAL AND SUSOIOAL JOURNAL. [Jamcabt 11, 18>4.

use of alcohol in warm countriec, are some of the
especial topics for discussion.

FiBK IN A London Hospital. — A fire oocnrred
in the Royal Free Hospital in London, last week,
which was extinguished with some difficulty. The
patients in the wards were all removed safely, and no
serious damage was done.

Small- Pox at Nashvillb, Tbnn. — Six cases of
small-pox were reported at Nashville, Tenn., January
8th, from four different sections of the city, all of the
patients being negroes.

BOSTON AND NEW BNOLAND.

Boston Watbb Consdm ption. — The daily aver-
age consumption of water in December last was as fol-
lows ; Sudbury and Cochituate system, 47,807,800
gallons as against 43,766,400 in December, 1892 ;
Mystic, 11,620,809 as against 10,475,700 for the cor-
responding month of 1892 ; total, 59,428,600, an in-
crease of 5,188.500 gallons over December, 1892.
The flow of the Sudbury and Cochituate is now about
10,000,000 gallons a day more than its consumption.

Bequests. — The Carney Hospital and the Free
Home for Consumptives of Boston, have each received
a bequest of five hundred dollars by the will of Mr.
Deunis Cawley.

Fbee Vaccination in Boston. — The free vacci-
nation stations were closed last Saturday evening.
During the two weeks in which they were open over
forty thousand persons were vaccinated. During the
present week a physician is to be sent to each public
school to vaccinate all children who are in need of it,
though the vaccination is not to be compulsory.

SitALL-Pox IN Boston. — There have been five
new cases of small-pox in Boston in the week ending
at noon January lOih. There have been no deaths.

Small-Pox at Lowbll — Several new cases of
small-pox have occurred at Lowell, Mass., during the
week and there are now seven (tatients at the small-
pox hospital, one of whom is not expected to live. In
spite of these cases much opposition is being shown to
vaccination in both Lowell and Lawrence, chiefly by
the German population.

Small- Pox at Worcestek. — A case of small-
pox occurred at Worcester last week, in an emplo}^
at a tannery. His boarding-house has been put under
close surveillance.

Influenza at Portsmouth, N. H. — The influ-
eiizi is prevalent to a serious extent in Portsmouth,
N. H. Over seven hundred persons are now ill, and
there have been many deaths during the last few days,
directly due to the grippe.

" Variolbna." — Several cases have come to no.
tice this week, in which patients have been given some
small white, sweet-tasting pills to take every two hours
or so for the purpose of " effecting vaccination with-
out the discomfort of scarifying and causing a sore
arm." In, at least, one case, the patient had been un-

successfully inoculated, and was told, " Well, no matr
ter, the pills will do just as well."

NBW tobk.

Academt of Medicine Elections. — At the an-
noal meeting of the New York Academy of Medicine,
held January 4th, the following officers were elected:
Vice-President, Dr. Joseph D. Bryant ; Member of
the Board of Trustees, Dr. Abraham Jacobi ; Treas-
urer of the Board of Trustees, Dr. Wm. F. Coshman ;
Member of the Committee on Library, Dr. W. Gil-
man Thompson ; Member of the Committee on Ad-
missions, Dr. John S. Warren.

Death of Mrs. Lewis A. Satbb. — Much sym-
pathy is felt in the profession and the community at
large for the venerable Dr. Lewis A. Sayre, on ac-
count of the loss of his estimable wife, who died sud-
denly on January 5th, in the seventy-second year of
her age. Mrs. Sayre was the daughter of the late
Charles Henry Hall, and came of a distinguised old
New York family. Up to a day or two of her death,
she enjoyed good health.

The Wat Small-Pox is Spread. — The way in
which small-pox is often spread is strikingly illustrated
by the discovery of three cases in a tenemeathonse in
Harlem. On December 20th, a man by the name of
Murphy was found with the disease in the annexed
district beyond the Harlem River, and sent to the hos-
pital for contagious diseases on North Brother Island.
The house was promptly fumigated, and the inmates
vaccinated, but the wife of the patient managed to es-
cape the vigilance of the authorities, and disappeared
with her child. On January 4th, the officers of the
Bureau of Contagious Diseases found the child and
two Italian children suffering from small-pox in a
house on East 111th Street. In the meanwhile, the
Board of Health is carrying on the work of general
vaccination vigorously, and the extra corps of vaccinsr
tors, whose term expired with the old year, has been
reappointed.

Appropriation for the Board of Health. —
The $425,080 mentioned in last week's Journal m
having been appropriated for the expenses of the De-
partment of Charities and Correction for ]89'4, should
have been set down to the Board of Health.

Tuberculosis ahono Levi P. Mobton's Cat-
tle. — Seventeen pure Guernsey cattle owned by ex-
Vice-President Levi P. Morton, at his country place
at Rhinecliff on the Hudson, have been found to be
suffering with tuberculosis, and the State Board of
Health, acting on the report of Dr. John Faust, of
Poughkeepsie, have ordered that they be killed. Dr.
Faust is of the opinion that the tubercle bacilli have
only recently invaded the systems of the cattle from
the fact that the animals are to all outward appearance
entirely free from disease, the presence of tabercalosis
having been revealed only by the Koch test of the
hypodermic injection of tuberculous matter. Among
the infected cattle are a number which were exhibited
and won prizes at the Chicago World's Fvr, iwi4 U is

Digitized by

Google

Vol.. CXXX, No. 2.] BOSTON MEDICAL ASD SVBGICAL JOVBSAL.

49

probable tbat the disease was contracted there. It is
stated that over one hundred head of cattle exhibited
at the Fair from the State of New York, have been
found, by the Koch test, to be saffering from tubercu-
losis, and have been killed.

INAUGURAL ADDRESS OF THE GOVERNOR
OF MASSACHUSETTS.

In his inaugural address, Governor Greenhalge rec-
ommended the passage of a medical practice act by the
State Legislature. He said :

" I ask yon also to consider the expediency of re-
quiring that practitioners of medicine be registered, in
somewhat the same manner as pharmacists are now
registered.

" In every State of the Union, except five, such a
system of registration has been established, and it can-
not fail to protect the public, and at the same time
help to maintain a high standard among medical prac-
titioners."

Other matters of medical interest of which he spoke
were the various State boards and their work.

"The work of the State Board of Lunacy and
Charity is one of vast scope, comprehending the super-
vision and visitation of the public and private insane
hospitals and asylums of the State, State almshouse
and State farm, and three State schools, and the State
and town almshouses containing insane inmates; the
care of insane patients boarded in families, with the
supervision of juvenile offenders, and the administra-
tion generally of the laws concerning the support of
State paupers by cities and towns, together with many
other duties of kindred nature.

"The importance to the community of this great
work of charity cannot be overestimated. It is in
such lines of work that Massachusetts has won her
high reputation among the States of the Union and
throughout the civilized world.

" The care and improvement of the nnfortunate
coming within the jurisdiction of this Board is no in-
significant standard by which to mark and measure the
degree of civilization in this community.

" The work assigned to the Board appears to have
been faithfully and efficiently performed in all its de-
partments."

After calling attention to the need of new buildings
to prevent overcrowding, and the necessity of separat-
ing the different classes of inmates, the innocent from
the criminal, he said :

*' Various suggestions will be made by this Board in
their forthcoming report in regard to amending the
statutes relating to the form of mittimus, the commit-
ment laws, the record books in the State hospitals, and
on various other points which I regard as practical
and beneficial. The propriety of furnishing to the
insane some light and interesting employment merits
also your consideration.

"The Board of Health is performing its difficult
and responsible duties in a most effective and satisfac-
tory way. The Board exercises a strong and salutary
influence over local Boards of Health. The year just
closed has been marked by faithful and intelligeut
labor, and by excellent results, as the report of the
Board will plainly demonstrate.

"I commend this report, with its suggestions and
recommendations, to which I find no occasion to add
anything, to your careful examination."

THE DUTIES OF ARMY MEDICAL OFFICERS.

At the opening session of the newly established
Army Medical School, Colonel Aldon, President of
the Faculty, spoke of the important duties of an army
medical officer. He should be a sanitarian first and a
practitioner next. His primary duty is to prevent dis-
ease and preserve the efficiency of the command. The
questions of practical sanitation which be must deal
with at every turn he has had but little experience in.
Questions of soil, buildings and ventilation, of drainage,
sewerage and disposal of garbage, the wholesomeness
of water-supplies and animal foods are but a few in-
stances of the many points bearing on the preservation
of the health of the military comitia under his sanitary
care, on which the ordinary medical graduate needs
further instruction to fit him for military service.

"The actual duties of the medical officer are divisa-
ble into three branches. First, he is to see that none
but able-bodied and effective men fit to perform the
duties and endure the hardships incident to military
life are admitted to the service. He must therefore
critically examine the voluntary recruit or person about
to receive a commission. Second, he must carefully
watch over the health of the command to which he is
attached in order that no causes that may mar its ef-
ficiency can gain headway. He knows that the mere
aggregation of men leads to disease and that the ex-
perience of all campaigns shows that disease kills more
than does the enemy. He must be ever ready to draw
attention to unsanitary conditions. Third, he must
keep himself always ready to relieve the sick and
wounded in garrison and in the field ; to endeavor to
make them effective again at the earliest possible
moment, or extend such measures of relief as may be
possible if restoration to duty is impracticable."

DRUNKENNESS IN WASPS.

SoMS of our readers may have seen a flock of crows
fed on corn or meal previously saturated with, whiskey,
and grieved at the wickedness of man in extending the
vices of civilization to the innocent animal world.
They may be relieved, or perhaps even more grieved,
to learn that the desire for strong drink is natural in
other orders than man. Mr. Lawson Tait, in an
address on the use of alcohol, relates the natural fond-
ness of wasps for intoxication. He says ;

"I have watched wasps with great interest, and
have noticed the avidity with which they attack cer-
tain fruit when fully ripe, rotting, in fact, and I have
also noticed some of the peculiar results of their doing
so. The sugar in some fruits which are most attacked
by wasps has a tendency to pass into a kind or kinds
of alcohol in the ordinary .process of rotting, a fact
which is easily ascertained by the use of a still not
large enough to attract the attention of the excise
authorities. On such fruits, particularly grapes and
certain plums, you will see wasps pushing and fighting
in numbers much larger than can be accommodated ;
and you will see them get very drunk, crawl away in
a semi-somnolent condition, and repose in the grass for

Digitized by

Google

60

BOSTON MEDIOAL AND SURGIOAL JOURNAL.

fjANUi-BT 11, 1894.

some time, till they get over the "bout," and then
they will go at it agaia. It is while they are thus
affected that they do their worst in stingiog, both in
the virulent nature of the stroke and the utterly un-
provoked assaults of which they are guilty."

WORK AS A THERAPEUTIC AGENT.

A CORRESPONDENT has Bent to the Spectator the
following short letter from Sir Andrew Clark :

Dear : There are two tbingg about all patients

which help us to discover their maladies : whatis found by
the physician and what is felt by the patient. What is felt
helps us very little ; what is found, for the moat part settles

our judgment. What is felt by Mr. amounts to a

great deal. Various disturbances cf digestion, weakness,
inaptitude for work, recurring faintnesses, malaise, and the
feeling of getting worse and worse. What I found amounts
to very little. . . . Every organ that I can reach is free
from obvious structural disease; and as the patient has
suffered for years in this way and nothing lias come of it,
it is reasonable to say that there is no structural disease.

Mr. , therefore, is ailing, and perhaps suffering, but

not in the ordinary sense ill ; furthermore, I think that he
is introspective, morbidly nervous, and occupied with him-
self. He cannot at present be made well ; but he may
reach his best by a simple regular diet, by self-effacement
(dying to live), by light, regular, daily occupation, by the
resolution to give a deaf ear to his trying Sensations, and
by a determined lighting and struggling to lose himself in
outward things. . . . To do nothing would be to go back-
wards and downwards. True, he may suffer if he works ;
nevertheless, it is best to work. Hundreds suffer to work.
I have always suffered to work, but work keeps me where
I am ; 1 have to wrestle with it, but thus my antagonist be-
comes my best helper. Yours sincerely,

Andrew Clark.

VACCINATION IN ANCIENT TIMES.

A correspondent of the Aauriecm Praelitioner
and Newt writes that at a recent meeting of the £pi-
dermiological Society of London Dr. Fringle called
attention to the following passage, he had found in an
ancient Hindu work, which he thought proved that
TacciuatioD was known and practised in India centuries
before the birth of Jenner :

" The small-poz produced from the udder of the cow
will be of the same mild nature as the original disease,
the pock shall be of good color, filled with clear liquid,
and surrounded by a circle* of red. There will only be
a slight fever of one, two, or three days, but no fear need
be entertained of small-pox so long as life endures."

A REMINISCENCE OF THE NICARAGUAN FILI-
BUSTERS.

In a recent number of the Journal of the American
Medical Atiociation Dr. L. C. Lane describes the con-
dition in which he fouud the American filibusters who
had been taken prisoners by the Costa Ricansin 1858.
He was at the time assistant surgeon on the U. S.
Sloop Decatur, which was moving from port to port
for the purpose of aiding or protecting Americans who
might be fouud in distress.

On arriving at Puula Arenas, the Pacific port of
Costa Rica, they fouud a body of American prisoners,
most of them under thirty years of age, half-naked,
and suffering from starvation. Nearly all were troubled

with ulcers of peculiar type, seated chiefly on the arms
and legs and due to wounds received from thorns or
insects. These ulcers consisted of half- formed tissue
which, in the exuberance of its growth rose two or
three lines above the adjacent surface. They were oE
a pale-yellow color, and so non-vascular that when
touched they did not bleed. This pseudo-formation
differed widely from any form of granulative tissue,
and in appearance it resembled a thick emulsion, rather
than an organized animal tissue. In fact, it was a
new type of structure, so low in organization that it
was the analogue of a fungoid plant, and was no more
sentient than the latter. This fungoid neoplasm had
arisen in the human body that was saturated with ma-
larial poison, half-starved and living on a non-nitroge-
nous food. Under the simple treatment of cleanliness
and feeding on man-of-war's rations the ulcers rapidly
healed.

THE LITHOTRIPTIST.

In a recent address on the progress of surgery
during the present century, Professor Clark, of Glas-
gow, gives the following interesting bit of medical his-
tory. Speaking of the great advance in operations on
the urinary bladder, he says:

" I have in my possession an old English dictionary,
the author of which was James Knowlei, the father of
Sheridan Knowles, the playwright and poet. In that
book, on the usual blank page behind the title, is this
note:

" ' N. B. — X>ook for a New Word after the last word in
P, and a further explanation in an added Page at the end
of the Preface.'

" The new word thus indicated is Lithotriptiet, and
the meaning is ' A professor and operator in the re-
cently discovered art of lithotripsy ; which consists in
breaking, triturating, and pulverizing the stone in the
bladder, and removing all the panicles of it. The
word is here, with thanks to God, a sense of duty to
the public, and a deep feeling of gratitude to the Pro-
fessor Baron Heurteloup, associated with hia uaoie ;
he having on Saturday the fourth of April, iu pres-
ence of several surgeons and physicians, in about five
minutes operated upon the author, whose age is
seventy-three, without giving him much uueasmeas;
and by his consummate skill, not ouly relieved him
Irom a state of suffering, which he had endured for
twelve months, but preserved his life, which, in all
human probability, he must have lost under the opera-
tion of lithotomy.' This book is dated 1838, and we
have thus a deUuite time from which to date the com-
mencement of the operation for crushing stone."

PHARMACY, THERAPEUTICS AND CREDULITY.

Professor Cash opened the Edinburgh session of
the Pharmaceutical Society with an address ' ou some
of the present aspects of therapeutics. In tracing the
relations that connected the scientific chemist with the
therapeutist, he said it was the part of the chemist to
produce a pure substance, so that the pharmacologist
might be able to asbign to it its definite and proper,
value. The product once obtained, the question arose,
Why do we use this drug ? The answer involved an
> BrIUth Medical Journal.

Digitized by

Google

Vot. CXXX No. 2.] BOSTOm MEDICAL AND SVUGtOAZ JOXmHAL,

51

answer to the pharmacologist's questions, How is it to
be used? which gave scope to the dexterity of the
pharmaceutist to prepare it in many forms for the
exigencies of practice ; and When should it be used ?
To this third query the therapeutist gave the final
reply. He it was who, bearing in mind and relying
opwn the labors of the men who answered the ques-
tions. Why ? How ? applied the accumulated knowl-
edge to the cure of disease. It was not rash to fore-
cast that the advent of new remedies would be through
the channels of close research and study, and that the
scientific practitioner of the future would refuse to
make use of anything which reaches bis hands by less
certain ways. Pure empiricism was decaying, although
its decline Was likely to be slow. Credulity was losing
its hold on all, and whether the cry was a new cancer
cure by green or yellow electricity or a great Chinese
cure, the rush of the credulous amongst those who had
been educated to know the left baud from the right in
medical matters was but a trifling one. Still, it was
not likely that this generation nor the next would fail
to contribute its numbers to those who chased the will-
o'-the-wisp into medical bogs. But credulity might be
shaken by firm example, and he hoped much from the
confidence that could be justly obtained from what had
been weighed in the balance and not found wanting.

♦

THERAPEUTIC NOTES.

Local Anesthesia. — A mixture of chloroform
(ten parts) ether (fifteen parts) and menthol (one
part), used as a spray, is recommended as an excellent
and prompt means for obtaining local anaesthesia last-
ing for about five minutes.

CoKTZA. — Hayem ^ gives the following prescription
for the relief of acute coryza:

Aqa» ammonite) •» ohm

Alcohol 3t

Aqneedmtll 31 M.

SIg. Inhale from Mveral drop* upon a piece of blbnlotis paper.

Lotion for Prdritdb Vulve.*

K Hydrargyri perchlorlde gr. 1

AlumliiTa or. xx

PuIt. amyli , 3 iM

AqusB inenUueptp, q. (. ad . . . . Jri

H. et fl. lotto.

SIg. Apply externally te the affected parts.

To Prevent Cocaine Intoxication. — Profes-
sor Parker, in the British Medical Journal, states that
he has discovered that the unpleasant or even poison-
ous symptoms which occasionally follow the applica-
tion of strong solutions of cocaine in the nasal and
buccal cavities, may be entirely prevented by combin-
ing the drug with resorcin.

An Inhalation for Polmonart Tuberculosis.
— Dr. Carasso Michele, Director of the Military Hos-
pital at Genoa, has used since 1888, in the treatment
of pulmonary tuberculosis, constant inhalations of oil
of peppermint. He combines the inhalation with the
internal administration of an alcoholic solution of
creosote, glycerine and chloroform, to which is added
oleum menthas piperiiae, 1:100. His results are re-
ported as remarkable. Not only were incipient cases
cured, but advanced cases also, some thirty-nine in all,
with cavity-formation and abundant bacilli in the

> Ber. de Laryagol. d'Otol. et de Bhlnol., 1898, No. 18.

> Practitioner.

sputum. All the cases treated were of pulmonary
disease only, without tubercular affection elsewhere.

Inhalant fob Acute Lartnoitib.* — Casselberry
recommends the following combination as a soothing
spray in acute inflammation of the larynx and trachea:

Bi 01. pinl canadensis m. t

Ol. gaultherlflB m. 11

Ol. eucalypti m. 11

Menthol gr. 1

"Beniolnol" §11

" Vaseline oil " q. s. ad 31 M.

SIg. To be nsad with a doable-bulb atomizer.

Whooping-Cough.* — Bergeon reports that for six
years he has successfully treated his cases of whoop-
ing-cough by rectal injection of carbonic acid gas.
Immediately after the paroxysm one or two litres of
the gas are injected into the rectum provided that three
hours have elapsed after the last meal. The injections
are repeated every four hours if necessary. They
cause no gastric or intestinal disturbance and the child
can eat immediately afterwards. Under this treat-
ment his cases usually yield at the end of a week.
Unruh* directs his treatment chiefly to the initial
bronchial catarrh, and advises the insufllation of a
grain and a half of powdered quinine ouce a day. In
young children where this cannot be accomplished, he
uses turpentine inhalations by means of face masks.
Internally, he gives every three hours a teaspoonful
of a three-per-cent solution of antipyrin, which is the
only drug he has found of value. Pizzocaro * calls at-
tention once more to the favorable effect of vaccina-
tion upon whooping-cough. In several very severe
cases, with twenty or thirty coughing spells a day,
which had been unrelieved by the usual remedies, in-
oculation with animal lymph resulted in a complete
cure in from eleven to eighteen days.

CorreiBtponDence.

"HIGHER MEDICAL EDUCATION."

Chicago, January 10, 1894.
Mr. Editor : — The following notice will be of interest
to many of your readers. Hoping that its publication may
induce other colleges to enter upon the same policy,
I am yours truly,

E. Fletcher Inoalb, Registrar.

" In pursuance of the policy recently announced in the
resolution to be presented to the American Medical Col-
lege Association, the Trusiees and Faculty of Rush Medi-
cal College have decided to require foiv years' attendance
at college from students who begin the study of medicine
this year with a view to graduation in 1898 ; however,
those who have already studied medicine one year or more
with a preceptor, so that the four years of study, already
required, will be complete before July, 1897, may gradu-
ate after three courses of lectures, as heretofore. To en-
courage proper preliminary study, graduates in Arts and
Sciences from high-grade colleges, and graduates in Phar-
macy and Dentistry from colleges requiring a proper
amount of study and two full courses of lectures will, until
further notice, be allowed to graduate after an attendance
on only three courses of lectures."

[We think announcements of this sort would be more
useful if the length of the school year were stated, as well
as the facilities for taking a four years' course in three
years. — E».]

1 New York Medical Journal, October 24, 1893.

• Lyon MMIcal, No. 26, 18»3.

> Jahrbuoh fur Klnderhlelkunde, vol. xxxvi, 1893.

• Bafonna med., No. X, 1833.

Digitized by

Google

62

SOSfOU MSDtOAL AS1> StJttGtOAL JOUJtlfAL. [Jaitoabt 11, 1894

METEOKOLOOICAL BECORD,

For the week ending December SO, la Boston, •coordlnK to ob-
servations furnished b; Sergeant J. W. Smith, of the United
States Signal CorpB:—

Baro-

Tbermom- BelatlT*

Direotlon

TeloeltT
of wind.

We'th'r.

1

meter

eter.

hnmiditT.

of wind.

•

Date.

i

a

a

§

a
S

i

n

*

1

n

a

n

«

n

M

B

1

I

a
40

■4

s

CO

1

s

00

S

oo

8

a.
8.

oo

■4

S

K

S

00

§

8.. 24

30.17

48iE6

70

78

74

w.

s.w.

8

13

O

0.

M..2,1

29.117

62167

J6

79

72

76

w.

8.W.

12

19

P.

c.

T..26

80.09

24130

19

64

47

66

N.W.

N.W.

19

19

o.

c.

W.aT

311.06

28

37

1"

64 67

60

w.

W.

12

;o

p.

0.

T-.a-

29.72

31

42

26

60 77

68

s.w.

S.W.

14

12

p.

p.

p.. 28

29.66

44

49

40

78

68

73

sw.

W.

9

12

0.

0.

.06

S..30

30.08

28

33

22

69

97

83

N.

N.

12

16

0.

N.

.14

tr

29 9S

43

30

70

.20

talBK

0..eloildjt C.,cle«ri F., f»iTt ti.,fcisi H.,hoi7i B.,unok7i R..rmtni
ngtN..»DOW. t Indloatet tTmne of runfatl. iV Moon for wMk.

T.,thnu-

RECORD OF HORTAUTT
Fob thc Wm kndimo Satdbsat, DacBMBia 30, 1803.

I.

•1

Percentage of deaths from

•a »^

*6.

Oltlee.

o —

a o
d >

1

1^

is
1'

5"

¥

II

11

Mew York . .

1,891,306

824

296

14J»2

22.44

1.80

.48

8.64

Cbloago . . .
Philadelphia .

1,438,000

—

•^

—

—

—

—

—

1.116,662

—

—

—

—

—

^

—

Brooklyn . .

978,3»4

370

121

8.91

23.76

.27

1.36

4.lf6

St.Lonla. . .

eto.vou

—

— .

^

—

—

—

•^

Boaton . . .

4h7,39;

264

74

10.92

29.64

.39

.78

6.07

Baltimore , .

eou.uoo

—

—

—

—

—

_

—

Wacihliigton

3U(i,431

119

24

12.90

17.20

,H6

6.16

4.80

Cloelnnatl . .

306,1100

130

3d

14.63

20.79

4.t>ii

3.86

3.tf6

Clevelaod . .

290,000

71

27

12.69

22.66

1.41

._

11.28

Pituburg . .

263,7U9

102

40

9.r0

20.68

—

.98

2.94

Milwaukee . .

260,0110

76

31

1I-.62

18.62

3.90

2.66

—

Nashville . .

87, 7M

46

10

2.17

10.86

—

—

Charleston . .

65.1b5

40

12

2.6U

16.00

—

—

^

Portland . . .

40,000

24

0

-.-

24.96

—

_

~.

Worcester . .

96,217

39

Iv

5.12

30.72

—

—

2.66

FallKlver . .

87,411

31

13

».6»

3-2.30

9.69

—

^

U>well . . .

87,191

64

18

M.tfO

20.36

7.40

3.70

—

Cambridge . .

77,100

40

12

12.60

27.60

2.60

2JiO

Lynn ....

62,666

19

2

^

6.26

—

^m.

—

Springfield . .

1C,684

24

7

4.1t(

24.96

—

—

4.16

Lawrence . .

48,366

—

—

—

—

—

^

—

New Bedford .

46,886

26

8

4.00

20.00

—

—

4.00

Holyoke . . .

41.278

—

—

—

—

—

—

—

Salem ....

32,233

12

3

—

68.31

—

—

—

Brockton . .

32,140

9

1

_

88.88

—

—

^~.

HaTerhiU . .

81.3S6

7

1

—

14.28

—

—

^

Chelsea . . .

30,264

16

8

—

13.33

—

^

—

Maiden . . .

29,384

13

3

—

16.38

—

^

^

Newton . . .

27,666

—

—

—

—

^

—

—

Fltchbnrg . .

27,146

7

3

—

14.28

—

—

—

Taunton . . .

26,972

12

2

8.33

—

—

_

—

Qloucester , .

26,688

8

1

—

—

—

^

—

Waltham . .

22,068

4

0

—

76.00

—

—

—

Quincy . . .
Pittsfield . .

19,642

4

2

—

—

^

—

^

I8,i'02

1

1

—

—

—

—

—

Everett . . .

ll,6h6

6

1

—

16.66

—

^

—

Northampton .

16,331

6

2

—

22.22

—

—

—

Newbnryport .

14,073

12

2

—

—

_

^

_

Amesbnry . .

^,9-^0

b

1

^

•~

^

-*

"~

Deaths reported 2,44(>: under five years of axe 774; principal
infectious diseases (small-poz, measles, diphtheria and croup,
diarrboeal diseases, whoopinfr-ccagb, erysipelas and fever) 30(i,
acute lung d iseases 652, consumption 2Ht), diphtheria and croup
131, diarrhosal diseases 33, typhoid fever 28, scarlet fever 24,
whooping-cough 24, measles 22, cerebro-spinal meningitis 6,
small-pox and erysipelas 6 each.

From scarlet fever New York 7, Boston 6, Brooklyn and Pitts-
burg 3 each, Cambridge and Somerville 2 each, Milwaukee 1.
From whooping-cougb New York 6, Brooklyn 4, Boston, Cin-
cinnati and Pittsburg 3 each, Washington, Charleston, Worces-
ter, Somerville and Tannton 1 each. From measles New York
12, Milwaukee 8, Brooklyn and Cambridge 1 each. From
cerebro-spinal meningitis New York and Lowell 2 each, Brook-
lyn and Washington 1 each. From erysipelas New York, Boston
and Washington 1 each. From small-pox New York 2, Bos-
ton 1.

OFFICIAL LIST OF CHANOBS IK THE MEDICAL COKP8
(. F THE U. 8. NAVY FOR THE WEEK ENDINO JANU-
ARY 6, 189*.

Fkakk C. Cook, Washington, D. C, commissioned an
taut surgeon in the Nsyj, January 4, 189t.

SOCIETY NOTICE.

Hassachubbttb Mxdicai. Socixtt, Suitolk Distbict. —
The Section for Clinical Medicine, Pathology and Hygiene will
meet at Vi Boylston Place, on Wednesday, January 17tta, at »
o'clock.
Papers: Dr. G. Q. Sears: " Pregnancy and Heart Diseaae."
Dr. R. C. Cabot: " Diagnostic and Prognostic Significanoe of
Lsucocytosis."

F. C. Skattuck, M.D., Chairman.
Hbnrt Jacksom, M.D., Hecretary.

HARVARD MEDICAL SCHOOL.
EvKxixa Lkctckms.

The next lecture will be given on Wednesday eTeaine, Jaao-
ary 17th, at 8 o'clock, by Assistant Professor Ernst. SabJ«et,
" Advances in Bacteriology." Physicians are cordially inTited.

RECENT DEATHS.

Olitxb AuonsTUB WiLLABD,M.D.,M.M.8.S.,diedin LoweU,
Mass., January 7th, aged thirty-eight years.

Francis Himot Wsij>, M.D., died in Jamaica Plain, Decem-
ber Slst, aged forty-three years. He gradnatad from Harraid
College in the class of 1860, and while a student in the Medical
School, received an appointment as medical cadet and waa soob
commissioned as assistant surgeon at the Naval Hospital ia
Chelsea. During the year 18ii3 he served on the ironclad moni-
tor tfantvcket In blockade service at Charleston and Sawannah,
and later in the year served on the frigate Waba»h. He was
relieved from naval doty in January, ISM, and completed his
course at the Harvard Medical School. In April, 1861. be en-
tered the army as a surgeon and was with (4rant io the Cam-
paign from the Wilderness to Petersburg, and with the Army of
the James before Richmond, and joined Sherman at Raleigh.
During his service he was at diifereut times brigade and di-
vision surgeon, and In charge of various field and post hospitals.
After the war, October 1, 18l>5, he began the practice of bis pro-
fession In Jamaica Plain, but moved the next year to New York
City, where he practised until 1887. He was medical saperin-
tendent of the New York Hospital in 187(>-7. He was for twelve
years a member of the board of overseers of Harvard UiiiTer-
sity.

Hamptok E. Hill, M.D., died at Saco, Me., Jannary 9th,
aged forty-three years. He was at one time demonstrator of
anatomy In the Bowdoin Medical School and a member of the
medical staff at the Soldiers' Home at Togns.

Lucius Flaoo Billinos, M.D., M.M.8.S., died in Barre,
Mass., November 28, 18H3, aged seventy-one years.

PiBaBX J. Van Benkskm, M.D., D.Sc, LL.D., Professor in
the Faculty of Sciences at Louvain, died at Louvain, January
9th, aged eighty-four years. His life was spent in scientific
research in many departments of knowledge, anatomy, zoology,
physiology and ethnology. He was a member of the Academy
of Science of Belgium ; a foreign member of the Royal Society
of London ; a member of the Institute of France.

BOOKS AND PAMPHLETS RECEIVED.

Thirty-eighth Annnal Report of the Trustees of the Northamp-
ton Lunatic Hospital for the Year ending September 30, 1893.

The Healing of Rodent Cancer by Electricity. By J. laglis-
Parsons, M.D., M B.C.8., H.R.C.P. (Lend.). London: John
Bale & Sons. 1893.

Outline of Physical Diagnosis of the Thorax. By Arthur M.
Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in
Rush Medical College ; Attending Physician to the Central Free
and Bethesda Free Dispensaries, Department of Rhlnolog|y,
Laryngology and Diseases of the Chest. Chicago: The W. T.
Keener Co. 1894.

A Text-book of the Physiological Chemistry of the Animal
Body, Including an Account of the Chemical Changes Occurring
in Disease. By Arthur Gamgee, M.D., F.B.S., Emeritus Pro-
fessor of Physiology In the Owens College, Victoria University,
Manchester; Lately Fnllerian Professor of Physiology in the
Royal Institution of Qreat Britain. With two cbromolitho-
graphlc charts by Spillon and Wilkinson. Vol. II. The Phy-
siological Chemistry of Digestion. London and New Ton:
MacmiUan&Co. 1883.

Digitized by

Google

Vol. CXXX, No. 8.] BOSTON MEDIO AL AND SURGICAL JOURNAL.

63

ON THE VALUE OF EXAMINATION OF THE
BLOOD OF THE INSANE.^

BT J. A. HOCITON, V.C, KOBTRAJlPTOir, MASS.,

Aitiitant Pkniician, Northampton Lwiatia Hotpital.

It is a truiem that the mind reqaires, for the proper
mainteuance of its operations, a sound body.

Ton are all cognizant of the influences which mind
aud body have upon each other. Their interdepend-
ence is noted every day by the hospital physician ; he
sees it in many cases on admission, it having been esti-
mated that in 55 per cent, of admission to hospitals for
the insane the bodily health is considerably below nor-
mal ; he notices it in convalescents by the advance-
ment together of mind and body toward a condition of
soundness, the weightcbarts of recoveries showing
almost universally an upward curve ; he realizes it in
those cases that retrograde till death seems to result
solely from the physical exhaustion induced by the
mental state; and finally he admits it by his method
of treatment, which is largely directed toward the res-
toration of the body to its normal tone.

How great a factor impaired vitality is in the eti-
ology of mental troubles is not easy to determine,
because in so many of our cases it is a result rather
than a cause.

Of 1,678 admissions to the State hospitals of this
commonwealth last year, the assigned cause of insanity
was ill-health and privation in 74 cases, or 4.5 per
cent., while in seven per cent, additional cases the as-
signed causes were such exhaustive diseases as in-
fluenza, phthisis, typhoid fever, pneumonia, rheuma-
tism, neurasthenia, etc.

Inasmuch as numerous agents and conditions which
influence the quantity of blood supplied to the higher
nervous centres, thus increasing or diminishing the
amount of nutriment, do thereby cause disturbances of
the normal action of those centres, it has been inferred
with reason that marked variation in the quality of the
blood-supply may similarly produce impaired action of
the nervous centres.

To determine what connection, if any, exists be-
tween certain mental states and pathological conditions
of the blood. Dr. S. Rutherford Macphail several years
ago made an extensive series of examinations of the
blood of the iusaue with special reference to its rich-
ness in corpuscular elements and in haemoglobin.

The results of his investigations, which are pub-
lished in the •/ouma/o/i/mto/iSctencM (Vol. XXXII),
appear to be quite conclusive that poverty of the blood
is in many cases a predisposing cause of insanity.
Later observers couSrm the results obtained by him.

An account of my experience in the examination of
the blood of the insane within a few months past may
be of interest to any who have not personally made
such examinations. For estimating the number of
corpuscles I made use of the Thoma-Zeiss instrument,
which is probably the best adapted to the purpose of
those made. For estimating the percentage of hsemo-
globin several methods are in use. Probably Fleischl's
hemometer is the most accurate instrument for prac-
tical use. I made use of Glower's method, which is
simple, and which, I am informed by Professor Henry,
of Philadelphia, an authority on the subject, is suffi-

> Bead before the New England f a jchologtoal Soeiety, September,

1893.

ciently accurate for clinical use — probably within two
or three per cent.

In my examination of men in sound health, I found
that Gower's standard tint for comparison is appar-
ently too high, none of the examinations showing
more than 90 per cent, of haemoglobin. Learning that
other observers had the same experience, I made a
new standard, as follows : taking blood from 1 1 men,
as many as I could conveniently obtain at the time,
whose blood registered 90 per cent, by Gower's stand-
ard, I diluted each 100 times with distilled water and
mixed the dilutions. Taking the tint thus obtained
for normal, I copied it with glycerine jelly tinted with
picrocarmine, which makes a stable tint. I corre-
sponded with Professor Henry about the matter, who
replied: "I have found the standard of Gower's
Haemoglobinometer too high, and am accustomed to
regard as normal a blood which contains a normal
number of red corpuscles, and of which the color corre-
sponds to 90 or even 85 of Gower's or Fleischl's test.
. . . Your method of obtaining a color standard is the
only correct one."

Stimulated by the results obtained by others, I had
hopes of obtaining satisfactory results in my own ob-
servations. But when, after a few trials, some of the
enumerations showed an abnormal plethora in appar-
ently anaemic individuals, and other enumerations in-
dicated an immediate need of tonics in those robust to
outward appearance and 'enjoying the blessings of
health ; and when finally the same individual would be
found rich and poor in the formed elements of the blood,
all in the same day, I may add that my enthusiasm was
somewhat lessened aud my faith was tinged with doubt.

My further experience and further knowledge of the
experience of others convince me that conclusions
based upon single observations are quite unreliable.

There are many opportunities for making an inaccu-
rate estimation of the number of corpuscles. The
chief source of error, in my opinion, lies in the quali-
ties of temperament peculiar to the observer — in the
method of conducting the observation from the punct-
uring of the skin for the blood to the final count. As
for the errors of manipulation, I will mention those of
importance. Pressure on the finger to induce a flow
of blood from the puncture is said to disturb the rela-
tive proportion of corpuscles and serum. I do not
know as to this ; it is easily remedied.

Of more importance is the mixing of the blood and
diluent. It should be done thoroughly to ensure an
equal distribution of blood-corpuscles through the mix-
ture. I believe this can be done with more certainty
in the bulb of the pipette than in an open jar with
stirring rod, as some observers do. The objection to
mixing in the bulb is the difficulty with which the
bulb is afterward cleansed aud dried. I thiuk accu-
racy will outweigh inconvenience in the method. I
would recommend having the solution for diluting the
blood at blood-heat, and would then rotate the pipette .
from two to three minutes. In my practice I expel
nearly or quite half of the mixture, that I may gel a
drop from as near the middle as possible. I would
not recommend the common practice of counting a
second drop from the same preparation, because I fear
some undue proportion of liquid or of hasmacytes may
adhere to the sides of the bulb during the second mix-
ing, which is rendered necessary by the settling of the
corpuscles in the bulb while the first count was in
progress.

Digitized by

Google

64

BOSTON MEDICAL AND SUSOICAL JOUBNAL. [Januabt 18, 1894

The size of the drop placed upOD the cell for coanU
ing \b supposed to influeiice the result, though, theo-
retically, from the nature of the cell's ooDstruction,
the variation should be slight.

And finally, the care with which the corpuscles on
the squares are counted has much to do with the result,
since each corpuscle counted, in a dilution of 1-200,
represents 3,125 corpuscles in the total estimated.

Considering these facts, it is well-nigh impossible
for the observers to obtain the same results from the
same individual, and even from the same . drop of
blood.

Dr. Daland, of Philadelphia, has recently sent me a
paper embodying the results of examinations of blood
by himself. From a study of eight cases counted by
himself and Dr. Sadler conjointly, he reaches conclu-
sions which I will briefly notice. First, he states that
when the same squares are counted by two competent
observers with the minutest care, a difference between
the two counts of between 50,000 and 150,000 cor-
puscles may be expected, 5,000,000 being the normal
average. In the case cited bv him where he and Dr.
Sadler differed by 150,000 in'a total of 4,150,000, he
must have counted in 64 squares 320 corpuscles, and
Dr. Sadler's count must have been 332 corpuscles, a
difference of three corpuscles per field of 16 squares,
which seems to me to be an error three times too great.
I think 50,000 corpuscles should represent the highest
limit of difference.

I would state here that I invariably count 256
squares, and feel more confident of results, though it
requires more time.

To ascertain the liability of error when two observers
count the same squares, my associate, Dr. Holmes,
and myself ccuuted eight cousecative cases with care,
though not with minutest care. The greatest differ-
ence between our counts was 34,000 corpuscles (con-
siderably less than one per cent.), while the average of
difference was less than one corpuscle per two fields,
as is shown by the accompanying table.

Dr. Holmes's. Dr. Hotuton's. Difference.

Case No. 1.

. 6,066,000

6,062,000

6,000

Case No. 2. .

. . 6,860,000

6,881,000

21,000

Case No. 3. .

. 6,T3t,000

6,703,000

81,000

Cam) No. 4. .

. B,l(»flm

6,i»i,oao .

34,000

Case No. 6. .

4,108,000

4,091,000

16,000

Case No. 6. .

4,712,000

4,678,000

34,000

Case No. 7. .

4,800,000

4,928,000

26,000

Case No. 8. .

. . 6,478,000

5,460,000

28,000

Again, Daland states that when two preparations
are made from the same diluted blood, and counted
immediately by the same observer, a difference rang-
ing from 187,500 to 525,000 may occur. In my ex-
perience I have found liability to error in making the
second count from the same mixture, as to the reason
for which I have already expressed an opinion. I
prefer to verify by counting from a fresh mixture of
blood.

Daland further says, " When two observers take
blood from the same drop, dilute, and each prepares
two slides and counts 128 squares, the results of the
two observers may differ as much as 1,381,250."

Dr. Holmes and myself have never been so unfortu-
nate when verifying each other's count by separate
preparations of blood. It seems to me that the great
differences in results obtained by observers may be due
to the small number of squares counted, to differences
in the instruments used, and to the personal equation of

the observers. The error from the last cause should be
nearly constant

Dr. Henry has shown that differences in instruments
exist; and Dr. Daland shows that his enumerations
are almost invariably smaller than Dr. Sadler's.

Dr. Daland considers the hgematokrit a more accu-
rate instrument. It is designed to exhibit the volnme
of corpuscles in a given amount of blood by means of
centrifugal force.

Referring to the unsatisfactory results obtained by
Dr. Daland and Dr. Sadler in blood counting, Profes-
sor Wilcox, of New York, in a pamphlet on anaemia,
writes that he has abandoned making estimations of
the numbers of blood-corpuscles, but continues the use
of the heemoglobinometer.

In spite of the donbts of accuracy thus mentioned,
my experience convinces me that much reliability may
be placed upon the results. By careful and methodical
operation the error should be reduced to three per
cent, at the highest. I have numerous cases which I
have counted repeatedly, from fresh mixtures each
lime, and on different days, in which the results agree
within a range of one per cent.

When we consider the error peculiar to each ob-
server, the same percentage of variance would seem to
attach to each case of a series counted, which series
for purposes of comparison would thus not be vitiated ;
the relative significance of the cases would be just as
valuable.

I have dwelt at some length on the question of ac-
curacy in blood counting, because thereon . binges all
the value of the operation.

Owing to lack of time the number of oases observed
by me has been small, though the number of observa-
tions has been several times larger.

In 13 cases, well mentally and physically, whose
blood was examined by me I found the average for
males to be 5,101,000 per cubic millimetre and for
females 4,764,000 per cubic millimetre. Sonae ob-
servers obtain greater, some smaller, numbers than
these. The mean of averages by 17 observers, as com-
puted by Dr. Daland, is for males 5,130,000, wbich is
but a fraction of one per cent, larger than the average
obtained by me.

Of the insane I examined 25 males and 27 females,
as appears in the accompanying table.

These are average cases representing several of the
various forms of insanity. The results, which largely
confirm the conclusions of other observers, show that
in a large proportion of the insane there is marked
diminution in the number of red blood-corpuscles sluA
noticeable deficiency of haemoglobin.

Considerable decrease in the number of corpuscles
was found in 60 per cent, of the males (averaging
4,427,000) and in 40 per cent, of the females (averaging
4,196,000). The percentage of haemoglobin was much
below normal in 84 per cent, of the males (averaging
74.3 per cent, of haemoglobin) and in 77 per cent, of
the females (averaging 69 per cent, of haemoglobin).

Since many of the cases had been undtir tonic treat-
ment for some time when examined, and since there
are in the list but four cases of dementia which of all
forms of mental disorder presents the greatest povertv
of blood in the elements under consideration, 1 think
an examination of all cases in the hospital would give
much lower averages than the above. An analysis of
the cases in detail would prove tiresome to listen to. I
will give only general results.

Digitized by

Google

Vol. CXXX, No. 3.] BOSTON MEDICAL AND SVRGIOAL JOOSNAL.

55

24
25

MAIiU.

1

Form of Dlaeane.

Age.

Wght.

Hemo-
globin.

No. of Cor-
puaelea.

1

3
8

4
5

e

Mania a poto
Toxic maoia
Aoate mania

(C K
«C (1

Reourrent mania

SS
30
2«
40
43
74

ITS
170
108
160
166
137

SO

to

70

6,520,000
5,260,000
5.260,000
5,400,000

6,270,000
4,910,000

Arerage

85

5,268,000

Aoato melanoholla

24

1T6

75

4,940.000

26

181

78

8,875,000

15

117

T2

4,380,000

10

!tt

160

T5

5,100,000

It

it tt

57

127

82

4,960,000

12

46

140

81

5,0!«,000

IS

Ohronio melaneholla

58

180

74

4,660,000

14

•* (1

70

108

40

4.100,000

15

48

182

T8

4,015,000

16

Senile melanoboUa

T2

145

T6

4,460,000

ATerage, T2.5 4,561,000

Epilepsy

136
ITO

80
T2

Organle dementia
Senile dementia
Seoondi^ry dementia

ATerage,
Total avenges, males,

77.3
T6.4

Aeate melaoehoUa

Ohronio melaneholia

Epilepey

ATerage, 86.6

61 Senile dementia

81

66

6,130,006
4,900,000

76

6,016,000

19

Paresis

40

125

70

4,820,000

20

**

85

146

T8

4,1140,000

21

48

129

80

4,880,000

22

44

170

T3

4,840,000

Average, 76.2 4,745,000

50

140

82

73

141

80

40

128

70

4,486.000
8,480,000
4,220,000

4,028,000
4,732,000

rsMALKS

26

Aonte mania

16

78

68

4,820,000

27

18

123

60

4,300,000

28

22

123

00

6,260,000

29

20

112

TO

5,000,000

8U

62

84

T5

4,640,000 '

ATerage, T0.6 4,804.000

32

140

76

86

97

77

33

ISO

T4

33

118

80

88

90

78

36

96

T2

47

88

62

3T

lie

69

84

140

68

83

M

60

39

109

67

38

97

63

4,875,000
4,820,000
3,976,000
4,800.000
4,275,000
4,840.000
6,260,000
4,726,000
4.T20.000
3,»97.0«0
4,319,000
4,231,000

Average, 69.6 4,628.000

23
31

106
106

80
72

4,876,000
3,980,000

ATerage

. T6

4,427,000

46

Prim. del. tnsan.

60

ITS

88

5.013,000

48

46

ISO

86

6,435.000

47

36

166

96

5.035,000

48

30

140

96

6.100,000

49

88

180

86

4,600,000

60

48

216

T8

6,803,000

6,252,000

3,460,000

Total aTeiagei. females, 73.6 4,698,000

I shall make no mentioD of white corpuscles in the
analysis of the cases, because in none did I find any
considerable departure from the average number to be
found in health.

Reasoning a priori would lead to the inference that
in those forms of mental disease characterized by
qaickeued mental processes, such as the manias, the
blood would be found rich in corpuscles and hsemoglo-
bin — while the converse wonid be found to exist in
psychoses characterized by an abeyance or loss of
mental powers as in the melancholias with sluggish
circulation and in dementias. Such is in a measure
the case, though the relationship between the conditiou
of the blood and the mental state is far from conataut.

Macphail says the proportion of corpuscles and of
haemoglobin in mania is equal to or greater than the
normal percentages. Dr. W. Bevan Lewis says that in
his experience a diminution in the number of red cor*
puscles is more frequently met with in maniacal condi-
tions.

Of eleven cases of mania (six males and five females)
examined by me, there was an excess of corpuscles
over the normal average in five males and in three
females, a deficiency in one male and in two females.
The percentage of btemoglobin was nearly normal in
three males and in one female.

Examination of 22 cases of melancholia shows a
marked tendency to deterioration of the blood in this
form of disease. In numbers of corpuscles about 50
per cent, of those examined were below normal : 6 of
10 males (averaging 4,272,000) and 6 of 12 females
(averaging 4,195,000). All the cases were deficient
in hemoglobin, the males averaging 72.3 per cent, and
the females 69.6 per cent. Oue woman had the large
number of 5,260,000 verified by repeated counts on
different days. This was a case of melancholia with
excitement.

Of four cases of epilepsy, too few to be of much
value, two cases were found to be considerably below
the normal as to corpuscles : one of these latter cases
was counted while the patient was in the status epi-
lepticus. In all the cases the amount of heemoglobin
was subnormal.

As was expected, the percentage of corpuscles and
of haemoglobin was low in the cases of paresis ex-
amined, four iu number, all males, and still lower in
the cases of dementia, three males and one female.
The case of paresis which presented the lowest per-
centage was considerably demented.

The six remaining cases, all females, were cases of
primary delusional insanity — paranoia. The results
of the examinations in these cases were of much inter-
est. I expected they would register high, probably at
the normal average, but was unprepared to find them
exceed the normal and by so much. Only one case
was below the normal. One case showed more than
6,000,000 corpuscles, verified repeatedly ; while five
of the cases averaged 700,000 more than the average
of females in health, and 860,000 more than the aver-
age for males in health. These cases also exhibited a
higher percentage of haemoglobin than did any other
class of cases, 86.5 per cent., which is not much below
the normal for females.

I have examined several of my cases at intervals to
watch the progress of the disease and the effect of
remedies with interesting results.

Cask XV. Male. Hypochondriacal melancholia,
chronic, do delusions. Patient was pale and weak

Digitized by

Google

66

BOSTON MEDICAL AUD SURGICAL JOVBSAL. [jAStJiKT 18, 1894.

at times did not feel able to go out-of-doors. Arsenic
had been administered for about a month, with no im-
provement in mental symptoms or in the number of
corpuscles and quantity of haemoglobin. Iron, quinine
and strychnine were then given. In about eight weeks
he was discharged much improved. The amount of
htemoglobin bad not increased from 76 per cent. ; but
the number of corpuscles bad increased from 4,045,000
to 4,923,000, and he bad gained in weight five pounds.

Case XXVI. Acute mania in a girl fifteen years
old. She was much excited and very irrational. The
first count, taken during her excitement, showed the
number of corpuscles to be 4,820,000 and the percent-
age of heemoglobiu to be 68. Her weight was 78
pounds. In six weeks from the time of the first count
she had become quiet and rational. The second count
then showed a loss of corpuscles to 4,360,000, but her
weight had increased. Enumeration of corpuscles
just prior to her discharge (recovered) showed au in-
crease to the number of 4,775,000. The hemoglobin
had increased (seven per cent.) to 75 per cent, and
her weight (20 pounds) to 98 pounds. For a tonic
she had taken iron, quinine and strychnine.

Case XXVII. Female, eighteen years old. Acute
mania, with remissions. The first count was taken
after she had passed through a period of great excite-
ment lasting; about six weeks. She was then quiet and
rational, but a little above par mentally. The number
of corpuscles was 4,300,000 per cubic millimetre ; the
haemoglobin showed a percentage of 50 ; and her weight
was 123 pounds. The second count, taken ten weeks
later while she was again excited, showed a loss in
number of corpuscles to 4,050,000. The corpuscles
were at this time very irregular — in the condition
called poikilocytosis. Five weeks later she had be
come quiet and rational again, when it was found that
the number of corpuscles was about the same as at the
second count (4,078,000) but the amount of haemoglobin
had increased (17 per cent.) to 67 per cent., and the
body weight had increased by four pounds.

Case XL. Has for a number of years been subject
to periods of melancholia attended by delusions and by
hallucinations of sight and hearing. Several of these
periods have been concurrent with attacks of pelvic
peritonitis. In March she was cheerful and as well as
she had been for years, weighing about 120 pounds.
In April and May she suffered from dysmenorrhoea,
followed by peritonitis. She became very melancholy
and delusional. In July she was convalescing both
mentally and physically. On the first of August she
weighed 84 pounds. Examination of blood showed
50 per cent, of haemoglobin and 4,000,000 corpuscles.
The first week in September she was cheerful and
rational; her weight had increased 14 pounds; the
haemoglobin bad risen (10 per cent.) to 60 per cent.,
and the number of corpuscles to 4,500,000. The tonic
was eaccharated oxide of iron.

Case XXXIII. Fetnale. Acute melancholia, com-
ing on during lactation. At the time of first blood count,
July 8th, she was much depressed and very irrational,
with some delusions of persecution. Her weight was
130 pounds; percentage of hsemoglobin 74, and num-
ber of corpuscles 3,975,000. September 4th, the
weight had increased by seven pounds ; the haemoglobin
remained at 74 per cent. ; but the number of corpus-
cles had increased to nearly 5,000,00(1. She is cheer-
ful at present, but mentally rather above par.

01 the cases thus far examined to leara the results

of treatment about S3 per cent, show no mental or
physical improvement, and the condition of the blood
remains practically unchanged ; but these examinations
have not extended over a long period, and their num-
ber is not large. Macphail says : " The result of in-
vestigation, comprising over two hundred observations,
would seem to indicate that the four tonics which
alone or in combination were most efficacious in im-
proving the quality of the blood may be classed iu
order thus: (a) iron, quinine and strychnine; (b) iron
and quinine; (e) iron alone ; (<^) malt extract." With
him the blood of epileptics was found to improve with
use of bromides, prolonged use having no deteriorating
effect

One of my cases of paresis improved much under a
course of iodide of potassinm, whether from effects of
the remedy or not I am not prepared to say. On ad-
missioo he was so feeble as to require being kept in
bed ; and he soon had a syphilitic ulcer appear on his
leg. It was thought he would not live long, but be
gradually improved. He has gained in weight over
twenty pounds ; the number of corpuscles has increased
by about 400,000, and the hasmoglobin by 10 percent.;
and he is less boisterous and somewhat more rational.

It would be of interest to compare a series of consec-
utive admissions to a hospital with a similar series of
those discharged recovered. Macphail thinks there is
impoverishment of blood in more than 50 per cent, of
cases admitted ; and he says of patients who recover,
that the quality of blood improves, and is not much
below the normal standard on discbarge.

While I am not prepared to endorse the opinion of
one enthusiastic observer, that the time is coming when
we shall examine the blood of our patients as regularly
as we count the pulse and take the temperature, my
experience convinces me that such examination will
show with approximate accuracy auy deterioration of
blood iu our patients, thus indicating need of, and per-
haps line of, treatment, and that it will also aid us
greatly in observing the progress of our cases and in
studying the efi^ects of remedies administered.

HYPERTROPHY IN THE POST-NASAL SPACE,
ESPECIALLY AFTER CHILDHOOD.*

BT JOHN W. FABLOW, M.D., B08TOH.

The importance of nasal respiration has been so
frequently insisted on in the last few years that there
is no need for me to call your attention tQ it this even-
ing. The post-nasal space, where the horizontal pas-
sage through the nose turns to become (he vertical
passage to the larynx and trachea, should be free from
obstructions and encroachments, just as the bent heat-
ing and ventilating pipes of our houses should not be
choked up or narrowed at the elbows and beuds. The
fact that air goes through the nose, and the naouth is
not habitually open does not, by any means, prove
that there is no nasal obstruction. The body can
adapt itself to various abnormal conditions and over-
come them after a fashion, but the work perfornaed is
almost certaiu to be imperfect in certain particulars.
It has seemed to me that a very erroneous idea of the
nature of free nasal respiration was prevalent. The
post-nasal space may contain a large amount of hyper-
trophied tissue; the patient may claim that he can

I Read before tl>e BM^oa Society for Me41oal ObserrsUon, VoYvm-
ber 6, 1893,

Digitized by

Google

Voi. CXXX, No. 3.] BOSTON MEDIOAL AND SURGICAL JOURNAL.

57

breathe well through the nose; he may not be a
mouth-breather ; he resents the idea that there can be
any obstruction to his breathing; he has never had
any other uose, and has never breathed better than be
does DOW. But after the removal of the hypertrophy
he will confess that he never really breathed well
before.

I have seen so maay instances of this, and have
beeo told so many times by physicians that such and
Boch a case had no poat-nasal hypertrophy because
there was no moatb-breathing, cases where I have
later removed large, obstructing masses, that I feel
the importance of insisting that mouth-breathing is
only one of the symptoms of uasal obstruction, and
that considerable obstruction can exist without mouth-
breathiug, especially in adults.

The same holds true of snoring. If the soft palate
is pushed forward and kept from applying itself against
the posterior pharyngeal wall by large growths behind,
it becomes paretic, and easily flaps backward and for-
ward in sleep, giving rise to marked snoring. But
the palate may be strong, the obstruction high upon
the posterior wall, and snoring entirely absent.

If, then, two of the great cardinal features of post-
nasal hypertrophy may be wanting, we should natu-
rally expect that many cases would be overlooked, and
such I believe to be the case. The degree of obstruc-
tion depends upon the relation of the size of the ob-
structing mass to the space in which it is contained.
In young children the post-nasal space is very small,
and a small amount of growth would naturally cause
very different symptoms from the same amount in a
larger child, if the tonsils are very large, narrowing
the throat from side to side and preventing the free
play of the palate, a smi^ller amount of growth behind
the palate would suffice to cause more marked symp-
toms than where the tonsils are small.

If the growth is spread out uniformly on the upper
part of the posterior pharyngeal wall, the symptoms
will differ from the cases where the growth is massed
together near the posterior openings of the nose.

With regard to the frequency of post-nasal hyper-
trophy after childhood, I should say that such cases
are very common. The idea that adenoid disease
nearly always atrophies after puberty, leaving no en-
larged or diseased structures behind, is entirely erro-
neous. That many such cases are called nasal or
post-nasal catarrh, or are attributed to slight devia-
tions and ridges of the septum, or to large tonsils, pre-
' vents them from being properly recognized and placed
in the category where they belong. But whoever
makes frequent aud thorough examinations of the
post-nasal space with the rhiooscopic mirror must soon
be convinced that a pathological amount of adenoid
disease is very common after puberty, even up to
thirty-live years of age. At puberty the whole region
of the throat enlarges, and more open space for respi-
ration exists in the back of the uose ; but the diseased
glandular tissue is not so prone to disappear, and con-
tinaes to secrete, inflame and cause trouble by its pres-
ence in a different way, ordinarily, from what it did
before.

Let us consider what symptoms we may look for
where there is no respiratory obstruction. The post-
nasal space is a great centre for reflex action, and
naturally resents the presence in it of any growth, just
as it would a foreign body. A very common symptom
in such cases is a dry, backiug cough, often very per-

sistent and more or less paroxysmal. This is quite
apart from the cough due to secretion dropping down
into the pharynx. Scraping of the throat and suifflng
are also endeavors to get rid of an irritant. 1 have
occasionally seen picking of the nose, aud more often
an outward forcible expulsion through the nose, an
evident desire to get rid of an irritant behind the nose.
Particularly in youug persons is it important to ex-
amine the post-nasal space in cases of obstinate cough.
I have seen one case of torticollis apparently caused
by the presence of a small, firm adenoid. I have also
seen several iustances of chorea where the post-nasal
congestion and irritation seemed to be a factor iu the
disease.

The glandular nature of the growth shows itself by
profuse secretion, tendency to engorgement and prone-
ness to inflammation. Repeated colds are common,
and constant sniffling and a loose cough become a part
of the daily life. The secretion dropping in the throat
keeps the tonsils and pharynx in a state of congestion
and hypertrophy. A gland does not need to be large
to secrete a surprising quantity and hence the impor-
tance of not overlooking the post-nasal space even
when there is good nasal respiration. In acute follic-
ular disease of the tonsils, we should also bear in mind
that the follicular tissue of the vault is probably also
involved and merits attention. I have seen a number
of cases where the faucial tonsils were hardly affected
at all, while the pharyngeal tonsil was swollen and
covered with a whitish exudation aud the constitu-
tional symptoms were very marked. In adults, it is
not uncommon to find considerable secretion at the
vault, apparently having its origin in old diseased
glandular remains. I have seen the sSme after op
eration where the follicular tissue had been only par-
tially removed, leaving a certain amount of diseased
and secreting gland behind, an argument in favor of
thorough removal. I have sometimes thought that
the amount of secretion had been increased by the in-
complete removal.

I shall say nothing of the bearing that large adenoid
masses have on the hearing. Such cases usually have
other marked symptoms which attract attention, and
hence are not likely to be overlooked. But the smaller
growths, less easily recognized, and occurring iu adults,
have a very great significance as they are apt to be
overlooked until the heariug has become quite im-
paired in one ear, or tinnitis aurium has demanded at-
tention. They act more slowly and accompany or
cause the more chronic disease of the hearing. It is
the situation and nature of these growths which makes
them of such importance to the aurist. Small growths
in the fossa of Rosenmiiller, which keep the Eusta-
chian tubes closed, swollen and bathed iu secretion,
require careful removal. I have seen a number of
iubtances where bands, the remains of old adenoid tis-
sue, stretched across from the Eustachian eminence to
the vault, interfering with the function of the tube.

While the post-nasal space remains in a state of'con-
gestion and hypertrophy, the ear must suffer. I am
sorry to say that many of the cases of chronic disease
of the middle ear, probably caused by a moderate
amount of adenoid disease existing undiscovered for
many years, are often not much relieved by the re-
moval of the adenoid growth. I think the attempt
should certainly be made to free the tubes and the
post-nasal space with the hope of relieving the ears,
but the benefit is much less certain to follow than io

Digitized by

Google

68

BOSTON MEDICAL AND SUBOIOAL JOURNAL. [Januabt 18, 1894.

the early, acute cases of childhood. This is all the
more reason for systematic examination of the post-
nasal space at as early an age as possible, even when
there are no special symptoms.

The deformed mouth, the high arch and projecting
upper teeth, are well recognized results of nasal ob-
struction. The alienist lays great stress on the high
palate as a mark of mental deficiency, but the dentist
and the physician who sees much of nasal disease are
certainly aware that a high palate often has no con-
nectiou with mental inferiority. In an article on de-
formed vaults in the Dental Coimo$, for November,
1893, Dr. £. S. Talbot says : " In cases of arrest of
development of the bones of the nose, and adenoid
growths, when it is impossible for the child to breathe
through the nose, and mouth-breathing is a necessity,
the jaws are separated, and the teeth not having a
resting-place, the alveolar process elongates, and a
high vault is almost always noticed ; hence the reason
why imbeciles, and ail degenerates who keep the month
open, as a rule, have high vaults." There remains
much to be learned on this subject. I have seen a
number of cases of high palate in children where there
had never been nasal obstruction and where the men-
tal faculties were very bright, and also a smaller num-
ber of instances of marked adenoid obstructive disease
where the palate was not high. Where the palate is
very high arched, the post-nasal space is sometimes
narrow and very high. In operating in such cases, I
have been surprised on removing a large amount of
growth to find that I needed to go still higher to a
second or even third story of growth before reaching
the high vauit. Such cases are sometimes deceptive
in the rbinoscopic mirror. The post-nasal space be-
ing narrow, the growth may look small, and one is
surprised on learning the vertical diameter of the
growth. When dentists attempt to spread the upper
jaw in young persons where the post-nasal space con-
tains a considerable amount of obstructive hypertrophy
there is sometimes a degree of nervous irritation caused
which renders it impossible for the patient to submit
to the spreading-plate. I have seen several such cases
with dentists, and not until after the removal of the
adenoid growth could the dental work be continued
with satisfaction.

The importance of a free post-nasal space can hardly
be exaggerated. There may be plenty of room for
nasal respiration, there may be little or no secretion,
but if the posterior wall and vault are covered to a
greater or less extent with a thickened tissue, the voice
loses just so much resonance, carrying power, and part
of its upper register. Our New England climate is
held responsible for many thick, catarrhal voices, but
this can be overcome in many cases by attention to the
post-nasal space and removal therefrom of secreting
and hypertrophic structures. I have seen a gain of
several notes in the upper register after the removal
of a small, soft mass at the vault. The voice does not
tire BO soon, and can be used much longer at a time in
speaking or singing.

The diagnosis is most surely and accurately made
with the mirror. I am not speaking of cases of great
mouth-breathing, etc., where the symptoms are very
marked, and where the finger readily determines that
the post-nasal space is filled, I refer rather {o cases
where the symptoms have to do with the other
functions of the post-nasal space than the respiratory.
The upper jaw may be very long, and it may be diffi-

cult to reach the vault with the finger. The patient
can tolerate the finger for a short time only, and accu-
racy in diagnosis is impossible. I once operated, un-
der ether, on a case where I had not made a positive
diagnosis. The space between the uvula and the pos-
terior pharyngeal wall was so small, owing to projec-
tion of the spine at this spot, that I was unable to see
anything with my smallest mirror, and the upper jaw
was so long that I was unable to reach the vault, even
during ansesthesia.

There is sometimes more hypertrophy at the vault
than appears in the mirror, as the growth may be of a
fairly uniform thickness, or the vault may be very
high and able to contain a great deal more tissue than
usual. The probe is an aid in such cases. We often
see irregular masses with clefts between, and are sur-
prised to find how far the probe will enter into these
clefts, from which there may exude a copious secretion.
Such are remains of Luschia's tonsil, which has taken
on a diseased action.

The regions near the Eustachian tubes should be
carefully examined for bands, or small projections,
which interfere with the function of the tubes.

The size of the cavity should be carefully noted, as
the smaller the space, the greater the discomfort from
a given amount of hypertrophy. I should say that in
young persons great enlargement of the tonsils was
almost invariably accompanied by a considerable de-
gree of hypertrophy at the vault, especially if there is
any mouth-breatbing.

Treatment in the mild, soft, secreting cases consists
in the use of cleansing sprays and various astringents,
such as iodine and glycerine. But most cases will re-
quire removal by surgical means. Cocaine serves to
diminish the pain, and with the co-operation of the pa-
tient, the desired pieces can be removed with great
accuracy. If anaesthesia is necessary it should be light,
as it is much safer than deeper ansesthesia where con-
siderable quantities of blooid may enter the air-pas-
sages.

Sometimes caustics or the galvano cautery are of
use, especially where the diseased and secreting clefts
and sinuses are present. My own preference is for
forceps, while others favor curettes and various snares.
The important point is to remove all the diseased hy-
pertrophied tissue. The lower pharynx should also
be treated whenever there are any large follicles
present.

THE EFFECT OF CLIMATE AND ENVIRON-
MENT ON THE NEW ENGLAND GIRL.

BV J. WAKBBH A.CH01UI, M.D., BBOOKLIHB. MASS.

Man and the forest, man and the mountains, naan
and nature grow together. Wherever you find the
highest mountains, the mightiest forest, (the forest
that knows no ancestry,) the deepest ocean, the most
graceful lakes (like those one sees in Switzerland), and
hear the roar of the cataract that tells of a mighty
river, there the most rugged and characteristic in
nature abounds (the climatic conditions being also
favorable), there you find the noblest type of man —
the finest physically, and if civilization has reached
him, and educated minds have helped bis own to think,
the physically and mentally proportionate man. There
you find the most potent man and the most thoughtful ;
not necessarily the tallest, though the race grows tall-
est in the tallest country ; not uecessarily the shortest.

Digitized by

Google

Vol. CXXX, No. 8.] BOSTON MSDIOAL ASD SXTBGIOAL JOUMIfAL.

59

thongh the shortest nsnally grow where the bills are
stunted; not necessarily the brawniest, though the
brawniest grow where the physique is greatest and the
heart and the perception and the emotions, as well as
the endarance and skill, are all appealed to. When
yoD bare that combination of brain and body in keep-
ing with a mighty country and its climate, other things
being equal, there man works out the longest life and
the greatest measure of happiness and usefnlness, for
happiness and usefulness depend more upon a well
body and a contented mind than upon anything else in
the wide world.

Who ever thought of hunting for grizzly bears on
the rice islands in the delu of the Alumaha ? The
fierce Numidian Hon is no longer a lion if born in a
cage and fed with a fork. The gray wolf of the
Michigaa forest stands you at bay, and snaps and
snarls defiance at your coming. I bare seen a whole
pack of prairie coyotes disappear at the twirl of a fin-
ger. Who ever thought of looking for the white-pine
of the Maine forests or the pink-pine of Oregon — the
muts for ships that sail the world around — in the
coastpplain country about Albemarle and Pamlico
Sounds, where only the stunted loblolly grows —
rough-barked, all sap, with little heart, standing ther^
with half-starved look among the coarser grasses of the
great morass ? Who ever thought of looking for the
finest typ« of negro among the sand dunes that rise
above the level of the waste places in the Great Dis-
mal Swamp? Why the darkey of the uplands de-
spises the rice-island "nigger"; and the southern
planter vrben he would harvest seeks not the coast-
plain idler but the foot-hill dweller. Who ever saw
the coast- plain negro seeking a home among the moun-
tains that stretch from Harper's Ferry to the Missis-
sippi? Never does he do it. The negro of to-day
weds the plain. He loves the hummock lands that lie
along the Suwanee River far better than the sight of
mountain peaks that, rising in succession, overpower
his imagination and appear to him but the tents of
great giants who are resting for the night but with the
mornlDg will go on ; and the thought for his life, like
the great bills he is gazing upon, makes him supersti-
tions and afraid. Mentally be is not equal to the
eternal bills. His cabin home is not found beyond the
uplands. His mind is still in the beginning of its
thought. Later on he may exchange the plain for the
moantains, the muddy lagoon for the crystal lake, the
red-ranning river for the sparkling waterfall, the
Btnnted low-land pine for the mountain valley variety
with its longer shatter, whose top sighs an hundred
feet io air and the whisper of whose voices make for
silence. The Sioux Indian of the northwestern
prairies is no match for his neighbor, the Chippewa,
whose possessions rise where those of the Sioux leave
off. The Sioux knows only his pony and the prairie.
His arms are small and his chest narrow; and his
strength, aside from his hips, is slight. The Chippewa's
shoulders are broad, bis arms powerful and his back
strong. His horse is not the prairie pony but the
birch canoe. His battle-field has not the sameness of
the plain nor has his physique, but the grandeur of the
hills and the ever-restless waves of the great inland
seas.

I have been trying to show that the country marks
the man. The American is recognizable from what-
ever part of our country he may have come, not only
because he is imbued with the American spirit which

crops out and betrays him, but also from his American
physique — the elongated head, the fine and trans-
parent skin, the quick-glancing eye, the mobility and
flexibility of body, the changing features, the genuine
laugh, the nervousness of his movements. But if the
four present types of Americans from the north, south,
east and west are brought together, their likenesses
are not so apparent. There yet remain differences doe
to climatic influences and the topography of that par-
ticular section of country from which he came, envi-
ronments that declare for him what manner of man he
is. Never could I persuade the old darkey woman of
the South, the Auntie whom everybody knows, that I
was a Southerner. " Ah, boss," she used to say,
"you's come a long ways north of hyer."

The Yankee is recognizable everywhere; there's no
mistaking him. The figure of Uncle Sam is the tradi-
tional Yankee. Here in New England the people
grow tall and lank, and their temperament becomes
vital and nervous. I believe the New Eagland people
are becoming nervous and dyspeptic, although bom in
a rugged, picturesque country that is reputed to and
should produce a rugged, characteristic race. They
eat.little and hurriedly ; they sleep little ; they have a
burned-out look that bespeaks nervous strain and mal-
nutrition. They worry and they tremble. The women
lose their rotundity and the men strive ; and both
grow thin.

The Southerner comes among us from the land of
flowers and ease, with the grace of one accustomed to
repose and leisure ; but before the Indian Summer is
over and the birds are flown, the feeling that he must
hurry begins to possess him, and by the ides of March
he is on the run with the rest.

The foreigner comes to us from the rational-living,
slow-going countries of the Old World. At first he is
astonished to see us get up from the table and leave
him to take his dessert alone. He preaches modera-
tion ; but the wild race of the people, and the climate,
will not let him have it.

And the German of to-day, whose grandfathers
landed here two hundred years ago, is no longer a
German in appearance ; the country has trade-marked
him. In spite of the lymphatic, phlegmatic tempera-
ment of his ancestors, who were thick-set, broad-
shouldered, beer-loving and sausage-eacing, he has the
refinement of figure and the vital temperament of the
Yankee. " lie is the European " as somebody has
said, " with a drop of nervous fluid added."

Gladstone's longevity may be due in part to this act
of his life, that he never cuts a string from a bundle,
but takes time to untie the knot. Wtiat are we born
and living for ? Is it to hurry ? For money ? For
dyspepsia? For a pain in the side (the virtues of
which we recite every morning at table)? For the
bubble of a reputation ? Or is it rather for happiness
and usefulness, so that some one at least, may say of
us when we are gone, that he has been happier and
better because we kave lived?

At ten, the school-girl is physically the equal of the
boy. She can run as fast as he; she can jump as
high ; she can tussle him down over half the time in a
rough and tumble; she can skate; she can slide knee-
fashion on a sled. The one thing she cannot do that
he can do is, throw a ball ; but that is not due to her
physical condition but rather to an anatomical differ-
ence in the shoulder.

What is it then that between the ages of ten and

Digitized by

Google

fiO

BOSTON MEDICAL ASt) SVMGlCAL JOOMBAL. [•'AurABT 18, 1894.

twenty kills the girl physically, and establishes apon
this continent and particularly in New England, a new
disease which the Germans style Americanitis —
American nervousness ? And why, if the boy escapes,
in part at least, does not the girl escape also?

And first the boy ; the country has marked him for
its own. Like the man of whom we spoke at length,
he is tall and spare and active. He is a typical child
of New England parents. But he escapes; and there
are two reasons for his escape. The ttrst is, that he
toill play ; that he will stay out-doors, will indulge in
recreation of all sorts ; that he will not study, that is,
will not exert himself to the point of going to bed
tired from study, rather than tired from play. That is
where he is right. In other words, his physical status
keeps abreast of his mental advancement and savors
constantly of it, so that at the age of twenty, when his
mind is really beginning to get on its legs and think
for itself, he has a body back of it that is equal to the
demands made upon it. And so he continues to grow.
At twenty his physical strength is twice that of the
girl with whom, at ten, he used to play as an equal.

Now how is it with the girl ? At ten, she u the
physical and mental equal of the boy. She is doing
the same amount of school-work, brain-work, as the
boy, and, if anything, is doing it better. To this is
added for each day an hour or two of nerve-work at
the piano, or at the easel. By the time she is fifteen
her dresses have grown, in length, to the ground, and
in weight, beyond what any woman's hips should ever
carry. By this she is hampered. In addition to these
burdens and drain upon the strength, she is helping
her mother in home (iuiies daily. Then because every
daughter or young woman at home should know the
world and learn to carry herself in it, social exertion
and excitement are beginning to crowd upon her and
eat up her evenings and prolonged periods of rest.
Time for recreation of the physical strengthening sort
is denied her. Or, perhaps this is not her case ; she
may have gone out for work and bread-winning as a
stenographer, type-writer and book-keeper combined,
to become a sort of an electric machine, an organette
that wilt play three diSerent tunes, with her nerves
for wires, and her body for a key-board. This com-
parison, as you will see, is in favor of the organette as
against the girl ; for the girl has not only to furnish
the music, but she has also to turn the crank.

Our typical girl then, does not only the work of the
boy, during the formative years, the growing years,
when she is naturally perhaps the weaker vessel, but
she is doing also, house-work, needle-work, music-
work or painting, or taking care of pouibly invalids or
children. To these must be added social forms of
which 1 spoke, most exhausting demands upon her
strength, such as making three-minute calls (which a
boy will never do, bless him !) or playing good angel
to family hand-downs, stupid people who come and stay
and absorb one's time and strength as a sponge absorbs
water. Add to this the growing dress and the pro-
prieties that must attend its wearing, its hiuderance to
free movements, and we have one factor more in the
count of the things that go to destroy the health of
our school-girls. Woman's dress with her entering
the avocations of men is a tremeudoas negative. Not
au element in it belongs to a busy, open, exhaustive
life. It was devised under and is a result of conditions
wholly at variance with such a life. It is fit only for
the retired, protected, domestic living within doors, like

that our grandmothers enjoyed. They dipped candles,
made apple-butter by September firesides, pickled
meats, and knitted their own stockings. It belongs to
the time of homes, and not flats and janitors.

Now, further, add to what I have already summed
up the fact that a young woman's work is almost
entirely mental, spiritual, or vital, preying upon emo-
tions as well as intellect, all through her school life,
and that her physical development is practically cut
o£F at fifteen, when she needs physical training most;
that the very best blood in her veins is constantly used
to develop her brain at the expense of her body, when
it is just as necessary, and more necessary, that the
hips and shoulders get their share, since they are the
parts physically the most used and needed and abused
afterwards, and the first to suffer because they have
been robbed. Consider that in whatever capacity she
works, the girl of to-day is pitted against men, working
under laws set for men, working under negative ioflu-
enoes — for in many of the pursuits into which they
have entered they are not wanted ; and is it any wonder
that they grow tall and gaunt and have a burned-out
look, and finally break — not mentally, but physically,
before they are thirty ?

At twenty the boy is just beginning to put on steam.
At thirty, if he has not broken himself in some vain
effort to get rich in a hurry or wear his father's shoes
before he is out of college, he is in a poeition, both
mentally and physically, to do his life-work. But if
he has taken the other course, he is on a par with the
girl I have been describing to you. At twenty, she
has mental development in excess ; but at thirty she is
only a shell — mentally developed, physically good for
nothing. Good for a trip down-town perhaps, or two
hours' work in the morning ; good for one child, but
an invalid after that ; good to adorn the end of a sofa
for the rest of her life; always a cause of concern and
regret for others ; never contented ; never quite happy ;
never altogether useful in the best sense. Always, as
a bird in a cage, she struggles against the bars that
fetter her freedom.

I contend then that whatever we do, it is not so
much a question as to whether we have brain enough,
but have we body enough ? Whatever we do we must
keep within the phyncal limit. If one is not held by
mental inability, but is held by physical disability, then
gracefully accept fate and be guided by that. If, on
the other hand, the physique is perfect and never tires,
then work as hard as you please and drive the mind of
mediocrity to its highest level.

" Going to college, are you ? " said an old physician
to his son. " Well, if you come out all head and no
body, or all body and no bead, I wouldn't give a copper
for you ; but if you come out pretty well mentally and
pretty well physically, you'll get along in the race."

" Getting along in the race " is exactly the idea.
We cannot all of us be orators or great poets, or great
singers. We may have the brain but not the physique,
or the physique and not the brain; though on the
average I think it is fast becoming, with Americans,
not so much a question of brain as physique.

Particularly 1 think this true here in the East where
there is repose of neither body nor mind. This ner-
vous climate is telling upon us, but more upon the phy-
sique of our women than upon that of our men. What
advantage is it to be first mentally in some accomplish-
ment, as, for instance, first in English literature, if
after yon get it you spend yonr life in semi-invalidism.

Digitized by

Google

Vol.. CXXX, No. 8.] BOSlOar MEDWAL AND SUBOIOAL JOURNAL.

61

Of -what advantage is it to become an inteneotaal slab,
tatooed with Greek and Latin, if after yon are so
adorD«d and honored you can neither work nor walk,
but DDust go to bed with it. If yoa are acquiring
aometliing for the nee yon intend to make of it — hrod
Ktudim — what dbes it profit to give all your health
and strength to approximating perfection when you
never shall be able to use it to any advantage for the
purpose for which it was intended ?

And now about these women whose occnpations are
not essentially intellectual. Watch the eight-o'clock
eirl as she hips it across the Common toward Park-
Street Church on the way to some of those great
kitchen emporiums down -town, where she stands all
day long and sells dippers or diamonds. She is alone.
They are birds of solitary passage. She has a busi-
ness nose and the air of publicity. Shoulders high —
she is lugging them. Hips narrow — a fact not infre-
quently commented upon by the stranger physician in
the town. A bunch of clothes hang from her unde-
veloped hips, practically from the small of her back.
She tips forward to offset their weight and settles back
to ease the strain. Her life during the formative
years fitted her for anything but what she is now do-
ing. She taxes every part of her body every day to
its utmost that all through the growing years she un-
consciously and nnknowingly robbed and starved. From
ten to eighteen she was worked and taxed from her
waist up, since that time the strain has been from the
waist down. Her early attainments, if any, are little
called into this daily bread-winning account.

Watch the nine-o'clock girl, as she comes an hour
later. She is a little better dressed, a little fresher in
look, a little less hurried ; but still she has that inde-
finable something in her general appearance that tells
she is working on her nerves, or with them to an ex-
tent that is drawing upon her general health and
strength. She is the personification of the organette
I have already pictured.

And now comes the half-past-ten-o'clock girl. She
is well-dressed, with a rounded figure and a lazy air
and an expression of intelligence and mental alertness
that is both refreshing and pleasing. Perchance she
is the rich man's daughter and has lived, a part of her
life at least, where the balm and aroma of the orange
and magnolia, and the swaying grace of the gray
Spanish moss has coaxed her into repose and forget-
fulness of ambitions and the cutting north winds of
this land of ice and industry. Mere beauty needs no
appeal ; it makes its own. Physical health with ade-
quate harmony of mind and heart, however, be the
. woman ever so plain, has its attractiveness and its re-
ward in a long and useful life.

Wheuever I hear a young man or woman say, he or
she is working on nerves, I know at once that sooner or
later, the break will come. And when they do break
they break all over. The wreck is often complete.
All other parts of the body are servants to the nervous
system. The nervous system is the last to be perfected,
the last to be matured. It is the last to give way. It
is king, but the most unsympathetic of all rulers.

One's head is one's capital city ; one's body the out-
lying country. The city people are consumers ; the
country people, producers. Jf the body — the country
— is thrifty and prosperous and peopled, iu time,
and time enough, the br»'' - will be fall.

Bat if tllb city is filled city is over-

peopled in proportion t ry parte ar9

able to provide for, in time the city, that is, the brain,
will starve. In other words, an acute brain by its very
activity makes demands upon the body that only a
well-conditioned body can supply.

The boys and girls of to-day, born of nervous parents,
when they become fathers and mothers cannot but
produce children more nervous than they themselves
were. The law of hereditary transmission is unerring
and never-failing. We are made up of two-thirds of
what has been and one-third of what is.

Train the mind, but not at the expense of the body
during the formative years. They do better life work
hand-in-hand together, since they are mutually depend-
ent and inseparable as links in the golden chain of
right life and living. Whatever else we do or don't
do, we should keep within the physical limit and be
satisfied to stay in that field and upon that plain to
which we are fitted, both mentally and physically.

Happiness and usefulness depend more upon a well
body than anything else in the wide world. Success
in life, as the world sees it, does not necessarily bring
happiness. Gratified ambition satisfies only vanity.
But vanity satisfied and ambition satisfied — bodily
strength nil, and the nervous system shattered — what
avails it to live ?

€(tmca{ Dqiartmettt.

APPENDICITIS, WITH APPARENT RESOLUTION
OF ABSCESS; RELAPSE; DEATH; AUTOPSY.*

' Br FBAHK B. PECKHAM, M.D., PBOVIDKNCB, B. I.

The case which I shall report this evening occurred
in the practice of Dr. Coxe, of Riverside, R. I., who
has kindly given me the history of the first four days
of the disease.

The patient was a young man, twenty years of age.
On Friday, November 10, 1893, he went to work as
usual ; but during the afternoon complained of severe
pain over the ileo-caecal valve, and in the evening
there were chilly sensations followed by several at-
tacks of vomiting through the night

On the morning of the 11th the temperature was
101", pulse 108. Percussion note normal over entire
abdomen, but there was considerable tenderness over
the region of the appendix. The bowels had not
moved in four days. In the evening, the pulse was
120 and temperature 102°. There was a little fulness
over the appendix, with slight dulness and tenderness
on percussion. During the night there was a severe chill.

On the 12th, the third day of the disease, the condi-
tion being unchanged, the bowels were thoroughly
evacuated by castor-oil, and in the evening there was
some improvement. The temperature had dropped to
100° and pulse to 96. There was less tenderness and
tympanites. During the night the bowels moved freely
twice.

On the morning of the 18th, the fourth day of the
disease, there was a change in the symptoms. There
had been no vomiting for eighteen hours. The tem-
perature was 99° and pulse 90. The skin was moist.
There was no tenderness, no tympanites. The patient
felt better and wanted something to eat. Resolution
had apparently taken place. The diet was restricted
to milk and lime-water.

On this day, a kind friend brought in some grapes,
> l^ead be(or« tbe p'roTi4eao« Medloal Sooletjr, December 4, 18S3.

Digitized by

Google

62

BOSTON MBDICAL AND SURGICAL JOURNAL, [Jahuabt 18, 1894.

which, of conne, were eaten. Daring the night there
was a severe chill, with yomiting, which contained
bile for the first time. After the chill there was pro-
fuse sweating.

On Tuesday, Noyember 14tb, I saw the patient
with reference to operation. At this time, while
talking, there was another slight chill, lasting perhaps
five minutes, followed by profuse sweating. There
was no sign of mental disturbance. The tongue was
coated, the centre being dark brown. Temperature
102°, and pulse before the chill being about 100 and
of fair strength. The abdomen on the left side uf
median line was soft and easily compressible. No
tenderness on pressure. On the right side, there was
some resistance to pressure, most marked over McBur-
ney's point, and radiating outward to the median line
and upward to the bonier of the liver. Firm and
deep pressure revealed considerable tenderness, but
nothing could be felt in the shape of a tumor. There
was also slight tenderness near the border of the liver.
On percussion there was very slight dulness over the
area about McBurney's point, and even with the hand
pressed well down during the percussion nothing more
definite could be learned. There was some tympanites
which was generally distributed over the abdomen.

Here was a case of appendicitis which had reached
its maximum on the thinl day, with apparent resolu-
tion on the fourth day.

On the fifth day or during the first twenty-four
hours of the relapse, with no palpable tumor, and
nothing definite on percussion, the patient being in
fair condition, I deemed it best to wait twenty-four
hours, and to watch the patient carefully in the mean-
time. I left about three p. m. on Tuesday ; and the pa-
tient died in collapse about three a. m. on Wednesday.

ACTOPSr.

The autopsy was performed by Dr. W. W. Hunt,
who kindly asked me to assist. Dr. Coxe was also
present

The abdomen was opened by a long median incision
from the ensiform cartilage to the pubes and also by
an incision extending from the lower end of this one
diagonally into the area about McBurney's point.

The omentum in the middle and all over the left
side and some distance to the right of median line was
perfectly healthy. In the right iliac region it was
congested and matted together into a bunch. This
portion was adherent to the intestines beneath.

On lifting the omentum the intestines were found
considerably distended with gas. In the hypogastric,
the right inguinal and right lumbar regions, the peri-
toneal surface of the intestines was congested. In all
the other areas they looked perfectly healthy.

Pus was found, to the extent of two or three
drachms, ,free in the abdominal cavity, in the right
lumbar region. The intestines were adherent to them-
selves and to the abdominal wall ; everything being
bound down to one point, where, when the adhesions
were broken up, the appendix was found. It extended
outward and upward on the outer surface of the
cecum, being closely adherent. About the appendix
was a circular ulceration, nearly as large as a silver
dollar. The appendix was easily separated, was con-
gested, but not gangrenous. The ulcer had not ex-
tended through the intestinal wall, but the tissue broke
down at the slightest touch. This was evidently where
the small abscess had existed.

Another small ulcer, about the size of a stiver quar-
ter, was found on the anterior surface of the ascendiag
colon near the hepatic flexure. This point was also
adherent to the abdominal wall, and the colon was ad-
herent to the liver.

Looking at the case from the post-mortem appear-
ances, it is probable that an operation on Tuesday
would have hastened death.

The usual incision would have revealed the appen-
dix and the ulcerated surface to which it was adherent ;
but whether or not the second ulcer would have been
discovered is a question.

The only time that an operation could have resulted
favorably was during the first attack ; and at this time
it was not demanded, as the disease apparently ended
in resolution.

It is fair to presume that if the case had been
operated as soon as the diagnosis was made, a life
would have been saved.

The great question to decide in all cases of appendi-
citis is, when and when not to' operate. There are a
few surgeons who have placed themselves on record
as being ready to operate as soon as the diagnosis is
established, and the tendency of surgical opinion to-day
is undoubtedly toward that point.

I offer this case in detail as a plea for immediate
operation.

•

REPORT ON DISEASES OF THE NERVOUS
SYSTEM.

BV rHIUF COOMBS KHAPP, AJC, M.D.

INFLUENCE 07 INFECTION UPON THE NBBVOU8 STS-
TBJI.

Roger,' recognizing that all infectious diseases may
affect the nervous system to a greater or lesa degree,
admits the following divisions :

(1) Reaction of the nervous system in the course of
the most diverse acute affections: fatigue, headache
and sometimes delirium and convulsions may occur in
the course of all forms of infectious disease. These
symptoms may depend upon an accumulation of the
noxious substances which are constantly forming in
the organism, or upon diflSculties of elimination.

(2) By the side of these general phenomena of a
toxic order we must place the secondary localizations
of the infectious process in the nervous system. We
often observe paralysis following acute diseases
analogous to the paralysis which follows diphtheria.
This paralysis may be transitory and due to no organic
alteration, or it may be due to lesions of the peripheral
or central nervous system. " We admit for tabes, or
rather for all scleroses of the nervous system, what we
admit for scleroses of other organs. It is demonstrated
by clinical observation and by experiments that visceral
scleroses may arise from infection or intoxication. In
this way syphilis plays a more important rdle than
other infections, and represents a chief caoae of the
sclerotic process, its localization depending upon the
predisposition of the individual affected."

(3) Certain nervous diseases may represent a pri-
mary localization of the morbid process, in particular
infectious multiple neuritis and acute poliomyelitis ;

■ Bsvue gtodrale dw lolsnoas. 18 April, IStS.

Digitized by

Google

Vot. CXXX, No. 8.] BOSTON MEDICAL AND SVSGICAL JOURNAL.

68

others always represoDt a primary infection of the
nervoos system, as is the case with hydrophobia.

(4) Infection may be the starting-point of nervoas
accidents which are sometimes very persistent, but
which seem to be due to no material lesion ; it may
provoke the onset or the reappearance of various
neuroses. Hysterical phenomena, epilepsy, paralysis
agitans, and especially chorea, frequently present
themselves under these conditions. With regard to
chorea the author thinks that the influence of rheuma-
tism has been somewhat exaggerated, yet he considers
that rheumatism is to chorea what syphilis is to tabes.
[Tet the statistics with regard to the two affections
ahow a much more intimate relation between syphilis
and tabes than between rheumatism and chorea. Rep.]

Many of these facts can be verified by experiments :
paraplegia represents in the lower animals an ordinary
reaction, observed after the inoculation of all sorts of
microbes. The author has even produced experiment-
ally a chronic poliomyelitis of infectious origin, which
demonstrates the rdle of infection in the development
of certain systemic forms of myelitis ; and other obser-
vers have obtained analogous results. The microbe
acta as poison does, and both may give rise to troubles
or lesions which the most elaborate vivisections are in-
capable of realizing.

DISTtTRBAMCKS OF SENSATION IN VISCERAL DISEASK.

Head * has made an extremely valuable and interest-
ing study of the distribution of pain and cutaneous
tenderness in visceral disease. He found that the pain
was in many cases associated with cutaneous tender-
ness, and, where tenderness existed, the pain lay in
that area. If the tenderness be present at one time
and not at another, but if the pain remain, tenderness
always makes its appearance in the area said to be
painful. The tenderness is not deep-seated, but is
purely cutaneous or subcutaneous. One of the best
methods of eliciting it is to pick up the skin gently be-
tween the finger and thumb, or the pressure of the
broad blunt head of a large pin may be used. These
areas of tenderness bear a definite relation to the dif-
ferent organs affected, but in many cases they lie at a
considerable distance from the organ affected. The pain
produced by stimulation is not produced by any action
on the organ itself, which may lie at a considerable
distance from the tender spot. Again, the tenderness
may be on the right side, though the organ affected
lies on the left side of the body. The superficial re-
flexes are usually exaggerated over the tender areas
produced by viscera] disease. Suspecting that these
areas bore some definite relation to nerve distribution,
Head undertook the study of the distribution of herpes
zoster. The eruption of herpes does not follow the
distribution of the peripheral nerves at all, and these
areas of the herpes eruption agree with the areas of
tenderness in visceral disease ; in neither case do they
overlap, and they have the same maxima. They are
also clearly defined. It is not at all likely that these
areas have any relation to the cortical distribution, and,
as has been said, they certainly have none to the dis-
tribution of the peripheral nerves. The areas of dis-
tribution of the posterior roots overlap greatly and the
border of anaesthesia is not definite. The areas of
herpes and tenderness in visceral disease do correspond
most closely to the areas of analgesia in lesions of the
spinal segments. (The areas of anesthesia in lesions
* Bnln, Spring and Smnmar Knmber, UtS.

of the segments are less extensive and less definite.)
After a careful study of the tenderness in different
forms of visceral disease, the author concludes that the
pain and tenderness are referred along the distribution
of certain somatic nerves corresponding to the different
spinal segments, and this sensory supply of the viscera
corresponds very closely to Gaskell's ' scheme of their
motor and inhibitory supply. The sensory supply is
as follows :

Hbabt,— 1st, 2d, Sd dorsal segmeDts.

Gerrloal plexus [= depressor 7]
LCHOS.— 1st, 2d, Sd, 4tb, Bth dorsal.

Cerrloal plexns [= Tagos 7 ]
Stohach.— 6th, 7th, 8th, 9th dorsal.

Cardlao end from Sth and 7th.

Pyloric end from 9th.
iHTBBTiiiKS,— [A] Down to app«r part of reotam.

»th, 10th, nth and 12th dorsal.
[b1 Beotum.

2d, 3d, 4th sasral.
LiTBB AHD Gall Bladdbb.— 7th, (th, 9tb, 10th dorsal. Perhaiw

6th dorsal.

CerTical plexns [=Tagn8?]
KiDHBY AjiD TTbbtxs.— 10th, nth, 12th dorsal. The nearer the

lesion lies to the kidney the more Is the pain and tenderness asso-

oiated with the 10th dorsal. The lower the lesion in the ureter

the more does the 1st lumbar tend to appear.
Bladdbb.— [a] Mucous membrane and neck of bladder.

[1st], 2d, Sd, 4th sacral.

[b] Orer-dlstenslon and Ineffectual oontraetion.

nth, 12th dorsal, 1st lumbar.
Pbostatb.— 10th, 11th, ri2th] dorsal.

1st, 2d, 3d sacral, Sth Inmbar.
Epididymis.— nth, 12tfa dorsal, 1st lumbar.
Testis.— 10th dorsal.
OVABT.— 10th dorsal.

Appendaobs, etc.— nth, 12th dorsal, 1st Inmbar.
0TBBDS.— [A] In contraction,

loth, nth, I2th dorsal, 1st lumbar.
[B] OS uteri.

[Ist], 2d, 3d, 4th sacral, [and Sth lumbar rery rarely].

In unilateral affections the pain and tenderness is
very apt to be bilateral, possibly because the organ
may receive some fibres from either side of the cord.
In most cases if the patient be debilitated, or if the af-
fection persist at all, the pain and tenderness tend to
spread to other areas, often very remote from the orig-
inal area; as is seen by the aching and tenderness in
the legs in follicular tonsillitis. Ansemia and fever
are very common causes of this generalization of ten-
derness, which generally occurs in various acute dis-
eases, such as influenza and typhoid fever.

AGBOFAlL£8THESIA.

Schultze * describes under the name of acroparsesthesia
that form of parsesthesia which is often painful and is
localized chiefly at the ends of the extremities. He
reports twelve cases, and gives the following account
of the symptomatology :

The affection is most common in women (although
half his cases were men) who have passed the thirtieth
year, and its chief localization is in the hands and fin-
gers. It usually takes the form of formication, but it
may increase to actual tenderness and may extend up
the arms or legs. The affected parts feel stiff, and
fine movements may be slow or limited. The parees-
tbesia may be worse at night or on waking in the
morning ('* waking numbness "), and it may be worse
in winter. It is usually obstinate and it may last for
years. The color of the skin is usually unchanged,
but it may be very white and cold during the attacks ;
it is never red. The sensibility is usually normal, but
during the attacks it may be blimted, and hypersesthesia
and hyperalgesia are not uncommon. The nerves are

• Journal of Physiology, toI. tU. 18SS.

< Deutwihe ZelUchrifi fUr Nerrenheilkiinde, 111, 300, 1B93.

Digitized by

Google

64

BOSTON MSDICAL ANJ) SVitOtOAL JOUBSAL. [Jawuart 18, 1894r

not tender ; there is no atrophy ; hysterical symptoms
are wanting; the joints are not affected; but the af-
fected limbs may be weak.

Schaltze then discusses the various theories which
have been advanced to explain the disturbance. He
admits that the occasional pallor of the affected parts
lends some support to Nothnagel's theory of a vaso-
motor disturbance, but this pallor is by no means
to be observed in every case, and it is bard to under-
stand why, as sometimes happens, the warmth of the
bed should cause arterial contraction. He therefore
regards the contraction as merely a co-ordinated symp-
tom. The absence of pain and tenderness, of muscu-
lar atrophy and degenerative reactions, and of any
progress in the symptoms are alL arguments against
ascribing the symptoms to neuritis. He recognizes
the possibility of pressure on the brachial plexus from
connective- tissue changes, and of the influence of
cold water or chemicals, but these factors are not of
universal application. Central lesions are not to be
thought of. It has no relations to any general neuro-
sis, but it has some analogies with neuralgia.

The aetiology is obscure, but in many cases there is
exposure to hot and cold, with sudden changes in
temperature, and to injurious chemical influences ;
manual labor has little influence. Many cases occur
about the dimactric period, but the influence of that
change is wholly unknown. In the diagnosis we must
distinguish the condition from neuritis, tabes, Ray-
naud's disease and erythromelalgia. The treatment is
not very efficacious. Drugs are of little use, except to
relieve pain when present; electricity, warm baths
and warm local applications may do some good, but
the affection, although never giving rise to more seri-
ous consequences, is often very obstinate.

Friedmann * considers the affection to be as indepen-
dent and individual as neuralgia, yet similar pareesthesia
is sometimes seen as a symptom of more serious affec-
tions, such as tabes. In itself, however, it is harmless,
although annoying and persistent. He divides the
affection into temporary and intermittent forms, acute,
subacute and chronic, the transitory forms being usu-
ally limited to one extremity, possibly extending to
other parts, and being often subject to exacerbations.
In women the menstrual period often has an influence
in increasing the severity of the parsesthesia. The
acute form is the commonest, and the prognosis is
usually very good. The average case usually lasts
either a few days or weeks, or else months or years ;
intermediate, sub-acute forms seem to be rare. The
more persistent forms vary in severity at different
times in the day ; the parsssthesia is apt to be worse at
the beginning of the night, or on waking in the morn-
ing. In cases of short duration there may be recur-
rences, yet they are less common, but there are chronic
forms where there are remissions of several months.
Friedmann has also seen cases with a different distrib-
ution, sometimes involving the region of a single
nerve. In cases of simple parsesthesia, without
severe symptoms or anaesthesia, Friedmann is disposed
to ascribe the trouble to general anaemia, with a weak
circulation, and he thinks there is often some cardiac
affection, especially a slight amount of fatty degenera-
tion of the heart. General neurasthenia seems of
little importance. When cold is an aetiological factor
there is often pain, with a burning, swollen feeling, and
objective disturbances of sensibility. Friedmann puts

• DeutMbe Zeltschrlft fUr NerrenheUkande, ir, 4S0, 1893.

in a third group of cases which begin suddenly, are'
often unilateral and are associated with vertigo and
occasionally are followed by slight paresis, but these
cases are probably due to focal lesions in the brain.
A fourth class of cases are often accompanied with
pain, either in the affected parts or elsewhere, and
occur in persons with a strong tendency to rheumatic
troubles. These cases are allied to cases of neuralgia
and neuritis, where the pain is slight but where there
is obstinate and severe paraestbesia and burning.
The severe chronic forms are seen usually in women at
the period of the menopause. Friedmann is disposed
to refer the trouble to two pathological conditions —
passive hypersemia of the extremities, and irritation ol
the peripheral end branches of the nerves. Acroparaes-
thesia is a typical mild functional neurosis of the sen-
sory nerves of the extremities. In treatment electricity
holds the first place, and tonics and cardiac stimulants
are often indicated.

Laquer,* basing his experience of eighteen cases, in
women between thirty-five and forty, recognizes the
picture described by Schultze, and notes the absence
of anaesthesia, nerve-tenderness, motor disturbances,
electrical changes, muscular atrophy and cntaueons
changes, and he also has not observed the pallor of
the hands, nor any angio-spastic conditions. In several
of his cases he has noted a previous history of severe
labors with profuse haemorrhages. The distress and
burning often became so severe at night as to render
sleep diflBcnlt. Menstrual disturbances and the meno-
pause were not considered as causal factors. The in-
fluence of hard work with the hands seems to Laquer
to be of great importance. He is disposed to regard
the affection as an exhaustive neurosis.

The subject cannot be abandoned without a brief
reference to the paper by Collins^ in a recent number
of this Journal, in which he holds that the trouble is
due to defective innervation in the blood-vessels which
causes a low degree of blood-pressure and lack of
proper blood-supply to the terminal branches of the
peripheral sensoriail nerves.

A.0BOHBOALT.

Claus and Van der Shicht * report an autopsy on a
case of acromegaly made two or three hours after
death. They were therefore able to obtain the tissues
in a fresh state, which enabled them to elicit certain
new facts. The lymphatic ganglions of the neck had
undergone profound modifications. Their structure
had become uniform, and they no longer contained
lymphoid follicles. All varieties of white corpuscles
were found: those with a single nucleus, with a poly-
morphous nucleus, and with multiple nuclei, even
megacaryocytes and polycaryocytes. The muscular
tissue of the neck was sclerosed and atrophied ; the
nuclei had many budding processes, and the sarcoplasm
had undergone a vascular and fatty-granular degenera-
tion. The glandular tubes of the hypophysis of the
patient, an old man, were filled with principal and
chromopbilous cells, both rich in fatty granulations.
As intermediate forms existed, it seemed probable that
one variety engendered the other. The hypertropbied
and acromegalic pituitary gland was necrosed and its
constituent parts were liquefied. The parts which hatd
escaped this destruction were formed by a lymphoid

• NeurologlMihes Centralblatt, IS March, 1893.
' Se« this Joarnal, cxzlz, 264. 14 September, 1893.
■ Ann&les et Bulletin de la 8oelet4 de medielue de Qaad, Mos. II
and 72, 1893.

Digitized by

Google

Vol. CXXX, No. IJ 60StO» MBDlOAt A^D SVMGIOAL JOVktfAl.

66

tissue analogoas to that of the lymphatic gangliong of
the neck. Several megacaryocytes and polycaryocytes
were also found. There was do trace of the primitive
glandular tissue. The organ was poor in blood-vessels,
and its degeneration and necrosis was attributed to in-
sufficient nutrition. The thyroid gland showed both
atrophy and glandular hypertrophy, and hypertrophy
of the connective-tissue structure with lymphoid infil-
tration. The liver showed fatty degeneration and
atrophy of the glandular elements, with a slight lym-
phoid infiltration in the interlobular connective tissue.
There was chronic parenchymatous and interstitial
nephritis. There was hyperplasia of the splenic pulp
and the follicles of Malpighi. The enlargement of the
tongue was due to connective-tissue hyperplasia.

DISEASES OF THE CAUDA EQUINA.

Komayer ' has collected twenty-six cases of disease
affecting the cauda equina, on which he bases an
account of the symptomatology. The affections have
the double character of diseases of the peripheral
nerves and diseases of the cord. Its resistance and
its greater mobility protect the cauda from more fre-
quent lesions, and, furthermore, the lumbar vertebrae
are more resistant than the dorsal or cervical. One
of the constant symptoms of lesions of the cauda is a
disturbance in the functions of the bladder and rectum.
There is also more or less paralysis of the lower ex-
tremities, the paralyzed muscles rapidly losing their
electrical excitability and becoming atrophied. There
are very severe pains and paraesthesia. In all cases
the sensibility in certain regions is diminished or lost,
and the reflexes may disappear. Vaso-motor and
trophic disturbances are also noted. The causes of
disease of the cauda are traumatism, tumors, and syphi-
litic, tubercular and inflammatory processes, and the
course varies according to the cause. Traumatic
lesions are apt to be due to hssmorrhage into the spinal
canal. Sometimes there may be hssmorrhage into the
canal or the cord and spinal roots, without any lesion
of the vertebrae. The symptoms depend upon the seat
of the lesion. Ordinarily in traumatic cases, the
muscles of the posterior part of the thigh are paralyzed.
In meningeal haemorrhage the course is more benign.
Death is often due to purulent infection (bed-sores) or
ascending nephritis. Seven out of thirteen cases died
within ten weeks, the others made a relative recovery.
Paralysis of the bladder, and anaesthesia resist treat-
ment. Lesions of the conus medullaris cannot be
distinguished from lesions of the sacral roots. If there
has been no injury the disease develops insidiously,
and is almost always attended with pain and paraes-
thesia. The pain is intolerable and is situated in the
lumbar and sacral region, extending to the legs.
Vesical and rectal symptoms follow, but paralysis of
these organs is not so complete as in traumatic cases.
In both forms there is impotence. The anaesthesia is
also somewhat characteristic. It involves the genitals,
the perineum and the posterior parts of the buttocks
and (highs. In traumatic cases the conus is more apt
to be affected ; in idiopathic cases the pain and the
greater sensibility of the vertebral column indicate an
affection of the nerve roots. The most hope in treat-
ment is from surgical interference.

AocoBDiNQ to a police census, there are nearly four
thousand doctors' signs in New York City.

• Lei maladlM de Is quena da oheTal, Prague, I8S3.

lElepoct^ of 4boctetie^*

BOSTON SOCIETY FOR MEDICAL OBSERVA-
TION.

3. 0. MDHKO, M.D., BBOKSTA.Br.

Rkodlab Meeting, Monday, November 6, 1898,
Dr. Chablks P. Putnam in the chair.
Dr. J. W. Farlow read a paper on

UTPEBTBOPBT IN THE POST-NASAL SPACE, ESPE-
CIALLT AFTER CHILDHOOD.'

Dr. Spraoub : I think this is a very important
subject. Post-nasal hypertrophies are without doubt
the cause of many troubles. As Dr. Farlow has said
it is almost a daily occurrence in the clinic to find these
cases where the patients have never complained of
any nasal obstruction, and in fact almost deny that
there is any trouble there. It is surprising how small
an amount of hypertrophy will cause a great deal of
trouble. 1 think that the vast majority of cases of
deafness, and hypertrophic condition of the middle
ear, are due to primary trouble in the naso-pharynx.
I remember one case where there were adhesions from
the anterior portion of the orifice of the £u8tachian
tube stretching backward to the posterior pharyngeal
wall, so that the tube was almost entirely occluded
and thereby backing up the mucous into the middle-ear
and causing a great deal of trouble iu that direction,
finally resulting in mastoid inflammation and requiring
operation.

Db. A. CooLiDOE, Jr. : Dr. Farlow has covered
the ground very thoroughly and very well. I have
noticed many of the things of which he has spoken,
and agree with him that these hypertrophies are often
the unsuspected cause of different symptoms. In
addition to the evil results of these hypertrophies, I
have noticed in several cases a marked atrophy of the
adjacent mucous membrane, and of the mucous mem-
brane lower in the pharynx, apparently as a result, a
condition which has been noted by Dr. Delavan in the
recent Pan-American Congress. There is no doubt
that the adenoid hypertrophies of children sometimes
do not atrophy, or only very slowly when persons
have attained their full growth ; but I think that we
can hardly say that this is the rule. The number of
children who have more or less of this tissue is very
large. In young adults the percentage is not nearly
so large. I agree with Dr. Farlow that after the re-
moval of part of these growths, in adults, the remainder
often remains apparently the same size for a long tiine ;
and L agree with him as to the necessity of thorough
removal. Unless the amount of growth is large it may
not obstruct nasal respiration ; but, as Dr. Farlow has
shown, this is only one of the numerous evil results of
their presence. In reference to diagnosis, in a full-
grown person an unusually l6ng finger is required to
reach to the vault, if the person is not etherized. It
is very difficult to judge of the amount of hypertrophy
with insufficient light. By far the best view of thia
region I have got by sunlight. In using sunlight it is
better to have a flat bead mirror, one that does not
focus the rays. If such is not at hand an ordinary
head mirror may be used, but care must be taken not
to focus upon the patient's uvula, which may burn the
patient's palate. It is sometimes possible, with cocaine,
to thoroughly remove the growths in a few sittings,

> Be* paca 86 of the Journal,

Digitized by

Google

66

BOSTON MEDICAL AND SOBGIOAL JOURNAL.

[Jaitcabt 18, 1894

without mnch discomfort, but in many patients the
naso-pharynx is too sensitive to make this practicable.
A long etherization is often a good deal of an under-
taking. I have on many occasions been able to
operate very satisfactorily by primary etherization.
Everything is ready at band before beginning the
ether ; the patient sits in a chair in a position to be
operated on ; the operator also sits in position. The
patient is then told to breathe as rapidly as possible
from a sponge well soaked with ether. After breath-
ing in this way for from three-quarters of a minute to
a minute, the sponge is removed, a gag immediately
put in, and the naso-pharynx cleared with a Gh>ttstein
curette and the finger-nail. This gives about from
half a minute to a minute of aniestbesia. In two min-
utes after beginning the ether, the patient has suffi-
ciently recovered to understand directions given him,
and in two or three minutes more he is ready to go
home. No pain has been felt, and there is never any
vomiting. It is not always possible to induce the pa-
tient to breathe rapidly enough for this method of
etherization, but in many cases of older ohildrea or
adults, it is very satisfactory, provided that all that is
necessary can be done in the short time. In advocat-
ing this method of anassthesia I do not mean to say
that I prefer such an operation to the careful removal
of all traces of hypertrophy. The latter is the more
complete method of treatment and produces better re-
salts, but it implies a longer etherization with its at-
tendant discomforts, if after beginning this short
operation it is evident that it is impossible to do satis-
factory work in the time, it is always possible to pro-
long the ether.

Dr. Jack : The connection between the ear and
naso-pharynx is a very important one. Ear diseases
are perhaps as largely influenced by the post-nares as
by causes operating through the auditory canal. The
pharyngeal tonsil probably operates as much if not
more than any other one thing in causing middle-ear
inflammation. The air is cut ofi from the air cavity
by swelling around the Eustachian tube, or by a piece
of growth obstructing the mouth of the tube, produc-
ing a collapsed drumhead with possibly fluid accumu-
lations, a condition with which you are familiar.

I am in the habit in my work of paying especial
attention to the posterior part of the nose, and try to
obtain as free breathing through the nose as possible.
Childhood is the time to arrest any tendency to ear
trouble. From the attention given to adenoids it seems

probable that the number of cases in adults will grow, tion being so much out of the field of general surgery <

less lis time goes on. It has been my custom in remov-
ing this growth in young adults to operate under
cocaine. The success of this method depends largely
upon the patient's self-control. It is better in some
oases to do the thing thoroughly in one operation under
ether. In children an anaesthetic is absolutely neces-
sary, for the growth should be entirely removed to
prevent recurrence. The vegetations may reappear
after apparent removal, although it is known to be a
rare exception to the rule. The Gottstein curette is
useful in removing loose ends left by the forceps, but
is not as effective in sinking into the base of the tonsil.
Careful attention should be paid to the neighborhood
of the Eustachian tubes. The growths are usually
soft here, and the finger furnishes a safe and satisfac-
tory substitute for the forceps. Profound anassthesia
is not necessary or safe. Hemorrhage, as we know,
is often copious, and threatens to invade the larynx.

Important as is the position of the head in cleaniog
the throat of clots, of still greater importance is the
action of the larynx in case blood tries to enter it.
One early experience with this accident, which forta-
nately, as 1 was able to remove the clot, did not result
seriously, has made me very careful not to give ether
to complete anassthesia of the throat.

Dk. Cobb : I have very little to add. 1 have seen
Dr. Coolidge do the: e operations under primary anaes-
ibesia, and it seems to me a very excellent method.
With regard to the forceps in operating without ether,
there is a great deal of difficulty on account of the
contraction of the soft palate and the danger of wound-
ing it with the post-nasal forceps, even in exercising
great care ; and 1 think for that reason in certain cases
that the Gottstein curette is preferable. With regard
to the diagnosis of these growths simply by the post-
nasal mirror, it is not always satisfactory, because the
mirror pointing somewhat forwards and upwards in-
stead ol backwards, one does not get as satisfactory a
knowledge of the posterior wall as he does if he ex-
amines with the finger ; and often when the naso-
pharynx has looked comparatively clean, the finger
feels considerable growth on the posterior wall of the
vault not shown by the mirror. Therefore, I think
both methods practised together are much more saUs-
factory than reliance on either one of them. The
tendency of these adenoids to recur is, I think, interest-
ing in cases where one feels quite sure that one has
eliminated them ; for even wben after examination
with the posterior nasal-mirror and with the finger one
finds that they are practically gone, one will some
years afterwanls see signs of them, and I do not be-
lieve it is entirely due to lack of radical operation. I
think there is certainly a fair chance that adenoids
have recurred in these cases. Dr. Jack spoke of a
case in which he suspected that he had not operated
thoroughly. I think that may have been one of these
cases.

Dk. H. F. Vickeht : I should like to say that a
fatal case of secondary haemorrhage is reported in the
November number of the Ameriean Journal of MtdMol
Heieneu. The operator was called to the little boy
just in time to see him die. He makes some valuable
remarks on the care which should be exercised.

Db. M. H. Richabdson : 1 have seen this opera-
tion performed many times by the specialist in dis-
eases of the throat and nose. Personally I have bad
uo experience whatever with the procedure, this opera-

I was glad to hear what Dr. Coolidge said about the
dangers of complete anaesthesia ; and on this subject 1
should like to say a word. We are too confident in
the use of ether. We feel much safer in giving it
than we ought; not as regards its physiological action,
but the methods of administration. Whatever dangers
there are in the use of ether lie in the latter considera-
tion. It is to the most inexperienced persou present
that we intrust this most important function. This
fault is not peculiar to those presumably the least
familiar with the subject ; it is the practice of every
hospital to have its junior men give the ausssthetic.
This practice is open to criticism, it seems to ate, not
only because it increases unnecessarily the inherent
dangers of etherization, but because it may disconcert
the operator, and at times embarrass him even more
than the operation itself. Whenever possible, there-
fore, anaesthesia should be at least supervised by an

Digitized by

Google

Vor.. CXXX, No. 8.] BOSTON MEDIOAL AND SURGICAL JOVSNAL.

67

experienced man. At times, of course, the nurse, or
even one of the family, must be intrngted with the
ether. I think all operators will agree, however, that
the anxieties incident to the operation are much in-
creased at such times.

The first operations I ever saw on adenoids were

among the bloodiest in my experience ; the hsemor-

rhage in excisions of the upper jaw does not exceed

that occasionally seen io the removal of adenoids.

Moreover, in the former operation the head can be

put forward and the blood allowed to run out ; while

in the latter there is nothing to prevent the blood

from running directly from the posterior nares into

the larynx. It seems to me, therefore, that the only

safe plan is either to have the anseathesia so light that

the patient can himself keep his pharynx clear of

hlood, or to adopt some position, like that of Rose, in

which the blood by gravitation leaves the air-passages

free.

Db. Coolidob: In regard to getting blood into
the larynx and trachea, if the patient is profoundly
etherized, the danger is great ; but I think if lightly
etherized, it is not great, provided the person is not
cyanotic. If there is anything in the pharynx, cyano-
sis, with or without ether, is dangerous ; for instance,
in opening a retro-pharyngeal abscess we sometimes
hear that there is danger of drawing the pug into the
lungs. I believe that the danger is slight, provided
the child is not cyanotic. In operations in the throat
it is sometimes tempting to complete a proceeding iu
apite of the fact that the patient has begun to get blue.
Most patients will swallow anything in the pharynx
unless they are either profoundly etherized or cyanotic
Occasionally a case is met with, which from the start
acts badly. The reflexes do not seem to be quite
right. In such cases it is necessary to proceed with
extra caution.

Db. Db Blois : There is an operation with the head
thrown back over a block or pillow, in which case the
posterior nares would be filled with blood before any
could escape into the larynx. Dr. Major, of Montreal,
always operates in this way. In cases of retro-pharyn-
geal abscess which I have frequently opened, I in-
variably turned the patient upside down just as soon
as I have dropped the knife. In cases where I operate
on adults I take them by the hair and push their heads
down on the floor, because as soon as you cut into the
abscess the rush of pus is more than can ordinarily be
cleared even if there is no ansssthesia. There is a
great deal of the pus, and it comes with a gush. I
never have operated on a retro-pharyngeal abscess
under ether. I think they should always be opened
without ether, because you should have what assist-
ance the patient can give to keep himself from as-
phyxia.

Dr. Spbaode : I was very much interested in the
suggestion of primary anaesthesia. About a week ago
I haid a patient in whom I tried primary anassthesia.
I asked the etherizer to get along with as little ether
as possible. As soon as the patient was under primary
anesthesia I had her set up, and operated immediately.
I cleared out the vault of the pharynx with the forceps,
and the fossa of Rosenmnller with my finger. By the
time the patient began to struggle she began to clear
the throat, and everything was over. I do not know
how long it was. It was not more than three minutes
perhaps. I think that ordinarily too much ether is
given.

Db. Fablow : With regard to the use of anass-
tbetics, ether or cocaine, I spoke of them with refer-
ence to adults. Many people, especially young ladies,
have a great dread of ether, and prefer to have the
growth removed under cocaine, even if there is some
pain, unless the amount to be removed is large. I am
glad to hear what Dr. Bicbardson has said about the
danger of anassthesia iu these cases. I think the
anesthesia should be very light, and great attention
paid to the amount of blood lost. It is important to
look after the respiration and the pulse. I have seen
patients go into a state of collapse even when the an-
aesthesia was light and the amount of blood lost incon-
siderable. I have seen one case of secondary haemor-
rhage. It was in a young man, twenty-five years old,
from whom I bad removed considerable hypertrophied
tissue on several occasions without much bleeding.
One afternoon I removed several large pieces with
forceps, and thirty-six hours later he had a haemorrhage
which lasted several hours.

I think the mirror by all means the best aid to diag-
nosis, though the finger often gives valuable informa-
tion as regards the depth of the growth.

With regard to cases becoming less numerous in the
future, this is probably true ; but I also think that
there will continue to be a great many cases where
the bearing is involved, where there is cough and a
considerable amount of secretion trickling down from
the post-nasal space, keeping the nose and pharynx in
an hypertrophied condition — cases which may not
have caused any great disturbance in childhood, but
which, instead of atrophying at puberty, have persisted
and even grown larger, requiring treatment iu later
life.

SPECIMEN OF aANGBENODS AND PBBFOBATBD AP-
PENDIX.

Db. M. H. Richabdson : This specimen is a very
beautiful one. The case is one of extreme interest.
It is the third case of appendicitis that I have operated
on within the last two weeks where the diagnosis was
very difficult indeed — in spite of what has been said
as to the ease with which the diagnosis of appendicitis
can generally be made.

In the first case Dr. F. C. Shattuck, on the second
day after admission, made a correct diagnosis of ap-
pendicitis where every one else was wrong. I had
made a correct diagnosis of it the first day, and had
advised immediate interference, but yielded to the
advice of all who saw the case that day — all the more
willingly because the type was one almost invariably
fatal iu my hands ; and I was glad to be supported in
the plan of waiting, for I wanted to see if any different
result would follow the let-aloue policy. The next
day I changed my mind as to diagnosis, and thought it
was not appendicitis. I was influenced partly by the
absence of leucocytosis, reported by Dr. Bichard
Cabot ; for this condition had been present in every
case of suspected suppuration in which an examination
of the blood had been made. Death followed oper-
ation in a few hours.

In the next case, seen about two weeks ago, all the
symptoms were in the region of the liver, and^the ap-
pendix was found there. The extravasation had ex-
tended up between the liver and the ribs and around
the foramen of Wiuslow. I have no doubt it would
have resulted in a large subphrenic abscess.

The third case was exactly like the second. The

Digitized by

Google

68

BOSTON MBDICAL AlfD SURGICAL JO USUAL. [Jamuabt 18, 1894.

patieot, a boy of eleven, was taken five or six days ago.
The operation was done on the fifth or sixth day — I
may say the fatal fifth or sixth. The fourth, fifth, and
sixth are the fatal days, and the mortality on these
days is frightful. Death results, of course, from the
general peritoneal infection. The reason why oper-
ations performed on the eighth, ninth, tenth, eleventh
days, or later, are more successful lies in the " survival
of the fittest" — the general infections have all been
fatal, and patients with localized abscesses only survive.
This young boy of eleven was taken with vomiting
and diarrhoea about a week ago. They sent for Dr.
Atwood, of Haverhill, ou Saturday, to-day being Mon-
day. I saw the case this morning and found the boy
with pain over the liver, and sensitiveness especially
marked over the hepatic flexure of the colon. Dul-
ness extended from the crest of the ilium into the lungs.
The right lung was flat all over its lower half; respira-
tion 40, temperature 1 02°, pulse 1 60. On going through
the flank with a long incision I came down on the
walled-off ascending colon with the appendix situated
externally to it at that point. There was a sero-puru-
lent effusion running up between the liver and the ribs
and over the kidney, and as far as I could see to the
foramen of Winslow. That the diagnosis of appendi-
citis is correct, is shown in this specimen by the per-
foration at the tip, with a small faecal concretion under
it. I tied off the appendix, drained and packed with
gauze. I have no doubt that there is an infection of
the pleural cavity and a pleurisy or some lung trouble
dependent on direct contagion. The prognosis is very
grave, even from the appendix ; and with the trouble
in the lungs it seems very severe.'

In appendicitis I do not believe that the peritonitis
is often cansed by these operations. The infection
already exists. Two cases of general infection are
apparently precisely alike ; the treatment is the same
in each ; one gets well and the other dies. The rea
son why one dies and the other gets well must gener-
ally be found in the nature of the poison. In one case
of general infection we get pure cultures of the bacillus
coli communis ; in another we do not. In a third we
get nothing, or very mild micro-organisms. We arc
going to find, in the bacteriological elements, the ex
planation for the prognosis of these cases. Since the
first of May I know of at least twenty deaths from
appendicitis in this community. You cannot say that
they were all due to surgical interference, because
many of them were beyond surgical aid, and no oper-
ation whatever could be done. From my own experi-
ence I can say that the diagnosis in many cases is very
difScuU indeed; and as to the prognosis, you cannot
tell anything about it. Some cases get well where
you think there is no chance of recovery, and some
you think very favorable, die.

Baptism by Brandt's Mbthod. — Baptism by
immersion was performed in an unusual manner in a
Pennsylvania town not long ago. A patient too ill
to leave his room was desirous of baptism. A large
portable tub was filled with water at the bedside. The
man was lowered into it on a sheet quite in the Brandt
manner, and the ceremony successfully performed.

> December 14, 1803. Tbeae two cuea recorered. The laat had an
empyema OD the right side, which Dr. Atwood opened. The abdom-
inal wound clusad rapiilly. Prom the appendix lit. McCollom ob-
tained pure cultures of the bacillus coli communis. The Infection
of the pleural cavity was probably from tbU microbe, though no cul-
tures were made.

NEW YORK COUNTY MEDICAL ASSOCIATION.

Stated Meeting, December 18, 1892, the Presideat,
Db. S. B. W. McLeod, in the chair.
A paper by Db. T. Gaillabd Thomas on

THE IMUKDIATE CAUSATION OF THB DISEASES PECU-
LIAR TO WOMEN,

was read by Dr. C. C. Carmalt, Dr. Thomas being
unavoidably prevented from being present. There
were, he said, four great climacteric periods in the life
of the female in connection with which the great balk
of the diseases in question occurred. It could be safely
stated that eight-tenths of them took their rise from
these climacterics. The first of these was puberty,
marked by the development of ovarian activity ; the
second, marriage; the third, child-bearing; and the
fourth, the menopause, marked by retrograde processes
ill the ovaries.

It was with the ovaries, and not the uterus, that
the woman advanced and retrogressed ; the activity
in the uterus being entirely dependent on the former.
The changes in the ovaries constituted the phenome-
non, and those in the uterous the epi-phenomenon.
During the first two-thirds of the period between birth
and the age of puberty the ovaries, uterus and annexia
remained almost entirely undeveloped. During the
last third, they gradually increased in size, and just
before the girl reached puberty developed with amaz-
ing rapidity. If, when the time of puberty came the
appropriate changes had not taken place, if the uterus
had not properly grown or had become misplaced, if
the ovaries remained undeveloped, or the Fallopian
tubes were impervious, diseased conditions would in-
evitably arise. If ovarian abnormalities existed, the
most serious consequences would result, and the young
woman might perhaps become the victim of hystro-
epilepsy. If the tubes had become strictured, dysmen-
orrhoea would be the consequence.

Tht Fint Olimaeteric was a period to be watched
with the greatest anxiety. Ou the first of the month
the girl might he blooming and in the full tide of
health, on the 15ih of the same month she might suf-
fer in a way that would indicate to the experienced
physician that she was to be a chronic invalid. A
system of appropriate treatment for the existing dys-
menorrhoea and other symptoms might be iustituted,
but if the normal changes hari not taken place in the
ovaries and tubes, every means would be exhausted in
vain, and eventually it would be necessary to perform
the humane and entirely justifiable operation of re-
moving the ovaries and tubes.

The Second Climacteric. — After passing the time
of puberty in safety the young girl would live in health
and happiness up to her secoud climacteric, marriage,
unless she was unfortunate enough to take cold during
a menstrual period or suffered from other accidental
illness. As a result of marriage she was liable to eu-
couDter new ills, the three principal of which were
vaginismus, gonorrhceal infection from specific ure-
thritis in her husband, and abortion. In speaking of
the second of these Dr. Thomas quoted from an ad-
dress of his which he had delivered upon a former occa-
sion. Until twenty years ago, he said, specific urethritis
was but lightly thought of. It was to Dr. Emil Neog-
gerath, formerly of New York, that the profession was
indebted for ite present knowledge of the enormous
importance of this afieclion as « factor in the etiology

Digitized by

Google

Vol.. CXXX, No. 8.] BOSTON MEDICAL AND SURGICAL JOURNAL.

69

of the digeases of women. He had shown conclusively
tbat behind the strictures in the male urethra pro-
duced by gouorrhcea, which were so extremely com-
mon, the germs of the disease were liable to linger,
and that they were capable, even after a long time, of
transmitting gonorrhceal infection to the female, with
the most disastrous results. Among the troubles to
vrhioh it gave rise were odphoritis, pyo-salpinz, and
peritonitis, which were always serious, and might re-
ault in death. For a timo the assertions of Noeggerath
were assailed with bitterness and met with ridicule;
but they are now universally reoognized as true.

In his (Dr. Thomas's) opinion, specific vaginitis was
one of the most frequent and active of all the causes of
the diseases of women. Its effects are often simply
appalling, and left us nothing as a last resort but the
operation of celiotomy, which might of itself prove
fatal to the patient under the circumstances. How
oommon it was for an unsuspecting young man of nine-
teen to slip from virtue. A few years afterward when
be bad married, still suffering from a low grade of
chronic urethritis, he would give all that he possessed
if he could undo the terrible results of that early in-
dieeretion. It was, therefore, highly important tbat
every intended bridegroom should be instructed by
bis physician as to the necessity of a clean bill of health
before entering the marriage state. The existence of
the gonocoocns should be carefully looked for, and a
marital quarantine was as necessary as a quarantine
for the ordinary contagious diseases.

Tk« Third Olimaeterie. — Even io normal labors
child-bearing was liable to be followed by serious re-
sults. Thus, comparatively slight lacerations of the
eervix uteri or of the perineum might give rise to the
most untoward consequences. In ordinary conditions
of the system such lacerations of the tissues would be
but a trivial matter, but in the puerperal slate it was
to be remembered that there were two circumstances
which rendered them of grave significance. In the first
place, from the moment of the fixation of the ovum
after conception there was a rapid development of all
the pelvic organs. Secondly, wounds made in the geni-
tal canal was bathed, after the birth of the child, by
the lochia, made up of cervical and vaginal epithelium,
blood and mucous corpuscles, bits of decitlua, and, at
times, shreds of membranes and of the placenta, tin-
der favorable circumstances the discbarge in contact
with the abraded surfaces would set up either a sa-
prsemia or septicsemia, with their attendant evils.
When it had become the general practice to carefully
examine patients at the time of delivery, and to at
once repair any injuries tbat might have been suffered
during labor, the diseases of women would be less
Bumeroas than they are at present and gynascologists
would have fewer operalious to perform.

T/ie Fourth CHmaeterie. — When we considered the
^■reaching nervous influences which attended the
process of ovulation, it was not to be wondered at tbat
the oeesatiou of this at the meuopause should be ac-
companied with marked changes. While, however, the
importance of the menopause as an etiological factor
was admitted, it could not be doubted that too much
significance had often been assigned to this. Not in-
frequently there are other causes of disease, which,
occurring at this period, were improperly referred to
the menopause. Care should therefore be taken to
avoid an over-estimate of it* importance and at the
same time an under-eatimate which might lead as to

postpone necessary operations. Having referred to
some of the changes incident to the menopause and its
effect upon uterine fibroids and other abnormal condi-
tions, be mentioned vaginitis and especially heemor-
rhagic vaginitis and procidentia of the uterus as affec-
tions liable to be met with at this period.

Dr. Gkurob T. Uarkisom dwelt upon the extreme
importance of gonorrhoea as a factor in the production
of the diseases of women. Perimetritis, endometritis
and peritonitis were the common result of latent
gonorrbcea in the female, as first pointed out by Dr.
Noeggerath, and it was with rare prevision that the
latter asserted his conviction that this affection was of
microbio origin. It was reserved for Neisser to fully
establish the existence of the gonorrhceal germ, and
the gonococcus was now as universally recognised as
the bacillus of tuberculosis. The diagnosis of acute
gonorrhoea was an easy matter. It was in the chronic
form of the disease that mistakes were made, and the
real cause ef many cases of oSpboritis and other seri-
ous troubles was thus often overlooked. But, if care-
fully studied, the clinical features would be found to
be characteristic. In speaking of the later infections
dne to gonorrhoea, he said that aalpingitis was rare.
Peritonitis due to this cause, was fortunately confined
to the pelvic peritoneum, as no ptomaines were gene-
rated by the gonococci. From his experience he be-
lieved that eyphilis was an innocent disease in the fe-
male in comparison with gonorrhoea. In this connection
be related the case of a young married lady who was
attacked with metrorrhagia and violent uterine pain,
accompanied with a high temperature ; an examination
showing the presence of endometritis, salpingitis and
peri-oSphoritis. She was placed upon appropriate
treatment, and began to improve, when suddenly
violent gonorrhceal ophthalmia developed, and, not-
withstanding tbe best efforts of two eminent eye-
specialists and the most careful nursing and attention,
she lost the sight of one eye entirely, and the other
was only saved with ditflculty.

We constantly saw young men entering on marriage
with bright hopes of offspring, only to see them blasted.
Sterility was the almost constant result of this chronic
gonorrhoea, and women affected with it were liable to
protracted ill health. Hysteria was frequently associ-
ated with their sterility.

Dr. H. J. BoLDT said that while the principal
causes of the diseases of women were given in the
paper, there were a few points which had not been
touched upon. Among the etiological factors were
dress and the neglect of hygiene. High-heeled shoes
had long been a potent cauie of trouble by placing the
pelvis in a bad position. Personally he l)elieved that
the agency of gonorrhoeal infection had been exagger-
ated, and that tbe puerperal state (including abortions)
was responsible for more ailments than this. Still, we
should not underestimate this factor. It was not the
acute form, but the chronic which gave so much trouble.
In the acute stages of the disease we could, as a rule,
cure the patient completely. In the chronic there was
apt to be an atrophic form of parametritia, with only
slight thickening of the broad ligaments.

Anothw point to be considered was, what amount
of troabie i» produced by uncalled-for gynssoological
interference. He had known pessaries, unadvisedly
employed, to produce intense pelvic irritation, and re-
lated a case in point. A patient took cold and suffered
from pelvic pain. Her physician diagnosed malpoai-

Digitized by

Google

70

BOSTON MEDICAL AND SUBGICAL JOURSAL. [Jampabi 18, 1894.

tioQ of the uterus aud iutroduced a pessary, aud this
bad the effect of setting up metritis and double salpin-
gitis. Yet wbeu he (L)r. Uoldt) made au examinatioii
he found that the uterus was not out of place at all.
In other cases he had kuowu the treatment for <1ys-
mt-norrhcea by diiatatiou, divulsion, eic, to result in
metritis, salpingitis and ovaritis. lu all such proced-
ures it was necessary that the patient should be fully
prepared beforehand, aud he looked upon the simple
iutrodactiou of the uterine sound as as much of au
operation as larger operations. In any case presenting
itself it was important to decide whether the patient
should be treated at all, and it was without doubt a
fact that hundreds of women suffer from unjustifiable
interference.

The suppurative diseases of the generative organs
were more frequent causes of trouble thau gonorrhoea!
infection. It was, however, impossible to make a dif-
ferential diagnosis between gouorrbcBal aud non-gonor-
rboeal conditions, aud we could only surmise that women
were suffering from specific trouble who remained
sterile for a number of years, (without any other as-
signable resson,) and had constant pelvic disorder. In
all cases where there was sterility without an evident
physiological cause he claimed that no treatment should
be undertaken for this condition until a microscopical
examination of the semen of the husband had been
made for the presence of spermatozoa. Exposure to
cold during menetruation was, of coarse, a generally
recognized cause of disease in women.

Dr. a. H. Goelet said that one common cause of
trouble was neglected dysmenorrhoea previous to
married life, aud it was one that was very apt to be
overlooked. He related an illustrative case aud then
called attention to an association which he had noticed
between fibroids of the uterus in married women with
dysmenorrhoea during maidenhood. Having referred
to neglect of proper care of the bowels as a potent
cause of pelvic disease, he spoke of abnormal obliquities
of the pelvis produced by faulty positions, in assumed
attitudes, certain occupations, etc., as another common
cause. He also mentioned tight-lacing and improper
suspension of the clothing, and to iuiproper interference
of the physician, said he would add improperly executed
uterine operations. lu all such procedures we should
use as much care to secure perfect cleanliness as in
operations in the peritoneal cavity, aud that we should
have as much respect for the uterine cavity as for the
peritoneal.

Dk. £. £. TuLL said that deformities of the pelvic
organs were found in a considerable proportion of
cases where the iudividual bad received all proper
care during early life and was in all other respects
perfectly healthy. This was usually, thou<;h not al-
ways, to be explained as the result of scarlet fever or
some other exaothematous disease occurring at the age
of 12 or 13. In some cases pelvic disease was due to
syphilis, and in one case of oophoritis where he had
removed one of the ovaries, he found gummata in the
organ. The patient was at once placed upon anti-
syphilitic treatment, aud was thus saved from another
operation, for the removal of the second ovary.
Gonorrhoea he believed to be the most potent cause of
pelvic iufiammations, although it was very difficult to
make a positive diagnosis from the fact that it was rare
to find a man who had never suffered from gonorrhoea.
Another frequent cause of trouble was neglect of
proper cleanliness of the genital organs, and the accu-

mulation of foreign matters in these parts, he believed,
often resulted in a mild septicaemia. To this sbonld
be added lack of proper cleanliness after childbirth.
As to displacements of the uoimpreguaied uterus, he
believed that they were of do importance whatever
from an etiological point of view, and that it was a
mistake to suppose that they gave rise to any trouble.

Dr. BoLDT having asked whether Dr. Tull meant to
say that he favored the use of the douche after child-
birth, the latter replied that ho would not recommeDd
the douche as a uterine treatment. After the third or
fourth day he believed it tu be of value, but he would
not employ it immediately after delivery on account of
the danger of introducing infectious material into the
uterus.

Dk. Harrison said that he wished to go on record as
protesting most earnestly against the 'practice of vagi-
nal irrigation after childbirth. After normal parturi-
tion the vaginal canal aud uterus were entirely free
from septic material, and said he had the authority of
the greatest of all obstetricians, Cred^, for this state-
ment. Personally he had performed all manner of
obstetrical operations, and neither before or after them
did he employ the douche. All that he required was
that the operator and everything that came in contact
with the woman's parts should be aseptic. Septie
hands and instruments were a common cause of puer-
peral infection. Dr. Harrison said he alao differed
with Dr. Tull in regard to the importance of uterine
displacements. He believed that retroversion was al-
ways pathological and a came of trouble, and that it
should be rectified.

Dr. Rubbbt Murray spoke of the practice that had
prevailed of late years at the Maternity on Blackwell's
Island, where he is one of the attending accoucheurs.
The same care as regards cleauliuess was used in all
cases of labor there, as surgeons were in the habit of
employing in laparotomy. At the beginning of labor
and just after the birth of the child a creoliue douche
was employed, and at all other times an antiseptic
occlusion-pad (in which a bichloride of mercury solu-
tion, 1 to 4,00U, was employed), was kept closely ap-
plied to the vulva. The results were equal to those
of any other maternity hospital iu the world. From
October, 1890, to October, 1893, there were 957 cases
of labor, with not a single death. In 110 of these the
forceps were applied at the middle strait or the outlet,
in 12 at the superior strait, before the head had en-
gaged at all, in 28, version was performed, in 8, crani-
otomy, iu 1, Caesarian section, and iu 2, symphyseot-
omy. Dr. Murray believed that the great cause of
disease in married women, was the bad treatment of
childbirth aud miscarriage. After the latter they
were especially apt to act imprudently. In unmarried
women (setting aside the effect of tumors), he thought
the great cause of trouble was the lack of kaowledge
as to how to take care of themselves during the meu-
strual period. *

Doctors' Bills as Debts of Honor. — Doctors'

bills are said to be classed as debts of honor in Austria,
China and Sweden. They 'are left, as gambling debts
are here, so far as the law is concerned, to be paid or
not, according to the inclination of those incurring
them. This way may not, however, be entirely a dis-
advantage, because it is well known that such obliga-
tions are frequently paid where legal debts could not
be collected.

Digitized by

Google

Vot. CXXX, No. 8.] BOSTON MEDIO AL AND SURGICAL JOURNAL.

71

Vittvut literature.

The Phyneian'$ Visiting Litl/or 1894. (Lindsay and
Blakiston'B). Philadelphia: P. BlakistoD, Son &
Co. 1898.

This coDvenieutly arranged visiting-list is now in the
forty-third year of its publication, and deserves the
ooutiDued success which it hits met. The various
tables upon doses, poisons and antidotes, disinfectants,
diaeases of the eye, asphyxia, examination of the urine
and utero-gestation are well arranged for reference.

^ SyllcAuM of Leelurtt on the Praetiee of Surgtry.

By JN. Senn, M.D., Ph.D., LL.U., Professor of

Surgery, Rush Medicail College, etc. Philadelphia:

W. B. Saunders. 1894.

The title describes accurately this volume, which is
compact, of convenient size, and contains 21 1 pages.
It is dearly and concisely writteo. Its contents are
arranged in tabular form, with broken lines and sepa-
rated headings, so that a particular affection is readily
found. It is a syllabus in the true sense of the word.
The work is arranged in conformity with " The Amer-
ican Text-Book of Surgery," and whenever the text
was deficient, the writer has added facts and names of
authors and operation. It is practically an index, and
a very good one.

Descriptive Catalogue of the Anatomieal and Patho-
logical Specimens in the Museum of the Rogai Col-
lege of Surgeons of Edinburgh, By Cha.rle8 W.
Catucabt, Conservator, Fellow of the College.
Vol. I. The Skeleton and Organs of Motion.
Edinburgh : James Thin. 1893.
The Museum of the Boyal College of Surgeons of
Edinburgh dates from the end of the last century.
The former printed catalogue was published in 1836;
but as it contained only the specimens illustrating
pathology, the present catalogue is in no way a coutin-
' nation of the old, but rather a new and more systematic
arrangement of the collection. The labor involved in
new classification must have been great; but Mr.
Cathcart has given the college a catalogue which is far
more than a list of specimens. It is a book which has
a value in itself, and which is made readable, even to
the stranger, by the short clinical notes added to the
cases.

Clinical Gyneeeologg, Being a Hand-Book of Dis-
eases peculiar to Women. By Thomas Mobb
Maddeh, M.D., F.R.C.S., Ed., etc. With 259 il-
lustrations. Philadelphia: J. B. Lippincott Co.
This work embodies forty-seven lectures, which con-
tain the results of the author's teaching, extending
over a quarter of a century. They have been thor-
oughly revised and put into form for publication, and
the result is on the whole very satisfactory.

It covers the whole range of gynaecological subjects,
and even includes the diseases and abnormalities of
pregnancy, which, with the exception of ectopic gesta-
tion, are not usually treated in a work of this kind.

The general tone of the work is conservative and
safe, perhaps too much so for our American ideas, in-
asmuch as he rejects entirely various operative pro-
cedures which have proved their usefulness and their
right to be employed in suitable cases. For instance,
be does not recommend the employment of the Alex-
ander operation, and utterly rejects ventro-fixation

as a cure for obstinate and adherent retro-displace-
ments.

The book, taken as a whole, is interesting and in-
structive reading. The illustrations are not quite up
to the standard of the latest works on gynsecology,
and some of them have outlived their usefulness.

A Dietionarg of Medical Science, Containing a Full
Explanation of the Various Subjects and Terms of
Anatomy, Physiology, Medical Chemistry, Phar-
macy, Pharmacology, Therapeutics, Medicine, Hy-
giene, Dietetics, Pathology, Bacteriology, Surgery,
Ophthalmology, Otology, Laryngology, Derma-
tology, Gynaecology, Obstetrics, Pediatrics, Medical
Jurisprudence, Dentistry, etc. By Robley Dun-
OLisoN, M.D., LL.D. Twenty-first Edition, thor-
oughly revised and greatly enlarged, with the Pro-
nunciation, Accentuation, and Derivation of the
Terms, by Richakd J. DnNOLisoN, A.M., M.D.
Philadelphia : Lea Brothers & Co. 1893.
This Dictionary needs no introduction to the medi-
cal public. The former editions were the standard
medical dictionary for many years. The last was issued
in 1874. Since that time, and especially within the
last ten years, a number of rivals of greater or less
pretension have laid claim to public favor.

With the great progress and many changes in medi-
cine and the allied sciences during that time, a new
edition was much needed, and we are glad it has been
supplied. Forty-four thousand new subjects and terms
are contained in this edition. The volume is enlarged ;
but by rigid condensation and the omission of obsolete
matter the dictionary is still kept within the limits of
one volume — a large volume it is true, but not nn-
wieldly or incoovenieut for consultation.

The title-page gives the scope of the work and the
aim of the editor, which have been faithfully and
judiciously executed. Without entering into detailed
criticism, and admitting frankly at once that any such
work must necessarily exhibit some errors and some
omissions, we do not hesitate to recommend this old
friend in a new form as once again admirably adapted
for every working medical library.

Sciatica: A Record of Clinical Observations on the

Causes, Nature, and Treatment of Sixlyeig/it Gases,

By A. Syuons Eccles, M.B., Aberd. Small 8vo ;

pp. viii, 88. London: Macmillan & Co. 1893.

This little monograph, which was originally pub-

libhed in the Practitioner., states nothing that is new

with reference to the cause or the nature of sciatica.

Based on a limited number of cases, the author states

a few well-known facts, but he has omitted to give the

results of more thorough recent observations, — much

of the work is devoted to the treatment. He commends

rest, warmth, masiage and electricity, swinging the

leg in a Salter's swing, and swathing it in flannel. He

commends ironing the leg with a hot flat-irou electrode.

The book is clearly and pleasantly written.

Db. Kent, in the Glasgow Medical Journal, says :
" 1 would make the degree in Arts compulsory upon
all candidates for the degree of Medicine and Surgery,
and I undertake to say that not one medical graduate
of five years' standing out of a hundred would, upon
looking back, consider the time spent over his Arts
course bad been wasted." '

Digitized by

Google

72

BOSTON MEDICAL AND SURGICAL JOURNAL. [Jaiiua«t 18, 18»4

THE BOSTON

Thursday. January 18, 1894.

A JtmmaX t/Mtdieime, Burgirji.amd Allied SeUmett.piMUhtd at
JbMtm, weektff, 6y tht umdenigiud.

SUBSCBIPTIOH TSBlfa : 15.(10 per ftar, in advaiue, pottage paid,
forthe UMtedStatee.Camadaamdileaieo; 9t.it per fear fir all ftir-
etgneowUrietMtmgimttotk* Potial Uni4n.

All eoMmnMeoMoM ftr the Sdttor.aad all toot* /or review, titouM
teaddrenedtoth* KdUor<tf'the BoeUmitedleal amd Smrfleal Journal,
M8 Waeklmgtam Street, Boetoa.

All lettert oonloMng kiu«iien oommimieaHou*, or referrimt to tht
pnbliaatkm, tubeariptkm, or adverUiimg deparimeiU ^ U
thotild be addreeeed to Ike tuulertigned.

Bemittemeet tkotUd be wtade by wtemeg-order, draft or regitttrtd
tetter, pamatU to

DAMRKLL * CPHAM,
t8S VuHinoTOS Stuut, BoaTOV, Mam.

REPORT OF THE MASSACHUSETTS STATE
BOARD OF LUNACY AND CHARITY.

Thb State Board of Lunacy and Charity, in ita
Report for the year 1893, make* fire reoommenda^
tioua for lefpslation ;

(1) A separate hospital for epileptics.

(2) The appointment of mediod examiners in lanaoy
by local judges, as in New York.

(3) Six months' residence in the State m a pre-
requisite to a commitment to a State hospital for the
insane, in order to avoid haring insane persons brought
here from other States for the sake of being committed
to our hospitals.

(4) Aotbority to transfer insane patients from the
hospital for dipsomaniacs and inebriates to one of the
hospitals for the insane without new commitment
papers.

(5) A medical registrar for each of the hospitals for
the insane, whose duty it shall be to keep the hospital
records, which are now quite imperfect.

The Massachusetu law provides for the ordinary
oommitment of an insane person to a hospital for the
insane by the judge upon the sworn certificates of two
physicians, each of whom is a graduate of some legally
organised medical school, and has practised three years
in the State, and neither of whom is connected with
any hospital or other establishment for treatment of
the insane, emergency cases being committed by the
judge within fire days after the patient is placed in
the hospital, with the least possible delay, and under
proper restrictions to prevent abase. There is no
penalty if onqualified physicians sign certificates, or if
judges accept their certificates without sufficient scm-
tiny of their qualifications. Go the whole, oor law
has worked reasonably well in all respects and re-
markably well in most respects, although certificates
of insanity are sometimes valueless by reason of their
meagreness and incompleteness, as happens under all
laws and in all countries, England and Scotland even
included. In November last, a patient was received
at one of the State hospitals, committed in doe form

by the judge, but upon the certificates of two " doc-
tors" possessing diplomas of a bogus medical college,
in violation of the statutes. The patient wu dis-
charged as not insane two days later, after a briet ex-
amination of the evidence as to his insanity, although
it is only fair to say that in court his insanity was tes-
tified to by one of the leading experts on tusauity io
the State. In commenting on this case, the Board
says:

" In New York, any judge of a Court of Record
may qualify a physician properly recommended as so
examiner in lunacy, and give him a certificate to that
effect, and no mittimus can be signed by a physician
not a qualified examiner in lunacy. This would seem
to be an excellent provision in lunacy laws, and the
Board recommends its adoption in this State."

It is not ditficnlt for a respectable general practi-
tioner in New York to get his certificate, which is
simply an official declaration of the qualifications re-
quired by the Siassachasetts law, except in its limita-
tion as to being connected with any institution for
treating the insane ; and the question of the insanity
of the patients committed, there as here, " must of
necessity fall to ihe snperintendaot of the hospital to
which they are committed," especially ip some doubt-
ful or difficult oases, where " judges of ooarts of record
appear to be going farther than the aot«ial require-
ments would seem to justify. If this tendency con-
tiones in any marked degree, it will be necessary to
have such cases determined by the courts." ^

The New York law also has its difficulties, and ex-
perts are by no means agreed that it is in any way
better than ours, except that it would be a great gain
if our Central Board should provide uniforaa and com-
plete blank certificates for oommitment, and if their
use should be required in all cases, as is the law in
New York. Our law is so liberal and flexible that
many fear that the effect of calling the attention of
the legislature to it would be to make it worse than it
now is, as has been twice unanimously voted by the
councillors oF the Massachusetts Medical Society.

The Board urges the necessity of frequent inspec-
tion — in fact, of a supervision at night as constant as
that by day — and of some appropriate way by which
patients can be inspected io thoir rooms at night with-
out being disturbed. Certain established rules of pre-
caution are seemingly more uniformly followed in
other States than they are in MMsachusetts, where
the institutions for the insane show a wide differenoe
in the manner in which nlght-snpervlsion is conduoted.

The law concerning commitments to the West-
borough Insane Hospital permits those desiring ho-
moeopathic treatment to be sent there at their own
or their friends' request. When patients are seat
from Suffolk County to Westborough, those desiring
other treatment than hommopathic have no option ia
this matter. There are disadvantages connected with
this liberality of method.

The Board recommends laboratories for scientiic

> Fourth Annnal Keport of the New Tork State OooubImIod In
Lauuv, Aibaar, ISSS, pp. MS ud StI.

Digitized by

Google

Vol. CXXX, No. 8.] BOSTON MEDICAL AND SURGICAL JOURNAL.

n

research, medical-improvement dabs and training-
schools for nuraes in all hoapitals for the insaDe, and
aaggests that all patients be photographed upon admis-
sioD, as is done at the Westborough {hospital, by
'which means escaping dangerous patients might be
identified. Occupation is advised so far as it is prac-
ticable to employ the patients, and " something more
than a loug-ezisting routine treatment, into which it u
easy to lapse, may properly be looked for in Massa-
chusetts hospitals."

Of the hospital for dipsomaniacs and inebriates,
the Board disapproves of too much lenity and consid-
eration, and an indulgent parole system for drunkards,
suggests enforced labor and discipline, and condemns
the looseness of many of the commitments, by which
" an accumulation of inmates of disorderly and crimi-
nal habits and tendencies imperil the success of the
humane venture of the State in its effort to treat hab-
itual inebriety of itself by jast and rational methods."
A striking case is cited by the Board, which illus-
trates the possibility of gross abuse in the face of laws
prepared with the greatest care for the protection of
the insane and hospital management second to none
in the world in its solicitude for the welfare of its
' patients.

A private patient who had been in the McLean
Asylum twenty-seven years, legally committed and
detained, with the late Dr. Isaac Ray as one of his
certifying physicians, seventy-five years old, demented
and subject to convulsions which were increasing in
frequency, was summarily removed by a deputy sheriff
with a writ of habecu eorput and placed in the hands
of strangers in one of our large hotels, his old attend-
ant and his guardian being denied access to him. On
the fourth day he was returned to the asylum, the
judge deciding that his commitment was legal. On
the following day the judge passed a further order,

setting out that it was conceded that was not

of sound mind, and that he was properly in the custody
of the asylum ; and after reciting that it now only
" remained for the court to inquire whether it is best

for said to be further kept and cared for at

said hospital, or in some other manner," appointing a
guardian ad litem, " charged to care for his interest in
this investigation, and particularly to inquire in such
manner as to him shall seem- best, and to report to the
court at such time as he may find it convenient,

whether it is best for said to be cared for in

the said hospital, or in some other manner, and if in
some other manner to report to the court some scheme
for his care." The guardian ad litem, after a careful
investigation, lasting more than two months, reported

to the court that Mr. had better remain in the

hoipital ; and a final decree was entered, dismissing

the original petition, and remanding Mr. to

the custody of the hospital. In the ultimate result,
therefore, it may be said that no wrong has been done,
either to the hospital or to the patient confined there ;
hot the whole proceedings have been so extraordinary,
and so inconsistent with the carefully-guarded provi-

sions of our statutes relating to the insane, and to the
powers and duties of the judicial and other officers of
the Commonwealth as to such persons, that the case
should receive a more extended consideration.

With the evidence which we have given in the two
cases mentioned and in the quotation from the report
of the New York Commissioners, it may be doubted
whether the medical profession would be ready to give
to all judges the discretionary power of appointing
permanently such examiners in insanity as they might
see fit to appoint.

THE MICROBE OF SCARLATINA.

Despitb the progress of bacteriology, the patho-
genic microbe of scarlet fever still remains undeter-
mined, unless, in fact, the views enunciated by Berg6
at a late meeting of the Soci^td de Biologic (December
10, 1893) should find acceptance. He states that it is
useless any longer to search for a new microbe as the
cause of this disease, and that scarlatina is primarily a
local disease, with secondary infections (the eruption,
etc.) due to the formation and absorption of tozines ;
the pathogenic agent is the streptoooocns pyogenes, the
microbe of erysipelas, of puerperal septicemia, etc In
common or tonsillar scarlatina, the streptococcus finds
a rich culture field in the crypts of the tonsil and there
secretes (in all probability) "an erythematogenons
toxine," whose diffusion throughout the organism pro-
duces the cutaneous or mucous eruption.

Berg^ remarks that the tonsillar affection takes pre-
cedence in order of time, and that while the micro-
scope invariably reveals the presence of the strepto-
coccus in the tonsillar crypts, bacteriologists have never
found microbes in the cutaneous exanthem, even by the
recent methods of research formulated by Nicole.

Puerperal and traumatic scarlatina results from the
local streptococcus-infection of the uterine (or other)
wound, exception being made of morbid coincidences
and of cases of tonsillar scarlatina which may be met
with in the course of certain epidemics of puerperal
fever, and are sufficiently explained by the existence
of the common infectious agent, the streptococcus. It
is admitted, moreover, that there may be scarlatina
without eruption, characterized exclusively by the an-
gina.

The principal arguments on which this writer
bases his conclusions may be summed up as follows :
(1) the succession of the eruption to the tonsillitis in
common scarlatina ; (2) the fact that careful observers
have never found the tonsillar affection absent, even in
certain rare cases where its presence was overlooked
and denied (the so-called icarkuina tine angina) ; (3)
the existence of a scarlet fever, really without amyg-
dalitis, of uterine or traumatic origin; (4) the exis-
tence of a scarlatina without eruption in which the
streptococcus-tonsillitis and its complications consti-
tuted alone the disease ; (5) the constancy of the
streptococcus in the tonsils of scarlatinous patients ; (6)
the streptococcic nature of the complications of scarla-

Digitized by

Google

74

BOSTON MEDICAL AND SUSOJCJl JOVUMAJL (Jauvatit IS, 1891.

tina; (7) the relatione of tcarlet fever to the p«er*
peral infectiou ; and, lastly, the ready demonatration
of the " erythematogenoas " property of the atrepto-
C0CCU8 (pyemic eruptions, infectioas erythemata of
bacoo-pbaryngeal origin, etc).

These cooclnsions are also corroborated by the stndy
of the clinical comparison between the acnte amygda^
litis (generally due to the streptococcus) and soarlatioa
(contagionsness, the same duration of the incnbation,
the same possible complications, similarity of the febrile
cycle, the same symptomatology, save the eruptions,
etc).

The diffusion of the infectious agent is no argument
against the view advanced ; we know only in part its
modalities and its divers pathogenic actions. The non-
recurrence of the disease can be affirmed only in re-
spect to the eruption ; the tonsillar affection may
return again and again with the same violence.

It can hardly be said that M. Berg^'s theory, which
we have endeavored to state above, explains anything
more coan the complications and sequela of scarlet
fever in connection with which a variety of common mi-
crobes, and in particular the streptococcus, have been
found ; it does not sufficiently explain the specific erup-
tion, nor can it be said that this is identical with the
erythema of puerperal infection. It will now be in
order for M. Berg^ to isolate the specific " ery thema-
togenous " toxine, and show that it is produced by some
" modality " of the streptococcus ; then his chain of
evidence will be complete.

MEDICAL NOTES.

Pbofkssok Sknn's Gift to Chicago. — Prof.
Nicholas Senu has given his entire collection of medi-
cal books to the Newberry Library of Chicago. A
large part of this collection was once the library of
Prof. William Banm, of Gdttingen. Dr. Senu re-
tains only his working library ; all the others are now
at the use of the medical profession of Chicago. The
money value of the collection is estimated at fifty
thousand dollars.

A Four-Ykabs' Cousbb at Jeffebbom Medi-
cal College. — At a meeting of the Faculty of
Jefferson Medical College held on January 8, 1894, it
was unanimously resolved to institute a compulsory
four-year course with the session 1895-96. This step
was taken in order that the large clinical service of
the Jefferson College Hospital (850 cases a day) might
be utilized to the fullest extent in carrying out the
desire of the Faculty to provide advanced medical
education of a practical character.

The Camebon Pbize. — Mr. Victor Horsley has
been given the Cameron Prize of the University of
Edinburgh for the last year. The prize consists of
the income from a sum of £2,000, and is given annu-
ally "to the practitioner or member of the medical
profession who shall be adjudged to have made the
most valuable addition to practical therapeutics daring

the year preceding} and in determining the word
' therapeutics ' sharl) be taken in its widest sense at in-
cluding every agent or agency capable of inflaendng
the human 'hodj in the maintenance or improvement
of health, avoidance or cure of disease, or the allevi-
ation of suffering."

The Rome Medical Cohobess. — The Interna-
tional Medical Congress at Borne will have no lack of
papers. Already a thousand articles have been given<
a place upon the programme. Up to the middle of
December there were nearly four thousand names-
registered of persons intending to be present to listen
to the one thousand papers.

An Imtebebtino Jenneb Relic. — The prevalence*
of small-pox in England, and the insufficient protec-
tion of the people by vaccination was a fitting time for
the discovery of an interesting relic of Edward Jenner'
not long ago. At a sale of unredeemed pledges at a-
London pawnbroker's, there was purchased the casket,
in which the freedom of the city of London was pre-
sented to Jenner on the 11th of August, 1808, for'
" his skill and perseverance in the discovery of, andi
bringing into general use, the vacdne inoculation."

BOSTON AND NBW KNOLAND.

Shall-Pox in Boston. — During the week endibg-
at noon, Wednesday, January 17th, there were two-
deaths from small-pox in Boston. No new cases were
reported. There are now eleven patients in the hos-
pital on Canterbury Street.

Small-Poz in Lowell. — There was another
death from small-pox in Lowell, Mass., this week,
making the third death from the disease this year.

Death at an Advanobd Age. — Mr. Edward
Ryan, the oldest resident of Newton, Mass., died
January 11th, aged nearly one hundred and ten years.
He was the father of sixteen children ; the oldest one
now alive, being the third of the sixteen, is seventy-
one years old.

A Gift to the Portshocth Hospital. — Mr.
George Bilbruck has given the trustees of the Cottage
Hospital at Portsmouth, N. H., ten thonsaod dollars
for a new hospital building fund.

Influenza in Fittbbubo, N. H. — A severe
epidemic of influenza is prevalent at Pittsburg, N. H.,.
nearly the whole adult population being ill. There
have been twelve deaths in this and the neighboring
town within the last few days.

An Escape fboh an Insane Astldm. — Two
inmates of the State asylum for the insane at Cranston,
R. I., made their escape last week after smothering the
keeper with a blanket and locking him in &□ empty
room. After the keeper was rescued he was discharged
for neglect of duty.

Vaccination : A Stddt in Black and Whitr.
— A physician in Boston who has been vaccinating the
employees of some of the large hotels, reports that he
was able to vaccinate forty-eight white persona an hour,
but only thirty-eight negroes in the same time. Aa all

Digitized by

Google

"V^oi.. CXXX, No. 8.] BOSTON MBDIOAL AND SUBOIOAL JOURNAL.

76

itbe other conditions were the same, the greater thick-
'neas of the black man's akin suggested itself as the ex-
planation.

KBW TOBK.

Tbk Governob's Annual Messagk. — The an-
nual message of the Governor, submitted to the Legis-
lature January 2d, contains considerable matter of
interest to the medical profession. In regard to the
preservation of the Adirondack forests, the Governor
says : " The year just ended has marked a new era in
the State in the matter of forest preservation. A
new policy has been established, whose good results
are already far beyond expectation." During the
year a large extent of territory, valued at a million
dollars, was added to the State Preserves, not only
wUkcmt expense to the State, but with an actual profit
m Bsoaey sufiScient to pay the expenses of the bureau.
S«oli a demonstration of the immediate money advan-
tage of the tax-payer from preserving forest land, to
«ay nothing of the climatic, meteorological and aesthetic
^ain, ought to be an incentive to the people of other
•'States to continue such good work.

Public Health. — On the subject of the public
health the Governor says : " The spread of cholera in
Western Europe last spring called for extra work on
the part of the State Board of Health to prepare for the
reception of the disease, should invasion take place.
Local boards of health throughout the State are re-
quired to report upon the sanitary condition of their
manicipalitiea, and as to what arrangements had been
made to care for cases of cholera, if any came. In
order to assure active and efficient work, six inspectors
were appointed by the State Board to visit all places
of entry into the State, and such other places as would
be exposed, reporting the needs for further sanitation,
erecUon of hospitals, disinfecting stations or such like
matters of importance to the public health. The wis-
dom of this work has been well shown in greater
energy on the part of local health authorities; and
while it is a matter of congratulation that cholera did
not reach this side of the Atlantic, had it done so, the
readiness in which the most exposed places were put
was an assurance that an extended epidemic would
have been prevented. The precautions at the Quar-
antine Station in New York Harbor were equally
vigilant and thorough."

Care of the Insane. — Much space is devoted in
the message to the matter of State care of the insane.
In regard to this the Governor says, in part : <' One
of the inevitable results of the new system of State
care was that the Central State Board should be en-
dowed with reasonably broad powers of supervision
and regulation. It was inevitable also that the crea-
tion of such a central board with broad powers should
lead to more or less conflict between it and the local
boards of managers which were established for each
hospital, and whose official life, in most oases, con-
siderably antedated that of the State Commission.
That conflict was quite marked and spirited immedi-

ately after the adoption of the State Care Act, but
subsequently subsided after the courts had upheld the
powers assumed by the Commission. It has arisen
again, however, within the last two months, and there
seems to exist to-day anything but a cordial feeling of
co-operation between the State Commission in Lunacy
and the local boards of hospital managers. ... I have
endeavored, by bringing local managers together with
the State Commissioners, to ascertain where the causes
for grievances lay, and to bring about their correction
so far as the administration of the law was at fault.
These conferences have disproven many published
allegations, and I am confident that as soon as the new
system is fully understood it will prove satisfactory to
the people. At the same time, the existence of the
local boards of managers will serve a useful purpose in
checking any arbitrary tendencies on the part of the
State Commission. Certainly, in carrying on so noble
a State charity, there should be no unnecessary friction
among public officers. Neither personal nor political
considerations should find any- place in the discharge
of this official obligation. For this reason, we should
not only establish sufficient safeguards around the ad-
ministration of the law, but encourage harmonious en-
forcement of its provisions by administrative officers."

Tdbrbculosis in Cattle. — This subject is thus
spoken of : " The examination of cattle for tuberculo-
sis has been steadily pushed. In all, since January 1,
1893, 19,001 head have been examined, and 618 killed
to prevent the spread of the disease. Microscopical
and bacteriological examinations have been made of
milk and specimens made pott-tnortem, showing the
presence of the tuberculosis germ in all. Care is
exercised in the examinations, and careful records are
kept. The result will be, if work in this direction is
continued, to improve the cattle in the State, enhance
the dairy interest, and add a further protection to
the public health by removing this source of disease
germs."

A Dislocated and Fbactcbed Neck. — There
is at present at the Grouvemeur Hospital, a lad nine
years of age, who was knocked down by a truck on
January 10th, and suffered a dislocation and fracture
of the cervical vertebrse. The dislocation was set, and
the patient placed in a plaster-of-Paris dressing. As
the fracture was slight and the spinal-cord apparently
uninjured, he seems to be in a fair way of recovery.
Since the apparatus was applied he has been gradually
improving. His mind is perfectly intelligent and there
is no paralysis of motion ; but he does not articulate
very well, and his respiration is somewhat labored and
irregular.

Dr. Stoddabd's Appointment to the State
Board of Charities. — Governor Flower has nomi-
nated Dr. Enoch V. Stoddard, of Rochester, as a mem-
ber of the State Board of Charities, to fill the vacancy
caused by the death of Mr, Oscar Craig, and the nomi-
nation has been coufirmed by the Senate. Dr. Stod-
dard was born in Cono^^ti^ot in 1840, and was grad«-

Digitized by

Google

76

BOSTON MEDICAL AND SVBGIOAL JOURNAL. [jAMtJ^T 18, 1894.

ated from Trinity College. For two years he was at
the Yale Medical School, and then completed his
stadies at the Albany Medical College, from which he
received the degree of M.D. in 1863. In the same
year he was commisgioned a surgeon of rolnnteers by
Governor Seymour, and went to the front with the
65th New York Regiment. Immediately after the
close of the war Dr. Stoddard commenced the practice
of his profession in Rochester, and for many years he
has been on the staff of the City Hospital there. In
1873 he was appointed to the chair of Therapeutics
and Hygiene in the Buffalo Medical College, and in
1892 was made Professor Emeritus.

ELEVENTH INTERNATIONAL MEDICAL CON-
GRESS.

A LETTER directed to Dr. A. Jaoobi by the Secre-
tary<General of the Eleventh International Medical
Congress, and dated December 19, 1893, contains the
following communications :

American member* will pay on the English, French
and Italian railways single fares for double journeys,
and will obtain a reduction of twenty per cent, on
fares for Italian round-trip tickets.

"The documents required for their identification
will be sent to yon in January, and Americans intend-
ing to visit the Congress will have to apply to yon for
them.

" Full particulars concerning the journeys will ac-
company the documents.

" Messrs. Thos. Cook & Son, London, Paris, Rome
and Naples, should be applied to for accommodation
and for tickets for the excursion at Rome, Naples, and
to Sicily. Such excursions will be arranged at Rome
under the guidance of Mr. Forbes, pember of several
scientific societies and correspondent of the 7Vm«( —
for Naples, three days, including Vesuvius, Pompeii,
Capri, Sorrento, Castellamare, Baje, etc. — for Sicily,
ten days from Naples, including Messina, Taormina,
Catania, Girgenti, Siracusa, Palermo, and return to
Naples.

" The fares for members of the Congress will be
considerably reduced and comprise hotel accommoda-
tions, carriages, guides, boats, etc. — about 70 francs
each, for the three days, and 285 francs for the ten
days.

" Full particulars concerning these excursions will
be contained in a leaflet to be added to the instructions
and documents for the journey."

Only the North German Lloyd (22 Bowling Green)
and the Compagnie G^n^rale Transatlantique (3 Bowl-
ing Green) have thought fit to grant any reductions to
Congressists.

FOOT-BALL VS. INSORANCE.

In a recent editorial in the New York Medical Ex-
aminer, Dr. G. W. Wells speaks of the bearing of
foot-ball upon tbe insurance of a player. The subject
of athletics is one which every insurance company
considers in a very practical way. As underwriters,

they are obliged to look upon foot-ball as upon sny
other occupation ; that is, in the light of danger to life
or health, or as a cause of shortening the normal
longevity of man.

There are in the game three classes of casualties :
namely, those which are fatal, either immediately or
shortly after ; second, those from which recovery takes
place sooner or later, with or without deformity ; sod
third, those from which recovery never takes place,
but ever after the victim carries with him results or
reminders, either physical or mental, which place him
in the category of chronic invalids.

If he is a policy-holder, and engages in this danger-
ous game, as now presented, he is putting his company
to an extra hazard, for be is in immediate and constant
danger of death ; and bis insurance may become a
claim, by death, at any moment during the season.

In view of the many insidious and secondary affec-
tions resulting from foot-ball, of which he gives a most
appalling list. Dr. Wells considers that a history of
having played foot-ball should cause a more rigid
scrutiny of the applicant for insurance by the exami-
ner than in ordinary cases. In spite of this view that
foot-ball and athletics are liable to render the appli-
cant a questionable subject for insurance, we can bat
think that the members of our foot-ball and athletic
teams are about as healthy and promising specimens
of young manhood as are often seen, and that, save
for social reasons, they stand in less need of insurance
than any other class of men.

SELF-MDTILATION IN CHINA.

Tbb Medical Preu gives the following account
of a curious custom which only the ancestral worship
of China could account for :

"Tbe dearest hope known to an elderly Chinaman
is to have descendants, and the main reason of this
appears to be that when he comes to die his last days
may be cheered by the conviction that he has left a
goodly following of his own flesh and blood to worship,
as the custom is in China, at his grave. But even the
calculations of the "Heathen Chinee" are, in this
respect, sometimes prone to be wof ully thrown out of
gear by a concatenation of circumstances, the occur
rence of which could not have been foreseen. Of
course, the Chinese father relies on his sons to pro-
pagate the race, and when there is only one son left
upon whom this responsible duty devolves, it is obvious
that much should be made of him. Facts go to show
that sons are fully aware of the important position
which in this particular they fill in the domestic circle,
and consequently they expect and demand a full meas-
ure of consideration and regard from their male pro-
genitors. Should it happen, however, that any serious
quarrel arises between father and son, tbe son has it
within his power to revenge himself to an extent
which is absolutely nnknown in more civilized com-
munities. Probably no one but a Chinaman could
understand the anguish of a Celestial father who
suddenly learned one day that his only son had by one
swoop of a razor relieved himself of his penis and
testicles ! But this is the mode of retaliation which
aggrieved Chinese sons adopt towards fathers who |
offend them. Dr. Robert Coltman, of Pekin, has just
recorded two cases in which, for the reason mentioned,
the sons made a clean sweep of their generative organs. |

Digitized by

Google

Vol. CXXX, No. 8.] BOSTOm MBDICAL ASD SURGICAL JOVBSAL.

77

A SANITARY SERMON IN DIAGRAM.

Dr. Jobn C. Sdndbero, the United States Consul
at Bagdad, bag sent to the Paeific Medical Journal so
telling a sketch of the sanitary condition of the water-
BQpply of Bagdad that it is worthy of reproduction.
It needs no comment.

Old Bagdad (vestorn bank).

'■6

i«:
k.
(I
ai
ii
m

m:

Thb Xiobis.

7 T T

4B666666

ssasssss

CO

I

Nbw Bagdad (eaitern l>ank).

2|

Street.

I

r

1. Vnlted State* Conralkte. 2. Board of Health. 3. A hooae botlt
out Id tbe rlTer, the Tall of wbleb stopi dead oaU and dogs, hnman
faoea, eto., floating down. 4. Plaoe where the water-carrlerB take
tbe water which we hare to drink. 6. Women and men wafbtng
clothes, rugs, etc., gtalned with cholera dejecta. 6. A row of men
defeeatlng In the water and washing their anl, also nrinating. T.
Dead buffaloes, horses, dogs, eau, etc., floatlDS down tbe river.
8. Water-oarrlers' donkeys always nrinating and defecating while
waiting for tbelr loads.

Ci:

*■

'f*

ki
to:
«.«
«t
tf

b«

.'»:
Fie:

?*
t»
m-
• y-
■■>'
\t
i'-
er

•(.'

*-■
!«■

PATHOLOGY AND THE SCIENTIFIC MIND.

In his introductory lecture at the Medical College
for Women, Dr. William Buasell ' spoke of the develop-
ment of our knowledge of pathology and the evolution
of the scientific mind to its present ideal.

The most primitive idea of pathology was simple
and spiritual enough. Disease and sickness were the
work of evil spirits who, by the initiated, could be ex-
orcised by charms and ceremonies. Prevention and
exemption from disease might be sought for in a devil-
worship. An advance upon this was the attributing
of disease to a spirit, not normally evil, but beneficent ;
disease being the manifestation of his righteous anger,
relief was sought not by propitiation but by sacrifice.
The Hebrew idea was but a modification of this in the
monotheistic belief of special revelation and punish-
ment. The speculative character of the Greeks led to
a different order of things, with them it became the
province of philosophy to explain the ever visible phe-
nomena of disease and death. There were hot, cold
and moist hypotheses — doctrines of one cause. From
tbis speculative chaos light arose when Hippocrates
separated medicine from philosophy, and began crudely
and falteringly to make medicine a science of observa-
tion instead of speculation. It was this that gave to
him the fatfaership of modern medicine.

No material advance was possible until the structure
of the body was followed and its various functions
more or less defined. As knowledge of these was
being acquired, as new facts were discovered, and new
light was thrown upon tbe working of the complex
animal organism, their bearing upon diseased processes

> Bdlnbnrgh Hedioal Jonmal, January, 1894.

led necessarily to controversies and contentions, and
there were solidistic and humoral schools of pathology,
there were beliefs in spontaneous generations, in epi-
demic constitutions, and so on, all of them indicating
and proof of the uncertainty of knowledge and its in-
completeness. ' However, the bounds of reliable knowl-
edge gradually extended. Following upon assured
knowledge of normal structure came the recognition
of abnormal structure in the various parts and organs
of the body.

This progress has gone on till such " is the state of
our certain knowledge of visible processes, that in the
great preponderance of instances there is no room for
differences of opinion amongst experts. Cases, how-
ever, remain in which from incomplete knowledge
there is still room for differences of view as to tbe in-
terpretation of appearances ; as to appearances them-
selves there is practically none. But even here it is
necessary for the truly scientific mind to candidly and
frankly dissociate appearances and their interpretation.
Interpretation is sometimes a matter of provisional
judgment or opinion, and often must and ought to re-
main so until knowledge is so complete that doubt can
no longer exist. And it is this candid openminded-
ness which is, I take it, the ideal scientific spirit to-
wards which we have all to work."

The aim of medical training is the development of
a well balanced judicial mind upon assured knowledge
and accurate observation. The unimpassioned search
for truth is the highest conception.

CorreieipoitDettce.

[Special CorrespondeDce.]

LETTER FROM PRAGUE.

Thb Study of Patholooy in Pragub.

Pkagck, December 17, 1898.
Mb. Editor : — The conditions for tbe study of pathol-
ogy are better here in Prague, so far as I can learn, than
anywhere else in Europe. Tbe number of autopsies is very
large, and the material ia well worked up from every point
of view. Anatomv, histology, embryolo^ and bacteriology
enter constantly into tbe difily work, and my respect for
each of these branches of medical science is rapidly in-
creasing. The view of pathology taken is very broad, and
tbe ideal taught by example is one not easy to attain.
The study of pathology is centred in the Pathological In-
stitute, a large building iu the suburbs of the city on Kran-
kenhausgasse. In close proximity to it, on tbe same street,
are the General Hospital, the Anatomical Instilute and the
Chemical Laboratory. The post-mortem examinations for
most of tbe hospitals in the city are made at tbe Pathologi-
cal Institute between the hours of eight and eleven in the
forenoon. The Secir-Halle, or autopsy-ball, is a large room
on the first floor, and is furnished with three marble
autopsy-tables. On the same floor are three large rooms
for tbe assistants, one for the demonstrators, a room, for
medico-legal autopsies, tbe lecture-room, a chapel, macerat-
inff-room, etc.

The present Professor of Pathology is Hans Chiari, who
was called here from Vienna ten years ago. In his depart-
ment are three assistants, two demonstrators and several
volunteers. The autopsies at the Pathological Institute
and at tbe hospitals are divided equally among tbe three
assistants. Chiari makes only those autopsies whicli are of
especial importance, and also wbat are called clinical
autopsies. These latter are made by special request before
a visiting physician or surgeon and bis class in interesting
cases, and they take place, as a rule, several times a week.

Digitized by

Google

78

BOSTON MBDIOAL AND SUROWAL JOURNAL. [StxvAXT 18, 1894.

By eleven o'clock the aatoptiy-room mast be id perfect
order, the bodies removed and the tables cleaned. Chiari
first reviews the diagnoses of the previous day, corrects
mistakes present, and adds any bacteriological or micro-
scopical notes that may be ready. Then each assistant
demonstrates the organs from the various autopsies which
he has made, and Chiari advises, corrects, commends or
reproves as necessity demands. All the diagnoses must be
given in correct Latin. After the organs have been looked
over and arranged for the demonstration, the two demon-
strators show 6r8t the fresh tumors which have been re-
ceived, and later slide-preparations of the tumors which
have already been hardened ; descriptions of the appear-
ances are entered in the histological protocoU, and the re-
ports of the completed cases are filled out for the surgeons.
In the protocol!, opposite each tumor is entered the name
of the demonstrator or special student who has taken it for
examination, so that if a report lags the one to blame is
easily traced. Every day in the week, from quarter-past
twelve to one, a lecture on pathology is given in the lecture-
room across ijie hall from the autopsy-room. As a lecturer
Chiari is delightful ; he speaks without notes, clearly, dis-
tinctly and rather rapidly; his subject is perfectly ar-
ranged in his own mind; and he never hesitates in the
expression of his thoughts or for the lack of the appro-
priate word. His lectures are illastrated naturally and
easily by numerous blackboard sketches and by many beau-
tiful and appropriate specimens from the Pathological
Museum. He calls his lectures demonttrative lectures.
Immediately after the lecture comes the demonstration of
the fresh pathological specimens in the autopsy-rooms, by
Chiari at one table and by one or more of the assistants at
the other tables. Three times a week an autopsy is made
by students during the demonstration, under the super-
vision of an assistant. Microscopical sections illustrative
of the subject of the lectures are also shown at the time by
the demonstrators.

The medico-le^al autopsies are made in a room adjoining
the autopsy-hall by Professor Dittricb, until lately Chiari's
chief assistant; and the material obtained is also used at
the demonstrations.

The following table will show the namber of autopsies
made each year for the last seven years :

Tear.

Pathological
Institute.

1886

1887
1888
1889
1880
18*1
1891

821
790
8S7
773
882
813
Ml

Children'!
Hospital.

144

1S2
212
186
209
176
157

Other
Hospitals.

76
68
46
44

03
102
74

Total.

1,043
1,010
1,116
1,008
1,184
1,130
I.ITS

The Children's Hospital is but two blocks away, and has
a large autopsy-room furnished with everything needful, as
have also the other hospitals at which autopsies are made.
Infectious diseases furnish a large part of the pathological
material, and include small-pox, influenza, scarlet fever
and diphtheria.

The room for pathological histology is on the second
floor, over the autopsy-hall. The class meets twice a week
from five to seven p. m., doing all work by lamplight, as it
is the only spare time left in the day. A student can take
the course only after having heard first the lectures on
pathology. Six specimens are given the class each time;
and towards the close of the exercise Chiari gives a talk
concerning what they have been studying. Smoking is in-
dulged in by every one during the exercise. The class
usually numbers from forty to fifty men.

The lectures on pathology are heard by about one hun-
dred men in the course of the year ; and, in spite of six

lectures a week, the field of special pathology is never coot-
pletely covered.

The Pathological Museum is in a large hall on the second
floor, and contains over six thousand rare and valuable
specimens, all carefully arranged and catalogued. On the
same floor are the professor's private rooms, library, and
also his home.

The assistants are also lodged in the Pathological Insti-
tute, and receive a salary of 600 guldens (9240) a year.
An e£Eort is now on foot to increase the salary to 900
guldens. Internes in the hospitals receive the same re-
muneration.

The examination in pathology consists of two parts,
practical and theoretical, and can be taken only after a
student has attended the university for five years. Any
time after that, when he thinks he is properly prepared,
he can apply for hit examination. Besides attending
the lectures and the course in pathological histology, it
is customary for each candidate for examination to take
three or four weeks' drill under an assistant in performing
autopsies and in examining microscopical specimens. The

fractical examination or rigorosum lasts about half an hour,
have attended several of them, and found them very in-
structive. Usually the candidates come in gronps of two
or three. One is requested to describe the external ap-
pearance of the body, and to make a part or even the
whole of an autopsy, demonstrating the lesions found.
Another removes the brain, and later is required to demon-
strate part of the organs from another autopsy. Each
man must do enough to show what he knows. Immedi-
ately after the examination of gross material each candi-
date is given a hardened pathological specimen, from which
he cuts razor sections, stains, mounts and makes a diagno-
sis. On the same day, but usually at some later date, comes
the theoretical examination, a fifteen minutes' quiz on a va-
riety of subjects in pathology. The examinations are pub-
lic, and the dean and one other official are usually present.

Besides the autopsies, the assistants have certain other
duties portioned out to them : the first assists at the dem-
onstration, and, with the second, has charge of the bacterio-
logical department. The secpnd assistant looks after the
instruments and the museum preparations. The third has
charge of the histological course, the protocolls and the
microscopes. They are appointed from the demonstrators,
two in number, who make microscopical preparations of
the various tumors, etc., and have numerous other duties.
The demonstrators are selected from the volunteers, of
whom there are usually half-a-dozen in the laboratory,
those having the preference who have worked in the ana-
tomical or other laboratories. It will tlius be seen that
each assistant has worked up to his position, and is well
trained in the various kinds of laboratory work.

The position of assistant in the Pathological lostitate is
greatly sought for, for the reason that it is a great stepping-
stone to the position of interne in the hospitals. Here a
clinical professor chooses his own interne, who not infre-
quently nolds his position for two, four and even for ten
years. The fact that the university and the hospitals are
State institutions has certain great sMivantages. A clinical

ErofesBor in the university receives a certain clinic in the
ospital, which is henceforth known by his name ; and his
instruction is continuous, a matter of great importance to
the student. The bodies of all who die in the hospitals
come to autopsy, so that the pathological lesions in each case
are known, and the diagnosis previously made is verified
or corrected. At home, clinical instruction is interrupted
by change of service, and autopsies are few, and rarely ob-
tained in the most interesting and doubtful cases, oyer
wliich, perhaps, much time and study have Iieen spent.

A special student in any of the various branches of
medicine could hardly find a better place for the study of
the pathological side of his subject tuan in Prague. The
number of autopsies is very large, and the material inter-
esting and varied, for the reason that chronic tubercular
cases are for the most part excluded. The museum con-
tains not only many rare cases, but also the best specimens
of all the more ordinary forms of disease. The number of

Digitized by

Google

Vol.. CXXX No. 3.] B08T0S MEDICAL AND SUttGIOAL JOtmSAl.

79

special students is constantly varying ; at present there are
tliree, of whom two are Russians. Chisri devotes consider-
«kble time nearly every day during the forenoon to his
special students, who are taught to work in a systematic
manner, and to make sketches and drawings with notes of
tlieir various preparations. His reception of strangers is
moat cordial ; and he treats them all as fellow-workers with
himself in the great field of pathology.

T'he bacteriological department is in two large rooms on
the ground-floor, and is well fitted up with the necessary
apparatus and with abundant culture media.

Briefly stated, the advantages for the study of pathology
in l*rague are the following :

The abundance and the variety of the pathological mate-
rial, including all the acute infectious diseases.

A. large museum stored with rare and valuable specimens
from previous autopsies and from operations.

A large collection of histological material from various
cases.

The personal supervision and instruction from the pro-
fessor of pathology.

The concentration of the autopsies, bacteriological and
microscopical work, museum, library and protocolls within
the same building, and all under the direction and immediate
control of one person.

The perfect order and system preserved in every depart-
ment, from the autopsy-room to the museum, and required
of every person working in the laboratory.
Very truly yours,

F. B. Mallort, M.D.

MODERN REALISM AND ZOLAISM IN SPAN-
ISH LITERATURE.

Mr. Editor : — The following passages are liUral trans-
lations from a modern Spanish society novel, and may be
interesting from a medical point of view in that they wow
to what source the present school of writers of fiction in
Spain is compelled to resort for matter interesting (?) to
the general public :

"All, all had she suffered with resignation up to tluit moment ;
the anscnltations, the palpations — which she considered shame-
ful — of the accoucheur ; the explorations to which she sub-
mitted her denuded body and enormous belly, in the lateral or
'dorsal decubitus, in order that this unknown man might exam-
ine the sides or fundus of the uterus — as he said — that he
might profane her body I — as she felt assured; — the stetho-
ecope constantly fixed upon her abdomen in order to perceive
«na count the foetal heart ; the spiderlike tickling in the inner-
most parts of her belly, so persistent and annoying that it pro-
'duceo spasms, a species of Incessant convulsions ; the vomitings,
the bnlkiness, the monstrous tumefaction of the breasts, wFth
pains so acute that they made her cry to heaven ; the nnwieldi-
oess of her belly, rounded, fluctuating, convex, really incom-
modious, which impeded the liberty of her movements; the
Insupportable tremblings of the foetus in its prison, at times
more constant and brnsqne ; the varicose and oedematous condi-
tion of her lower limbs and of her vulva, which made her think
of death with pleasure; the vaginal granulations so profuse
that they had made of her parts a deposit of pus rather than the
external genitals of a woman ; . . . the lenoorrhoeal flow,
abundant, viscid, trickling down her tliighs, staining the
sheets." . . .

"Rafaela was a case of rickets, or, better said, of osteomalacia :
he knew, because It was plainly evident, that the primipara had
DO hips, that she must, consequently, have a narrow and de-
formed pelvis ; and he knew, from a consideration of the pre-
liminary phenomena of pregnancy, the suppression of the
menses, the vomitings, the swelling of the breasts, the promi-
nence of the nipples, the deep and accentuated coloration of the
central areolse and the increasing extension of the mottled
areoise, the evacuations of milk, the disappearance of the
nmbilical depression, the albumen in the urine, the vaginal
granulations, the leucorrboeai flow, and in general the whole
symptomatology of pregnancy; he knew that failure to bring
aboot abortion at a cerMin time, and the sooner the better, be-
fore tbe sixth month, condemned Rafaela to death." . . .

"She had stained tbe counterpane of the bed with green
vomitas; and as her whole body was one convulsion, from bead
to foot, and the vomiting never ceased, that room was trans-
formed by her into a sewer so full of viscosities of erery sort
.that they almost reached to the doctor's ankles." . . .

" But the good doctor from the house of succor had reckoned
without bis host; the host in this case was Doctor Nieto, who
by his delay in operating, by his citations, and his ' distin^o's '
had caused the parturient grave injuries, such as 1>eginning
rupture of the uterus and of the bladder, inflammation of the
peritoneum, and an adynamic and febrile state, very evident
from the mental confusion of Rafaela. Moreover, the time
which he had allowed to pass without performing the operation,
and tbe force with which the foetal head had been compressing
the parts below the straits and of the excavation, had produced
in Rafaela violent contusions, which mijcht be tbe origin of
gangrene ; and as a result of it, the formation of veslco-vaginal
and utero-vaginal fistule, of a separation of the symphyses
pubis, and as a probable result of this, the determiuatlon of ex-
hausting inflammations and suppurations and perchance as
well of a great mobility of the articulations of the pelvis ! • • •
or what is the same, in clearer terms: of tbe impossibility to
walk or stand." . . .

" He made nse, this doctor, the saviour, with the dexterity
acquired by tbe hand of a man who is guided by great con-
scientiousness, he made nse, in order to accomplish bis bloody
operation, of a system which merits the term ' double ' ; a system
made up of the series of operations which together receive In
obstetrical science tbe name of craniotomy — perforation of the
skull by means of Smelley's scissors; - extraction of tbe cere-
bral sulwtance and crudting of the base of tbe skull by tbe
cephalotribe — and of decollation by Lee's method ; moreover
he amputated the foetal arms, perforated the chest and abdo-
men, and, finally, introduced tbe blunt hook into tbe pelvis of
Rafaela, making traction on it, once it was well fixed, with force
sufficient to extract the distorted creature." . . .

What a delicate and beautiful picture of the process of
pregnancy and parturition to place within the reach of Uie
modem Spanish woman under the guise of a society novel I
Very truly yours,

J. W. COURTHKT, M.D.

BoXBURT, January 12th.

RECORD OF HORTALITT
Fob thb Wuk aiiDiiia Baturdat, Jakvaby 6, 18M.

ti

li

Percentage of deaths from

Cities.

M

K

Se

4

Is

|1

go

1

r

1^

NewTork . .

1,891,306

878

830

13.86

20.90

1.21

M

8.26

Ghloaao . . .
Philadelphia .

1,438,000

—

—

—

—

—

_

1,116,662

613

188

8.48

22.66

.64

1.M

4.80

Brooklyn . .
Bt. Lonb. . .

9T8,3»4

367

111

12.42

26.66

1.08

.27

8J7

seo.uoo

_

—

^

_

~~

Boston . . .

4tt7,3»7

277

78

8.U

26.64

1.44

.72

6.76

Baltimore . .

600,000

—

—

_

— .

—

_

^

Washington

308,431

113

29

8.66

21.36

—

1.78

1.78

Olncinnatl . .

306,000

111

36

D.UO

13.50

.90

2.70

4JtO

CleTelaod . .

290,000

88

24

13.68

21.66

2.28

2.28

5.70

Pittsburg . .

283,709

—

^

^

—

—

._

Milwaukee . .

280,000

86

40

13.92

13.92

—

3.48

8.48

NasbviUe . .

M,764

26

9

—

23.10

—

Charleston . .

65,11)6

46

10

^

24.42

—

_

—

Portland . . .

40,000

22

4

—

27.90

_

^

^

Woroeater . .

««,217

87

6

2.7U

3':.40

__

FallBWer . .

87,411

40

16

16.U0

22.60

Lowell . . .

ST,1»1

20

\i

:i0.70

10.36

3.46

8.46

Cambridge . .

77,100

38

IS

17.98

16.36

16J6

3.66

Lynn ....

62,666

24

—

^

12.48

..

^

Springfield , ,

48,684

12

1

—

26.00

—

_

Lawranee . .

48,366

—

—

^

—

—

^

New Bedford .

45,886

17

3

...

6.88

—

^

__

Holyoke . . .

41.278

—

—

—

—

"-

—

_

Salem. . . .

32,233

7

1

—

14.28

—

—

^

Brockton . .

32,140

11

S

—

9.09

._

_

^

HaverhlU . .

31,396

13

—

—

16.66

—

.—

_

Chelsea . . .

30,264

24

8

4.16

33.44

—

_

^

Maiden . . .

29,394

12

1

—

33.33

—

—

^

Newton . . .

27,666

—

—

—

—

—

—

^

ntohborg . .

27,146

—

^

_

—

—

...

Taunton . . .

26,972

7

2

—

28.66

—

—

..

Qlonoeeter . .

26,688

6

0

—

—

—

—

.^

Waltham . .

22,068

10

1

10.00 30.00

—

10.00

_

QninoT . . .
Pittsfleld . .

19,642

6

1

^

33.33

—

_

I8,t4l2

6

0

~-

—

_

^

Everett . . .

16,688

6

8

—

60.00

—

_

_

Northampton .

16,381

6

0

33.33

—

—

_.

Newbnryport .

14,073

8

1

66.66

—

—

33.83

83.83

Amesbury . .

10,920

0

0

~"

^

~"

^

"~

Deaths reported 2,987 : under five years of age 911 ; principal
infectious diseases (small-pox, measles, diphtheria and croup,
diarrhoeal diseases, whooping-cough, erysipelas and fever) i&.

Digitized by

Google

do

Boston MkmOAL Airh SUAOiOAL JOVROIAL. [Jaxitakt 18, 189i

acuta luDg dlseasea 660, eonsomption 314, diphtheria and croap
173, scarlet fever 36, typhoid feyer 28, diarrb<eal diaeaies 24,
measles 23, wbooping-congh 22, cerebro-spinal meniDftitis 11,
erysipelas 6, malarial fever 2, small-poz (New Yorli) 2.

From dlarrfaceal diseases New York, Philadelphia and Fall
River 6 each, Brooklyn 4, Milwaukee and Lowell 2 each, Boston
1. From measles New York 18, Philadelphia, Brooklyn, Cleve-
land, Milwaukee and Fall River 1 each. From whoopinK-oough
New York 9, Philadelphia 6, Milwaukee 3, Brooklyn 2, Boston,
Cincinnati and Woburn 1 each. From cerebro-spinal meningitis
New York 4, Lowell 2, Brooklyn, Cleveland, Worcester, Somer-
ville and Chelsea 1 each. From erysipelas New York S, Brook-
lyn and Cleveland 1 each. From malarial fever New York and
Brooklyn 1 each.

bi the thirty-three greater towns of England and Wales with
an estimated population of 10,327,846, for the week ending
December 23d, the death-rate was 24.7. Deaths reported 4,896:
acote diseases of the respiratory organs (London) 68S, wbooping-
eongh 149, diphtheria 82, measles 81, fever 70, scarlet fever 63,
diarrhoea 31, small-poz (Birmingham 4, West Ham 2, London
and Liverpool 1 each) 8.

The death-rates ranged from 13.6 in Blackburn to 41.5 in Plym-
outh; Birmingham 26.8, Bradford 18.6, Bristol 33.6, Croydon
23.0, Hull 24.2, Leeds 17 .S, Leicester 22.6, Liverpool 31.6, London
26.3, Manchester 22.8, Newcastle-on-Tyne 19.1, Nottingham 24.4,
Sheffield 23.9, West Ham 19.3, Wolverhampton 35.3.

METEOROLOOICAL RECORD,

For the week ending January 6, in Boston, aoooidlng to ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corps:—

Baro-

Theimom-I Belative

DlreetlOD

Veloelty
of wind.

We'th'r.

S

meter

etor.

hiunldltT.

of wind.

•

Date.

a

f

§
B

1

21

i

a

a

i

a

)i

a

a

a

a

a
1

1

1

22

a

s

s

16

•4

S

1

'4

8

S

•<
8

*i

8. .31

S0.22

84

81

82

N.W.

w.

12

:o

N.

0.

.09

M.. 1

30.34

2«

28

18

gS! 64

74

W.

w.

U

6

0.

0.

T.. 2

SU.20

30

30

19

68i 66

67

S.W.

S.W.

«

16

c.

0.

W. 9

29.97

38 38

81

78, >Z

80, S.W.

S.W.

10

13

F.

c.

T.. 4

29.»3

44

44

ST

82 68

76' S.W.

S.W.

17

9

O

0.

F.. «

29.90

42

42

36

73 91

82, S.W.

N.

12

8

O.

<).

.08

8.. e

30.09

34

34

31

91 90

90

M.E.

E.

6

10

O.

N.

tr

30.0«

34

27

79

.12

*0.,filoiid7i Celcftrt F., fain U., foci U.,hU7f 8.,tiiiok7i R.,nlni T.,t]mat>
•nlBirt I>..mov. t IndleatMtnuwof mnfftll. i^ Mcui for WMk.

OFFICUL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM JANUARY 6, 1894,
TO JANUARY 12, 1894.

The extension of leave of absence granted Gaptaim Chablbs
E. WooDRcrF, assistant surgeon, U. S. A., is further extended
one month and twelve days.

Leave of absence for two months, on surgeon's certificate of
disability, with permission to leave the Department of Dakota,
is granted Fibst-Liiut. CHASLas F. Kikllbs, assistant sur-
geon, U. S. A.

FiBST-LiBUT. Edward L. Munson, assistant surgeon, U. S.
A., is relieved from duty at JeSerson Barracks, Missouri, and
will report in person to the commanding oflicer. Fort Assinni-
boine, Montana, for duty at that post.

AN ARMY MEDICAL BOARD.

An Army Medical Board will be in session at Washington,
D. C, during April, 1891, for the examination of candidates for
appointment to the Medical Corps of the United States Army, to
fill existing vacancies.

Persons desiring to present themselves for examination by
tite Board will make application to the Secretary of War, before
March 16, 18'J4, for the necessary invitation, giving the d.ite
and place of birtb, the place and State of permanent residence,
the fact of American citizenship, the name of the medical col-
lege from which they were graduated, and a record of service
in hoepital, if any, from the authorities thereof. The applica-
tion should l>e accompanied by certificates based on personal
acquaintance, from at least two reputable persons, as to his
citizenship, character and hnbits. The candidate must be be-
tween twenty-two and twenty-eight years of age, and a graduate
from a regular medical college, as evidence of which, his
diploma must be submitted to the Board.

Sacceesful candidates at the coming examination will be given
a coarse of instrnction at the next session of the Army Medical
School, beginning in November, 18i>4.

FurUter Information renrding the examinations may be ob-
tained by addressing the Surgeon-Oeneral, U. S. Army, Wash-
ington, D. C.

HARVARD MEDICAL SCHOOL.
ETBNiMa Lkctdbbs.

The next lecture will be given on Wednesday evening, Jann-
arr 21th, at 8 o'clock, by Dr. Edward Cowles. Subject, " Men-
tal Physiology." Physicians are cordially invited.

SOCIETY NOnCES.

Boston Bocistt roB Mbdical Ikfruvbm bkt. - A regnhu
meeting of the Society will be held at tbe Medical Library, No.
19 BoyTston Place, on Monday, January 22, 1894, at 8 o'cloek,

p. M.

Dr. B. C. Baldwin: " Two Cases of Syphilitic Origin; Hea-
ingitis and Progressive Mnscalar Atrophy." Discussion by
Dts. M. Prince, O. L. Walton and others.

Dr. F. W. Ooss: "Two Cases of Pulmonary Congestion and
CBdema Ocoorrlog daring Pregnancy." Discossion by Drs. E.
Reynolds, C. M. Green and others.

Dr. B. G. Brackett: "Tbe Use of Gymnastics in the Treat-
ment of Lateral Curvature." Discussion opened by Dr. E. H.
Bradford. Drs. E. M. Uartwell and C. Enebuske have been fai-
vited to be present and to take part in the discussion.

Members are kindly requested t4 show interesting cases sod
pathological specimens.

JoHH T. BowBN, M.D., Sterttarij.

SurroLX District Mbdical Socibtt. — Tbe Section for Ob-
stetrics and Diseases of Women will meet at 19 Boylstoo Place,
on Wednesday evening, January 24, 1894, at 8 o'cfock.

Dr. E. H. Stevens, of Cambridge, will read a paper on,
"Twelve Cases of obstetrical Septicssmia Seen in ConsalU-
tion." Discussion by Drs. W. T. Councilman, C. M. Oreen,
M. H. Richardson snd C. W. Townsend.

Dr. H. C. Baldwin : " Three Cases of Retroversion."

INWARD Rbymolds, M.D., ChairvMm.
Geo. H. Washbubm, M.D., Secretary.

APPOINTMENTS.

The managers of the Boston Dispensary have made the fol-
lowing appointments : HoKACB D. Arnold, M.D., assistant in
the orthoMidic department; Josbpb C. Stbduaji, M.D., assis-
tant in the department for diseases of the rectum and anas;
and F. R. Towbb, M.D., and Farrar Cobb, M.D., district phr
sicians.

RECENT DEATH.

Charlbs OuiM am Smtib, M.D., died in Chicago, 111., January
10th, aged sixty-five years. He graduated from Harvard College
In the class of 1847 and from the medical school of the Univer-
sity of Pennsylvania in 1851.

BOOKS AND PAMPHLETS RECEIVED.

Transactions of the American Ophthalmological Society,
Twenty-ninth Annual Meeting, New London, Conn., 18)d.
Hartford: Published by the Society. 1893.

Twenty-third Annual Report of the Bureaa of Statistics of
Labor, March, 1893. The Annual Statistics of Manafactnres,
1892. Boston: Wright & Potter Printing Co., State Printer*.
1893.

Essentials of Practice of Medicine. By Henry Morris, M.D.
And an Appendix on Urine Examination. Illustrated. By
Lawrence Wolff, M.D. Third edition, enlarged by some three
hundred essential formulte, selected from eminent authorities,
by Wm. M. Powell, M D. Philadelphia: W. B. Saunders. 1894.

The Art of Living in Australia. By Philip E. Mnskett, Late
Surgeon to the Sidney Hospital ; Formerly Surgeon Superinten-
dent to the New South Wales Government; Medical Superin-
tendent, Quarantine Station, Sidney, and Senior Resident Med-
ical Officer, Sidney Hospital. London, Edinburgh, Glasgow,
Melbourne, Sidney and New York: Eyre & Spottiswoode, Her
Majesty's Printers.

An American Text-book of Gynecology, Medical and Surgical,
for the use of Students and Practitioners. By Henry T. Byford,
M.D., John M. Baldy, M.D., Edwin Cragin, M.D., J. H. Ether-
idge, M.D., William Ooodell, M.D., Ho.vard A. Kelly, M O.,
Florlan Krug, M.D., E. E. Montgomery, M.D., William R.
Pryor, M.D., George M. Tuttle, M.D. Edited by J. M. Baldy,
M.D. With 360 illustrations in text and 37 colored and faalf-
tone plates. Philadelphia: W. B. Saunders. 1894.

Digitized by

Google

Ol..

CXJUX, No. 4.] BOSTOlf 3i3DlCtAL AND SUMOWAl JOVBISTAL.

81

Xectuce.

LECTURES ON SURGERT.^

BT DAVIB W. OHXBTXB, M.D.,

Pnftuor vf Swrfiery <• Banari UtavtrtUy,

XXIII.
HIP DISBA8B. — pott's DISBASK.

ITou must conceive, of coarse, that these lectures
are mere outlines ; and when you see the large books
that have been written upon these special deformities,
and reflect how much the student has got to carry in
order to learn all that is known on any given subject,
it seems to be rather discouraging ; but our business
is merely to mass together certain facts, to draw out-
lines, 80 to speak, which you can fill in afterwards ;
and, therefore, if a great many details are omitted,
you must expect that you can only get the principal
tliinga firmly fixed in year minds, and that is all that
I attempt to do.

In speaking of hip disease, I said that the earlier
symptoms of the disease were the slight limp, eversion
of the foot, apparent elongation of the limb, and that,
soon after, this gave place to more marked lameness,
drawing in of the foot, evidently inversion of the limb
with decided shortening, this marking the completed
stage of the disease. In the earlier stage of the dis-
ease the diseased condition begins in the synovial sac,
or it begins in the head of the bone. In one case it
proceeds to the pulpy degeneration of the synovial
membrane, ulcerating the cartilage and finally affect-
iog the bone ; and in the other case it starts as cheesy,
tubercular deposit in the head of the femur, destroys
the cartilage by ito contact with the disease and the
catting off of its nutrition, invades the joint, converts
it into an abscess, bursts through the joint, and finally
ends in dislocation of the bone. The child, at first a
little latne, now becomes a great deal more lame, and
shrieks out with pain at night. After a period of
great feverish excitement, a space of time follows in
which there is entire relief, and the child seems better.
This coincides with the bursting of the abscess throagh
the capsule of the joint, getting rid of the tension and
relieving the extreme symptoms of pain and fever.
Subsequently to this inversion and shortening of the
limb, another period of fever comes on, marked by
the progress of the abscess into the cellular tissue,
finally breaking through a small opening through the
skin, and this again followed by a period of relief.
The shortening and inversion which take place at this
period are due to dislocation of the head of the femur,
which occurs as perfectly on the dorsum of the ilium
as if it were in consequence of violence. In other
words, the ligaments have given way, the joiit.t being
disorganized, synovial sac ruptured, the head is pulled
out from the socket, thrown out on the dorsum by the
powerful action of the muscles, and shortening of one
aud a half to two and a half inches, with inversion of
the limb, takes place.

Subsequently to this, nature pursues one or two
courses, usually the latter. The first course would be
to try to establish a new and false joint on a new part
of the bone, the head resting on the dorsum. The
other and more common termination is to establish

* ThMe ue anvritten iMtorM printed from the steuograpben'
reports Verbal oorreotions are made In revision, bnt no rhetorieal
cliugts, Tbey were dsUrered to Um third and fourth nlMinni as
psrt «t the ngnlar eooise.

anchylosis — absolute bony anchylosis between the
diseased and wasting head of the femur and the false
socket, surrounded with osteophytic growths, on the
dorsum of the ilium. This is the asual termination.
The child who goes through all the stages of the dis-
ease from the first synovial infiammation ends with
anchylosis, with the head of the femur against the
dorsum of the ilium in the characteristic position of
dislocation of the thigh upon the dorsum of the ilium.
Sometimes, in fortunate oases, this is all the deformity
that ensues ; but in many other cases, on account of
entire neglect of treatment in keeping the limb in
the proper position while these changes are taking
place, the patient yields to the natural impulse to re-
lieve suffering by drawing up the leg. The leg, then,
is not only shortened by the disease, bnt the knee
is drawn up and shortened by the efforts of the patient.
In addition to this, powerful adduction takes place, so
that, in extreme cases, the deformity is great, the head
of the femur being dislocated and the leg shortened,
and the knee drawn up nearly in contact with the
abdomen. These are the extreme cases of deformity
which afterwards result in anchylosis, with a perfectly
useless limb; the child walking with crutches upon
one foot, and the other foot wasted, and carried
high (in the air). This is the natural course of the
disease if it pursues all its stages. It does not neces-
sarily, however, pursue all these stages, for sometimes
it becomes arrested in its progress, and then, in some
very favorable cases, the disease may be made to stop
short of dislocation, and in some cases, probably, stops
short of real abscess; or if slight abscess exists, it
does not become enough to burst the capsule, becomes
inspissated and absorbed, and the child gets well. The
head of the bone altered somewhat, but still inside the
socket, and fastened by fibrous if not bony adhesions.
That is in the mild cases.

Inasmuch as treatment, to be effectual to arrest the
disease, must be applied at a very early stage, it be-
comes important to know what are the exact diagnostic
signs of this disease when it is first beginning, for it is
in the very early stages only that we can do much
good.

Lameness, limping and pain moderately marked,
usually concealed a good deal by the child. The
hollow of the back is very peculiar. The child, laid .
down on a table, arches the back in such a way that the
hand can be readily passed under the small of the back
without touching the back. On examining such a
child and comparing the two sides, it will be found
that the first noticeable change is a loss in the sharp
contour of the line of the groin which separates the
femur from the abdomen and pelvis ; and next to this
a wasting of the glntsei muscles, due to disease, and a
consequent loss of that sharp fold which marks the
division of the lower edge of the glntsei from the pos-
terior femoral group of muscles ; in addition to this,
an increased prominence of the greater trochanter of
the femur. If now the two joints of this child are
examined, first the hip of the well side and then of the
diseased side, a marked difference will be found. In
case of a healthy femur, we may take the femur and
rotate it almost as freely as the humerus without elicit-
ing any movement on the part of the child. The
moment we touch a diseased limb we have a joint
locked by the muscles, firmly held by muscular spasm
set up at once by nature the moment we touch the
limb in order to avert the chance of suffering from

Digitized by

Google

82

SOSfOm MEDICAL AND SVttGIOAL JOVMJSTAL. [Jamcabt 25, 1894

moving the diseased joints upon each other; and al-
thongh.the child may go about with a moderate amount
of motion in these cases, yet the suddenness and com-
pleteness with which nature will lock the joint when
it is seized and attempted to be moved is a very signifi-
cant fact. We find a limited motion. We find that
the movement which we are making is moving the
pelvis as well as the femur ; that there is an andiylo-
sis which is false, and which, under ether, is shown to
be absolutely false, but which demonstrates the great
difference between the diseased and the healthy side.
I do not think that this mnscular spasm and anchylosis
is ever wanting in the well-marked case ; and that, to-
gether with the loss of the fold in the groin, flattening
of the nates, arching of the back and stiffness of the
joint, are the very early diagnostic marks of the dis-
ease itself. Direct pain by pounding about the joint
is not generally elicited, except in the advanced state.
Grating or rubbing in the joint itself is almost never
elicited unless the patient is not only etherized, but in
a very advanced stage of the disease ; and even then
it is seldom got, for the reason that, although the car-
tilages give way, and you would think the bony sur-
faces would be brought in contact, yet nature has
protected them with a bed of velvet-like granulations,
which cover all the diseased surfaces, and prevent
them from rubbing together with a crepitus like that
of diseased bone. No motion can be got without
ether, and with ether the signs of crepitus are not
usually to be found. Of course, when abscess has
taken place, when dislocation has taken place, we can
hardly mistake the disease for anything else, provided
we can eliminate any violent accident or injury, which
might have caused the dislocation or the abscess from
traumatic reasons.

Given a slow-coming-on disease with these phenom-
ena, it means hip disease, and the child will present
other signs of tuberculosis in its system, in its features,
in its nails, in the eye-lashes, in the shape of the lip
and a wasted condition, which speedily shows a state
of chronic scrofulous disease. So much for the symp-
toms and the diagnosis. If nature is left alone in the
favorable case, she produces a cure by anchylosis. If
this disease has begun early enough in life, and runs
on fast enough to complete its stages before the period
of puberty is reached, a cure by anchylosis, with entire
healing of the sinuses, and subsequently a strong limb,
are frequently the result. If, on the other hand, the
disease starts later in life, or does not conclude its
three stages by the time puberty has come on, then
nsually the disease remains permanently ; and although
partial anchylosis -may take place between the femur
and the ilium, still sinuses are apt to occur, caries is
apt to go on. The sinuses may heal and the patient
go on a few years, and then, after some sudden expos-
ure, it breaks out again from the old opening. There
is a new discharge of pus, a new attack of pain, and
new evidence of disease in the joint. This is espe-
cially the case in males after they have received a
slight sprain or injury, or exposure to cold, if they
have grown up with hip disease imperfectly cured ;
and, in females, it is quite liable to follow the condi-
tion of pregnancy, where, after childbirth, the diseased
condition is again lighted up, abscesses reopen, and the
old trouble about the joint asserts itself again.

As to the treatment we can employ. It must divide
itself into a number of stages. The most effectual in
the early stages ; the less effectual mode of treatment

in the later stages. In the early stages, the moment
these preliminary signs are detected, it is essential at
once to obey the voice of nature, which teaches as by
the muscular spasm that she is making every effort to
keep the joint at absolute rest. That is the first and
great essential of the treatment of hip disease. The
patient should go to bed and keep still. The bed,
with extension, is the first treatment of hip disease ss
soon as it is suspected ; and this should be continaed
until the nightly cries and pain and such symptoms
are gone. Frequently in these early cases six weeks in
bed will suffice to overcome all the active inflammatory
symptoms. The joint becomes almost like the other.
The patient is apparently almost relieved ; and when
that appears, then we can venture to let them get oat
of bed, and not before. The moment they get oat of
bed they must be supported by another form of exten-
sion, by a splint ; which can be applied in such a way
that the patient walks on the perineum. I will not
describe the apparatus used for this purpose. In ad-
dition to this it is of extreme usefulness to oblige the
patient for a while to go on crutches ; to put on a high
shoe on the sound foot, which forces them to keep the
sick foot up in the air. The child can get about in
that way freely ; with extension* kept up, so that the
diseased bones do not press and churn upon each other.
This mode of treatment must be continued a number
of months. When you are convinced that another
stage of the cure has arrived, you can venture next to
take off the high shoe ; keep on the splint, and allow
the patient still to go about on crutches, and put
weight on the limb. Eventually crutches are discarded
and the splint alone used ; and finally, after a long
while, several years, the patient may be trusted to go
without anything; and, if fortunate, you may have
succeeded in arresting the disease. All this treatment,
provided the disease does not go on to abscess, can be
continued without suffering, or interfering with the
health of the child. Although we consider it bad
policy to put one of these feeble children to bed and
shut them away from good air ; yet we have got to
balance this against the rest and ease and absence of
fever we shall produce by extending the limb and
keeping the joint still ; and the moment the early in-
flammatory stages are passed, the child can be got up
and out of doors, and put in the healthiest possible
circumstances. Tonics, of course, should be used to
build up the child's health.

When abscess comes on before treatment, or in spite
of treatment, extension is badly borne. When abscess
is forming, and before it has burst the capsule ; when
it is reforming and trying to make its way into the
cellular tissue ; extension produces no relief ; but pro-
duces terrible pain and has to be abandoned. In such
a state we must content ourselves by allowing the pa-
tient to lie still in bed ; apply soothing applications
to the limb ; wait for the giving way of the abscess at
some point; and try to keep the limb down with a
gentle splint into as good a position as we can while
these inflammatory changes are taking place. When
the abscess has burst, or is evacuated, extension can
be again applied. Now is the time when nature is
about to pull the bone out of the socket, and the time
when extension, if kept up vigorously, may avert this ;
or diminish the extent to which nature will get the
advantage of the bone and draw it up on the dorsum.
In these cases where abscess has formed, where dis-
location is bound to occur, extension in bed by weight

Digitized by

Google

Vox.. CXXX, No. 4.] BOSTON MEDICAL AND SUROIOAL JOURNAL.

88

and palley becomes of vastly more conBeqnence than
before. A good deal of weight should be put on ; the
parts held as still as possible; perhaps the child held
do'wn in bed by some brace or confioement; and if
the child does well ; if it does not sofFer ; if its conatitn-
tion holds ont ; anquestionably that is the best mode
of treatment for some months until the tendency to
dislocation has subsided. Then a splint can be used ;
and the treatment continued, for several years, in the
'way described. Supposing the disease has gone through
all its stages and made spontaneous cure by bony
anchylosis with the head in contact with the dorsum
of the ilium and the limb in an extremely deformed
condition, so that the foot cannot be got to the ground,
the legs cannot be separated at all, and the limb is
wasted and useless ; two alternatives present them-
selves ; one is to saw through, or cut through, this
anchylosis, or rather through the neck of the bone
below the anchylosis, to draw the limb down into place,
keep it there in splints for a considerable length of
tinte and to expect union to take place at the point of
section in the limb, in a better position ; or in some
rare cases we expect a false joint. Probably union
in the new position is the most favorable result we can
have. The only other alternative in this class of cases,
or in cases where the disease is still going on actively
with abscess and caries, great shrivelling of the limb
and uselessness — the only other alternative is amputa-
tion at the hip-joint ; which, if the patient survives it,
cares it. It takes off this mill-stone which is dragging
the patient down. Sestoration to health «nd a fat,
strong condition is usually the result. Formerly this
could hardly be thought of, on account of the immense
mortality of amputating at the hip-joint Now it may
be done with comparative safety by the new method
of amputating, where great loss of blood is avoided.
The vessels are best secured by the figare-of-8 rubber
twist held by an assistant with a firm twist which can
be tightened ; and the limB is amputated, not by the
old French method, but by the slower process of ex-
cision ; and amputating the remaining portion of the
thigh by the circular method. By this mode of operat-
ing the child loses very little blood ; and if in a suffi-
ciently strong state to stand any operation, will re-
cover promptly and get a useful life afterwards, with
a useless limb taken sway.

The other point of which I wish to speak is, as to
operative interference in the earlier stages of hip dis-
ease. That operative interference means either open-
ing abscess, and catting down and tunnelling out and
gouging the diseased bone; or doing a still more
marked operation, and endeavoring to excise the head
and neck of the femnr ; endeavoring to scrape the
acetabulum, if necessary ; and allowing the patient to
recover with what is called a false joint. The opera-
tion of excision of the head of the femnr was formerly
much more popular than now. In the first few years
I was on duty at the City Hospital I did the operation
a great many times and poblished a good many cases ;
and thought I obtained, sometimes, very excellent
results. More mature experience has proved that
these results are not so good as they first were thought
to be ; and the operation is dot to be resorted to, pro-
vided the patient can be trusted to make a spontaneous
core. The arguments used in favor of excising were
these : that you hastened the progress of cure ; took
oat the diseased portion ; gave thorough opening and
evacuation of the abscess; and made a more useful

limb and joint. The most useful limb the child with
hip disease can have is with a moderately well-placed
anchylosis with the femur fastened to the ilium. That
once firmly bridged over and solid, no subseqaent dis-
ease affects it ; and it is a strong limb which can be
ased without fear and without pain. The great de-
formity which was thought to be unavoidable, in
former times, not only from shortening, but from in-
version, is now known, as the child grows up, to be
largely overcome by sabseqaent mobility of the ankle
and knee, and of the pelvic joints at the sacrum ; so
that I have seen many of these cases where they were
not touched by the surgeon, where the patient could
walk very well indeed, and without the inversion
which was thought unavoidable. That takes away one
of the arguments in favor of excision. If you excise,
you get fully as much, if not more, shortening, than if
you trust to spontaneous care with the head of the
bone on the dorsum. Excision means two to two and
a half inches of shortening always ; and the subsequent
joint is a loose joint. It is not so reliable. It is
flexible, bat not so firm ; and it is liable to recurrent
abscesses, and to continuation of the carious processes
in the shaft of the femur. You cannot cut off much
without making a useless limb ; and there may still
exist a tuberculous focus. After excision this may
follow ; that although you have taken off all the dis-
ease of the head of the bone, still there remains a tu-
bercular condition of the acetabulum ; which after-
wards goes on to disease of the pelvic bones and
defeats your object.

In addition to this there is another argument against
great operative interference in hip-disease, and against
opening up medullary cavities ; and that is the chance
of rapid dissemination of tubercular material through-
out the system from any severe surgical operation.
Of coarse, many children with ordinary hip-disease wUl
die of tubercle in other parts of the body ; will have
tubercle in the mesenteric glands ; in the membranes
of the brain, or amyloid degeneration of the liver
and kidney ; so also they will have it in many cases
with excision ; and sometimes, to my surprise, it has
become developed with such rapidity after excision
that it seems as if the operation had started a new pro-
cess of dissemination throughout the body. It seems
to be pretty well conceded that the successful treat-
ment of hip-disease is the mechanical treatment ; that
the earlier yoo eet at it the better the result ; and that
operations should be reserved for two classes of cases ;
that operations to saw the bone and replace the limb in
a new position should be reserved for those cases where
there is anchylosis with such deformity that the patient
cannot walk or stand or use the limb in any direction ;
and that formal excision should be reserved for cases
where there is no prospect of cure by anchylosis, and
where you may do something by cutting open the parts
freely ; scooping ont the disease, and subsequently clos-
ing the wound.

In operating, yoa have an immediate mortality
which is considerable. I have seen several patients
die within the first forty-eight hours after excision;
and if you get the most perfect result, you have a
swinging joint and no more useful limb than before.
There can be hardly any doabt, I think, that while
surgery ought to interfere in advanced cases, where
the child is dying of hectic and suppuration and caries ;
and that surgery ought to interfere in cases where the
limb is so deformed that the child can neither stand nor

Digitized by

Google

84

BOSTON MEDICAL ASD SURGICAL JOVSHAL. [Janhabt 25, 1894

sit ; that in other oases it is safer and wiser to follow
the dictates of nature and seek her method of cure,
which is by anchylosis.

Early diagnosis and early treatment are the best
here, as in all acate diseases — in any disease, I do not
care what it is. In any acute disease, which is threat-
ening, you accomplish more in the first twenty-four
to forty-eight hours than in the subsequent weeks ; and
in any acute disease of bones and joints, you accom-
plish more in the first few weeks, than in the subse-
quent months.

The main thing is to keep the joint at perfect rest ;
to restore it to its natural functions very slowly indeed,
and with extreme care ; aud subsequently, if disloca-
tion aud anchylosis take place, to try to keep the limb
in as good a position as possible ; and to expect, if
these stages can be gone through with before the age
of puberty, that we shall get a permanent and sponta-
neous cure.

pott's diskase.

The next class of diseases of the joints that we shall
take up, are those of the spine ; and as we are on the
tubercular and suppurative class, I will proceed to that
which is called Pott's disease, or caries of the spine.

In the specimens passed around, it will be seen that
the disease generally begins between the bodies of the
TOrtebrsa, in the intervertebral cartilages ; that it is
distinctly a joint disease. It may proceed as an ulcera-
tion of the cartilage, finally affecting the bodies of the
vertebrsB, or may begin, occasionally, in the bodies of
the vertebrae themselves, as a tubercular deposit, af-
fecting and destroying the cartilage by cutting off its
nutrition ; then leading to erosion of the bones, and to
abscess and the deformity, humpback, which we recog-
nize as characteristic of Pott's disease of the spine.
Some authorities have gone so far as to say that caries,
or Pott's disease of the spiue is the result of injury;
that the child gets a fall which injures its back ; that
the fall produces the disease. On the other baud,
most authorities seem to be agreed chat a condition
existing beforehand of intrinsic delicacy of constitu-
tion, call it scrofulous or tuberculous or what you like,
is essential to the production of the disease ; that it
may be precipitated and brought into action by a fall ;
but that it may arise spontaneously ; that it is more
likely to arise if the child has a fall than without it ;
but that the fall is not the one sole cause of the du-
ease. One can hardly look at ordinary strong chil-
dren in the first period in which they run about, from
ten months to three years of age, and see their ex-
traordinary suppleness and activity, and the falls they
get, and the injuries they undergo without any perma-
nent result, without thinking that the mass of man-
kind, who are healthy, at that age are so built and
constructed, that ordinary injuries do not produce ca-
ries of their spines, or diseases of their hip-joints. On
the other hand, in the very delicate child, slight inju-
ries, which are thrown off and shed easily in the healthy
one, start up this preexisting tendency to inflamma-
tion of the cartilages between the vertebrse, or in the
bone. That, I believe, is the usual history. Delicacy
in the child, a slight injury or none at all, the com-
mencement of disease in the cartilages, and caries of
the vertebrte following. Unfortunately, in the early
stages, this disease is more likely to be overlooked than
hip-disease in its early stages. It is only in the very
earliest stages of this disease tbitt treatment can arrest

the diseased process ; and as time goes on treatment
becomes more and more hopeless ; and when we inter-
fere in the latter stages we should bear in mind that the
cure of nature in this disease is also wholly by anchy-
losis : anchylosis at the expense of deformity ; life at
the expense of deformity ; health at the expense of
deformity : and that a case of advanced Pott's disease
of the spine which recovers without deformity, and re-
covers straight and well, must be very rare — I mean
without some deformity. Of course, we have all de-
grees.

The cartilages ulcerate, the vertebrse break down,
their bodies drop together and melt away, ihe spines
are thrown backwards out of position, the body becomes
bent forwards, and in this fsJse position nature makes
a great effort at repair; throws out new bridges of
bone ; fastens together two adjoining vertebrs ; holds
the bones in their new position ; and finally makes a
cure with a stiff .joint, and with deformity. That is
the common result if left alone.

The early symptoms of caries of the spine are very
insidious. They are so because of the youth and ac-
tivity of the patients ; and also on account of the great
natural mobility of the spine, and the fact that pain,
or diseased conditions, are disseminated, so to speak,
up and down the long column, where one part can
compensate, to a considerable degree, for a loss of mo-
tion and usefulness in the other part of the spine.
This disease comes on generally soon after the child
begins to run about aud be active ; one and a half to
two years*of age, to three or foor years of age, is the
common time. It rarely begins after childhood. It
may begin in consequence of injury, or in consequence
of that active tubercular or scrofulous condition which
may be lighted up in the feeble child by the second
dentition, at ten to twelve years of age. It rarely be-
gins after puberty. If it does not go through its
stages and cure itself before puberty, it never gets
well, so far as my experience goes. It usually begins
as soon as the child faiiegins to run about and be active,
and is overlooked, in this way. The child complains
of being tired, and is thought to be merely fretful and
capricious, or cross. The child is unwilling to go
upstairs; it is unwillingto stoop down aud pick up
things with any celerity ; it complains of constantly
having pain in the stomach. This pain is about the
prsecordia and ensiform cartilage ; and is a transmitted
pain carried along the nerves between the ribs and to
their terminations in the centre of the body in front,
and the pain is experienced there, and is really a refiex
of a disease of the bodies of the vertebrae and about
the intervertebral foramina, from which two or three
of these pairs of nerves have made their exit. The
abdominal and prsecordial pain, pain at the pit of
the stomach, is a spinal pain; has nothing to do
with the alimentary canal. The child is tired ; unwil-
ling to make exertion ; complains of stomach-ache ;
frequently sits down to rest itself ; supports itself on
chairs and furniture ; seeks a position where it can get
its elbows on the table. A peculiar stiffness of the
gait becomes developed very early; the child walks
with care, instead of running with that perfect aban-
don seen in young children. It squares its shoulders,
differently from the ordinary loose gait of the child :
and it has a sort of military look in its whole bearing
and gait. The scapular muscles are set. The child
walks as if it were made of glass ; and this is very char-
acteristic, and unlike any other disease.

Digitized by

Google

I^ot. CXXX, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL.

85

A stiff back, square sbonlderB, dislike to stooping,

constantly supporting itself, and after a little while

spasm of the legs, legs adducted, and a totteriug gait.

If this child is examined, yon will find, probably, in

^he dorsal or lumbar region, a projection, a slight

Icnackle projecting beyond its fellows. This, however,

may exist without the other symptoms ; and when it

exists without the other symptoms, it does not mean

anything at all. You may ts^e a healthy child, strip

it, and stand it up, and if it is not very strong, you will

occasionally see one vertebra out beyond the others,

and looking as if it must have Pott's disease. You

will find on examination that this is a false sign. This

false sign is to be diagnosticated in this way. When

the projecting knuckle is the result of caries of the

TertebrsB beginning, it is immovable; can never be

thrown out of sight ; never be effaced ; and always stays,

in whatever position the child puts its back. Yon must

take this sign in connection with every other sign ; but

it is an extremely valuable diagnostic mark. But the

weakly child, with a loose, projecting spinous process,

retains the suppleness of the back, and if pricked or

pinched, hollows the back and draws the projecting

spinous process in, out of sight.

There is not much pain in the back in caries of the
vertebra. Very little pain is elicited on pressure.
Much more pain is elicited on pressure in ordinary
sprains of the back, or in an hysterical or nervous con-
dition of the spine, than in Pott's disease. You may
press on this vertebra; you cannot elicit pain or dis-
place it. It is held by the muscles, by the ribs, by
the locking of bones, in such a way that the pressure
has no effect on the diseased point There are two
modes in which yon can elicit pain. One is brutal and
dangerous ; the other is not. You are instructed by
some authorities to crush down the spine, and see if
the child will cringe. That is dangerous, because it
may produce new crushing of the vertebree already
softened. There is another way ; you may take the
child, that is, lift the child, with the hands around
the ribs, about opposite the seat of disease. The heads
of these ribs are crowded in against the diseased verte-
brsB by this effort, and while no harm is done, a scream
is almost always elicited ; while it does not hurt a
healthy child a particle. I do not attach so much im-
portance, however, to these methods, nor do I advise
you to pursue them. You can learn much by the gen-
eral symptoms, and the fact that the projection will
not disappear in the case of Pott's disease, and will
otherwise. The spasm of the limbs, tottering gait,
irritable bladder, wetting the bed at night frequently,
constipation, change in the shape of the arch in front,
so that the ribs become turned up, and the child be-
comes pigeon-breasted, the shoulders sinking more and
more ; the child ceases to grow in size ; the bead be-
comes sunken between the shoulders ; one knuckle of
the venebrsB becomes three, then becomes five, three
promiuent and two less so, until the marked and un-
mistakable bump is apparent in the back. This last
sign u much more evident in some parts of the back
than in others. In the dorsal region, where the curve
is ootvards, a prominence will show itself much more
quickly, than in the lumlMtr vertebrae, where the curve
u inward. The most marked and characteristic of all
are the deformities produced in the cervical vertebrae ;
not only from the sinking in of the head, but by the
great spasm of the muscles of the neck ; by the pecu-
liar position in which the child constantly carries

itself, and the deformity. Soon after this, signs
of abscess begin to come on, marked by hectic fever
and sweats. It is a long while before that abscess
shows itself on the surface. It is at a great depth. It
is near the centre of the body, in front of the verte-
brae. There it seeks an outlet in two ways : either
gravitates down and gets into the psoas sheath, and
emerges under Poupart's ligament, and makes a psoas
abscess : or else pushes directly backwards in the loins,
emerges from between or below the ribs, and becomes
a lumbar abscess. This abscess is essentially a cold
abscess ; full of caseous matter, and from broken-down
vertebrae. It is extremely slow, a matter of months
and years ; frequently passes away in the end, after
the child recovers by anchylosis, without breaking at
all. It is absorbed and inspissated in such a way that
the abscess finally disappears. When it does break it
is after a long period and by a minute opening, by
which nature guards the ingress of air into the sac,
and lets the pus trickle from a little valvular hole.
The abscess continues to discharge for several years.
Meanwhile the deformity of the back goes on to cure ;
reaches its limit ; ceases to press out further ; begins
to assume a fixed position ; grows more and more so
from month to month ; bony anchylosis takes place ;
the abscess dries up, and the child has recovered, at
the expense of great deformity of the back ; of de-
formity of the chest ; with strong arms and shoulders,
but weak and wasted legs.

These patients live to old age. They appear to
withstand other diseases with great vigor. When they
have Pott's disease, they rarely have anything else.
They are well and active. Moreover, in all this pecu-
liar'class of cases affecting the spine it is noticeable, I
think, that mental vigor is greater than the bodily loss;
that these children are distinguished by mental acute-
ness ; like the blind, who shut off from one sense, de-
velop all the others ; so these children, shut off from
locomotion and play, and possibly having some sort of
diseased condition of the nervous system at one part,
seem to develop a certain precocity of mind in the brain ;
so that wherever you see a humpback child, you find a
bright one, who knows a great deal, and has learned as
much by observation, as his fellows learn by education.

What shall be done in the way of treatment? Of
course treatment to do any good must be applied at a
very early stage ; and here, just as in hip disease, we
try to keep the part at rest. The treatment must be
mechanical. The child at first must be confined upon
its back on a frame, or with double extension, in
some way, so that anchylosis may take place ; or if
this is impracticable, the child must be allowed to go
about with a spinal support, in such a way as to take
off the weight of the shoulders and head from the dis-
eased part ; to support the spine on the pelvis, and
also to hold the parts at rest. The use of the frame
on which the child can be strapped and held tem-
porarily, is, I think, most useful, because this does not
necessarily confine the child to bed. It can be taken
up, turned about and kept clean, carried out of doors
and kept more or less iu the open air ; while at the
same time the spine is kept at a perfect state of rest.
On the other band, if this is not practicable, a' good
spinal support, and allowing the patient to run about,
is probably the best mode of treatment. That gives
nature a slight chance ; and a slight chance usually
suffices ; and unless an abscess has taken place, a cure
usually results by anchylosis.

Digitized by

Google

86

BOSTON MEDICAL AND SVBQIOAL JOURNAL. [Jandast 25, 1894

As to the treatment of these abscesses themselres.
Like all cold abscesses there are four methods of treat-
ment : repeated aspiration ; injection of a fluid to
promote absorption ; incision of the abscess, and fourth,
I should say, letting it alone- It may became inspis-
sated. Incise it and you run a great risk of septicse-
mia unless you can clear out and clean every pocket
and scrape the carious bone. Repeated aspirations
may be nseful, but they inevitably end in a permanent
opening throagh which the needle has been passed,
and establishing a sinus, so that you merely anticipate
nature a little, and prick an abscess, giving it exit
through a valvular hole. These abscesses must be
watched. There is no haste about them. They are
slow. You can afford to wait. If they are opened,
you must wash them out and scrape in so thorough a
manner that the development of septic absorption may
not take place ; and even then death sometimes takes
place in forty-eight hours from the shock of opening a
large pus cavity. Apparatus, if applied early, will
check the disease and hold the bones so that they will
get in good position and uniie by anchylosis. The
cure, to be perfect, must be before puberty. Abscesses
must be opened very slowly indeed. E>emember, the
best mode of treatment is to have the child secured on
a frame or splint, and taken out of doors ; kept in
warm air ; somewhere where it is constantly summer,
if possible ; or under the influence of sea air, and the
best hygienic surroundings. It is extraordinary how
much better these cases do in sea air, than in the air
of the hot, inland country.

LATSKAL CUSVATUBE OF THB SPINE.

This is very common. It is a distortion, but qpt a
disease. There is no caries, there is no affection of
the spinal canal. There is a twisting of the vertebrte
in various directions on account of the unequal action
of the muscles of the back. In consequence of this
twisting and distortion, the ribs and sternum also get
drawn out of place. One of the first signs which
attracts attention is the fact that the shoulders are not
even. Yon know how common this is in young people
and in those who are growing rapidly ; one shoulder is
a little higher than the other, preferably the left.
That is due in young subjects, however, frequently to
careless attitudes in sitting and studying and writing,
etc. But this comes on insidiously, and at the same
time the shoulder is drawn up, the hip on the opposite
side becomes pushed out, to compensate for it, so that
we have a high right shoulder and a prominent left hip,
for example. It is especially a disease of females,
though not confined to them ; probably more in females
because they have less active exercises than boys.
The curve is double, and when it inclines, for instance,
to the right side iu the upper portion of the vertebral
column, there always is what is called a curve of com-
pensation to the left in the lumbar part of the column,
in order to balance the body. These two things always
go together. In the early stages the spinal column is
flexible and movable, and by throwing the arms and
muscles in certain positions, the column can usually be
restored to shape. As time goes on, if this trouble is
not attended to, it begins to distort the cavity of the
thorax very much, so that it becomes one-sided, and
the child is also pigeon-breasted, so-called, from the
projection of the sternum, in a little while the verte-
brae begin to be rotated upon themselves, through the
action of the displaced and weakened ligaments and

muscles, and although they are not drawn apart from
each other, and although the spinal canal is never in-
fringed upon in a way to make meningitis, the resalt-
ing deformity sometimes is incurable. The vertebra
become so far twisted out of shape that it is impos-
sible to restore them.

The diagnosis and treatment both are most impor-
tant in the earliest stage ; and in that early stage the
trouble can generally be corrected by the proper use
of the muscles. One very useful exercise, which is
very simple, it to have the child drilled to carry light
weights upon the head. This may be any form of
light weight; but a very good way to teach the child
to do it is to place a little mat upon the head and set
in it a bowl of water ; and the child is instructed to
walk backwards and forwards so many times. The
slightest deviation will cause the tipping of the bowl
and the wetting of the neck, and speedily remind the
child to resume the upright position. It is a well-
known fact, that among the races of ihe tropics and
some parts of the south of Europe, the custom of
carrying heavy burdens upon the head leads to an no-
usually upright and steady form. It is not the custom
here in any form of labor ; and it is never practised in
gymnastic exercises. In addition to this, the child
should be watched carefully about sitting, studying and
sitting at school ; and instructed, if weak, to lie down
certain parts of the day in the prone position, on the
stomach and chest, and with the arms in such a posi-
tion as to bring the spine back to its natural curves.
These children are weak, and if the spine begins to
get out of place, the back muscles grow weak, and the
child droops more and more. The other exercises
which are more important are gymnastic and calisthenic
exercises, which may be done with light weights and
wands or dumb-bells and light gymnastic apparatus:
rings, pullies, chest weights, etc Care must be used
in these exercises that the weakened set of mnscles are
exercised more than those on the well side ; and the
left-arm exercise for example is especially aseful for
the child who has a curvature to the right. Take the
child and put it in different positions until you find
what will best restore the curve, and then outline the
exercises. By these, and the use of electricity and
rubbing, the recumbent position and the carrying of
weights on the head, the early cases can be cured ; but
when the disease becomes well confirmed and the
vertebrae are really twisted out of place, we must try
to force them back by the use of apparatus. This is
diflficult. Apparatus should not be used with the idea
of being the only means, or the great means of cure ;
but only in bad cases, as a support, to prevent the
parts from dropping over farther, until the muscles
can be restored by proper gymnastic exercises.

The disease leads to terrible deformity if untreated.
The child becomes dwarfed because the length of the
vertebral column is lost in these curves. And some
of the moat marked deformities you see on the street
are from this cause ; at the same time there is nothing
to interfere with the patient's living; and althongh
remaining deformed, they may remain reasonably
healthy ; but after the vertebrae are thoroughly twisted,
and the period uf puberty is passed, and the growing
age is beginning to diminish, a cure and perfect restora-
tion to the upright form is almost impossible.

Thb Royal Astronomical Society has awarded a gold
medal to Prof. S. W. Burnham, of Chicago.

Digitized by

Google

Vol. CJXXX No. 4.] BOSfON MMblOAl AHfD Sm&tOAL JOtmtfAL.

sr

(fPRgitial ^rticlej^.

FIVE CASES OF CHOLECYSTOTOMT.

BT JOHX ▼. PBBKIXS, I(.D.,
5«nior awrgtan, at. llarganei HotpUal, Kameu OUg, Mo.

Case I. Impacted gall-stone, with dropsy of the
gall-bladder and abscess formation aboat the stone;
recovery.

Mrs. B., age twenty-two, a well-deyeloped, rather
spare woman, I first saw in May, 1889, sufiering from
an intermitting fever apparently malarial in origin.
There was no history or symptoms of gall-stones
other than that she had been subject to " bilioas at-
tacks," and had been losing flesh for about eighteen
months. Early in July she had an attack of diarrhoea
with griping, apparently due to gross indiscretion in
diet. This lasted a week, at the end of which, July
16th, she had a chill, vomiting, great pain, at first all
over the abdomen, but later referred to the epigastrium
and right iliac fossa. Pulse 140, temperature 102".
About twelve hours after the chill she noticed a tumor
midway between the umbilicus and Poupart's liga-
ment. This appeared as an ill-defined, rounded, fluc-
tuating mass, slightly bulging the abdominal wall
forwarid — tense, tender and dull on percussion. The
area between it and the liver was tympanitic. Ex-
tension of the legs was painful. Five days later the
acute symptoms bad partially subsided ; she was still
vomiting, and in pun except when under the influence
of opiates.

On July 2l8t I operated. Dr. £. W. Schauflier
kindly assisting. Ether. The incision was made in
the right lioea semilunaris, from the level of the um-
bilicus, two and one-half inches downward. The peri-
toneum was much injected. The abdomen contained
considerable thin, yellow, flaky fluid. The gall-bladder
was one-quarter of an inch thick, free from adhesions,
and contained over a pint of glairy fluid of the color and
consistency of white of egg. There were three green
gall-stones, the size of large filberts, in the sac, and a
fourth firmly impacted in the cystic duct. The dis-
lodgement of this stone was followed by a flow of about
three ounces of pus into the sac. This had formed
between the stone and the liver, evidently from ulcera-
tion of the stone through the duct. I sewed the gall-
bladder into the wound, and she recovered with a
fistula which closed six weeks after the operation.
She gained flesh rapidly, and has remained perfectly
well up to the time of writing, four years after the
operation.
The points of interest in this case were :
(1) The youth of the patient, in connection with
the fact that the gall-stones had been present for
many months, if not years, as shown by their size,
their many and well-worn facets, and by the great
thickness of the wall of the much-distended gall-blad-
der. There had been no bile in the bladder for a con-
siderable time, its walls being pearly white. The
stone must have been impacted in the duct at a period
antedating the dropsy of the bladder and the subse-
quent hypertrophy of its walls. I know of no data by
which to estimate the time which such a process rep-
resents, but it is not improbable that the onset of dys-
peptic symptoms beginning eighteen months previous
to the operation marked the time of the impaction of
the stone, and that the symptoms were the result of
the continuous flow of bile into the intestine. The

chill in May, with the subsequent intermitting fever,
was probably not malarial in origin, but was an in-
stance of Charcot's hepatic intermitting fever, and
marked the beginning of the inflammatory action
around the impacted stone, which terminated in the
ulceration of the stone through the wall of the duct,
the abscess formation and the peritonitis.

(2) The degree of exactness with which this case
presented Fitz's cardinal symptoms of appendicitis.
A history of diarrhoea and griping for a week, at the
end of which occurred a sharp attack of general ab-
dominal pain, rapidly locating itself over the right iliac
fossa, followed by fever and the appearance of a tumor
within the necessary area, showed a rapid but proper
evolution of the symptoms. The position of the tumor
was higher and more internal than is seen in the ma-
jority of cases of appendicitis, yet not uncommon, for
in twenty-four cases observed by me in which the
situation of the tumor was noted there were two in
which the tumor occupied this high superficial position.
Mr. Treves ^ has called attention to the possibility of
the caecum and the-appendix lying as high, even, as
the liver, due either to the non-descent of the coecum
or an extreme mobility. He comments upon the pos-
sible difficulties of diagnosis in case of an attack of ap-
pendicitis in parts so placed. Similar difficulties arise
from the encroachment of a distended gall-bladder
upon the pelvic contents, as in the present case, and
one, more marked, related by Mr. Tait,^ in which the
enlargement was so great that he mistook it for a par^
ovarian cyst.

Cask II. Multiple gall-stones, with crystalline de-
posit in bile ; hepatic colic for twenty years ; recovery.

Ellen M., age forty, Irish, five children. Entered
St. Margaret's Hospital July 24, 1891, after a severe
attack of colic, daring which her medical attendant,
Dr. J. W. Thompson, thought several times that she
was dying. She was a slight woman, thin-visaged,
with a brownish-yellow skin, not jaundiced. She had
had repeated attacks of colic for twenty years, the at-
tacks lasting from one hour to a day, and frequently
preceded by intense jaundice. For ten years past she
has also had periodical attacks of so-called malarial
fever two or three times a year, and had been confined
to her bed for months on account of it. She was in a
state of constant distress, even when free from the
more acute attacks. Examination showed a marked
degree of tenderness over the region of the gall-
bladder, but otherwise nothing abnormal. Her urine
on two examinations was alkaline.

On July 29th I operated, with the assistance of Drs.
Gray and Bennett. Ether. The incision was made ver-
tically, two and one-half inches downward from the end
of the tenth rib. The gall-bladder was small, free from
adhesions and very elastic, so that its fundus was easily
brought into the wound. It contained bile and several
rough, black stones varying in size from a pin-head to
a pea. The bile was black, as thick as vaseline, so
ihat it had to be scooped out with a spwon, and con-
sisted for the most part of small, black, acicular crystals.
There was upward of an ounce of this material. I
sewed the fundus into the wound, and she recovered
rapidly with a fistula which did not show any tendeney
to close. At night the flow of bile was great, drench-
ing the dressings and running into the b^ ; during the
day there was scarcely any. The stools were normal.

* Surgical Treatment of TTpUltii, pace II.

* Note on a Oase of OholeoTvtotomy, Lancet, 1889, page 18M.

Digitized by

Google

«8

BOSTON UMbtOAL AH J) SVJtGiOAL JOVMHAl. [Jahdabt 25, 1894.

The failure of this fistula to close was due to the
fact that 1 had sewed the mucous membrane to the skio,
which was easily accomplished on account of the great
elasticity of the bladder, whereas in other cases I united
it to the cut edges of the peritoneum and transversalis
fascia, and found that they closed spontaneously.

A year after the primary operation the fistula still
remained open. On June 2, 1892, I made an attempt
to close it by dissectiog up the edges of the mucous
membrane and sewing the freshened surfaces together.
It held for three days, the viscus gradually becoming
distended, until there was an immense gush of bile and
the fistula was re-established. This was suggestive of
an obstruction in the ducts, but the stools continued
normal. Three weeks later I opened the original
wound and dissected most of the gall-bladder away
from the abdominal wall, leaving only a small portion
adherent. After sewing the inverted mucous mem-
brane, I united the peritoneum over it with a Lembert
suture and sewed the abdominal wound tightly. It
never reopened.

Since the removal of the contents of the gall-bladder,
now two years, she has gained much in flesh, has lost
ber sallow color, and has had neither colic nor fever.

Case III. Multiple gall-stones; contracted liver;
resection of rib ; recovery.

Frank S., age thirty-five, single, painter, American.
Admitted to St. Margaret's Hospital August 25, 1891.
He had been a soldier in the United States Army, but
was mustered out on account of frequently recurring
attacks of colic. Since 1883 he has had from two to
six attacks every year; generally became jaundiced
just before each attack ; had found that large doses of
£psom salts tended to keep the attacks away, and
always shortened them. He was a muscular, spare
man, with high color, and had been a drinker.

The question of diagnosis in this case was important.
He had had no attacks for six months previously, and
had no physical evidence of gall-stones. He had been
under the care of Dr. Walter, of Leavenworth, and
his post physician, both of whom had made a diagnosis
of gall-stones. The possibility of the colic being due
to lead was directly suggested by the man's occupa-
tion. The fact that he had changed his occupation,
and for six months had no attacks, gave it some color.
The history of a well-marked jaundice preceding the
attacks, and their comparatively short duration, seemed
to help out the diagnosis.

Granting the hepatic origin of the attacks, were
there any stones remaining in the sac ? The patient
insisted that there were. He dreaded another attack ;
and at his earnest solicitation I operated August 28,
1891. Ether. Drs. Scbauiiler and Porter were present.

A vertical incision was used, ihree inches long from
the end of the tenth rib downward. He had a long,
narrow chest, and his liver was tucked up under the
ribs so far that it was impossible to get the gall-blad-
der down to the edge of the ribs. I was obliged to
enlarge the wound upward and to resect the ninth rib,
taking out about one and one-half inches to get the
fundus into the wound. Moreover, the pitch of the
lower surface of the liver was much greater than usual
and the bladder placed well under it, so that it was
necessary to push up the lower edge and partly rotate
the liver in order to see it. On opening the gall-
bladder, I removed eight irregularly angular stones of
a bright-yellow color. With difficulty I sewed the
fundus into the peritoneum and fascia, between the

ends of the resected rib. This wound supporatsd
around the stitches. 1 believe thtf great tension apon
them was the cause. Bile flowed freely from the fis-
tula and continued for about five weeks, when thefistolt
closed, and has never reopened. He has remained in
excellent health up to the present time.

Cash IV. Multiple stones in the ducts (?); recov-
ery.

Mary D., aged twenty-uiue, American, four chil-
dreu. Entered St. Margaret's Hospital March 15,
1892. For two years past has had attacks of colic,
lasting from two to seven days ; is often jaundiced,
and has taken a great deal of morphine, under the di-
rection of her medical attendant, Dr. Drake. The
attacks recur every two to four weeks, and are accom-
panied by fever. I saw ber during one of the attacki.
The symptoms were typical. Physical examination
showed nothing beyond a very marked tenderness over
the region of the gall-bladder. She was a large, stout,
fleshy woman, with a white, pasty skin and a thick,
rigid abdominal wall.

On March 19, 1892, I operated, with the assistance
of Dr. Bennett. Ether. The same vertical incision
was used as in the preceding cases. There were many
tough adhesions about the neck of the gall-bladder,
but the fundus was free. This I opened, and found
one small stone. On passing the finger along the cys-
tic duct, however, I felt a large stone in the adherent
mass, and opened the duct from the outside after fiul-
ing to dilate a stricture from the interior of the vucus.
I removed the stoue with forceps, and then found
several more lying along the cystic and common ducts,
the latter seeming much dilated. The stones extended
beyond the reach of the finger so as to necessitate
another incisiou in the abdominal wall at right angles
to the first and parallel to the edge of the ribs. 'This
admitted the whole of my hand inside the abdomeu. I
removed eleven large, brown, faceted stones from a di-
lated pouch, the largest was three-quarters of an inch
in diameter. The line of stones extended beyond the
middle line of the body, but in what they were con-
tained— whether in the common duct, or whether they
were encysted in a pocket into which they had escaped
— 1 was unable to ascertain on account of the adhe-
sions which had matted the parts together into an un-
recognizable mass.

The sliu in the duct were closed with catgut as well
as the great depth of the wound permitted. I sewed
a fold of the omentum along the adhesions below and
the peritoneum above, to act as a shield in case an ex-
travasation of bile took place. I also put in a drain-
age-tube with its lower end close to the slita in the
duct. The fundus of the bladder I stitched to the
edges of the abdominal wound.

The operation was ditficult, long and tedioaa, and the
patient suffered from some shock after it. She rallied,
quickly, however, but vomited at intervals for a week.
Bile flowed freely from the drainage-tube and from the
wound on the day following the operation, but caused
no trouble. The wound healed rapidly, leaving a fis-
tula, which closed in about six weeks. Before this
happened, however, she had an attack of colic aiotilar
to those which she had before the operation, but milder
in character. After leaving the hospital, which she
did on the first of May, she had several of these dis-
couraging attacks. Just before an attack the wound
would reopen under tension, and an immense amount
of bile was discharged. There was much flataleinoe.

Digitized by

Google

Vox.. CXXX, No. 4.] BOS J ON MEDIO AL ASD SUBOWAL JOURNAL.

89

^Tbe attacks seemed to be occasioned either by taking
indi^restible food or making uonsual exertion. Was
there a stone left behind ? I believed that the colic
'wa.s occasioned in some way by the filling of the gall-
bladder, and the strictore at its neck associated with
the loas of the bile from the intestine. Pepsine and
hydrochloric acid seemed to relieve her immensely,
and the attacks soon ceased. She has had no attacks
during the past eighteen months, has gained thirty-five
pounds, and seems to be in perfect physical condition.
Case Y. Impacted gall-stone, with severe and pro-
longed vomiting; death from acute cedema of Inngs
due to ether (?) .

Miss M., age forty-five, single, Irish. Was first
seen in consaTtation with Dr. £. S. Bamsay, July 19,
1892. She had been sick three months. The attack
began with pain over the right hypochondriac region,
not especially suggusiive of hepatic colic, and three
weeks' later a tnmor could be felt over the region of
tbe gall-bladder. There was no history of previous
colic, janndice or vomiting. A diagnosis of gall-stones
had been made by Dr. Bamsay, and under the use of
anodynes and hot applications the tumor slowly disap-
peared. The patient seemed to improve rapidly until
the last of June, when she began to vomit, and devel-
oped a painful area in the epigastrium, just to the right
of the middle line. The pain radiated along the left edge
of the ribs and into the left shoulder — was paroxysmal
in character, not increased by food. The vomiting
and pain had steadily increased up to the time when I
saw her, and she had lost much flesh and strength.
She had been seen twice during the previous week by
another consultant, who was said to have expressed
the opinion that she had cancer of the stomach.

She was a large, fleshy woman, but very weak, and
showed plainly the effects of twenty days of vomiting.
Her respiration was short and rather quick, her pulse
90, and only fair in character. There was marked
tenderness over the area of the gall-bladder and tbe
epigastrium, but nothing like a tumor could now be felt
anywhere in this region. She had no cachexia. Her
urine and heart were both examined, but nothing ab-
normal was detected. Her lungs were not examined.
An impacted gall-stone was diagnosed and operation
advised.

On July 21st I operated, Dr. Bamsay assisting.
Ether was given by Dr. Bennett, who has given ether
for me in upwards of two hundred capital operations,
and always skilfully. I wish to mention this especially
on account of its connection with what follows.

The incision was made in the middle line of the epi-
gastrium. The viscera were adherent to each other
and to the abdominal wall by old firm adhesions which
seemed most dense toward the region of the bile-ducts,
and through which low dpwn a mass of gall-stones
could be indistinctly felt. I could detect nothing ab-
normal, however, about the stomach, other than the
adhesions at the pyloric end. I attempted to reach
the gall-bladder through the adherent viscera, but it
proved so difficult and large vessels were so numerous
that I quickly abandoned the attempt and made a
second incision directly over the fundus of the gall-
bladder. The adhesions were here more recent, and
the gall-bladder was reached with little difficulty. I
removed five brown stones, the size of peas, from
the bladder and four more impacted in the cystic duct,
which dilated easily under tbe finger. This was fortu-
nate, for it would have been impossible to have opened

the duct laterally, without the expenditure of much
time. The work up to this point had been necessarily
slow, partly on account of the very deep wound and
partly on accoant of the proximity of the large vessels
in the adherent mass, which rendered rapid work dan-
gerous. No accident happened, however, and she had
lost but little blood. During the operation, it had
been noted that her pulse was rising, and after the first
thirty minutes, was upward of 120, but strong and of
good character. Digitalin (gr. ^^,) and strychnine
(gr. 2>^) were administered at two separate times. The
respiration had been excellent, except that on one or
two occasions when tension had been made on the ad-
hesions in the middle line, the breathing stopped for a
moment but immediately began again on relaxing the
tension. The mass of adhesions was evidently at-
tached to the diaphragm. When ready to close up the
abdominal wound, the patient had been under the an-
esthetic one hour, four ounces of ether had been used
in a Clover's inhaler, and the anasthetic had been
temporarily removed for several minutes, when her
respiration suddenly became labored and pumping, her
face cyanosed and her pulse indistinguishable. Bub-
bling r&les could be plainly heard in the chest at every
breath, and frothy mucus flowed from her mouth.
She became quickly conscious in the struggle for breath.
Fresh air and nitrate of amyl relieved her temporarily.
Her pulse became much fuller and stronger, but she
remained cyanosed and the frothy mucus still bubbled
from her mouth, the respiration still being shallow and
pumping. Tbe operation was rapidly completed with-
out further anaesthetic, and the patient put to bed.
For two hours she remained cyanosed, her respiration
short and jerky, her chest bubbling, her pulse rapid
and rather tense. She then sank rapidly, and died
cyanosed two and one-half hours after the operation.
Neither the cold, clammy, pallid skin of shock nor the
pale restlessness of an internal haemorrhage were
present.

I afterwards learned that she had had at least two
similar attacks of so-called " capillary bronchitis with
hypostatic congestion and cedema" of the lungs, which
had barely disappeared two weeks before the operation,
the time when her lungs were last examined. No
worse subject for ether could have been found.

REVIEW OF A SUMMER'S WORK IN GYNECOL-
OGY AT THE BOSTON CITY HOSPITAL.*

BT JOHN O. BLAXB, X.D.

In reviewing tbe summer's work in Ward S, a few
words outside of the regular tabulated results may not
be out of place. These remarks may be considered in
the light of conclusions by the writer upon subjects
treated up to date. While they contain nothing ab-
solutely new, they at least enable him to revise previ-
ous opinions. And first a few words concerning

albxander's opebation.

This has been performed by the reader eighteen
times during the summer, usually at the City Hospital.
The results, in all but two cases, were successfal. In
one, the ligaments appeared to be in a state of fatty
degeneration. That on the left side broke off so easily
that it was not deemed expedient to undertake shorten-
ing the one on the right. In the other, there was so

> S«*d before tbe Otietetrloal 8oalet7 ot Boston, October 14, 1S9S.

Digitized by

Google

do

B08T0S MEDICAL AND SUSGIOAL JOVSNAL. [Jakvabt 25, 1894.

mach gluing together of the parts from old peritonitiB,
that it was impossible to draw the ligaments out ou
either side. A third case, at St. Elizabeth's, had a
ligament on the left side no larger than a knitting-
needle, while that on the right was rather above nor-
mal size. There was no difficulty in finding them, and
the union was perfect in every case. Not a drop of
pas formed in connection with any of these operations,
which shows that antigepsis was carefully attended to.
All proved perfect surgical successes ; and therapeutic-
ally they were equally so, relieving completely the
pain and pressure which called for their performance.
The question of permanence of relief, is often raised
by those who have not done the operation, or who for
any other reason are opposed to it. Pregnancy is
quoted as entirely destroying the benefit acquired. In
three cases, to my personal knowledge, and by careful
examination, the position of the uterus remained un-
affected by childbirth. Two were my own operations,
and a third, operated upon in Lowell, had the same
result. Dr. Davenport, in the Boston Medical and
Surgical Journal, Drs. Johnson, Kingman, Cooaut,
Bnrrage, and others whom we all know, say the same.
If it were necessary, the writer could obtain a mass of
absolutely incontrovertible testimony on this point.
So it may be considered settled, that Alexander's op-
eration neither prevents pregnancy, nor is impaired by
that condition. On the other hand, the permanent
emancipation of woman from dependence upon pes-
saries, is to my mind ample justification for the oper-
ation in cases of chronic displacement. Its simplicity,
comparative freedom from serious results, and short
period of confinement to bed, are large elements in its
favor.

DILATINO AND CUBBTTINQ.

This comparatively new fubstitnte for the old, te-
dious and unsatisfactory treatment, by laminaria tents
and .repeated applications of iodine and acids, has been
done sixty times without any unpleasant result to the
patient. It has been resorted to in chronic endometri-
tis, with or without catarrhal discharge ; in prolonged
metrorrhagia — narrowing or bending of the uterine
canal, causing sterility or severe dysmenorrhoea ; ca-
tarrhal salpingitis, where prolonged drainage was re-
quired ; and ovarian pain independent of organic change.
In cases of subinvolution it was also tried ; and whenever
it became necessary to explore the endometrium, it
was found to be the quickest and safest means. Other
conditions of the uterus, like hyperplasia, and granula-
tions, are familiar to all, and need not be enumerated.
I am prepared to speak very favorably of the results
in many of the above conditions, while but moderate
success attended others. For instance, in a case of
chronic endometritis with endocervical discharge, a
single operation will often diminish the size of the or-
gan and absolutely stop the discharge, leaving a healthy
normal uterus, and a cervix almost virginal in appear-
ance, shape and size. I have seen this result so often
that it is easy to foretell it. On the other hand, in
the relaxed, flabby, or leaky uterus, the best results
after dilating, followed the application of a mixture of
Churchill's iodine and carbolic acid, or Monsell's styp-
tic, to the endometrium, instead of packing with iodo-
form gauze. It must be borne in mind, that the con-
dition is often only a symptom of a state of constitu-
tional debility, and that local should be associated with
general treatment, Acting upon tbia hint will often

save disappointment. The same remark will apply to
all cases of pelvic inflammation oflong standing, which
are usually associated with marked debility and aniemia
— the result of pain and confinement to bed. Fintlly,
it may be necessary to repeat the operation after an
interval of two weeks or more.

In several cases I have seen marked benefit follow
a repetition of the dilating, without or with the ganze
packing, where a severe form of chronic enlargement
of the uterus existed ; or persistent salpingitis, iu which
long-continued drainage might be of advantage. The
operation may be considered in the light of a very safe
time-saver, since it enables one to accomplish in a few
weeks what in old times would have taken months.

In cases of sepsis following labor or miscarriage
which were treated in Ward S, and of which we hsd
fourteen during the summer, the results were not al-
ways successful. Two terminated fatally from lung
complications and septic pneumonia. This was after
the utmost care in treatment of the endometrium com-
bined with active general treatment, including the use
of salines. In both, the tubercular diathesis was well
marked. From observation extending over many years
of general practice, I have reached the conclusion that
there is marked susceptibility to this form of sepsis,
where the diathesis exists. I should not, because of
this, modify to any degree the thoroughness of treat-
ment, but would not feel the same confidence in its
result. On the whole, the success attending the
method has been gratifying, and justifies the remark
of Dr. Richardson, that " if we cannot always prevent
the disease, we may often cure it."

The cases of pelvic abscess were eight in number
and yielded to incision and drainage through the va-
gina. One, transferred from the medical department,
where it had been admitted by mistake, was an excep-
tion. Here the abtcess had burst into the rectum,
establishing a fistulous opening. This closed after a
time of careful, constant drainage, but the original
abscess cavity showed little tendency to contract. The
subject was a wretchedly poor one for treatment; a
confirmed inebriate, anssmic and flabby,'witboatBtrength
to set up reparative action. At the expiration of my
term of service, my advice was that she be transferred
to the surgical side for removal of diseased pelvic tis-
sue by laparotomy, as soon as her condition justified.
Dr. Bnrrili removed the left tube and ovary ; but the
patient died three days after. Another case, treated
at St Elizabeth's by suprapubic incision, contained
nearly a pint of fetid pus, got well rapidly. Two oases
of chronic inflammation of tubes and ovaries, were
transferred to the surgical service and the diseased
tissues removed successfully. These were the only
ones, which in my opinion justified resort to laparot-
omy. The number is certainly small in view of the
frequency of the operation in these days, and the num-
ber and character of cases treated.

We become more conservative as we advance in
years, and are loth to give up old and tried methods
for those more dangerous and brilliant. Hence we
prolong our efforte on the old lines, with a success that
is gratifying. Even the younger and more enthusias-
tic laparotomists are beginning to pause and consider,
whether milder means, longer continued, may not
after all be the best treatment in many forms of chronic
pelvic inflammations. I dislike to be classed as a fogy,
but will not the experience of the older naea of this
Society bear me out, when I say, that nutny of the

Digitized by

Google

Vol. CiSX No. 4] BOSTOHf MeDICAL A^i) SURGICAL JOVRHAL.

M

conditions for which laparotomy has been done of late
jears would have yielded to patient, persevering, non-
operative treatment? Dr. William Groodell, in the
lUieal Jfinot of December 9th, takes the same con-
servative view.

In the matter of malignant disease of the pelvis, the
number was twelve. None of the cases were suitable
for radical operations, with one exception. When the
body as well as the cervix was involved, and it was
reasonably sure that the disease bad affected the pelvic
glands and uterine appendages, the diseased tissue
within reach was removed by curettes, scissors, actual
cantery, and acids. By careful after-treatment, the
disease can be kept in subjection, and immunity from
psin and hsemorrhage assured. Life may be made
endurable for a considerable time — ' from one to three
years. On the whole, I cannot see that this is not as
satisfactory as the results following more radical meas-
nres. When Dr. Chadwick says that all his vaginal
hysterectomies died within a year, aad Matthew Mann
states that none were living at the end of five years,
it seems scarcely worth while to go through so much
for such doubtful gain. I am quite convinced that the
day is not far distant, when surgeons in the light of
thur experience with malignant breasts, will be satis-
fied to leave the treatment of advanced malignant dis-
ease of the uterus, to palliative measures alone.

One case had the disease at the fundus, with no in-
dications at the cervix; uterus enlarged, with only
slight local symptoms calling for treatment ; but rapidly
ninning down, and with marked cachexia. The pa-
tient was not treated locally farther than to explore
sod ascertain the nature and extent of the disease.
She was put upon supporting and alleviating treatment,
sent home, and is stUl living.

A very rare form of epithelial disease of the vulva,
invading to some extent the vaginal walls, was sent in
by Dr. Edward Beynolds. There seemed to be no
infection of the pelvic glands. The disease was thor-
ooghly removed and but little deformity of the parts
resolted. Tiaie alone will determine whether the dis-
ease returns.

As will be seen, I have commented briefly on some
of the operative cases ; and while there is nothing very
new in the report of such a service, there is confirm-
stion of the success of old methods, which, to the older
members at least, may afford satisfaction.

The following are the tabulated results prepared by
Dr. S. £. Courtney, my very efficient senior house-
officer, with the records of two cases which seemed of
•pedal interest to him :

Ca8> L a. R., single, twenty-three years of aee. Dys-
nenorriioea since the establishment of menstruation. £x-
unination showed the cervix to be acutely anteflexed, with
itenasii of internal o« and some endocervicitis. Extremely
Mrrous. The uterine canal was dilated, curetted and
pseked with iodoform gauze. The gauze was removed
iron the uterus oo the sixth day, and the patient discharged
OS the tenth day. Four months after operation the patient
Kports that she has no dysmenorrhcea, and has almost
tstirely recovered from the previously existing nervous
■poptoms.

Cask II. A young married woman ; always suffered
Iraia dysmenorrhcea. She became subject to epileptic
•einiRs immediately after her marriaee. These attacks
often numbered twelve a day, and had continued for six
■ODtha In order to straighten and enlarge the uterine
<*ssl, it was thoroughly dilated and packed with iodoform
After the usutu period had elapsed, the gauze was

removed. Subsequent examination some weeks after, with
a view to inserting a stem-pessary, showed that the uterine
canal freely admitted a large-size sound, and did not seem
to present more than the ordinary curve of a virginal uterus.
Patient has not had an epileptic seizure since the operation,
and has steadily improved in health and strength. She
has menstruated once since the operation was performed,
with but slight pain. In view of the fact that the epileptic
seizures apparently resulted from an aggravation of the
dysmenorrnoea resulting from marriage, it is only reason-
able to hope that the result will be permanent.

Boston Citv Hospital.
Gtsa coLOOicAL Opkbatioks bt Db. Jobm O. Blakb, Doauia

HIS FlTK MOBTBS' SBBVICE.
BUating tmd fWartttbug, SO ease*.

Endometritis, andoewTloltts, salpingitis, ete 4S

StmiMli -Sterility 12

Anteflexion of cerriz fi

Two euei of (slplngitls transferred to Sargioal Department
for laparotomy ; tnbea and ovaries removed ; dlaotaarged
well.
OperaMo* on Laeauttd Cervix, 19 oaaas.
OpercUiomm Lactrated Perinewn, 18 caaae.

One operation bad to be repeated.

Cervix and perinenm on same patient S

Akxander't Optration, 18 oases.

Right ligament ootfoond In two case*.

Ligaments small and adbering In the ring in one ease, failure.

Ligaments undergoing fatty degeneration In one case, failure.

The moet latlafaetory result was an Alexander and pertoenm
operation for oomplete prolapse o( the uterus.

Sixteen discharged well.
Septlemmla, li oases.

Six died and eight were dlsoharged well.
Cancer, 12 oases.

Two died, nine relieved, and one, sarooma of rulva, dls-
oharged well.
Pelvic Abeeeu, aspirated and drained by tube per vagina, 8 eases.

Three disoiuurged well and Ave relieved.
Vulvo-Taginal Abeeeu,! viMea,

All dlsoharged well. .

Cftoe«lt*,t cases.

AH faunres In as muoh as stitohes gave way.

PUnM$,be»Mat.

Removed in two oases only.
Pelvic Hmmalocelee, S ease*.

One died and two relieved.
Vrmnia of Pregnrnieii, S eases.

All died.

Clittital a>epaitmeiit.

A PERSONAL EXPERIENCE WITH SMALL-POX.

BT H. WABXBII WHITX, M.D.

Thibtebk years ago, amidst the pleasantest mem-
ories of my life, there happened an event which in
comparison was like a horrible nightmare.

After graduation in June, 1880, I had the good for-
tune to spend a year abroad. I had enjoyed immensely
the sights and sounds of Berlin, Dresden and Vienna.
I had been up the Rhine and down the Danube, as I
had never expected to do. My dreams of European
travel had become happy realities ; and at last I had
spent some months in Paris, the most enjoyable ex-
perience of them all.

Here I had applied myself to medical studies more
thoroughly than elsewhere. I had taken courses and
clinics with Jaccoud, Charcot, Fournier, Parrot and
Latteux. The remembrance of those days is delight-
ful. I enjoyed and profited much during that winter
of 1880-81. But amidst that success and happiness I
was to have a Waterloo indeed !

During the last week in February, while making a
hospital visit in a children's hospital with Professor
Parrot, I remember for the first dme in my experi-
ence seeing three or four cues of variola that for some
reason had been isolated and cared for in a distant
wing of the hospital. It was nearly noon at the end

Digitized by

Google

^i

iOStOS MiDlOAl AlTD SUttOtOAL J0V6SAL [;rAHUART 25, 1894.

of a long visit. I had only a roll and a bowl of choco-
late for breakfast those mornings, and was already feel-
ing the need of my breakfast with a fork, as they call
it Before entering these apartments Parrot turned
to the fifteen or twenty students and asked us if we
were vaccinated, for if we were not, he would not
advise us to continne the visit. Three or four tnrned
back, but I went in with the others : for it occurred to
me /had no need to fear this contagion. I had been
successfully vaccinated when a baby and again when
aboat fifteen years old ; and an attempt at revaccina-
tion when in the last year in the medical school had
been unsuccessful. I considered myself to have im-
munity from the disease, although this last time re-
ferred to I was vaccinated by a fellow-student with
virus which I have since suspected was inerL

The cases under Parrot's care were all children ;
his prognosis very grave. Their appearance was
lideming ; and the stench-laden atmosphere I had good
reason to remember again in about two weeks. This
peculiar odor, once thoroughly appreciated, I believe
can never be forgotten. It is like nothing else.

This exposure to variola was a positive one, occur-
ring but once and lasting not over fifteen minutes. I
handled neither patient nor anything in the room, but
simply inhaled this heavily-charged atmosphere while
tired and in a hungry condition. This was the first
part of the last week in February. My medical course
ended with the month of February ; and so promptly on
March Ist, I left Paris at 7 x. M., and ate dinner at
the Bedford Hotel, London, at 6.80 p. m. of the same
day. I felt particularly well ; and while crossing the
English Channel I was not in the least seasick, although
the passage that day was more than ordinarily rough.

I came to London on Tuesday, settled quickly in
my new quarters, arranged to attend a surgical clinic
of Lister's ; and Friday made my first visit with bim
at King's College Hospital. On Saturday I felt un-
usually tired and weak, and Saturday night was in
alternate fever, sweats and chills. It was about ten
days now since my exposure, which occasion had wholly
passed from my mind. Sunday the 6th, was quite
sick ; a miserable feeling throat ; sore and lame all
over; something like an approaching tonsillitis, to
which I had ever been very liable. Hoping to im-
prove by going out, I rode to Bloomsbnry Chapel.
Did not enjoy my trip oat ; nor the sermon, although
pronounced by good judges to be a most excellent one.
My headache increased, with dizzy, giddy sensations.
Glad to get back to the hotel and stay in the rest of
the day. In the afternoon I noticed an erythema on
the back of my hands and wrists, which increased.
Complete anorexia. Temperature 101^°. In bed I
felt better ; and although my sleep was disturbed and
uneasy, I worried through the night without calling
for help.

Monday morning I was much worse; could not
possibly suffer more backache and headache ; tried to
sit up ; vomited. Temperature 104". Erythema on
hands and face, chest and abdomen now very marked.
Called the landlord ; and he, frightened at my condi-
tion, called his physician. Dr. Hall. In a careful,
deliberate fashion he diagnosed scarlet fever as the
trouble we had to deal with. He called my attention
to the fact that a hotel was no place to be sick in (I
should have known better, of course). Said I most
go at once to the London Fever Hospital ; that it
would take all day to get an ambulance, and that the

law forbade using a public cab. It was " onJg a mile
away," and I most walk! Somehow — I never re-
membered just how — I hastily packed and locked my
luggage, carelessly dressed, and walked (with Dr. Hall'i
help) through the streets to the hospital. He dropped
me at the door, and I dropped after I got inside. Wai
given a private room and special nurse, in honor of my
youth and profession. Temperature after entrance
105". Dr. Smith, of the staff, diagnosed scarlet fever.
The fact that I had never had it and that it was very
prevalent just then in London made it seem quite
likely. Although variola later became very oommoD
in the city, just yet it had not become epidemic.

Tuesday. Still sore-throat, headache and high fever.
The rash did not act typically, and some doubts were
expressed as to its being scarlet fever. It had faded
instead of increasing. Some one suggested vsriola.
That day I remember how aggravating and unneces-
sary the noises of a hospital seemed to me. People
talked incessantly ; dishes rattled ; doors slammed ; ward
trucks squeaked excruciatingly, and the wheels rattled
miserably. I vowed, if I got well, I'd buy some lubri-
cating oU and rubber tires, aud present them to this
hospital. I would tell them how much a poor devil
suffered from noises which could be prevented.

Wednesday morning, before light, I detected about
myself that odor which was unmistakable. I recognized
the flavor of two weeks ago. I could not wait for
daylight. I called the nurse, and told her I had no
doubt now what I had, and to inform the house-officer
at once that I had small-pox. She hastened away with-
out a word. I put my hand to my face, and felt what
seemed like a lot of bird-shot just under the skin of
the forehead along the edge of my hair. The house-
officer came at once, and confirmed my diagnosis. You
can scarcely guess what chagrin, confusion and dis-
tress I caused in that hospital ; and to make matters
worse they had to wait all day long till evening for the
small-pox ambulance to come for me. They would
have got rid of me before, but they did not dare to use
their own ambulance. I remember that ride very well.
Their small-poz ambnlance was constructed something
like an American hearse. The patient was wrapped
in blankets, shoved in, and the doors shot. It was
like attending your own funeral. Lying in there uid
easily looking out the glass sides at the happy, healthy
people walking the sidewalks, made me feel extremely
miserable and unfortunate.

Thus I entered Higbgate Small-Pox Hospital on
the evening of Wednesday, March 9th, an unwelcome
encumbrance. The first night there, 1 believe, was
the most terrible in my whole experience. I arrived
late, and was put into the centre of a long ward with
twenty or thirty others. A howling snow-storm out-
side. There were large ventilators over each bed
(like those in dissecting-rooms), and they were so wide
open I felt the snow sift in upon my face during the
night. The patient in the bed to my right was in a
howling delirium all night long, but quieted down and
died about daylight. Another died across the room,
three beds away, on my left. There were no screens
to put around them. There were only a few private
rooms, and those were occupied by women. They
changed my bed to the end of the room next day,
where, by turning to the wall, I could avoid seeing the
misery around me. There was no attention worth
calling nursing, as good nurses would not accept such
a position. The nourishment dealt around was thick

Digitized by

Google

I^ox.. CXXX, No. 4] BOSTON MSDlOAl ASD SVttQtOAL JOVMNAL.

93

slaba of bread and batter and a bowl of tea. My moath
and throat were very sore, and I could not eat anything
like this. After much begging I got some millc For
three days after that I had a wild delirium, more, I
expect, from the excitement and shock of my experience
than from the intensity of the disease, though the attend-
ing doctor said I was very sick and was part of the time
in a camisole. My face was swollen and painful, and
my fever ran high. I would not stay in bed. Was
continaally trying to extinguish imaginary fires, rescu-
ing myself and bedding from the blase. Once they
found me with a handkerchief tied tightly around my
' neck, and I asked for a short stick to thrust under it
and twist it to strangle ipyself. All such fine plans
were prevented, and full doses of chloral and bromide
taken after much persuasion. Some dim recollection
of all this 1 have still — the most horrible remem-
brance of my life.

I saw myself for the first time on the following
Monday (clothed in my right mind). Nobody would
recognize me. It appeared as if my face had been
bornt with steam or powder. I would not know my-
self. I feebly asked the doctor if this was a case of
varioloid. I remember how he laughed. I tried to
laugh, but it hurt me too much. I looked at my chart,
which he showed me — " Discrete variola vera. This
I felt had been the trae article sure enough. There
was a fee of four guineas, I found out, due the hospital
for all this elegant entertainment ; and I got the land-
, lord to advance the same on the strength of my lug-
I gsgo still in his possession.

Tuesday, Dr. Smith, of the London Fever Hospital,
sent me some oranges, grapes and flowers ; but my
I mouth was too sore to eat the fruit, and somebody
stole my flowers.

I went into the convalescent ward on March 16th.
My face, itching unbearably, was relieved on applica-
tion of carbolized vaseline. My companions here
were very dull and stupid. The weather outside was
stormy most of the time, the epidemic increased, and
the hospital was crowded to the doors. Diet : boiled
' mutton and ale, t. i. d. Later 1 used to make the
rounds with Dr. Gronde (as my strength improved).
I remember one remarkable case of hsemorrhagic
small-pox iu an old man. This man entered strongly
pitted. It was his third attack. His skin was pur-
plish. He was bleeding from every orifice of his body
— mouth, nose, ears, bladder, rectum and stomach —
and very conscious of hu serious condition. He never
broke out fairly before he bled to death. Deaths oc-
curred daily. The mortality of confluent cases was
nearly fifty per cent; of the discrete cases, six per
cent. It was very dull and lonesome to me ; and it
was too sickening for me to have much interest in it
all, though the doctor did all he could for me. The
horror and distress of a severe confiuent case must
be seen to be appreciated, — the phlegmonous face,
sffolleu beyond possibility of recognition, swollen so
that the eyes cannot be opened ; the tongue protrud-
ing, so much swollen it cannot be held in the month ;
the foetid breath, drawn with great dilficuUy and much
noise. Happily such patients are comatose, muttering
or groaning in a typhoid-like condition, finally getting
exhausted and giving up the straggle, or wonderfully
living on, day after day, without nourishment, and
finally recovering (in some cases most miraculously),
but carrying the scars of the terrible struggle as long
as they live. I was particularly sorry to lose the

night nurse, who had been very kind to me. She
was found to drink the brandy ordered for the pa-
tients. I knew before that she had been drinking
by the odor ; but I was not surprised, considering
what a place that was to work in. There was often
in the night a confusion of howls from the long ward.
Poor lunatics ! I could scarcely believe that a few
days before I was as delirious and making as much
confusion as any of them. Many hundred patients
passed through that course and graduated into the con-
valescent wards while the epidemic raged ; but many
others went the way to the dead-house.

On March 22d I took dinner once more like a civil-
ized being, this being down-stairs with Dr. Goude, in
his private apartments. 1 told him how poorly his
patients were being nursed. He seemed to be much
surprised and shocked to hear of it. I never knew if
it was changed, or if it could have been ; and in writ-
ing this I fully realize how much easier it is to point
out defects than to remedy them.

On March 23d, after a thorough carbolic bath aud
baking of my clothes (letters sent out were thus
baked), I was given my liberty once more. Although
too weak to walk then, in about a week I was thor-
oughly convalescent. Always ansemic, I was extremely .
so for a month afterwards ; my breath short and pulse
rapid on the least exertion. 1 lost ten pounds. The
only special treatment I received was sedatives for
nervous symptoms ; cold, wet cloths to the face, and
carbolic ointments later ; ice for the throat ; and stimu-
lants freely during convalescence.

I went later to the London Fever Hospital, and gave
them £1. 1«. for their trouble (I hope they oiled the
truck-wheels), and paid £8. 8(. Qd. to the landlord to
cleanse my rooms at the Bedford and fumigate them
properly, a nice little sum of between eight and nine
guineas in all for my rather unusual clinical experience.

I could not help learning a few things about variola
during this vivid experience which may be interesting
just now :

(1) The feeble protection of old vaccinations.

(2) Importance of successful re-vaccination.

(8) That a previous attack or vaccination give
about equal protection.

(4) " Varioloid " is not only a foolish, bat a dan-
gerous superstition.

(5) The iutense virulence of variola.

(6) The long incubation.

(7) DifBoulty of diagnosis.

(8) Sapidity of the disease and its stages.

(9) Thb very general eruption on inner maoous
and serous membranes, alimentary tract from mouth
to anas, trachea, bronchi, urethra, vagina, conjunctiva.

(10) Horror of the disease because of the isolation
necessary, the pain and odor and delirium, and the
poor nursing generally.

REPORT OF TWO PREGNANCIES FOLLOWING
A LAPAROTOMY.!

BT K. F. CHAKDLKB, M.I>., MBDFOBD, MASS.

OoTOBBB 11, 1892, I was called to see Mrs. G.,
who gave me the following history : Age thirty-six.
Family history not remarkable. Up to the time of

> B*ad bj iBTlution twfwra the Obstetrieal Sooletr of Boston,
Oetobor 14, 18S8.

Digitized by

GoogL^.

94

BOSTON MBDIOAL AND 8UB6I0AL JOUBNAL.

[Jamcabt Si, 1894

her marriage, iu 1880, she considered herself well,
though not specially strong. Abont a year later, or in
1881, she began to have trouble which led her to cod-
•nit Dr. C. M. Green. She was under bis oare antil
the fall of 1883, when she went to Dr. John Homans,
who performed laparotomy Kovember 21 st, removing
a cyst of the broad ligament. For four years after the
operation her general condition was not good. She
coald not ride or walk any distance ; even slight exer-
tion caused fatigue. The catamenia were irregular,
seldom more than three weeks apart, profuse but with-
out mach pain. In 1887 she began to improve in
health ; and iu the latter part of that year she became
pregnant. Before a diagnosis of pregnancy could be
made a mucous polypus was removed from the cervix
by Dr. C. M. Green, April 27, 1888. Daring this
pregnancy, which was ended by miscarriage between
the fourth and fifth months, her condition was appar-
ently normal. She had the usual morning sickness,
but nothing more. She had little or no unusual dis-
comfort, and her general health steadily improved.
So far as I have been able to learn, the cause of the
miscarriage could not be explained, though the patient
thought she had done more walking than usual, and
felt that that may have been the cause. After the
miscarriage her health was better than before; but
even then she was not very strong, though she suffered
from no particular ailment. If she became overtired
or run down she was likely to have stomach trouble —
food causing some distress and occasional vomiting.
During June and July, 1892, she was not as well as usual.

From August 1st to the 8th, she was unwell as
usual ; and this proved to be the last regular period
before a very trying pregnancy, though on August
28th she began to have some irregular flowing, which
continued at intervals until September 14th, when an
examination made by Dr. C. M. Green led to the dis-
covery and removal of a cervical mucous polypus,
after which the flowing soon ceased.

Three weeks after her last regular period she began
to be troubled with nausea and vomiting, which soon
became so bad as to interfere with her taking and re-
taining proper nourishment. She found she was
losing flesh and strength and on October 10th I was
called to see her. At this time she was fairly well
nourished, though rather anemic. Physical examina-
tion showed nothing remarkable. Temperature was
normal and remained so all the time. Urine examined
at that time, and frequently during the pregnancy,
was always found to be normal. Bowels were con-
stipated. Uterus could not be felt above the symphisis.
At this time nausea was constant, and she was able to
retain very little nourishment. After October 12th
she was kept in bed, trying different articles of diet
and various medicines to overcome the vomiting. We
met with little success, however, and she continued to
lose flesh and strength, though not as rapidly as one
would have expected considering the small amount of
nourishment she was able to retain.

On November 20th she was seen by Dr. Green,
and a diagnosis of pregnancy was made. A few days
later all vomiting ceased, and she was able to retain
food without discomfort. Thinking the miscarriage
five years previous may have been due to adhesions,
resulting from the laparotomy, preventing the uterus
from rising as it naturally would, the patient was kept
in bed until January 1, 1893, or until the end of the
fifth month. After this she was up and abont her

room, but did not go down stairs until March 15th.
At this time she was in a very good condition, having
gained rapidly as soon as she was able to retun her
food. She continued to take excellent care of herself,
avoiding any exertion, going over the stairs only once
a day and occasionally walking out on the veranda.

On the morning of April 2d I was called in haste
to see her. I found her suffering from frequent severe
abdominal pains, and with each pain the uterus could
be felt to contract Vaginal examination showed the
uterus to be high in the pelvis, the cervix not taken
up and the os not dilated. Foetal heart distinctly
heard on the left side. Sufficient morphine was given
to check the pain at that time ; but during the next
two days the pains would return as soon as the effect
of the morphine would wear off, and more had to be
taken. April 5th she was free from pain, but nausea
and vomiting were more troublesome than ever. She
was not able to retain any food, and suffered con-
stantly from nausea, whether taking food or not.

This condition of things persisting, in spite of efforts
made to check it, Dr. Green was asked to see the case
again April 10^. He found the uterus low in the
pelvis, the head presenting, os admitting finger-tip.
He believed we had better delay any operative inter-
ference for the present, in the meantime trying rectal
feeding, and keeping close watch of the case.

On April 25ih, or at the end of the eighth month,
the mother's condition was such that further delay
was thought unadvisable in the interest of both mother
and child. Ether was given, and Dr. Green did manual
dilatation, turning the child and delivering without
any great difficulty and in a short space of time. After
the mother had recovered from the ether there was
no more vomiting, and her convalescence was uninter-
rupted. The child, a girl, appeared to be in very good
condition when born, and did very well for twenty-
four or thirty-six hours, when it began to have con-
vulsions ; and it died on the third day.

The points of special interest in this case, as they
occur to me, are, the history of two pregnancies after
an operation which changed the condition of the liga-
mentai which hold the uterus in place, and probably
left it less free to rise above the brim of the pelvis ;
the coincidence of a cervical mucous polypus appearing
early in each pregnancy ; and the obstinate vomiting
which came on as soon as there was any unusual press-
ure in the cavity of the pelvis, and remained until that
pressure was removed.

a^eHicAl l^ogrejfjf.

REPORT ON DISEASES OF THE NERVOUS
SYSTEM.

BT PHIUP COOMBS KSAPP, AJI., IC.D.

(Conoluded from No. S, page SB.)
CBBBBBAL IMFANTILB DIPLEOLA..

Fkeud '*■" unites under the above heading four types
of cerebral disease: (1) General rigidity of cerebral
origin (Little's disease) ; (2) Paraple^^c rigidity
(spasmodic tabes dorsalis of children); (8) Double
spastic hemiplegia ; (4) Congenital general chorea
and double athetosis. Greneral rigidity of cerebral
origin has two fundamental characters : the lower ex-
tremities are much more affected than the upper, and
» Berne nenrologitae, 30 April, 1883.

Digitized by

Google

Vol. CXXX, No. 4] BOSTON MEDICAL AND 8US6I0AL JOURNAL.

96

the phenomena of contracture exceed those of paralj-
818. It is also digtingaighed by a slowing and diminn-
tion of the cerebral inflaz on the co-ordinated actions
of standing, walking and articnlate speech, and by a
varying degree of mental impairment. Strabismus is
common ; atrophy is absent ; conTolsions are frequent
■oon after birth, but they do not continue. The affec-
tion remains stationary with a tendency to improve-
ment. Many writers consider double hemiplegia as
closely allied to this, but others make a sharp distinc-
tion. Paraplegic rigidity, once thought to be purely
of spinal origin, is shown, by the occurrence of strabis-
mus and mental impairment, to be allied to general
rigidity, but to be of a less severe type. Both of
them are regarded by Freud as related and connected
by many transition forms. The general form may
improve until there is only a trace of rigidity in the
arms, when the case resembles the paraplegic form.
In other respects they are very much alike. In the
general form there may be more or less paralysis, or a
facial paresis, which forms a link with the cases of
double spastic hemiplegia where paralysis predomi-
nates, and these transition cases are much more often
seen. Cases of diplegia may also show transitions to-
ward paraplegic rigidity. To produce double hemi-
plegic intra-cerebral or deep bilateral lesions are neces-
sary, but superficial lesions, especially near the median
fissure suffice for general or paraplegic rigidity; and
the meningeal hsemorrhages of difficult labor afford
precisely the lesions required. Congenital chorea and
double athetosis may be classed with the cerebral di-
plegias, for in ordinary spastic hemiplegia it is not nn
usual to see similar motor troubles develop after
paralysis, post-hemiplegic chorea. In other cases the
chorea is manifest from the first, choreic hemiparesis.
If this be the case in hemiplegia it must also be the case
in double hemiplegia. Chorea and athetosis are also
found in cases of rigidity. Consequently Freud would
class them all under the one head of cerebral diplegia.
Difficult labor is an important etiological factor in all
four forms, premature birth only iu the cases of gen-
eral or paraplegic rigidity. Rigidity may also follow
acute infectious diseases. Freud rejects classifications
of the causes, and thinks it by no means easy to say,
in cases where the symptoms do not manifest them-
selves antil a year or two after birth, that the trouble
was not of congenital origin. Many children are born
before term or after difficult labor, but they have not
diplegia, hence there must be a predisposing factor be-
side the accidental factor of traumatism. In syphilitic
cases this factor may be regarded as the fragility of the
blood-vessels, hence it is not illogical to suppose a similar
state of the vessels in debilitated or cachectic children.
It is a curious and unexplained fact that epilepsy is
common in double hemiplegia and spastic hemiplegia,
but extremely rare in general rigidity and athetosis.

EPILKPBT.

Hohn^ regards as epileptic cases of sudden and
periodic losses of consciousness, to which are generally
joined convulsions of a definite type, without any notar
ble modification of the central nervous system visible
to the naked eye. In three cases which he has studied
microscopically, he found an increase of the cells of
the neuroglia, a thickening of their ramifications, an
absorption of the intercellular substance, a considerable
growth of new vessels and a weakening of the nervous
u Mordlak. madie. Arklv. No. tB, IStS.

net-work. As a rule these changes are seen chiefiy on
the lateral face of the convolutions. In one case he
noted a colloid degeneration of the ganglion cells, evi-
dently connected with death during an attack. The
insula and the gyri recti and fornicati were most
affected. In the internal capsule was seen a degen-
eration of the fibres coming from the hemispheres,
especially the motor fibres. In the pons, medulla and
cord the pyramidal fibres were partly degenerated.
Epileptic attacks majf be explained by an irritation of
the cortex alone, but a generalization of the attack
demands that the bulbar and spinal fibres be equally
involved. Hohn believes that the attack itself is dne
to a vaso-motor process, in the course of which venous
stasis with acute oedema is produced in the central
nervons system.

Fonrnier" recognizes as occurring in syphilis a
form of epilepsy very different from what is ordinarily
termed syphilitic epilepsy, or rather the epileptic form
of cerebral syphilis. This form of epilepsy appears
as an isolated symptom, without any other general or
cerebral phenomena, and it continues under this form
without association with other marked phenomena. It
lasts a long time, it is neither cured nor checked by
antisyphilitic remedies, but it is relieved, although not
cured, by the bromides. True syphilitic epilepsy, on
the contrary, is associated with other cerebral phenom-
ena, rapidly assumes the symptoms of a specific en-
cephalopathy, progresses more or less rapidly toward
a cure or toward a fatal termination, and is very often
benefited by antisyphilitic remedies. He cites a case
in which, twenty years after infection, at the age of
forty-five, epilepsy developed and continued without
other complication for eleven years. Antisyphilitic
treatment was useless, but bromides checked the fre-
quency of the attacks, and was the only thing that did
any good. In this form of epilepsy the invasion is
sudden, unexpected and spontaneous ; it comes on in
full health, without prodromes or apparent cause. It
usually begins with an attack of grand mal, bat later
grand and petit mat may be associated. The attacks
of grand mal are like those of ordinary epilepsy, bnt
they are not very frequent, the attacks of petit mal are
much more frequent and may increase in frequency,
even replacing the attacks of grand mal. This form
of epilepsy occurs in the tertiary stages of syphilis.
Fournier thinks it due to syphilis on account of the
clear previous history, the advanced age at which the
convulsions begin, by the absence of any other cause,
and by the occasional co-existence of true syphilitic
accidents. It differs from syphilitic epilepsy in that it
is never partial, never is associated with other cere-
bral symptoms, lasts for years and never yields to anti-
syphilitic treatment. It is derived from syphilis, but,
like tabes, it has not the nature or the essence of a
syphilitic manifestation. Hence Fournier would call
it "parasyphilitic epilepsy." Mendel's investigations,
showing that epilepsy is not very infrequent after
thirty in non-syphilitic subjects, make it doubtful
whether Fournier's cases are really to be regarded as
a special type.

EpiUptia tarda. — It is a well-recognized fact that
the great majority of cases of epilepsy begin before
the age of twenty, and a number of years ago Delany
classed cases beginning after the age of thirty as " «pt-
kpiia tarda." Mendel," after a careful exclusion of

>' Berne nearologlqae, 30 Xorember, 1893.

» Deateohe mediolniielie Woebeoaehrlf t, 9 liorember, 1893.

Digitized by

Google

96

BOSTON MEDICAL AND SUBGJOAL JOUSNAL. [Jaruabt 25, 1894

•11 eu«8 simnlating epilApay, has studied 904 cases
oomiDg under his own obserration. Contrary to the
statements of Reynolds and Nothnagel, he found the
male sex more disposed to the disease, bbh of his cases
occurring in men. The largest number of cases begin
between the ages of ten and fifteen, and orer two-
thirds, 623, before the age of twenty. From the ace
of twenty the frequency of epilepsy becomes distinctly
less, bat in the de«ule from thirty to forty no less than
99 oases began, so that Mendel justly takes exception
to regarding the onset of epilepsy during that period
as particularly remarkable, and only for the cases
which begin after the age of forty would he admit the
term " epilepsia tarda." After the age of forty epi-
lepsy becomes much less frequent, only 53 cases begin-
ning after that age, and only three cases) one man and
two women) occurring after the age of sixty, the man
being sixty-one, and the women sixty-two and sixty-
three. Mendel's figures agree with die statements of
Bennett and Growers that epilepsia tarda is commoner
in men, 38 cases occurring after the age of forty in
men, and 15 in women ; 6.8 per cent of all cases of
epilepsy in men may be classed as epilepsia tarda, and
4.8 per cent, of all cases in women. Delany found
hereditary taint in one-half of the cases occurring
after the age of thirty. Mendel accepts this view, for
in one-fourth of his cases, where the history of any
hereditary taint was hard to be obtained, owing to the
social condition and the advanced age of the patients,
he found clear evidence of such a taint. The direct
exciting causes of epilepsia tarda seem to be the same
as those of epilepsy of early life, fright and trauma
playing distinct parts. In all Mendel's cases syphilis
was excluded ; hence he disputes SeeligmUlIer's claim
that syphilis is to be suspected in all oases of epilepsy
oooarring after the age of twenty. Arthritis, which
Charcot and Delany thought had some relation to epi-
lepsia tarda, was never observed. Neither pregnancy
nor the menopause seem to have much influence upon
epilepsia tarda. In a part of the cases the atucks in-
crease in frequency and severity, and the mental facul-
ties deteriorate, just as in the epilepsy of earlier life ;
but in general the course is milder and not so progres-
sive, and the mental faculties suffer less. The various
psychical equivalents, and mental disturbances pre-
ceding or following the attacks, or occurring daring
the intervals, are not infrequently observed, and in-
sistent ideas may be associated with the affection, bat
this is less common than in the epilepsy of early life.
The prognosis and treatment do not differ materially
from the prognosis and treatment in ordinary epilepsy.

INFECTIOUS NATUBE OF OBOBBA.

Pianese ^* has underUken an elaborate and thorough
study of the infectious nature of chorea, and has come
to some very important conclusions, which follow :

(1) From the cord of a young girl, who died of an
attack of ordinary chorea of a grave and generalised
type, he succeeded in isolating a bacillus 2 to 4/( long
and ^ to ^ ^ wide, deprived of cilise, and endowed with
slow movements. It grows on the ordinary culture
media, and takes a characteristic aspect on gelatine.
It is sporific, and grows well between 18° and 38° C. ;
it dies at 60° C. and — 5° C. ; it resists rapid dessica-
tion for seven days, action of light for thirteen hours.

(2) Inoculations of pure cultures in animals (dogs,

u La DSton InfetUrs della oorea del Bydanham. losUtntod'sna.
tomla patologtea dalU R. ITnlTenito dl Napoll, 1893. .

rabbits, guinea-pigs) give positive results when prac-
tised in the anterior chamber of the eye, along the
nerve sheaths and under the cerebral dura ; they are
negative if made into the subcutaneons coDDecti?e
tissue, the great visceral cavities or the blood-vessels.

(3) When the inoculations have given positive re-
salts the animals have presented a trembling, either
general or limited to certain muscular groups (the
muscles of the back or shoulder by preference); they
become apathetic, timid, frightened at trifles, aod
they utter piercing cries when the spine is roughly
touched. Ordinarily these phenomena appear twenty-
four hours after inoculation. At first they are slight,
but they increase; contracture develops, walking be-
comes more and more diflScult, and death ensues at the
end of five days. Dogs and rabbits inoculated along
the sciatic have presented for twenty or thirty days a
general trembling, with contracture and emaciation,
and then have almost completely recovered.

(4) The organs of the animals who died from these
inoculations were also tested; the brain, cord and
nerves have always given cultures, but the liver,
spleen, etc., have produced nothing.

(5) Inoculations of cultures sterilized in boiling water
and in other ways have given the following results on
animals ; no febrile reaction either immediately after
the injection or during the whole time that the animal
remained alive; some phenomena resembling those
which were presented by animals inoculated with pure
cultures ; apathy and some weakness for a few days,
and then progressive emaciation leading to death after a
period of time which varied with the siae of the animal.

(6) The bacilli probably travel in the organism of
the animals experimented on through the lymphatics.

(7) On a bacteriological examination, bacilli were
found only in the cord of choreic cases, and only in
the brain, cord and nerves of animals experimented on.

(8) The results of the histological examination in a
case of chorea were as follows : marked hypenemia of
the central nervous substance, with nnmerous punctate
hssmorrhages ; little foci of inflammation, very limited,
peri-vascular, and disseminated in a variable fashion;
slight ependymal myelitis ; beginning degeneraUon of
the columns of GoU ; in the lumbar cord, cellular in-
filtration in the gray horns, chiefly the anterior ; the
muscles were fissured, and showed waxy degeneration ;
marked hypertemia of the liver and spleen ; intra-
capsular hemorrhages, cloudy swelling and necrosis of
epithelium of the renij tubules ; the lungs were dotted
with htemorrhages, and there was some pigment for-
mation. In animals inoculated with pure cultures he
found hyperssmia of the whole central nervous sub-
stance ; pigmentary infiltration of the cells of the ante-
rior and posterior horns of the cord ; marked hyper-
asmia of the spleen ; a high degree of hypersemia of
the liver, with very small spots of necrosis; cloudy
swelling and necrosis of epithelium of the renal tubules.
In animals inoculated with sterile cultures he found
the same alteration of the ganglion cells of the cord ;
a little byperssmia of the central nervous substance ;
degeneration, chiefly fatty, of the endothelium of the
vessels of the liver; cloudy swelling, vacuolization
and necrosis of epithelium of the renal tubulea.

In this connection, it will be remembered that
Dana,'* in a case of chorea, found a diplocoocua in the
deep layers of the pia and the superficial layera of the
cerebral cortex,
u Sm this Jovmal, S MotmdIiw, UIB, rot. oxstz, p. MS.

Digitized by

Google

YoL. CXXX, No. 4.1

BOSTOA MEDICAL AND SUBQIOAL JOURNAL.

97

THE OBSTETRICAL SOCIETY OF BOSTON.

CBAJUiBS W. TOWHSBICD, If J>., SBCBITABT.

Mbktino October 14, 1893, the President, Db.
Chirles M. Gbebn, in the chair.
Dk. J. 6. Blakb presented a

BBVIEW OF A SUHMEB'S WOBK IN OTN^COLOOT AT
THE BOSTON CITY HOSPITAL.*

Jo closing, he said he wished to make three points :
first, that Alexander's operation did not interfere with
pregnaocj in any way ; second, the value of the oon-
aervatire as opposed to the radical operation in cancer
of the uterus ; third, the value of dilatation and drain-
age as opposed to laparotomy in catarrhal disease of
the tubes.

Db. F. H. Davbnpobt said that in regard to the
question of the infliienoe of the Alexander operation
on pregnancy, he had had no opportunity in his own
cases to judge. There were two effects to be feared :
one, the termination of pregnancy before full term ; the
other, the question of the position of the uterus during
pregnancy or after its termination. With regard to
the first, some statistics of value had been published
by a writer on the Continent, which showed that the
Alexander operation had very little tendency to inter-
rupt preguancy, while ventro-fixation, which has been
sdrised as a preferable operation in these cases, did
favor abortion. As regards the effect of pregnancy
on the subsequent position of the uterus, he had not
seen any statements. Within a few days, however, he
had seen a woman who had been operated on in the
early summer for prolapse of the uterus by the com-
bined operation of perineorrhaphy and Alexander's,
who was two or three months pregnant, and in whom
the uterus was so prolapsed as to lie half over the
vulva. H« replaced it in the knee-chest position, and
held it back by a pessary. It was not surprising that
this should have occurred, for it has been his experi-
ence that in not a few cases it is at least six months
before the soreness and tenderness about the incision
disappears, which seems to show that the ligaments
•re often as long as that in becoming firmly adherent
in iheir new position. In the present case, pregnancy
iopervening so soon after the operation, they would
be very apt to stretch. As regards the operative
treatment of cancer, the question of ultimate results is
still so aocertain that very little of value can be de-
duced from statistics in favor of one operative pro-
cedure or another. Within a day or two, Dr. Daven-
port had seen three statements by Grerman writers as
to the per cent, of ultimate cures after operative treat-
ment, which varied from five -per cent, to forty per
cent., showing either that they had different ideas as
to what a definite cure is, or that they restricted their
figures to one class of cases. As long as such uncer-
tainty exists in the prognosis it is wise to give the
patient every possible chance. Therefore he would
advise a radical operation in all cases except the abso-
lutely hopeless, feeling that even if the disease did
return, it was robl>ed of so many disagreeable features
that the patient's lot was preferable.

Dr. Davenport said that in his experience, when
cancer returned after the removal of the whole organ,

8m page 89 of the Joomal.

it came back in the broad ligaments, and did not ulcer-
ate through into the vagina. It was therefore un-
accompanied by the hsemorrhage and foul discharge
which is so distressing both to the patient and her
friends, and her condition was very much better than
if it had been left alone. He was also convinced that
there was less pain.

Dr. Geo. Haten has recently seen a case of preg-
nancy following Alexander's operation. The cervix was
almost outside the vulva, but the case went on to full
term and was delivered without complication. After
convalescence he found the uterus subiovoloted, but
not badly retroverted, and he thinks that she will soon
be in good condition. As to relief of epilepsy, spoken
of in one case reported by Dr. Blake, he has seen it
stated that almost any operation is often curative for
a year or so, but the epilepsy is almost sure to return.
He agrees with Dr. Davenport in preferring the radi-
cal operation for cancer, preferably the supra-pubic one.

Dr. Edwabd Rbtnolds has had charge of some
six cases of pregnancy referred to him because they
had previously had an Alexander operation performed.
All went on normally, and in all the uterus returned
after the labor to the normal position, so that he would
not have known that any operation had been per-
formed. As to dilating and packing, he is of the
opinion that good results are obtained when the tubes
are straight and there is but one collection of fluid ;
whereas, if they are tortuous and there is more than
one collection of fluid, this operation is a failure. As
to cancer of the uterus, the disease is so short and dis-
agreeable that he thought patients would run any risk
of escaping by a radical operation, which he would
perform as early as possible, especially if the disease
was at the fundus.

Db. G. Haven said in a case he reported the other
night the fundus and cervix were involved, and not
the vagina. Here radical measures were very effec-
tive, while palliative ones would have been of no avail.

Db. John Houans said that in his experience there
was little or no pain on recurrence of the disease after
a radical operation, while after palliative measures the
pain was as marked as ever; and he mentioned two
cases which illustrated this.

Db. Sinclaib spoke of a case where the uterus was
removed for cancer. Here a recurrence took place,
with great tendency to basmorrhage, which could be
restrained. There was, however, no pain.

Db. Davbnpobt stated that this had also been his
experience. With a recurrence after a radical opera-
tion there was absence of ulceration and discharge, no
odor, rarely haemorrhage, and much less pain.

Db. Charles M. Green : I confess that I am yet
to be convinced of the wisdom of performing the opera-
tion for shortening the round ligaments during the
child-bearing period. I have always supposed that
the uterus was intended to be a movable organ, free to
accommodate itself to a full or empty bladder or reo-,
turn, and free to rise and become an abdominal organ
in preguancy. If pregnancy ensues in a uterus raised
and held by the Alexander-Adams operation, one of
four things must happen :

(1) The uterus will be firmly held and prevented
from rising, and miscarriage will occur. It is known
that this sometimes happens, although probably less
frequently than after ventro-fixation.

(2) The uterus will rise and pull away the short-
ened ligaments from their stitched attachment to the

Digitized by

Google

98

BOSTON MBDIOAL AND SURGICAL JOVBNAL. [Jancabt 25, 1894.

pillara of the ring. This event would probably not
occur if the ligament had been carefully stitched,
unless pregnancy ensued very shortly after operation.

(3) The round ligament will stretch as the uterus
rises. If the ligament does stretch, what assurance is
there that after the lying-in month the uterus will be
held in the position to which it was drawn by the
Alexander operation ? What assurance that the pa-
tient will be any better off, in respect to the position
of her uterus, than she was before the operation ?

(4) The round ligament, which is made up in part
of muscular fibres from the thin, superficial, muscular
coat of the uterus, will partake with the uterus iu the
muscular hyperplasia which normally occurs in the first
half of pregnancy. If this muscular hyperplasia, this
physiological elongation of the round ligament can be
shown to take place, then we may expect that the liga-
ment will involute with the uterus, shorten, and, after
the lying-in period is over, hold the uterus where it
was before pregnancy.

In the absence of positive information on these
points, it seems to me that we need the evidence, not
of three cases, nor of six, but of many times that num*
ber. When it can be shown by a considerable series
of cases, observed for some months after the puerperal
period, that miscarriage rarely occurs after and in con-
sequence of the Alexander operation, and that the
uterus remains in essentially its normal position after
puerperal convalescence, my preconceived objections to
this operation will disappear; until then I must regard
it as unphilosophical from an obstetrical point of view.

Da. BLA.KE, iu closing, said that he restricted his
operations for draiuage to cases of catarrhal salpingitis.
As regards cancer, in the early stages, he himself had
no doubt of the value of hysterectomy ; whereas, if the
disease had extended, there was no gain to be had by
removal of the uterus, and life was endangered by the
operation. He preferred the palliative operation in
this case, and not to endanger life.

Db. N. F. Chandlbb read by invitation

A RKPOBT OF TWO PBBONANCIB8 FOLLOWINQ A
LAPAROTOUT.*

Db. Grben said that it was an interesting coinci-
dence in this case that in both pregnancies a cervical
mucous polypus should have developed, and that the
patient should never have had a similar affection at
other times. He was not aware that these glandular
polypi had any particular relation to pregnancy : they
are found in all ages, even in old women. The most
interesting feature in the case was the extreme nausea,
vomiting and emaciation towards the close of the
second pregnancy, and the explanation of these symp-
toms. When miscarriage occurred between the fourth
and fifth months of the first pregnancy, it was thought
at the time that the accident was due to adhesions,
consequent on the laparotomy for removal of a cyst of
the broad ligament, which adhesions prevented the
uterus from rising. With this theory in view, the
patient was kept very quiet, and much of the time in
bed, during the second pregnancy. When, however,
the early nausea and vomiting had disappeared, and
the uterus had risen above the site of the supposed
adhesions, it was hoped that all would go well. When
nausea and vomiting supervened later in pregnancy,
both Dr. Chandler and Dr. Green were at a loss to
account for the symptoms, Qreiit attention had been
' Se« page 93 of the Joamal,

paid to diet and hygiene, and there was no fault witli
the kidneys. Finally, it was found that the fcetsl hesd
had descended low into the pelvis, apparently becaaee
the tension of the abdominal wall, made more rigid by
the unyielding cicatrix, afforded more resistance to the
enlarging uterus than the girdle of contact at the pelvic
brim. The head descended, according to Dr. Green's
recollection, a month or six weeks earlier than niosl,
and it seemed to Dr. Green that the aggravated nsuses
and vomiting were attributable to the pressure of the
head on the cervical and pelvic nerves. It was well
known that nausea in the early months was often due
to pressure of the enlarged pregnant uterus while it
was still a pelvic organ, and that the symptom dis-
appeared when the uterus rose into the abdominal
cavity. By analogy, therefore, it seemed reasonable
that in a susceptible patient the same symptom might
be caused by a premature descent of the head.

Db. J. HOMANB said that the cyst in this case
weighed a pound, and was the size of an orange. The
tube was long, measuring seven inches ; that and the
ovary were removed. There were no adhesions, and
nothing remarkable about the operation.

Ds. £owABD Rbtnolds suggested that the partial
dilatation of the os was a cause of the vomiting.

Db. Gbeen presented an obstetric-case blank, which
he had prepared as a convenience in recording cases
at the bedside. The blank is similar to the one in use
at the Boston Lying-in Hospital, some changes having
been made to adapt it to the requirements of private
practice.

Para. Age,

Birthplace of F. Ooonpatlon,

Blrthplaee of M. General condition,

Last ctm., Qolokentng, Labor expected,
Preceding pregnandei and labors,

Labor began,

Color,

Preaentatlon and poaltlOD,

irate,
location,
lit stage ended,
3d stage ended,
3d stage ended,
Plaoanta and membrsnes,
Perlnnnm
Child's name,
Sex, Weight,

Left patient.

First Tlslt,

Cerrix, Oa nteri,

Maternal P., T.,

Membranes mptored,
Pulse, Temperature,

Poise, Htemorrhage,

Length of funis.
Duration of labor,

Length,
Pulse, Condition,

The first blank line is intended for the name and
address of the husband, the second for the wife's
name. Below are spaces for recording the birthplace
of both parents, the occupation of the father, and the
name and ser of the child: all of these data are
needed for the report required by law to be made to
the city registrar. There is purposely room for but
brief notes on the face of the blank ; but on the back
may be recorded any points of particular interest in
the labor or convalescence. The stereotyped plate
for printing these blanks is with Mr. George H. Ellis,
141 Franklin Street, who will furnish the blanks for
the cost of printing.

Digitized by

Google

ox.. CXXX, No. 4.] BOSTON MEDICAL AND SUROWAL JOURNAL.

99

THE BOSTON

Jlftenteal and ^u¥$tcal iouvnal*

Thursday, January 25, 1894.

jI Jommal itflfedieine, 3vrgery, and Allied Seiauet.imblithed at
«*toH, VBtekly, by the mutereigned.

SoBSCKimoir Txsms: 9S.O0 per year, in odeaitee, pottage paid,
or the United State; Canada and Mexico ; 96M per year for all for-
iflrm oounlriet belonging to the Pottal Union.

jLH commmnieationi for the Bdttor, and all book* for reviaie, ehonld
<« ttOttraetedtotheXditorqfthe Bottom Medical and awrgieal Journal,
83 fraaliingttM Street, BoHon.

JUI letter! oontaining butineu eommunioaiiont, or rtf^aring to the
ittblieation, tubtoription, or advertising department of thie Joamal,
Ikoultl be addretted to the tmdertigned.

Remittaneee ihould be made by money-order, draft or regiitered
«tter, payable to

DAMBELL ft UPHAM,
S83 WABHnroTOM Stbkxt, Bostoh, Mass.

AVOIDABLE RESULTS AND ESSENTIAL
PRECAUTIONS IN VACCINATION.

Ddbino the present season, there has been a large
amooDt of vaccinatioD done thronghoot this State and
reports have come to us from namerous quarters con-
cerning the prevaleuce of vaccine disease, especially
among school-childreD, and the results.

First, the vaccine which has been used is the cow-
pox virus obtained from some of the many establish-
meots that now guarantee to physicians a supply of
pure animal vaccine. The use of the humanized or
Jeonerian viros seems to be almost a thing of the past.
Nevertheless a few physicians still prefer the human-
ized virus, one remove from the cow, using for vaccine
material the clear lymph of a healthy child, taken
about the seventh day ; and it has been affirmed that
this virus acts more mildly than the animal vaccine,
while being equally efficacious in conferring immunity.
With regard to the results of vaccinations, the vac-
cine disease seems in most cases to have ran a fairly
typical course, occasionally being of rather severe char-
acter. The anosnal number of cases of marked general
vaccinia eruption is to be accounted for by the anosnal
number of cases of vaccinia now in the community,
and in proportion to the total number of children
undergoing vaccination at one time is not probably at
all increased, in one school in the vicinity of Boston
there were about a hundred children successfully vacci-
nated (primary vaccination) ; of this number fifty per
cent, continued their attendance at school without any
interruption ; twenty-five per cent, were obliged to
absent themselves from school for a few days only,
while the other twenty-five per cent, were confined to
their homes for more than a week.

A physician living in one of the cities on the coast
writes us that in his locality there have been an unusual
number of severe cases of vaccine disease. He has
never before seen so many " bad arms," and some chil-
dren have been very sick. All the physicians in that
vicinity have used virus obtained from the Vacci-
nal Institute. He has obaerved from the twelfth day

intense inflammatory oedema develop around the point
of vaccination, then lymphangitis and cellulitis, fever
and other general symptoms of a septicaemic character,
finally an extensive cutaneous necrosis in the region of
the vaccination. In one instance (in which about the
whole city was interested) he despaired of the life of
his patient; fortunately the child is now recovering,
but with a large slough at the point of vaccination.
He believes that in this, as in other similar but not so
violent cases, there was a complication of erysipelas
due to the introduction of the streptococcus by scratch-
ing. Other physicians in the same locality have had
cases of a similar nature, and it has been believed that

the vaccine obtained on a certain occasion from

farm was of a particularly virulent nature. The cellu-
litis, erysipelas or lymphangitis which have caused
such dire alarm and opposition to vaccination are to
be explained by the same principles as under any
other surgical operations ; some contamination of the
wound by micro-organisms. In vaccination the physi-
cian has not a complete control of the whole chain of
asepsis ; he must trust to the honesty and cleanliness
of the vaccine establishment, which should be above
suspicion.

Our correspondent writes that the ivory points in
those packages were stained red, as if from admixture
of blood; this certainly indicates that sufficient care
was not taken in charging the points.

These facts show that the owners of vaccine estab-
lishments have a responsibility to physicians and to the
public of which they cannot be too mindful. They
are expected to furnish vaccine of unexceptionable
quality ; obtained from healthy heifers, at just the
right time, and under conditions of perfect cleanliness
and asepsis. The lymph which is .furnished, should be
clear lymph, not lymph and blood or pus.

Physicians, too, have a responsibility in every case
of vaccination, and this little operation should not be
performed in a hasty and slovenly manner. Though
antiseptics may not be used during the operation, as
likely to interfere with the result which is sought, yet
vaccination should be performed with perfectly «lean
instruments, and aseptically. The scarification may
be made with the ivory points themselves, or with a
fresh needle for each case, which in addition may be
passed through an alcohol flame. Some physicians
wisely make a practice of washing the arm before vac-
cination. All should do so. The same point should
never be used on two patients : we fear this has been
done, though very exteptionally.

What shall be done with the vaccinated arm ? Some
apply immediately after the operation a little isinglass
plaster over the abraded surface, the vaccine being
allowed to dry in, and the plaster having previously
been dipped in boiling water. The piece of plaster is
taken ofif next day, and the arm covered with some
antiseptic dressing, such as carbolic gauze. This might
be expected to be sufficient to protect the vaccine sore
from extraneous germs, the gauze being renewed every
day. The dried lymph may be covered by aseptic

Digitized by

Google

loo

^OSTOJf M£i)IOAL AND SVSGICAL JOdtHAL. [Sahvamx 26, 1894.

gauze or cotton glued to the arm at the edge with
collodion.

We know physicians who take these precautions
every time they perform vaccination. It would prob-
ably be better that all should. The vaccinated person
is provided with a roll of antiseptic gauze for daily
dressings, according to the strict directions of the
physician. In this way, the danger that foreign mi-
crobes (staphylococci, streptococci, etc.) may enter
the solutions of continuity caused by the vaccine dis-
ease, and thus add to this disease the evils of microbian
associations — and we well know how much in some
diseases, as diphtheria, the original virulence is inten-
sified by such associations — this danger, we repeat, is
thus likely to be reduced to a minimum.

It might be better that vaccine farms should be es-
tablished and managed by the State, the points being
sold at cost or furnished free. Such a proposition is
at present under consideration in this State. Where
there is a good State Board of Health, a proper super-
vision for such a farm or farms already exists.

THE ARMY MEDICAL SCHOOL AT WASH-
INGTON.

It is always easy to find some matter of special in-
terest in the Report of the Surgeon-General. This
year, one of the first subjects to attract attention is
the Army Medical School authorized by a General
Order of June 24, 1893. Its object is the further in-
struction of newly-appointed medical oflSoers. Severe
as the ordeal of the Army Examining Board may be,
the saccessfnl candidate has still much to learn before
he is fitted to thoroughly perform his duties. In the
words of the Report, "Certain of these duties are
more important than the clinical treatment of individ-
ual cases of disease and injury, because the efficiency
of a command may depend upon their proper per-
formance."

The number of questions of practical sanitation on
which^he medical officers of the army must be well
informed are numerons, — matters of site and soil ; of
ventilation, heating and drainage; of sewerage and
the disposal of garbage; of water-supply; of food,
slaughtering and storage; of disinfectants; of bacteria
and ptomaines. Few recent graduates of our medical
schools can be supposed to have thorough knowledge
of such subjects, and it is to furnish snch post-graduate
instruction, as it would be called in civil life, that the
Army Medical School is established.

The school is situated at Washington, and its course
of instruction will extend over four months, beginning
annually on the first day of November. The faculty
consists of a president, who will deliver lectures on
the duties of medical ofiicers in peace and war ; a pro-
fessor of military surgery, including the care and trans-
portation of the wounded; a professor of military
hygiene, including practical instruction in the ezaoii-
nation of water, air, food and clothing from the sani-
tary point of view; and a professor of clinical and

sanitary microscopy, including bacteriology and Drinol-
ogy. Truly, the young army surgeon will not find
any encouragement to idleness in the first four montbi
of his service.

One of the companies of instrnction of the Hospital
Corps is also stationed at Washington, and its presence
there is of value in connection with the work of the
school. The Army Medical Museum and the library
of the Sorgeou-General's 0£Sce cannot fail to be also of
service. The direct value of such instruction will be
evident at once to any one familiar with the experi-
ences of the late war.

The question naturally arises whether the medical
schools of the country furnish to civilians equal oppor-
tunities for becoming skilled sanitarians.

There is also a suggestion for the volunteer forces,
for it is hinted that the medical departments of two
State* were not so fully prepared for actual work
when the emergency arose as they should have been.

MEDICAL NOTES.

Influenza among the Pink Ridok Indians. —
The influenza has been epidemic and exceedingly fittal
among the Indians at the Fine Ridge Agency daring
the last month. The Indians are poorly protected
against the cold weather, and are often sick but a day
or so before they die.

A Nabhow Escape fboh Boeial Alite. — A
town councillor of Barton-on-Trent in England bad a
narrow escape from burial alive last week. At the
very last moment, during the committal service in the
cemetery, a friend detected what he thought was a
sign of life. On examination the man was found to
be still breathing, and was carried home.

DeLKOATES "fo THE INTERNATIONAL SaNITAHT

CoNFEBENOE. — Dr. Edward 0. Shakspeare of Phila-
delphia, Dr. Stephen Smith of New York and Dr.
Preston H. Bailhache of the Marine Hospital, are the
delegates appointed by the President to represent the
United States at the international sanitary oonferenoe
which meets in Paris to-day.

The Qoabcentenabt of Pabaoelsos. — The

four-hundredth anniversary of the birth of the famous
Tbeophrastus Paracelsus von Hohenheim, at one time
Professor of Medicine at Basle, was celebrated the
26th of last November by the villagers of his native
place, Maria-Einsiedeln in Switzerland.

The Husband's Liability fob the Wife's
Medical Expenses. — The Supreme Court of Cali-
fornia recently ruled that where the husband is liable
for his wife's support, the wife's estate cannot be
charged for medical survices, medicines and nursing
which he secured for her in her last sickness, but that
he alone is liable for them.

Ttpboid Fetbb on a Wabship. — A warship is a
rather unusual place for an epidemic of typhoid fever
to occur in ; but over thirty of the crew of the British

Digitized by

Google

Vol. CXXX, No. 4.] BOSTON MEDICAL AlTD StJMOtCAl JOVltlfAL.

101

wanbip Canada, hare been sent to the hospitals at
Bermuda or Barbadoes. The admiral has requested
that the vessel be ordered home at once before the
whole crew gives oat. It woald be interesting, and in
such a case probably not diflicalt, to trace the infection.
So far no explanation has been pablished.

Shall-Pox on a Nbw Toek Steamer. — The
Ward-line steamer Seguranea, which sailed a fortnight
•go frona New York, has been qaarantined at Vera
Croz with twenty-two cases of small-pox on board.
It is thoDght that the disease was brought on board at
Havana by some steerage passengers.

" Vabiolim " Again. — The use of " variolin ". for
the internal administration of vaccination has beeq
sanctioned, it is said, in Brooklyn by the principals of
tome of the public schools, who hare accepted certifi-
cates of treatment by this means as a snbstitate for the
required certificate of vaccination.

A FOUB TbABS' GOUB8E AT THB NATIONAL MEDI-
CAL CoLLBOE. — At a meeting of the Faculty of the
Medical Department of Columbian University, of
Washington, D. C, held on April 11, 1893, it was
nnanimoasly agreed to make a four-year course of
study necessary before graduation. This measure went
into operation at the beginning of the present session
of 1893-94. Each of the four courses covers seven
months of lectures.

BOSTON AND NBIT ENGLAND.

The Nkw Cbematobt at Boston. — There have
been already six bodies cremated at the new crematory
at Forest Hills this year, and several engagements are
made for the next week or two. The possibility of
being cremated in New England has apparently in-
creased the interest in this means of disposal of the
dead.

Small-Pox in Boston. — During the week ending
at noon on Wednesday, January 24th, there were four
new cases of small-pox. There have been no deaths
during the week, although one of the last patients, a
woman, is critically ill. There are now in the hospital
fifteen patients, five of whom are convalescing. Since
die first case on October 80th there have been thirty-
six cases and seven deaths. *

Deaths at Boston Fibbs. — The records of the
Boston Fire Department show that there were twenty-
lix deaths at fires in 1898. Only one of those was of
a fireman, a ladderman who was crushed between his
tmck and an electric-light pole while on the way to a
fire.

Small-Pox in Massaobosbtts. — There have
been reported to the State Board of Health since the
21 St of last September, when the first case occurred,
nineteen cases of small-pox from places outside of
Boston. Of these seven occurred in Lowell, four in
Holyoke, two each in Worcester and Methuen, and
one each in Somerville, Brookline, Marlborough and
YarmoDth.

Vaccination at Newton. — The free vaccination
stations in Newton were reopened for three days last
week ; and 729 persons were vaccinated, which is about
twice as many as previously registered.

The Newton Hospital. — At the annual meeting
of the Corporation of the Newton Cottage Hospital,
held last week, it was unanimously voted to change the
name of the institution and corporation from Newton
Cottage Hospital to the Newton Hospital. The annual
reports showed an increase of thirty-two per cent, in
the number of patients during the past year, and that
the new wards for contagious diseases had not been
vacant at any time during the year. A nurses' home
has also been completed.

Diphtheria at Calais, Yt. — So many cases of
diphtheria have occurred at Calais, Vt., the last ten
days that three of the schools have been closed for the
present.

DiPHTHBBiA in Gbanbt, Conn. — There is a con-
siderable epidemic of diphtheria at present in Granby,
Conn,, so that the county health-officer has ordered the
schools closed. .

Small-Pox in Winsted, Conn. — Several cases
of small-pox, some fatal, have occurred the last week
at Winsted, Conn.

The New Hampbhibe State Insane Abtlum. —
The annual report of the Superintendent of the New
Hampshire State Insane Asylum shows that during
1893 there were 248 men and 60 women under treat-
ment in the hospital. The mortality rate during the
year was 7.2 per cent. The percentage of recoveries,
based upon the number of cases admitted, and exclud-
ing all recoveries from opinm or alcohol habits, was
25.30 per cent.

NBW TOBK.

Mobtalitt. — During the week ending January
20th the number of deaths reported in this city was
888, as against 929 the previous week, which latter
mortality was 103 less than the average of the corre-
sponding weeks for the past five years. The deaths
from influenza were 18, which was an increase of 8
over the week ending January 13th; but the deaths
from pneumonia, 150, were 16 less. There were 6
deaths from small-pox, against 8 the previous week,
and there was a slight increase in the mortality from
diphtheria and typhoid fever.

Annual Meeting New Yobk Codntt JiBDicAL
Association. — The annual meeting of the New
York County Medical Association was held on Janu-
ary 15th, and the attendance was the largest in the
history of the Association, about 300 members being
present. The report of the Corresponding and Statis-
tical Secretary, Dr. A. D. Ruggles, showed that during
the past year 121 new members had been elected, and
that the Association had lost 14 members by death
and 27 from other causes. The total membership is
now 951. The following ofBcers were elected : Presi*
dent. Dr. S. B. Wylie McLeod (re-elected); Vice-

Digitized by

Google

102

BOSTOlf MSDIOAL AND SUROWAL JOURNAL.

f jAMtrABT 25, 1894.

President, Dr. Augastos D. Boggles ; Recording Secre-
tary, Dr. P. BryDberg Porter (re-elected) ; Corre-
sponding and Statistical Secretary, Dr. Wm. W. Van
Arsdale ; Treasurer, Dr. John H. Hinton (re-elected) ;
Member of the Executive Committee, Dr. John Blake
White.

OUTBHEAK OF ShALL-POX AT CbABITT HOS-
PITAL. — A serions outbreak of small-pox has occurred
at Charity Hospital, and the history of it is of more
than ordinary interest. On January 9th, Dr. Henry
M. SiWer, Demonstrator of Anatomy at Bellevue
Hospital Medical College, was about to give a lecture
before a class of students at that college, and on re-
moving the cloth from the subject on which he was to
give his demonstration in the anatomical room adjoin-
ing the amphitheatre, he was astounded to find the
corpse covered with the pustules of small-pox. He at
once notified the Bureau of Contagious Diseases ; the
building was disinfected, and about 125 students were
vaccinated. On inquiry, it was found that the body
which bad recently been received from Charity Hos-
pital was that of Louis Schmidt, sixty-three years of
age. It seems that in the latter part of December
Schmidt was taken from a lodging-house in E^ast
Broadway to Grouverueur Hospital, suffering from ma-
lignant syphilis. Whether small-pox had also devel-
oped at this time has not transpired ; but, at all events,
the latter disease was not diagnosticated by the physi-
cians in charge, and on December 26th he was sent to
the reception ward of Bellevue Hospital. Here the
examining physicians confirmed the diagnosis of sy-
philis, and on the following day he was sent to Charity
Hospital and admitted to the syphilitic wards. The
man continued to grow worse, and on January 2d he
died. It still being believed that he had suffered only
from syphilis, the body was removed to the city
morgue, where it was kept for nearly a week, that
friends might have the opportunity of claiming it.
Then it was taken to Bellevue College and placed
among the subjects for dissection ; and it was not until
January 9th, as mentioned, that the real cause of death
was discovered by Dr. Silver. The correctness of his
diagnosis has now been abundantly attested. On
January 16th three cases of small pox developed in
the male wards of Charity Hospital, and the patients
were at once sent to North Brother Island. That
evening Dr. Doty, Chief Inspector for Contagious
Diseases, sent four of his corps to Charity Hospital,
who vaccinated over eight hundred persons — patients,
physicians, nurses and servants — and the whole insti-
tution was placed in strict quarantine. On January
18th seven additional cases of small-pox developed,
and among those attacked with the disease was the
warden of the hospital, Mr. Roberts. They were all
removed to the hospital for contagious diseases on
North Brother Island. On the same day a case of
small-pox was reported at the Florence Mission for
Fallen Women on Bleecker Street, and an investiga-
tion showed that the patient, a young woman twenty-
two years of age, had recently been discharged from

the work-house on Blackwell's Island. While serving
a term of imprisonment there she had been detailed as
a scrub- woman in Charity Hospital, and it was while
she was engaged in cleaning the ward where Schmidt
was lying that she contracted the disease. The Flor-
ence Mission, which has about thirty inmates, has also
been placed in quarantine for three weeks.

TO ABOLISH THE OFFICE OF CORONER.

Tbb following is an abstract of recommendations
contained in the memorial of the select committee of
the Medico-Legal Society of New York, addressed to
t||e Legislature of the State and dated January 10,
1894:

Your memorialists, after duly considering the premises,
unanimously recommend to your honorable body that you
amend the existing statutes, regulating the powers, daUes,
and compensation of coroners

(a) By creating a new officer to be styled " Medical Ex-
aminer," aa in Massachusetts and Connecticut; or " County
Physician," as in New Jersey, who shall be authorized to
conduct inquests or examinations in all cases where death
has occurred by violence, or there is reason to suspect that
the same is due to other than natural causes, having charee
of all autopsies and all questions on the medical side of the
inquiry, without a jury before a competent court, or before
the coroner as a judicial officer, if retained after the plan
adopted in Connecticut.

(i) That said medical examiner be appointed by the
county judges of each county, except New Yoric, and by
the Chief Justice of the Court of Common Fleas in that
county, and only physicians skilled in their profession, of
at least five years' practice, to be eligible to such appoint-
ment, and so far as possible without reference to parttsan
political considerations.

(e) That only persons learned in the law shall be eligible
to the office of coroner, and that if the inquiry is conducted
before the coroner, he shall have charge judicially of all
legal questions, and that the hearing, inquest, and proceed-
ings shall be the same as if before tlie Police Magistrate in
the City of New York or other cities of over 100,000 in-
habitants, and before Justices of the Peace in all counties
of the State except New York and King's Counties.

Clark Bkll, Chairman, Thkodorb H. Ttmdale,
Charlks 6. Garrison, Wyatt Johmsom, M.D.,
Abram H. Bailky, H. W. Mitchell, M.D.,

MoRiTZ Ellingsr.

CHOLERA.

It may be interesting to our readers to read some
extracts from a letter from Constantinople written last
December. The letter is not from a physician, but
from a person having such opportunities for accurate
observation as to entitle his account to the readiest ac-
ceptance :

" Cholera is said to be increasing. I pity the poor,
especially the natives, for they have no protection
from the municipal doctors, who seize them on the
slightest pretence. One man was reported to be ailing
a little. The municipal doctor came, said it was
cholera, covered him all over with chloride of lime,
wrapped him in a cloth, then smeared that with tar,
then injected a solution of phenic acid behind his ears
and into his nose. The priest was called, was sprayed
with a solution of phenic acid till his robe was soaked

Digitized by

Google

'OL. CXXX, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL.

108

▼ith it, and his beard and hair ; then he was told to
>ay the prayers for the dying. Then the man was
Married off to the cholera hospital ; and the next day
(vord came that he was dead and buried.

*' A. few days ago, a hamal (porter) who bad too
heavy a load stopped to rest on the bridge — pot off
his load, pot bis bands to bis sides and gave a groan.
^Naturally, he looked a little pale. In a moment a
crowd gathered ; then the police came and carried him
to the cholera hospital, iu spite of his protestations
that it was his heavy load, that he was not sick. In

due* time bis friends heard that be was dead and buried.
'* The poor people are frightened, and try to conceal

themselves if they are really sick. Doctors generally

are having an easy time, for no one likes to have a

doctor seen entering his house."

to'
atp) :

, 1-
me'-

itiH-

.dike
liiii*

SIR JAMES SIMPSON'S EARLY EXPERIMENTS
WITH CHLOROFORM.

SiK James Simpson's danghtcr has written in the
January Century an interesting account of the intro-
duction of chloroform in England, and of her father's
early experiments in narcotic and ansestbetic drugs.
She says:

" Round the table in the well-known dining-room in

Dean Terrace it was his custom every evening to have

an anesthetic liance with Drs. Keith and Duncan.

£ach bad a glass or saucer from which to inhale the

various substances under trial. On the evening of

!Novemi)er 4, 1847, on returning home after a weary

: day's labor, Dr. Simpson and his two friends sat down

to their somewhat hazardous work. Having inhaled

, several substances without effect, it occurred to Dr.

. Simpson to try a small bottle of chloroform which he

had had, he wrote, 'for several days in the house

i before trying it, as, after seeing it such a heavy and

anvolatile-Hke liquid, 1 despaired of it, and went on

dreaming about others.'

"The tumblers were uewly charged, and the in-
halers resumed their vocation. Immediately an un-
wonted hilarity seized the party, which became bright-
eyed and very loquacious. Suddenly there was a talk
of sounds being heard like those of a cotton-mill ; a
moment more, then all was quiet ; and then a crash.
On awakening. Dr. Simpson's first perception was
mental: 'This is far stronger and better than ether.'
His second was to note that he was prostrate on the
floor, and that among the friends about him there was
confusion. Hearing a noise, be turned and saw Dr.
Duncan beneath a chair; his jaw had dropped, his
eyes were staring, bis bead was bent half under him.
He was quite unconscious, and snoring in a most deter-
mined manner. More noise still and much motion,
and then his eyes overtook Dr. Keith's feet and legs
making valorous efforts to overturn the table."

The interest in these experiments was not confined
to the master of the house. The butler experimented
also — only on the cook. On one occasion, finding
some chloric ether in aerated water, he gave a glass of
it to the cook, who, drinking it hastily, fell down un-
coDicioua. The butler rushed into the dining-room,
laying, " For God's sake, sir, come down ! I've pu-
ghioned the cook." After the woman was restored to
eoDtcioDsness the man was chary and contemptuous of
an; other concoction, and to the end repeated stub-
bornly his sentiment, " Cblory's the thing."

FOUR TEARS' COURSE AT RUSH MEDICAL
COLLEGE.

Rush Medical College,
Mbsioal Department of Lake Forest Univebsitt.
Chicago, January 16, 1894.

Mr. Editor : — My attentioa wascalled yesterday to the
editorial note following the notice of the four years' course
established by this college, published in your last issue.

Replying to your queries, I would say that the required
annual course in Rush Medical College is eight months.

Regarding the facilities for completing a four years'
coarse in three years, — there is no possible way whereby
any nnder-graduate could do this ; but graduates in phar-
macy and dentistry, on account of their previous studies, we
think would be well qualified to enter the second year in
the Medical College; or graduates from dental colleges or
pharmaceutical colleges requiring three full years of study,
would be qualiRed to enter the third year of the Medical
College.

Regarding graduates in arts and sciences, — we believe
that they would be able to acquire as much information in
the second and third years in the college as the ordinary
graduate from a high school would be able to acquire in
the first, second and third years ; therefore, it seems to us
only just to allow them this privilege. The fourth year
will be the same for all ; and it appears to iis that it will
encourage young men who wish to study medicine to make
a better prelimmary preparation. The schedules for re-
citations and lectures to tnese classes are so arranged that
the hours do not conflict.

Hoping that this fully answers the questions which arose
in your mind, I am. Yours very truly,

E. Fletcher Ingals, Regittrar.

RECORD OF MORTALITY

Fob TBI Week emdiho Saturday, Januabt 13, 18M.

|i

1.

J-

Percentage of deaths from

i a
P

o c

OIUm.

ir
&

a

i..

|l

i

1

New York

. 1,891,806

928

366

17.28

•-•4.96

1.32

9.00

3.48

Ghioago .
PUladelpUa

. 1,438,000

436

162

13.67

11.73

1.84

6.67

.69

. 1,116,862

670

161

6.84

21.86

1.08

3.06

.36

Brooklyn
Bt. Lonto .

. 978,3M

330

112

9.30

20.70

1.80

4.60

.80

560,000

—

—

—

—

—

^

Boston .

. 487,3>7

218

67

8.80

36.60

.40

6.20

_

Baltimore

. 600,000

—

^

^

—

^

^

«.

Washington

808,431

119

30

10.32

18 78

2JW

6.02

_

Cloolnnfttl

306,000

123

42

9.72

17.82

iM

6.67

.^

Cleveland

290,000

e3

22

15.TU

10.99

3.01

7.86

.^

Plttabarg

283,708

—

—

—

^

—

—

_

Milwaukee

2SO,0<IO

86

39

17,40

17.40

i.ie

8.12

6.80

NaahTiUe

87,764

29

7

3.46

17.26

^

8.4S

Charleston

69,lt>6

39

10

2.66

7.68

^

^

^

Portland .

40,000

17

1

B.tS

17.84

6.88

—

^

Worcester

86,217

46

18

13.U2

21.70

^

6M

2.17

Fall BWer

87,411

34

19

14.70

29.40

—

1L76

Lowell .

87,191

44

16

24.97

24.97

9.08

_

_

Cambrldce

77,100

29

11

10.36

27.60

•^

3.46

_

Lynn . .

62,666

13

—

7.69

23.07

—

—m

^

Springfield

48,684

14

3

—

28.66

—

—

_

Lawrenee

48,366

20

»

i\i£

•^

^

__

New Bedfon

1 . 45,886

23

7

8.70

4.86

—

^

Holyoke .

41.278

—

—

—

—

^

—

..

Salem. .

32,283

16

6

12.60

37.60

—

12.60

..

Broekton

82,140

8

1

—

12.60

—

■^

_

HaTerUU

8I,S9«

12

6

—

8.33

—

—

_

Chelsea .

30,261

12

6

—

41.66

^

—

.»

Maiden .

28,394

16

3 ; 18.76

26.00

—

12.60

^

Newton .

27,666

6

0

—

16.66

—

— .

^

Fltchhnrg

27,146

—

—

—

—

—

—

__

Taunton .

26,972

26

6

7.70

23.i0

—

^

..

26,688

7

2

14.28

14.28

U.28

«.

^

Waltham

22,068

8

0

—

37.60

—

—

_

Qnincy .
PittnSeld

19,642
18,802

7

i

2
0

14.28

60.00

^

^

—

ETerett .

. . UJM

10

4

30.00

10.00

—

—

_

Northampto

n. 16,331

7

1

—

42.64

—

—

_

Newbury poi

t . 14,073

6

0

—

^

—

—

^

Amesbory

. . W,»2«

8

1

66.66

-"

"■

"—

—

Digitiz

ed by

G(

30<

3le

104

BOSTON MSDICAL AND SURGICAL JOURS AL. [Jakuart 25, 1894. j

Deaths reported 8,883 : under five 7ean of age 1,186 ; principal
infectlona dlseasea (small-poz, meaialea, diphtheria and croap,
diarrfaoaal diseases, whoopfng-coneh, erysipelas and ferer) 406,
aoate Inng diseases 714, consnmption 364, diphtheria and cioap
190, typhoid ferer 44, measles 41, scarlet fever 38,' diarrhoaal
diseases 29, cerebro-spinal menlDKitis 24, whooplng-ooagh 16,
small-poz 13, erysipelas 7, malarial fever 4.

From Bcsrlet fever New York 9, Chicago 7, Philadelphia 6,
Boston 4, Somerville 3, Cambridge and Amesbury 2 each, Brook-
lyn, Cleveland, Milwaukee, Tauuton and Everett 1 each. From
diarrhoeal diseases New York 11, Chicago and Philadelphia 4
each, Brooklyn 3, Worcester and Lowell 2 each, Hilwankee,
Charleston and Fall River 1 each. From cerabKhtpinai menin-
gitis New York 4, Chicago and Lowell 3 each, Cleveland, Pitts-
field and Everett 2 each, Philadelphia, Brooklyn, Washington,
Worcester, Lynn, New Bedford, Chelsea and Quincy 1 each.
From wbooping-oough Chicago fi. New York and Brooklyn 3
each, Philadelphia, Boston, Lowell and Tannton 1 each. From
small-poz Chicago 8, New York 3, Boston and Lowell 1 each.
From erysipelas New York 3, Chicago, Boston, Washington and
Maiden 1 each.

In the thirty-three greater towns of England and Wales with
an estimated popalatton of 10,327,846, for the week ending
December SOth, the death-rate was 22.6. Deaths reported 4,481 :
acnte diseases of the respiratory organs (London) 616, wbooping-
congh 150, diphtheria 101, measles 8S, fever 61, scarlet fever 49,
diarrhoea 38, small-poz (Birmingham 6, Bristol and Bradford 3
each, Nottingham and Oldhsm 1 each) 13.

The death-rates ranged from 16.6 in Preston to 49.3 in Plym-
outh; Birmingham 21.3. Bolton 20.0, Brighton 27.0, Croydon
aO.l, Huddersfleld 19 2, Leeds 20.6, Leicester 16.7, Liverpool 26.3,
London 23.3, Manchester 24.9, Newcastle-on-Tyoe 20.4, Norwich
20.5, Portsmontb 17.1, ShefBeld 20.0.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,327,816, for the week ending
January 6th, the death-rate was 22.8. Deaths reported 4,567 ;
acute diseases of the respiratory organs (London) 666, whooping-
cough 166, measles 102, dij^theria 89, scarlet fever 60, fever 43,
diarrhoea 32, small-poz (Birmingham 6, Bradford 8, London
and Oldham 2 each) 13.

The death-rates ranged from 11.2 in Halifaz to 40.3 in Plym-
outh: Birmingham 24.7, Bolton 16.7, Croydon 16.8, Gateshead
19.0, Hull 23.5. Leeds K.9, Leicester 15.2, Liverpool 26.0, London
24.5, Manchester 22.6, Newcastle-on-Tyne 19.1, Nottingham 23.8,
Portsmouth 17.7, Saltord 22.6, Sheffield 17 9, West Ham 25.8.

METEOROLOGICAL RECORD,

For the week ending January 13, in Boston, Moordingto oh-
aerrations furnished by Sergeant J. W. Smith, of the United
SUtes Signal Corps:-

Baro-

Tbennom-i Belative

DlTMtiott VeloeltT
of wind, of wind.

We'th'r.

meter

eter. hnmidltT.

•

Date.

^

i i i

i

a

■i

n ■

n

■i

*

2

36. 40 32

X

81

8

61

ft

8

8.00
8.00

s

s

s

0.

».. 7

29.05

76

w.

W.

8

:o

o.

M.. «

30.-/8

28 32 24

681 62

6j;

w.

W.

12

16

0.

0.

T.. 9

30.36

2G 30,21

73 80

62

w.

N.W.

6

7

0.

o.

W.IO

30.20

22 27

IK

70' 92

81

N.W.

|N.W.

8

9

o.

N.

T..11

29.80

23 82

14

92j 96

94

N.W.

S.

6

^

0.

0.

P..1!

20.68

18 26

10

BO' 49

fiO

N.W.

N.W.

20

32

0.

0.

8.. 13

29.97

13 24

2

50

38

44

N.W.

N.W.

25

16

c. c.

BT-

3t).03

^70.17

67

1

.03

.08
.08
.08

.27

•0.,el*iidji C.olMri F., (alrt U.,foiri H, huqri B-nsokyi R.,rai>t T.,Uin«t-
•BlBKi N..aiiow. t Indleatc* trart of rmtnfall. i^ Mean for weak.

OFFICIAL UST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM JANUARY 13, 1894,
TO JANUARY 19, 1894.

Leave of absence for one month, on surgeon's certificate of
disability, is hereby granted to Major Edward B. Mosklst,
surgeon, U. S. A.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
f;F THE U. S. NAVY FOR THE WEEK ENDING JANU-
ARY 20, 1894.

Clbment Biddlb, surgeon, detached from duty. Marine
Rendezvous, Philudelphia, Pa., and await orders, Rendezvous
closed.

E. P. Stoxk, passed assistant surgeon, detached from Bfarine

Rendezvous, Boston, Mass., and oontinne on special duty in
Boston, Mass.

T. A. Bebbthill, passed assistant snrgeon, authorized to
take a oonrse of instruction at the Naval Hospital, Brooklyn,
N. Y.

F. J. Mills Brownb, medical director, retired, granted two
months' leave with permission to go abrwul.

SOCIETY NOTICES.

Nbw Yobx Statb Mbdical Asbociatioh, Fifth District
Brasch. —The tenth annual meeting of the Fifth District
Branch of the New York State Medical Association will be held
in Brooklyn, on Tuesday, May 22, 1894. All Fellows desiring
to read papers will please notify

E. H. SociBB, M.D., Stcrttary, P. O. Boz 760, Brooklyn.

Mbdical Socibtt of thb Statb of Nbw Yori. — The
eighty-eighth annual meeting of the Medical Society of the
Suta of New York will be held in the City Hall at Albany, on
Tuesday, Wednesday and Thursday, February 6th, 7th and 8tb.
The anniversary address by the President will he given Wednes-
day evening, February 7th, at 8 r. n. in the Senate Chamber.
The annual dinner at the Delavan Honse at 9.30 r. h.

Hbbmam Bbndbll, M.D., Prttident.
Fbbdbric C. CnBTia,'M.D., Secretary, Albany.

APPOINTMENT.

EbwABo Jacob Fobstbr, M.D., of Boston, has been appointed
Medical Director on the staff of Brigadier-General Bridges.

RECENT DEATH.

J. O. Nava, M.D.. died in New Orleans, La., Jannai? 16th,
aged sizty years. He was bom in Cuba and after graduating
from the University of Havana stndied dentistry in Philadel-

Shia. He then studied medicine in Paris where be received bis
egree in 1859. Returning to Cuba he became active in the
struggle for the independence of the island and at the close of
the war against Spain was obliged to leave the country as a

Erice was set upon nis head. He escaped to New Orleans where
e has since lived. He was editor of La Libertad, a French and
Spanish paper published In the interest of Cuban freedom. He
was a member of the Academic dea Sciences of Paris.

BOOKS AND PAMPHLETS RECEIVED.

The Nerve Theory of Menstruation. By Christopher Martin,
M.B., Edin., F.R.C.8., Eng. London. 1893.

The Harvard University Catalogue, 1893-94. Cambridge,
Mass.: Published by Harvard University. 1893.

A New Pathology and Treatment of Nervous Catarrh. By
Seth Scott Bishop, H.D., Chicago. Reprint. 1893.

Concerning Posture. A New Holder for Sims Speculum. By
B. H. Daggett, M.D., Buffalo, N. Y. Reprints. 1893.

Cnnrent Fallacies about " Nervous Prostration." Traumatic
Neuroses in Court. By Dr. L. Bremer, St. Louis, Mo. Reprints.
1893.

Transactions of the Medical Association of the State of
Missouri at the Thirty-sizth Annual Session held at Sedalia,
Mo., May, 1893.

The Bacteriological Examination of Water and the Informa-
tion it has Furnished. By Percy Frankland, Ph.D., B.Sc.
(Lond.), F.R.8. Reprint. 1894.

Proceedings of the American Microscopical Society, issued
quarterly, Sizteenth Annual Meeting held at filadison. Wis.,
August 14, 1893. Vol. XV. Washington, D. C. ; Judd & De-
troeiler. 1893.

Syllabus of Lectures on the Practice of SuKery arranged in
Conformity with the American Tezt-book of Surgery. By N.
Senn, M.D., PhD., LL.D., Chicago. Philadelphia: W. B.
Saunders. 1894.

The After-Treatment of Cases of Abdominal Section. By
Christopher Martin, M.B. (Edin.), F.R.C.8. (Eng.), Surgeon to
the Birmingham and Midland Hospital for Women. London:
Slmpkin, Marshall, Hamilton Kent & Co. 1894.

The Physiology of Death from Traumatic Fever : A Study in
Abdominal Surgery. By John D. Malcolm, M.B., C.M., Fellow
of the Royal College of Surgeons of Edinburgh ; Surgeon to the
Samuitan Free Hospital. London : J. & A. Churchill. 1893.

Twelfth Annual Report of the SUte Board of Health of New
York for 1892. Thirteenth Annual Report of the State Board
of Health of New York for 1893. .Maps to accompany the Thir-
teenth Annual Report of the State Board of Health of New York
(or 1893.

Digitized by

Google

OL. CXXX, No. 5.] BOSTON MBDIGAL AND SURGICAL JOURNAL.

106

Original %xtitW,

OVARIOTOMY FOE NERVOUS DISEASE.*

BT HOBBBT T. KDSS, U.O.

I DO not wish to andervalae by a thought the
riamphs of that branch of oar art which has made
uch enormoas strides within the last three decades.
. look apon the introduction of the principles of anti'
lepsis or asepsis in surgery, as the onlj step forward
\t all comparable to the discovery of anaesthesia. But
Jiere may be, as has been often remarked, some dis-
idvantages connected with the freedom from great
risk ; and the fact that an operation may be done with
oQuch less immediate danger to life than it would have
caused twenty years ago, seems to be to some extent
looked upon as a sufficient reason for doing it. .1 have
been credibly informed that the removal of the nor-
mal ovaries is not a very difficult nor, with a reason-
able degree of cleanliness, a very dangerous operation ;
and the history of its popularity is likely to be of
greater interest to the psychologist than to the scientific
surgeon who prides himself upon the knowledge and
skill involved in or obtained by his operations, rather
than open the mere number of incisions or the array
of specimens he can display, like the scalps banging in
the wigwam of the Indian brave.

I trust that the time has passed when normal ovari-
otomy can decently be urged upon a patient by a sur-
geon who has simply a desire to " make a record " ;
but I think that there is still some room for testimony
as to the ultimate value of the operation from a stand-
point other than that of the surgeon, who is likely to
lose sight of the patient as soon as the wound has
healed.

I do not pretend now to be an unprejudiced witness,
though I was more nearly so a couple of years ago ;
but 1 have made up my mind decidedly as to the ex-
pediency and justifiability of removing ovaries not
seriously diseased for the relief of uervous symptoms
not immediately dependent upon them, and among
these latter I include the so-called ovarian neuralgia
or pain in the ovarian region. I have not, however,
in the cases mentioned in this paper, with two excep-
tions, the interest of having advised either for or
against the operation.

It may be admitted, moreover, that my field of ob-
servation has not been such as to furnish material for
impartial statistics, since, of course, the favorable cases
do not demand further treatment. I have taken some
paina, however, to follow the history of a number of
patients who have undergone the operation, and who
have either before or afterwards been inmates of the
Adame Nervine Asylum ; and a few histories not im-
mediately connected therewith.

Case I. Miss , physician, age forty (more or

lest). No signs of menopause. Had herself never
saapected any disease of the pelvic organs. For some
yesra worked very hard and anxiously, starting a dis-
penaary and carrying it on under trying circum-
(tancea. She had been unfortunate in her domestic
relationa, having experienced losses, and ill-treatment
of a very aggravated character. In the early summer
of 1892, which was very hot, she remained at work
until the went into the country to take care of a pa-
tient There she began to lose health, and finally had

> BMd (In iwrt) to tbe DoroheitCT M«cU«al Clab and to the Boxbnrr
Socletjr for Medical Impromnent.

a severe fit of some kind, which seems to have been
opisthotonic and was attributed by her partly to the
strychnine that she was taking as a tonic. It is quite
as likely, however, to have been hysterical.

In September she returned to the city, her life be-
ing considered in danger ; and after three weelLS in a
private hospital and a consultation of several physi-
cians, one at least of whom was far from an enthusias-
tic advocate of the operation in general, it was decided
to remove the ovaries as a last resort. They were
said to have been diseased, but I have no description
of any lesion except that a cyst was mentioned. She
had also a fibroid, which was not removed. She had
had pains in her bead and back and a defect in her
vision so great as to have been spoken of as blindness.
A careful ophthalmological examination revealed no
visible changes. These symptoms are said to have
improved after the operation, which, in a purely surgi-
cal point of view, was eminently successful. She re-
covered rapidly from its immediate effect, but was de-
pressed, and her sight did not return to any useful
extent.

Early in December she came under my observation.
Her general condition seemed pretty fair. She had a
good appetite, with only occasionally dyspeptic symp-
toms and usually constipation. She had at times severe
pain in the back of the neck, but not often severe
headache. At times attacks of " going off," in which
she became l>ewildered and more or less delirious.
On one occasion she said hundreds of little imps were
saying, " Suicide, suicide," to her. Her mental condi-
tion was distinctly childish, and her attention directed
almost exclusively to the history of her case, which
she kept going over and over with great minuteness.
Vision was much impured. At one time she said she
saw only one-half of the objects at which she was
looking ; but as it appeared on a little closer examina-
tion that, at one moment, the side on which she saw
was opposed to that which was visible the next, the
symptom lost the significance which it might otherwise
have had as indicating localized cerebral disease. This
mental condition frew no better, but she became more
suspicious. She jumped out of a window and broke
her arm, and was removed to an insane hospital,
where she now is.

In a word, this case is evidently one of severe ner-
vous break-down of the hysterical type, in which the
operation, however well meant, has had no beneficial
effect whatever.

Case II. Mrs. , teacher of music, age thirty.

No children. Severe dysmenorrhoea since girlhood.
In October, 1890, both ovaries were removed, there
being a cyst of the right and adhesions of the left.
She improved up to the next February, but entered
the asylum in July, remaining until the subsequent
June. During this time she gained about seventeen
pounds in weight. She menstruated at irregular in-
tervals, and with much suffering, though, as she states,
less than she had experienced before. She complained
chiefly of weakness, and inability to make any exertion
without feeling it greatly. There was no mental
affection. She has been heard from at various times,
nearly up to the present, as having made no essential
improvement.

Case III. Miss , age twenty. Was in the

asylum in 1881 with severe hysteria and ovarian pain.
Was operated on two or three years later. The oper-
ation was considered a success surgically, and " so faur

Digitized by

Google

106

BOSTON MEDWAL ASD SVB6I0AL JOURNAL. [Fkbbdabt 1, 1894.

u nerves were concerned.'
Died two or three years ago.

Became a morphinist

Cask IV. Mrs.

In asylum in 1881. Soon

after went to a private hospital, where she was operated
on. She afterwards brought a sait against the hospital
and against the surgeon. Presumably, the surgeon,
at least, would not be willing to give a very favorable
opinion as to state of her mind from the side of moral-
ity.

Cask Y. Mrs. , age thirty-fpar. At asylum

in 1884. Moody soon after operated on. Ovaries not
diseased, but badly prolapsed. Is said to have been
" in a wretched state of health ever since, a chronic
nervous invalid."

Cask VI. Miss , age thirty. Was in the

asylum in 1887. Was operated on a few years later.
Was an invalid until she died of an overdose of cocaine.
The ovaries were normal. The autopsy revealed noth-
ing abnormal in any part of the body.

Cask VII. Mrs. . In asylum in 1888. Oper-
ated on later. Becent information represents her as a
confirmed invalid.

Cask VIII. Miss ^,age thirty-seven. Was

sick twelve years, "though no one knew it." In
asylum in 1889. Had been operated on two months
previously, the cirrhosed ovaries and a cyst of the broad
ligament having been removed. Acted strangely all
the time she was in the asylum. The records show a
long list of hypnotics and nervines. Has since grown
fleshy, but by no means strong. Still (1892) suffers
pain in region of right ovary. In December, 1893,
she was said to have been very much better during the
preceding six or eight months. Has done considerable
work.

Cask IX. Miss , age twenty-nine. Dysmen-

orrhosa. Both ovaries, " without pathological change,'
were removed together with the tubes. Came to the
asylum to recover from the effects. Took a great deal
of morphine. Her physician writes in 1892 : " She
has gained slowly but steadily for two years. If she
gains as much during the next year as she has done
during the last, she will be pretty comfortable." She
now (189S) has the old menstrual pain twice a month,
requiring morphine, and "menstruates occasionally,
wasting as much as those who flow the most."

Cask X. Miss , age twenty-nine. Was in

the asylum in 1882 and 1883. After an absence of
nine months she returned to the same, minus her
ovaries. The ovaries were enlarged and imbedded in
inflammatory exudation. Nervous and hysterical, say-
ing that she had a misplaced womb. Pains in back
and bladder. Menstruated. For several years was
unable to work, but at last accounts was tmching in
the South.

Cask XI. Mrs. , age forty. In the asylum in

1884. Overwork, neurasthenia, irregular menstru-
ation, dysmenorrhoea. " Both ovaries were removed
in 1885. They were much enlarged and badly dis-

The results of the operation were good, and
she has since been in a fair condition of health. For
the past five years she has had charge of the manage-
ment of some kind of institution for ladies."

Cask XII. Miss , age twenty-seven. Was in

the asylum in 1888, nervously prostrated, with no
organic trouble. In 1892, having had her ovaries
(which were cystic, hard and adherent) removed two
years previously, she applied for readmission having
been of late profoundly neurasthenic and losing flesh

rapidly. In 1893 her " symptoms had somewhat dimin-
ished in intensity by operation, but the character of
them had not been changed, except that the abdomiDsl
pain of which she complained so bitterly is now a factor
of little importance."

Case XIII. In 1892 application was made for the
admission of a married woman, age thirty-four, with
neurasthenia and adynamia for more than a year.
Her uterine appendages were extirpated a little mote
than two years before, with " improvement in some
directions."

Cask XIV. Another applicant (married, age forty-
three) has lately had her ovaries removed, and is now
suffering from the shock of the operation.

Cask XV. Another application from a patient who
had had the uterus and ovaries removed. Was prob-
ably in a condition of incipient melancholia.

Case XVI. Mrs. , age thirty-seven. Was at

the asyluin in 1888, a few months after having had
her ovaries and tubes removed. There had been a
long history of pelvic inflammation, and the organs
were diseased and adherent. She never fully recovered
from the nervous shock, bat some of the symptoms
were slightly relieved by the operation. At the time
of her entry, her physician stated that she had been
suffering many of the ills of the change of life. She
herself said in September that she had had pelvic peri-
tonitis three times since April.

Case XVII. Miss , age thirty-three. Was

in the asylum in 1890, with neurasthenia, depression,
headache, spinal tenderness and too frequent but scanty
menstruation. Her cystic ovaries were removed ; and
her physician states that she is not much improved as
to her neurasthenia, perhaps a little. Certain local
symptoms are better.

Cask XVIII. Miss , age thirty. Never well

since seven. Lost eyesight at that time. Diphtheria
with paralysis at the age of fourteen. A cyst of one
ovary removed four years ago, the other ovary one
year ago. Uterus stitched to the abdominal wall. She
now enters the asylum for neurasthenia, and has made
little, if any, improvemenL

Cask XIX. Mrs. , age forty. Invalid for

nine years. Nervous at menstrual epochs. Appar-
ently some metritis. Discharged from Adams Nervine
Asylum somewhat benefited. After remaining in bed
for more than three years longer, her healthy ovaries
were removed. "She made an uneventful recovery
from the operation ; and since then she has been a well
woman," doing her own work, making calls and so on.

Cask XX. Miss , age twenty-nine. Severe

dysmenorrhoea and hysteria. Dilatation of cervix with-
out relief. Remained in the Adams Asylum over ten
months. Upon her own decision both ovaries were
removed on November 2d. They showed some degree
of cystic degeneration. There was no local trouble
afterward ; but she fell into a condition of " stuporous
melancholia," and died on November 9th. The au-
topsy showed absolutely nothing abnormal.'

casks not opkratrd on.

Case A. Mrs. . Four children. An anxious

mother, nervous, with profuse menstruation amount-
ing nearly to menorrhagia. She was seen by a physi-

' since the MS. of tbe abore left my hendi, another ease hu »V
piled, both of vboee dlieased oTVies were reraoTed In Ootober or
MoTember. "She doe* not rally from the operation . . . and In my
opinion a tew veek* of rest and freedom from care will enable her
again to beeome self sapportliic.'' Would that oar experience en-
abled ns to share In her physlelan'* hopefal view I

Digitized by

Google

Vox.. CXXX, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL.

107

nan (who now figurea as Case I on my Hit), who,
vrith another lady called in consultation, was anxious

for the operation. Mrs. , at my request, visited

another well-known sor^on, who, without absolutely
declining the operation, spoke so doubtfully of its prob-
able benefits that she concluded to wait. In the mean
time circumstances having prevented anything from
Y>eiDg done immediately, nothing was done at all. She
nowr for some reason or other, perhaps from a dearth
of medical attendance, for a portion of which I was
responsible, is very much better, and retains all her
pelvic viscera.

Case B. Miss , age thirty-six. Chronic in-
testinal catarrh for eight years. Abdominal neuralgia
for six years. Tingling, numbness, and pain all over
body, bat especially in extremities. At the urgent
request of the patient and somewhat against his own
jadgment, an abdominal incision was made by a well-
known gyntecologist ; and nothing wrong being found,
with praiseworthy self-denial, he declined to remove
anything. The moral effect boasted of in these cases
did not ensue ; but a new anxiety was added to the
former symptoms, that is, that adhesions might have
taken place which were the cause of the additional
pains, now constantly located in the neighborhood of
the incision, which she was willing to have repeated
on the chance of relief.

Cask C. Mrs. , age thirty-one. Two children.

Has suffered much at the hands of the general practi-
tioner and gynaecologist. Entered the asylum with
severe abdominal pains. A tumor of a Fallopian tube
had been diagnosticated and an operation planned. In
the absence of the first surgeon, and (on account of
fever) the operation being considered urgent, it was
done by another. Nothing whatever was found in the
tube. The second surgeon told me that he thought it
more probable that there had been an accumulation of
serum which had escaped into the abdominal cavity
(there having been no gush from the uterus) than that
the first surgeon had been mistaken in his diagnosis.
This is a point on which there appears to me to be
room for two opinions. After recovery from this
operation the pains remained as before. A year after
much better.

These cases were collected with the object of throw-
ing light upon this operation solely from a neurological
point of view. The removal of the pelvic organs for
surgical reasons is an entirely different matter, although,
of coarse, there may be cases which involve both. I
believe that in these the surgical considerations should
predominate ; and in proportion as nervous symptoms
can be clearly shown to depend upon definite lesions
of a character which are not likely to recover without
an operation, just so increases the justifiability thereof.
UnfortDnately, we cannot say so much for the prospect
of a care. There are two, possibly more, cases in this
list of this character (Nos. X and XVI). For others,
where the ovaries are healthy, or nearly so, as far as
can be ascertained without removing them, the oper-
atioD finds but little support from this series, which is
to be regarded, however, as consisting of illustrations
rather than as making an important addition to statis-
tics already perhaps suflSciently numerous and decisive.
The liat of five thus marked furnishes the only com-
plete and decisive recovery apparently due to the oper-
ation (No. XlX), one invalid still suffering from dys-
meBorrbcBa, one death from cocaine, one death from

the operation, and one case of apparently hopeless
insanity. The nine cases in the second and third
columns give eight invalids, one of whom is able to do
a little work, and one teaching after some further years
of invalidism.

It would have been easy to add dozens if not hundreds
of cases from the literature of the last few years ; but
the truth is not to be sought in the reports of oper-
ations called " successful " because the wound has
closed without unfavorable local conditions. Then,
indeed, they do appear in a more favorable guise, being
discharged perhaps as " needing only rest and feeding "
to complete the cure, until they are again found in the
beds of hospital after hospital or doomed for years, if
not for life, to the reclining-chair of the chronic invalid.

8DHHABY OF OASES OFEBATED ON.

1

S

•a"

go

S y>

OQ

}1

t

BMults.

I

X

Insane.

2
3

4

X

X
X

CbroDlo iDTalid. Heostriuted with pain (two

DM after aoine yean of inTalidlsm of ehronio

morphia, palmonary taberanloela, and ne-

7 [oroals of spina from an aooldenU

5

X

Chronlo Inralld.

6

X

Ohronlo Invalid. Death by oocalne.

7

X

Chronlo ioTalid.

8

X

Chronlo InTalid.

10

X

X

InTalld. ImproTlog slowly. HoDstroates

with pain.
Invalid lome yean. Now teaching.

11

X

Fair health.

12

X

Invalid. Does aome work.

13

X

Invalid.

H

X

Invalid.

IB

X

Melancholia?

IS

X

Invalid.

IT

X

Invalid.

1«

X

Invalid.

19

X

Well woman.

20

X

Died a weelt after operation.

REMARKS ON DIPHTHERIA.>

BY J. B. MOCOLLOH, M.D,, BOSTOK.

The marked prevalence of diphtheria in this city is
Bufiicient reason for an investigation of the prevalence
of mild cases of the disease, which are not recognized,
and which, therefore, become sources of infection. It
is a well-recognized fact that a mild case of any infec-
tious disease is a greater source of danger to the public
health than the severer cases. There are many in-
stances in which the local manifestations of diphtheria
are so slight that it is impossible to arrive at a posi-
tive diagnosis without a bacteriological investigation.

Since 1878, when there were 1,370 cases, the fre-

> Read at the meeting of the Boston Society for Hedtoal Observa-
tion, November 6. US3.

Digitized by

Google

108

BOSTON MEDICAL JJSD SVBGIOAL JOVRBAL. [Fbbbcast 1, 1894.

qnency of the disease baa varied from 1,814 cases in
1889 to 831 cases in 1891. The greatest number of
cases reported was in 1889, when the number reached
1,814, with 564 deaths. The smallest number of
cases was in 1891, when the number was 8S1, with
232 deaths. Last year, 1892, the number of cases
was considerably greater, being 1,353, with 414 deaths.
The percentage of deaths to the number of reported
cases since 1878 has ranged from 35.7 to 26.44. For
the decade from 1883 to 1892, the average percentage
to the number of cases has been 29.42.

An analysis of twenty-five of the principal causes of
death in this city for 1892 shows that diphtheria is the
seventh on the list ; and this comparative frequency,
with certain slight variations, has existed for the past
ten years. In other words, diphtheria causes more
deaths than any of the other infections diseases. For
the last ten years, ending with 1892, the percentage of
deaths from this disease to the total mortality has
ranged from 5.50 in 1889 to 2.19 in 1891, with an
average for the same period of 8.82. A study of the
cases reported, by months, for the past five years shows
that in the summer months, during vacation time, there
is a marked diminution in the frequency of the disease
as compared with term time. An analysis of the ratio
of cases of diphtheria to the thousand of population in
each ward of the city, for the five years from 1888 to
1892, shows that neither elevation above mean low
water nor a crowded condition of a locality are impor-
tant factors in causing the prevalence of the disease.

In view of the fact that diphtheria is so much more
prevalent when the public schools are in session, and
also that situation with reference to tide level and a
crowded condition of a locality do not have any marked
inflaence on the frequency of the disease, it is evident
that contagion from the mild and unrecognized attacks
is a potent factor in causing its spread.

With a view of discovering the actual number of mild
cases. Professor H. C. Ernst has insUtuted a series of
bacteriological investigations. It is now universally
conceded that the Klebs-I^offler bacillus is the cause
of diphtheria, and that by suitable methods of observa-
tion it can always be demonstrated by a microscopical
examination of cultures from the false membrane found
on mucous surfaces. The importance of these inves-
tigations, not only to the well-being of the public, but
also to the advancement of medical science, cannot be
overestimated. The investigation of severe cases of
sore throat has been carried on in a great many in-
stances ; but the investigation of mild cases, such as
are more likely to occur in private practice, has not
been conducted to any considerable extent. While it
may be said that a bacillus morphologically similar to
the Klebs-Ldffler bacillus has been found in the
throats of persons apparently well, yet this bacillus
cannot materially affect the correctness of the diagno-
sis any more than can the Deueke cheese spirillum
affect the accuracy of bacteriological examinations in
cases of cholera, for it is now generally conceded by
the best observers that this bacillus is an attenuated
form of the Klebs-Loffler bacillus, and differs from it
only iu virulence.

The case which is to be used in the investigations
offered you by the Bacteriological Department of the
Harvard Medical School contains two test-tubes par-
tially filled with blood-serum, two platinum needles,
two cover-glasses and labels. The tubes are to be in-
oculated at the bedside of the patient by taking a small

portion of the false membrane on the point of one of
the platinum needles and making one distinct streak
on the right of the culture medium, one in the centre,
and one on the left. The object of this is to get the
necessary amount of dilution, so that the streak on the
left may have distinct oolonies, which may be easily
isolated for the purpose of microscopical examination.
A small portion of the membrane should also be placed
in the centre of one of the cover-glasses. The other
cover-glass should be placed upon it, and the two
rubbed together for a few moments, in order to render
the layer as thin as possible. The cover-glasses should
then be separated and allowed to dry in the air for a
few minutes. They should then be placed with their
smeared sides together, put iu the paper box in the
case, which, with the inoculated tubes, should be sent
to the laboratory, where the tubes will be placed in
the incubator for twenty-fonr hours. At the end of
that time, if the inoculation has been successful, a
growth having the form of minute, rounded colonies,
or of larger white colonies, will be evident.

Cover-glasses are made from these growths by stain-
ing with Loflier's solution ; and these, together with
the cover-glasses prepared at the bedside of the patient,
stained in a similar manner, are examined by the
microscope. If the Klebs-Liiffler bacillus is found it
is evident that the case is one of diphtheria, and the
requisite treatment can be adopted and the proper
amount of isolation enforced. If, on the other hand,
small, round organisms, known as cocci, are seen under
the microscope, it is evident that the patient is suffer-
ing from tonsillitis or from some other form of non-
infectious throat disease. To those of us who have so
many times been in doubt regarding the nature of the
disease of the throat in mild cases, these bacteriologi-
cal investigations will be of great value. If it were
possible to carry out these investigations in the public
schools, while we might not hope to absolutely stamp
out the diphtheria, it is perfecdy evident to any one
who has studied the subject that the disease would be
diminished in frequency to a marked degree.

A second object of this investigation, which is in a
measure dependent upon the first, is to show how
many cases there are of diphtheria associated with
scarlet fever. This is of interest not only from a
scientific point of view, but also is of importance re-
garding prognosis and treatment. A similar remark is
true regarding diphtheria and measles. In many cases
it is absolutely impossible, without a bacteriological
investigation, to say definitely that a false membrane
appearing in the throat in the course of scarlet fever
and of measles is caused by the presence of the Klebs-
Loffler bacillus, or is due to some change caused by
the poison of scarlet fever and of measles.

A third object, although not directly connected
with mild cases of sore throat, but of great scientific
interest, is to show whether the false membrane that
is observed in cases of puerperal septicsemia is a true
diphtheritic membrane, or whether it is caused by
other organisms.

In Bulletin No. 4 of the Harvard Medical School
Association, in an extremely valuable article on diph-
theria. Dr. A. L. Mason says that of the 759 cases ad-
mitted to the City Hospital from July, 1890, to Janu-
ary, 1893, 113 cases of non-diphtheritic tonsillitis and
laryngitis were sent to the City Hospital as diphtheria,
or about 15 per cent. It must be borne in mind, how-
ever, that these were severe cases, in which the diag-

Digitized by

Google

i^ot. CXXX, No. 5.] BOSTON MBDIGAL AND SURGICAL JOURNAL.

109

aosis, although difficult and in many oases impossible
withoat a bacteriological examination, do not present
suoh a difficult problem as do the milder cases, which,
as a rale, are not sent to the hospital. This is onlj
another argument in support of the importance of the
proposed inrestigatiou which has been explained in
detail.

Abbott, in 1891, published the result of his bacterio-
logical investigations in 53 cases of mild sore throat.
Of these 53 patients, 9 were found to be suffering from
acute pharyngitis, 14 from acute follicular tonsillitb,
8 from ordinarj post-nasal catarrh, 2 from simple en-
larged tonsils, 15 from chronic pharyngitis, 1 from
sifb-acute laryngitis, 1 from chronic laryngitis, 1 from
rhinitis, and 2 from an affection of the tonsils and
pharynx. In only 4 of the 53 cases was an organism
foand that resembled the Klebs-Loffler bacillus. This
investigation is of great interest as showing that the
pseudo-diphtheritic bacillus is not a great source of
error.

A word might be said regarding the degree of isola-
tion in a case of diphtheria. Although the disease is
contagious to a certain extent, it is not nearly so con-
tagions as scarlet fever and small-pox in the unvacci-
uated. Actual contact with the patient or with the
discharges from the mouth and nose are necessary in
order to contract diphtheria. Provided that a person
does not enter the room of the patient, or does not
come in contact with clothing, linen and more particu-
larly handkerchiefs soiled by the discharges, there is
very little danger of contracting the disease. Dr.
Mason says, in the article to which allusion has been
made, that of the twenty-three cases admitted to the
diphtheria ward and recorded as doubtful, although
isolation was only limited, not one of the number con-
tracted the disease.

In the Philadelphia Mtdieal Newt of December 10,
1892, Wyatt Johnston, of Montreal, has suggested a
ready method for the diagnosis of diphtheria. It con-
sists in boiling an egg hard, and then chipping off a
small portion of the shell, which, of course, lays bare
the albuminous portion of the egg. This exposed sur-
face can then I>e inoculated with a portion of the false
membrane from the throat. The egg can then be in-
verted in an ordinary egg-glass and put in a warm
place over night. If the inoculation has been success-
ful there will be a growth on the exposed surface of
the egg, which can be examined by the usual methods.
The only objection to this method is the fact that the
sterilization cannot be so effective as when tubes of
blood-aernm, properly prepared, are used; but this
remark is not intended to militate in the slightest
degree against the value of this device in those cases
where it is impossible to. obtain other culture media.

The bacillus of diphtheria may retain its viulity for
months. Recent experiments prove that the dried
diphtheritic membrane in small fragments has retained
its vitality for nine weeks, and in larger fragments for
from twelve to fourteen weeks. Welch and Abbott,
from their investigations, have found that the thermal
death-point of this organism is 58° C, 138° F. Loffler
prerioosly found that this bacillus did not survive ex-
poBore half an hour to 60° C.

With regard to the use of disinfectants, the experi-
ments of Boer prove that in bouillon cultures of the
diphtheria bacillus twenty-four hours old, after an ex-
posure of two hours in a solution of carbolic acid, one
part to three hundred, this organism was killed.

Recent experiments show that a solution of the mer-
curic chloride, one part to a thousand, and an exposure
for half an hour, caused the death of this organism.

It has been attempted in this brief paper to outline
the method of this investigation, and also to call the
attention of the members of this Society to its impor-
tance. As the number of cases examined thus far has
been small, no definite results have been reached,
except in individual instances.

A CASE OF MULTIPLE RUPTURE OF INTER-
NAL ORGANS PRODUCED BY A FALL.*

Br W. T. COUVOILMAH, UJ>.,

Pathologitt to the Botfon City Hotpital; STuMuok Prqfetior Patholog-
ical Anatomy, Harvard UninertUy.

The patient, a laborer, was brought into the hospi-
tal for injuries sustained in a fall from a roof. There
had been a very severe snow-storm and the man had
been engaged in cleaning off the snow from a roof.
He fell to the ground, bringing with him a large
amount of snow. The height of the roof was some-
what under twenty-five feet. l7o previous history
could be obtained from the men who brought him in.
On physical examination the pulse was weak and
somewhat fluttering. Pupils of equal size. Knee-
jerk increased. The man was very noisy and hyper-
SBSthetic. No definite external bruise could be seen,
and no localized tenderness was made out. A few
hours later the man became quiet and unconscious.
The next day the patient was still unconscious; the
diagnosis was made of right meningeal btemorrhage,
and a button of bone taken out. There was a consid-
erable escape of clear, watery fluid from the opening.
No hsemorrbage to be made out. The pulse was very
weak at the time of operation, and numerous subcu-
taneous injections of brandy and digitalis were given.
The pulse became somewhat stronger. Later the pulse
gradually grew weaker, respiration became slower and
slower, and death took place at 6.30 p. h., thirty hours
after the injury. After death information was ob-
tained from a friend of the man that he had been pre-
viously subject to periods of insanity, which in some
cases were of a violent character,

ADTOPST (tWKNTT-FODB HODB8 AFTKB DEATH).

The body is that of a large, strongly-built, muscular
man. On the right side of the head there is a cres-
centic-shkped incision, commencing close behind the
left ear and extending upwards and forwards, terminat-
ing over upper portion of the frontal bone. On the
posterior surface of the thorax on the right side there
is a large, subcutaneous haemorrhage, evidently due to
contusion. No evidence of injury elsewhere.

In the right side of the skull, corresponding to the
incision through the scalp, there is a round opening
with smooth edges, the anterior portion of which is
one centimetre posterior to the middle meningeal
artery. The dura at this point has been opened.
The calvarium smooth. No evidence of fracture.
The dura is thickened and slightly adherent to calva-
rium. The thickening is more marked on the right
side. On the inner surface of the dura, on the right
side, there is a slight membranous formation, which
can easily be stripped off, and in which numerous
small haemorrhages are seen and points of brownish

> A oontributioD to the forthoominc Hedloal and Surgioal Report
of the Boston City Hoepttal.

Digitized by

Google

110

BOSTON MBDIOAL AND SURGICAL JOURNAL. [Fbbbuabt 1, 1894.

pigmentation. There are seTeral foci of softening on
the right side of the brain. TbeM are more marked
in the temporal region than elsewhere. The largest
of these is in the first temporal convolution. It is
three centimetres long, with irregular edges and quite
superficial. The base is smooth and firm. The edges
are yellow and sharply defined. At no place does the
loss of substance extend more than three millimetres
into the brain. There are similar but smaller losses
of substance in the second and third temporal con-
volutions, and a very small one in the angular gyrus
just above the fissure of Sylvius. There is also an
area which is yellowish and slightly softened in the
anterior central convolution opposite the second frontal
involving a portion of the cortex one centimetre in
diameter. The pia is of ordinary thickness, easily
stripped oft. The vessels at base of brain and through-
out brain, perfectly normal. No pathological condition
is made out within the brain itself. The base of skull
shows no change. The ears and drum membranes
perfectly intact.

The subcutaneous fat is slightly developed ; muscles
red. The peritoneum is smooth, and its entire posterior
surface is elevated by an extensive hssmorrhage be-
neath it, giving to it a dark, almost black color.

Liver and spleen free from adhesions. Diaphragm
on right side at lower margin of fourth rib ; on left,
at fifth intercostal space.

Both lungs are voluminous ; the left free from ad-
hesions. The pleura smooth. The entire posterior
portion of left lung and the entire lower lobe are in-
tensely congested aud show numerous areas of haemor-
rhage, which in part are small and circumscribed and
in part form large irregular areas which are evidently
due to confluence of the smaller. These areas are
somewhat similar to areas of broncho-pneumonia, and
are in connection with the bronchL The blood-vessels
of the lung are normal. In the bronchi there is a
small amount of mucus mixed with blood. In addition
to the areas of hsemorrhage, the entire lung is some-
what oedematous. The most congested portion of the
lower lobe floats in water. The parietal pleura along
the vertebrae is congested, and there is an infiltration
of blood beneath it.

The right lung shows a few old and tolerably firm
adhesions, which are most marked along the lateral
surface of the lung. Almost the entire sub-pleural
tissue of the wall of the thorax on this side is infiltrated
with blood. This is most marked along the posterior
surface, and extends from this around the apex of the
thorax and down to the diaphragm, gradually becom-
ing less in extent. There is no blood within the
pleural cavity. The entire right lung is heavy and
volumiuous. The entire lower lobe, especially the
posterior portion, is dark and hsemorrhagic. In one
or two places the pleura is slightly elevated, appar-
ently from haemorrhage beneath it. Over the entire
lung the pleura is perfectly smooth, with the exception
of the places corresponding to the attachment of the
old adhesions, and shows no rent or fissure. A section
through the posterior surface of the lower lobe shows
an extensive, irregular cavity filled with blood. The
cavity is six centimetres long, and represents a long,
irregular fissure of the lung, with lateral fissures radiat-
ing out from it. In several places it is immediately
beneath the pleura, and the pleura in this place is
separated from the lung by a mass of blood-clot which
communicates with the cavity. The cavity contains

about fifty cubic centimetres of dark, clotted blood.
The wall of the cavity, though irregular, is compara-
tively smooth. It does not represent a definite lots of
substance in the lung ; and on removing the coaga-
lated blood contained within it, the walls of the cavity
come into perfect apposition. The hssmorrhage here
extends over the entire posterior part of the lower
lobe. The lung is solid and sinks in water. Else-
where there are smaller and more circumscribed haem-
orrhages. The vessels of the lung are normal. No
single, large vessel can be traced into the cavity. The
cavity connects with the bronchi in several places.
Elsewhere in the lung there is a alight amount of
oedema.

Both layers of pericardium smooth. On the left
ventricle, just at the juncture of the ventricle with the
auricle, there is a large ecchymosis beneath the peri-
cardium. The heart of ordinary size and weight.
Firmly contracted. All of the valves of the heart
normal. Coronary arteries normal. In the left side
of the heart there is a firm mural thrombus two centi-
metres in diameter, which is attached to the auricle
and the mitral valve at its ring of insertion. It is at-
tached just above the middle of the aortic segment of
the valve. On removal of the thrombus, it is found
attached to a fissure in the endocardium of the auricle,
which commences in the auricle just above the valve
and extends downward into the valve. This fissure is
one centimetre in length, and corresponds to the situa-
tion of the sub-pericardial haemorrhage. The papillary
muscle corresponding to this place also shows small
fissures at the insertion of the cordu tendinse, with
haemorrhagic infiltration of the myocardium about
them. These fissures are covered with a thrombus.
The aorta is smooth.

The intestines are somewhat distended with gas, and
are hyperaemic. The mucous membrane of the entire
intestinal canal normal.

The entire posterior peritoneum is elevated by an
extensive haemorrhagic infiltration beneath it. This
infiltration is more marked in the lower portion of the
peritoneal cavity extending into the pelvis, and is
more on the right than on the left side.

The spleen of normal size and consistency.

The liver large, rather pale and anaemic. The
peritoneal surface smooth, the lobules visible. The
gall-bladder coutains rather thin, yellowish bile ; the
bile-ducts open.

Pancreas and adrenal glands normal.

The right kidney has an extensive haemorrhagic in-
filtration around it. Its capsule is loose, and elevated
by the haemorrhage. There are numerous irregular
fissures on both sides of the kidney ; and in the middle
there is a large fissure with au interval of one to two
millimetres between the edges, which is filled with
coagulated blood. Most of the fissures do not extend
into the kidney for a distance of more than one to five
millimetres, aud none of them oommunicate with the
pelvis. On section, there is a haemorrhagic infiltra-
tion in the neighborhood of the fissures. £lsewhere
the kidney is pale. About the left kidney there is
also an extensive haemorrhagic infiltration of the peri-
renal tissue. The surface of left kidney is smooth
and free from adhesions. The capsule of the left
kidney is slightly elevated above the surface. On
section, the entire organ is distinctly congested, and
blood can be pressed from the cut surface everywhere.
The renal artery is occluded by a thrombus which ex-

Digitized by

Google

Vot. CXXX, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL.

Ill

tenets up to the aorta. The renal rein is also throm-
l>OBed.

Both adrenal glands are imbedded in the hsemor-
rbagic infiltrated tissue. The pancreas shows no
ch&nge. The urinary bladder and genitalia are nor-
mal.

Xhe most careful examination showed no fracture
of the walls of the thorax nor of the pelvis nor verte-
brae. No fractured bone could be found in any por-
tion of the body.

ANATOMICAL DIAGNOSIS.

Traumatic rupture of the right lung, heart and kid-
ney. Pulmonary haemorrhage from rupture. Throm-
Ikmis of heart. Sub-plenral, sub-peritoneal hemor-
rhage from rnptnre. Embolus of left renal artery.
Thrombosig of renal vein. Hemorrhagic infarction
of left kidney. Operation wound in scalp and skull.
Old areas of softening in brain. Chronic pachymen-
ingitis.

This case is in many respects an exceedingly inter-
esting one. Although there are many cases reported
of rapture of the lung and other internal organs with-
out injury of external parts which would correspond
with them, I have found no case in which the injuries
of the viscera were so extensive. Most of the cases
of mptnre of the lung without injury of the thorax
which have been reported have been due to direct
violence applied to the wall of the thorax. The most
frequent cases are those in which a wheel has passed
over the thorax, or in which the thorax has received
a violent blow. Cases have also been reported in
military surgery of injury to the lung, sometimes fol-
lowed by gangrene, from the effect produced by a
spent cannon-ball striking the thorax. In all of these
cases it has been assumed that the thorax was in a con-
dition of extreme distention at the time of the injury,
and the glottis firmly closed.

The man in this case fell from a height of less than
twenty-five feet, bringing a lot of snow down with him.
It could not be ascertained whether the contusion of
the thorax was due to his having fallen on a project-
ing body. It is interesting to see that the rupture of
the Inng had been produced without any injury to the
pleara over it. The hsemorrhagic infiltration extended
over the rupture to the base of the hing, and from here
on all sides, still beneath the pleura. There was no
blood at all in the thoracic cavity. A close examina-
tion failed to show the rupture of any large vessel in
the lung.

It is hardly possible to conceive that there should
have been a rupture of one of the pulmonary vessels
which had caused the destruction of the lung tissue.
The case would have been more easily explained bad
there been numerous adhesions between the chest wall
and the lung, but the adhesions in this case were
almoat entirely wanting. It is still more difiBcnlt to
explain the rupture of the endocardium, and I have
not been able to find the report of an analogous case
in the entire literature. It is hardly possible to con-
ceire of such a sudden increase of iutra-thoracic pres-
aare combined with intra-cardiao pressure which could
prodace such an injury. It would be more easily ac-
ooanted for by a diminished intra-thoracic pressure
combined with an increased intra-oardial. There was
an entire absence of any disease of the valve or of the
endocardium which would h*— * — -»-> t.he liaUlity of

injury greater. The blood-vessels in the body every-
where were normal.

When we think of the anatomical structure and the
situation of the organs in the thorax, it is difficult to
understand how, in such an elastic tissue as the lung,
an injury could take place as the effect of indirect vio-
lence. A consolidated lung is, of course, easily torn,
because, owing to the inability of the lung to collapse,
any violence applied to it only acts on a small portion
of the tissue at a time. But here there was no evi-
dence of there having been any previous consolidation.
How the injury of the heart took place we have no
means of knowing.

The rupture of the kidney is more easily under-
stood, and cases are not uncommon of rupture of the
kidney which have resulted from various forms of ex-
ternal injury. I know of one case in which a man
fell from the roof of an omnibus, and, striking on the
right shoulder, rupture of both liver and kidney took
place. It is probable that the thrombus of the left
renal vein was due to the injury of the tissues around
the vein produced by the infiltrated blood. The em-
bolus which plugged up the artery on the same side
had evidently come from the thrombus in the left
heart. That infarction of the kidney should have
taken place after closure of both renal artery and vein
is a direct confirmation of Litten's experiment. In
Conheim's explanation of infarction after the closure
of an artery, he assumes that the blood in the infarcted
territory comes from a backward flow from the veins.
Litten afterwards showed that the infarction took
place when both vein and artery were tied, the blood
entering into the tissue from the anastomosing vessels
of the capsule and from the vessels along the course
of the ureter. No infarction followed the ligation of
the artery and vein when the capsule was stripped
from the kidney and the nreter tied.

A REVIEW OF NINETY-TWO CASES OF DIS-
EASES OF THE HEART OBSERVED IN THE
OUT-PATIENT DEPARTMENT OF THE BOS-
TON CITY HOSPITAL.*

BF HBIWT JACKSON, M.O.,
P^ticion (a Out-PotHeiU».

Mamt cases present themselves for diagnosis and
treatment in an out-patient clinic with symptoms sug-
gestive of some disturbance of the circulation, as dysp-
noea, cough, oedema, or inability to work, in whom the
diagnosis may be more or less difficult. Many of the
difficulties may be removed if the physician directs his
attention to a careful consideration of the size of the
heart, to the relative proportion of the cavities and the
muscular tissues of the heart, to its regularity of action
and force, rather than to the presence or absence of
endocardial murmurs. Again, many cases are found
to have some disease of the heart, more often valvular,
but occasionally of the substance of the heart which
present no symptoms of such trouble, and in which a
careful examination of the history may not elicit any
symptom suggestive of cardiac trouble. As a matter
of fact, a valvular lesion in itself gives rise to no un-
toward symptoms, causes no inconvenience to the indi-
vidual, until as a result of the pathological change, of
the incompetency of the affected valve, the heart be-

> A oontrlbation to the forthcoming Medloal knd Sargleal Beport
of the Boston Olty Hoapltal.

Digitized by

Google

112

BOSTON MEDICAL AND SURGICAL JOURNAL. [Fkbkcart 1, 1894-

comes 80 dilated and the moBcalar tissues so weakened
that it is no longer capable of suppljing the system
with properly oxygenated blood. Daring the stage of
compensatory hypertrophy, as long as the defect in the
yalve is overcome by the increase in the muscalar
force, the disease is not suspected by the patient, and
a diagnosis of the condition is made only by chanoe.
Practically, from a therapeutic standpoint we do not
treat the valvular lesion, but can help our patient only
in so far as we are able to assist the heart to overcome
the difficulties dependent upon the defect of the valve.

Clinically, disease of the heart may be divided into
three essential classes : valvular, dilatation and hyper-
trophy, functional. Aside from the cases of dilatation
or hypertrophy of the heart dependent upon valvniar
lesions, many cases are observed in which it is difficult
and often impossible to determine the etiology during
life. From some cause or other the muscular sub-
stance becomes weakened, and secondarily there fol-
lows a gradual enlargement of the cavities, with dimi-
nution in the thickness of the walls. The dilatation
may be dependent upon fatty degeneration, fatty over-
growth (infiltration), some disease of the myocardium
dependent upon obstruction of the coronary arteries,
or may be met with as the result af prolonged over-
work or alcoholic abuse. Again, the enlargement may
be dependent upon arterio-sclerosis or renal disease.

The nomenclature of these various conditions is
unsatisfactory ; it cannot be baaed upon a probable
pathological process, as in most cases this cannot be
determined during life. In hospital records such cases
are often entered as " Cardiac " or " Heart," etc ; and
many death-certificates signed " Heart failure " might
be more properly characterized as dilatation of the
heart. It seems to me that the term " parietal disease
of the heart," suggested by Dr. W. W. Gannett in a
paper read before the Clinical Section of the Suffolk
District Medical Society in March, 1893, is applicable
to a large number of such cases. It expresses tersely
and exactly the condition of the heart without commit-
ting one to an opinion as to the cause of the difficulty.

During two services of four months each, the one in
the summer and the other in the spring, 92 cases were
seen in which the heart was principally or only at
fault as a cause of the symptoms complained of.

In 48 cases no valvular lesion was found as a factor
in the production of the heart trouble ; and these may,
I think, be properly classified as " parietal disease of
the heart." in these cases the diagnosis of some disease
of the muscular substance of the heart was based upon
a modification of the size of the heart, together with
more or less disturbance in its action, as determined by
enfeebled action, increase of rate, irregularity in rate
or rhythm, or intermittency. Undoubtedly, in a cer-
tain proportion of these cases post-mortem examination
would show some valvular disease. Further, in cer-
tain cases a first sound that I describe as short and
valvular, would by some observers be considered as ac-
companied by a murmur ; but in none of the cases was
there a murmur defined in character, or localized with
sufficient accuracy to warrant the diagnosis of a specific
valvular lesion.

Five of the cases were classified as functional. In
all the symptoms were palpitation and pain in the car-
diac region ; one, a man, said he " was afraid to work
on account of his heart." In three, excess in tea, and
in two, excess in tobacco, was assigned as the cause of
the trouble. Two were young men of eighteen, and

three young women. In all these cases physical ex-
amination showed a rapidity of action, but no modifica-
tion in the sise of the heart or in the strength of the
pulsations. The diagnosis of " functional disease "
may here, as in so many other cases, be merely a mssk
to cover our ignorance as to some hitherto unexplaJDed
pathological change ; but at the present time we can
only assume some disturbance of the nerves regulating
the action of the heart, as we have no evidence of any
other pathological condition. In 89 cases there was
some valvniar defect.

The large proportion of cases of some heart trouble
which present no evidence of valvular lesion shows as-
the importance of a careful consideration of the dis-
eases of the parietes of the heart ; a classification of
the symptoms presented by such cases is interesting;
and a uniform nomenclature, if obtainable, is certainly
desirable.

FORTT-BIGHT CASES OF PARIKTA.L DISEASE OF THB
BEABT.

Thirty-six were men, ten were women, and two
boys (aged respectively six and ten years). One of
the boys bad just recovered from diphtheria, and came
in with a complaint of pain in the chest and palpita-
tion. ExaminaUon showed an enlargement of the
heart ; the apex was outside the line of the nipple ;
the pulmonic second sound was accentuated; there
was a slight soft systolic murmur, not transmitted,
heard at the base. Here a diagnosis of fatty degenera-
tion might be with propriety considered. The other
boy, ten years of age, complained of loss of flesh,
general debility and poor appetite ; he had never been
strong. Examination showed an enlargement of the
heart; the apex was just within the line of the nipple,
and the action was violent Though no murmur was
present, congenital deformity was suspected, though
impossible of diagnosis. The age of the other cases

was as follows :

9 OM*, so to 40 yean.
13 oaws, 40 to ISO yaan.

7 eaaM, 50 to 60 jeiCn.
10 OMB, 60 to TO yean.

S oaws, TO to 80 yean.

Where noted, the symptoms which caused the pa-
tients to apply for relief had existed for the following
periods :

12 oases , 3 to 4 yean.
9 aaaea, 1 to 2 yean,
T oases, sereral weeks.
9 cases, sereral months.
2 eases, 10 and 14 yaan respeotlTely.

Seven cases were seen which presented no symptoms
referable to the heart, but came in on account of some
general disease ; as one for herpes zoster, a second on
account of a mastoid abscess, a third for some trouble
with the eyes.

The symptoms complained of were as follows :

16 eases, pain In the chest, sometimes referred to the

region of the heart, more often not looallced.
22 oases, dyspnoea or shortness of breath.

T cases, oough.

8 oases, palpitation.

4 eases, dluiness.

4 eases, general weakness.

2 oases, sadden attacks of faintness.

7 cases, wdema.

The most frequent and prominent symptoms were
dyspnoea and distress, or sharply-defined pain in the
chest, symptoms which in many instances have existed

Digitized by

Google

7oL. CZXX. No. 5.]

BOSTOer MEDICAL AND SUROWAL JOURNAL.

118

for a long time, and often prevented the patients from
doing their nana] work. In none of the cases was
oedema a marked feature, and in only a very few was
albumen noted as present in the urine. In a few of
the cases palpitation was given as the essential symp-
tom which cansed the patient to seek for advice.

Oology. — In 28 cases no definite cause could be
Msigned for the condition of the heart. In 10 the
confession was made of excess in alcohol, and it is
probable that a good many more had used alcohol in
Urge quantities, as patients are not inclined to make
this admission to a house-officer. Seven patients had
tCDte or chronic rheumatism. An examination of the
age of the patients shows that all of them were in
middle life, or past that period.

Phj/tieal Examination of the Heart. — In all the
heart was enlarged, and the apex seen or heard, or
both, outside of the line of the nipple. In one case
the area of cardiac dulness extended two inches to the
left of the line of the nipple. Irregularity of the
action of the heart was noted in 13 cases, and irregu-
larity with intermtttency in 8 cases. In 7 cases rapidity
alone was noted, while in 14 cases the only abnormal
aascaltatory sign was a marked feebleness of the pulsa-
tions, with a short valvular sound at the apex instead
of the booming sound usually beard with the first
loand at this place. T give a few typical cases :

Case I. Man, fifty-three years of age. Complained
of pain in the right chest. Dyspnoea for three or four
years. Had been addicted to the abuse of alcohol.
The heart was enlarged, irregular in force and rate,
aad the sounds were weak.

Case IL Man, forty years of age. Complained
of vertigo, slight dyspnoea on exertion, general malaise ;
was nna'ble to work. Symptoms have existed for
about a year. !No cause could be assigned for his
trouble. Heart was enlarged one-half inch to the left
of the nipple line; the apex was seen and felt just
beneath the nipple. Action of the heart occasionally
irregular ; first sound short, faint and valvular.

Cask III. Woman, forty years of age, a seamstress.
She had noticed shortness of breath and palpitation
for two years, which had interfered with work. No
cause coald be assigned for the trouble. There was
slight enlargement of the heart; its action was very
irregular in rate and rhythm. There was slight oedema
of the legs ; no albumen was found in the urine. It
is possible that in this case there may have been a
stenosis of the mitral valve, but the absence of any
history of rheumatism or any abnormal sounds at the
mitral valve renders the diagnosis at least doubtful-

TBIRTT-NIIfE CASES OF VALVULAR LESIONS OF TBE
HEART.

Hen, 26 cases; women, 10 cases; children, seven
to ten years of age, 3 cases. The duration of the
symptoms, when noted, was as follows :

6 eues, MTeral veelu.
10 emsM, HTeral months.

4 MM>, a jrearor mora.
6enM,3to37Mn.

5 nam, Mtmnl yean.

2 eases, 8 and 15 7«an reapeotlTeljr.

In 7 cases no symptoms were presented suggestive
of any cardiac trouble. One case came in on account
of gonorrhoea ; another, who complained only of pain
in the Inmbar region, had a mitral regurgitation, with
ao enlarged heart in which hypertrophy was the essen-

tial factor in forming the increase of size. Fifteen
years ago, when a boy, he had acute articular rheuma-
tism.

In some of the oases the symptoms which brought
the patients to the clinic had been noticed only for a
few weeks ; others who engaged in hard labor had
suffered more or less for many years.

The symptoms complained of were these :

7 eases, a sense of pain or distress In the

oardlao region.
15 eases, dyspnoea.
7 eases, oongb.
4 oases, dizziness.
2 cases, osdema.

It is extremely interesting to note the ability to work
as an index of the effect of the cardiac lesion on the
individual. Only seven had given up their work on
account of dyspnoea or shortness of breath ; while, as
stated, seven made no mention of symptoms sugges-
tive of any cardiac disease. Only two of the men
were engaged in light work, the others being day-
laborers, or otherwise employed at hard, manual labor.
Several of the patients who had marked valvular defects
with great increase in the size of the heart were actively
employed in bard labor. One case is especially note-
worthy, that of a blacksmith, twenty-five years of age.
He complained of dyspnoea on exertion, and a consider-
able swelling of the body and extremities which had
existed for several months. He had acute articular
rheumatism two years before he was seen at the out-
patient department. Physical examination showed
pallor and cyanosis ; the heart was enlarged two inches
to the left of the nipple ; there was a loud double mur-
mur at the base, a systolic murmur at the apex and in
the tricuspid area. He came to the out-patient depart-
ment for several months ; and during all this time
continued to support his family as a blacksmith.

Such an analysis of cases shows us very vividly that
because a man has valvular heart-disease he is by no
means to be considered incapable of working, and may
live in comfort for many years, as in several instances
the rheumatism which appeared to be the etiological
factor of the disease had occurred many years before
the patients were seen at the clinic.

Etiology. — In 14 cases no cause assigned ; in 1 6
cases, acute articular rheumatism ; in 7 cases, chronic
rheumatism.

A boy of ten years was seen who bad never had
rheumatism or any acute infectious disease. He came
in on account of epistaxis, but the mother said that he
had never been " rugged." There was great enlarge-
ment of the heart, with violent action and a pre-systolic
and systolic murmur.

The following forms of valvular lesion were seen :

16 eases, mitral regnnitation.
y oases, mitral obstractlon and regurgitation.
1 ease, mitral obstruetlon.
6 eases, aortlo obstrnotlon and regnrgitatioo.
4 oases, aortle and mitral regargitatlon.
1 case, aortie and trioospid regurgitation.
1 case, aortic regargitatlon.
1 ease, aortic stenosis and mitral regurgitation.
1 ease, aortlo stenosis.

Tbb Faculty of the Medico-Chirurgical College of
Philadelphia has created three new clinical chairs,
namely, genito-urinary surgery, orthopedic surgery and
otology. These, together with the vacancy in the
chair of clinical medicine, will be filled permanently
at the end of the present session.

Digitized by

y Google

114

BOSTOS MBDIQAL AND SURGWAL JOVBHAL. [Febrcabt 1, 1894

A BLOODLESS OPERATION FOB H^MORr-
RHOIDS.

BT THOIUA H. ICAWLBT, l(.D.,
VUMng Surgeon to Harlem Boipital, Neto York.

As bsemorrhoidal diseases of tbe rectum and anus
are very common, and very often lead to very grave
distarbances of the whole system, any line of treat-
ment which will relieve or wholly sobdne them, with-
out any serious inconvenience or involving danger to
life, will be welcomed by the profession.

At the beginning, it may be well to consider for a
moment what we understand by the term "hsemor-
rboids." From the etymology of the word we expect
to find blood-tumors; but, in strict truth, in very
many cases of so-called haemorrhoids or piles the vas-
cular system is totally devoid of any implication what-
ever; the small neoplastic formations which present
themselves along the base, annular rim or roof of the
anus and rectum, being histologically purely adenoid,
papillomatous or vegetative. It is important that the
anatomical distinction be made clear in this instance ;
for the treatment about to be commended applies espe-
cially, and almost solely, to those anal tumors which
are, or were, entirely dependent on a diseased condi-
tion of the bsemorrhoidal veins, in other words, those
which are of a veinous origin only.

Another important question arises with respect to
the relative frequency of these anal varices, designated
piles. Are anal varices, dilatation of the veins or
those tumor-like formations, either internal or external
to the external sphincter, essentially a pathological
condition ? and, as such, in all cases, does it require
active, radical measures for its abolition ?

Very naturally, our course will be determined largely,
in those cases, by a definite answer to this question.

If piles are all superfluous, neoplastic excrescences,
then there can be no question as to oar coarse in all
cases.

During the past five years, I have made an exami-
nation of a very considerable number of supposed
healthy recta on the living ; and, in the dead-house,
have carefully inspected under good light a large
number on the cadaver. It was found that in both
more than fifty per cent, had veinous varices of the
rectum. In many of the living, in whom varices of
large calibre were numerous and extremely turgid,
they never in their lives suffered from piles in any
form, that they were aware of. Therefore, it seems to
me that the hsemorrhoidal dilatation in man is rather
a physiologically degenerative condition, which, in
late life, is a source of no inconvenience, but which, at
middle age, is often attended by or associated with
such complications as to render it a distinct pathologi-
cal lesion.

This view is further supported by the fact that cat-
ting out, injecting or ligating oS sundry hsemorrhoidal
masses will not in all cases cure the disease. The
varicose state of the upper rectal vessels remains, and
nothing is wanted to promote their return but the ex-
citing circumstances which caused their irritation in
the beginning.

COMPLICATED H^HORBHOIOS.

IHtea$ed hasmorrhoids may be divided into three
principal classes: (I) inflamed haemorrhoids, (2) ul-
cerating haemorrhoids, (3) bleeding hsemorrhoids.

Besides, we say internal or external, according as

they are without, or outaide the external sphincter, or
internal to it.

When internal medication has not succeeded, and,
when palliative, topical applications have failed to
afford permanent relief in chronic hasmorrboids, ia
their radical treatment by the bloodltu operalioD tbe
majority may be cured, or at any rate greatly re-
lieved.

TBB ADTANTAOBS OF TBB BLOODLESS OVBB OTHER
SDROICAL MEA8USES IN TBBATMBNT.

(1) The operation may be performed with a less
number of assistants, and is very simple in its tech-
nique.

(2) As there is no division of the tissaes, the dan-
gers of infection, of abscess, ulceration and fistula are
eliminated.

(3) There is no danger from the immediate loss of
blood during operation or of serious secondary hsmor-
rhage.

In all cases, the evening before operation the patient
should have the colon well cleared of all faecal matter
by a brisk purgative.

In the morning, when everything is in readiness,
the patient should be given from two to four ounces of
whiskey, the quantity to be gauged according to pre-
vious habits, its effects, etc. After having cleansed,
shaved and scrubbed tbe integuments over the ischio-
rectal fossa, we are prepared for the first step in the
operation, which is, effective eoeainizaiion, hypoder-
mically applied. Local analgesia, when practicable,
is much more preferable to pulmonary ansesthetics.
Our patient is more manageable, and there is no spurt-
ing of the faeces over the operative field during manip-
ulation.

Cocainization complete, the next and most vital step
is complete and thorough anal dUaloHon. Without
this being efficiently carried out, all else is a failure;
but, to be painless and safe, it must be gradual and
steady, or we shall rapture the muscle and leave our
patient incontinent. In chronic, old cases, wherein,
owing to malnutrition and interstitial changes in the
sphincter, it has parted with its elasticity, laceration it
very easy if we do not exercise caution.

Thorough anal dilatation accomplishes two purposes
of great importance : First, it opens widely the anal
portal, and so paralyzes the levator-ani that the lower
fourth of the rectum — that part always implicated in
haemorrhoids — prolapses through the open vent, when
it can be most minutely inspected and raidically treated.
This, however, is of minor importance compared with
the profound effects which dilatation produces on the
rectal disease. It is not material whether the hsemor^
rboids belong to the infiamed, intensely itchy or irri-
table type ; this stretching exercises a most salutary
influence on them.

Tbe third step, in simple hsemorrhoids, will be the
separate treatment of each tumor by forcible pressure-
massage. Before thi^ is commenced, the entire cluster
should be - wiped clean and dry, and be then freely
mopped with the cocaine solution. Now each htemor-
rhoid is separately seized, close to its base, firmly
between tbe tip of the thumb, index and middle fingers ;
first, put on a moderate but full stretch ; then twisted;
and finally so completely crushed that it is reduced to
a pulp, and none of the investing tunics remain except
the mucous membrane and its under stratum of fibrous
tissue. When this has been completed the entire

Digitized by

Google

Vol. CXXX, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL.

116

mass u again pressed up inside the sphincter, a sup-
pository of opium introduced, a pad and bandage ap-
plied, when the patient is returned to bed. An active
bat painless inflammation follows, and, as a rule, within
two or three weeks absorption and atrophy have so
rtidaced the vascular masses that nothing now remains
bnt their shrunken, diminutive stems.

The ulcerative and hssmorrhagic varieties, along
with cocatnization and dilatation, must have super-
added a special therapy appropriate to each.

Since January of this year, 1893, 32 cases of hemor-
rhoidal disease have come under my care, in the hos-
pital and ontside. Many have come to me who feared
antesthetics, and others who were averse to having any
cutting operation performed. In all, the permanent re-
sults have been eminently satisfactory ; and from what
previous experience I have had with this procedure,
there is no reason to believe that the cures will not be
as durable as those effected by other more sanguinary
measures, which are not without danger in themselves,
and are sometimes followed by the most lamentable
consequences.

Of my latest series of cases, 17 were men and but
15 women. Fourteen were cases of simple, chronically
inflamed haemorrhoids, nine ulcerating and itchy, and
nine bleeding. Four of the female cases were of the
bleeding variety. Of the ulcerating type, in six of
them there was a well-marked tubercular cachexia.

Vix^wt^ of JbtnUtuit*

BOSTON SOCIBTT FOR MEDICAL OBSERVA-
TION.

3. 0. KDKBO, M.O., SSOBKTABT.

Bkgulab MeeUng, Monday, November 6, 1898,
Db. Cbasi.es p. Potnam in the chair.
Db. J. B. McCoLLOU read a paper entitled,

SOUK BBMABKS ON DIPBTHBEIA.'

Db. Mason: The interesting paper of Dr. Mc-
CoIIom deals with a subject which is practical and im-
portant to every one who is practising medicine. The
bacteriological investigations seem to have left the
matter in such a position that to-day no one is justified
in making a diagnosis in a doubtful case of sore throat
without cultures. The difficulty of an off-hand clinical
diagnosis by inspection is obvious. In former years
mistakes were very often make, and they are still
made, as is evident from the number of cases that
oome to diphtheria wards, which, after a day or two,
by the application of this method, are shown not to be
diphtheria. In October, perhaps a dozen cases entered
our ward at the City Hospital which turned out to be
pharyngitis, tonsillitis or stomatitis, all sent to the
hospital as diphtheria. The inspection of such cases
always raises a doubt with regard to the diagnosis,
which may not be determined for a day or two, and
the question of isolation becomes important. In the
hospital DOW building there will be facilities for isolat-
ing considerable numbers of doubtful cases, so that
they will run no risk of contracting further disease.
But fortunately, as Dr. McCollom remarked, these
milder sore throats seldom become diphtheria. It is a
rare thing for such a case to contract diphtheria, even

' Bee page lOT of the Joonal.

when ID the presence of a considerable number of
malignant cases. Such patients are sent away as soon
as possible, either into another ward or away from the
hospital. That, however, cannot be done until suit-
able cultures are made, a matter of a day or two.
Occasionally, from some fault of the technique or
some mistake or other, the bacilli of diphtheria are not
found at the first examination, but are found subse-
quently. Therefore, it is best to have more than one
culture made in cases in which the result is negative
before sending such patients away from the hospital.
This involves the stay of a few days, and by that time
the patients are probably well enough to go out
From the clinical standpoint, the experiments at the
City Hospital have been of great value, not only in
separating these classes of non-diphtheritic sore throats
from true diphtheria, but also in differentiating the
mixed throats, the cases of scarlatina in which diph-
theria exists from those in which no diphtheria exists.

With the disappearance of the visible membrane in
the throat diphtheria does not end ; that is, the bacilli
may be found for a considerable length of time, and it
is a question whether patients whose throats have
cleared up and who present no discharge from the nose
— nothing to indicate continuance of the disease —
are to be regarded as well and sent home, or whether
they should be retained for a longer time. The Klebs-
LOffler bacillus may be found for an indefinite time
in the secretions of the nose and pharynx. The
longest period that I have observed is three weeks
after the membrane had disappeared. The child was
apparently well, the symptoms bad gone, the appetite
was good, the patient was becoming ruddy, and yet
the specific bacillus persisted for three weeks. With
our present knowledge, it does not seem proper to
send patients in that condition away from the hospital
or into another ward; therefore they are retained
until the Klebs-LSffler bacillus is absent from the
secretions of the nose and of the pharynx. I believe
that this organism may persist for a much longer time
than three weeks. Perhaps Dr. Williams has more
knowledge on that subject than I have, but I think I
have read of a case in which some fifty days elapsed
before these organisms entirely disappeared. Fortu-
nately, these cases are few, and we do not have to
crowd our wards with patients requiring such a length
of time for convalescence. It may be doubted whether
these late bacilli are not of the modified form, to
which Dr. McCollom referred, which are not active
conveyers of the poison. Although every one is now
upon the alert in the examination of throats, it does
not seem probable that in the near future differentia-
tion with this great degree of care will be the general
practice. In the lower parts of the city I suppose
that bacteriological cultures are not practicable, unless,
indeed, this very excellent scheme which Dr. Ernst
wishes to inaugurate can be carried out by the majority
of physicians practising all over the city.

Dr. Williams : I am sore we have all been very
much interested in Dr. McCollom's paper, and it is
certainly very important that this question should be
spoken of repeatedly. Very much has been said and
done about cholera, and comparatively little said about
diphtheria, a disease which is always with us and very
fatal in its character. A good deal is now being done
but there is more still to do. It seems as if the disease
were transmitted from patient to patient directly in the
majority of cases. Many of the cases which come to

Digitized by

Google

116

BOSTON MEDIOAL AND SUMOIOAL JOUMNAL. [Fsbbdabt 1, 1894.

the City Hoepital give a history of having been in the
game house with diphtheria or having had a brother or
a Bister ill with the disease recently. Sometimes, of
coarse, we do not get a history of exposure ; but it is
rather significant that we do in so many cases get a
history of direct exposure. The question of bacterio-
logical examinations interests me very much. I be-
lieve I was the first to use that method of diagnosis in
this community, and its importance will soon be gen-
erally recognized. As regards the mild cases of which
Dr. McCollom speaks, they are especially dangerous
to their neighbors, because their true character is
often not realized and therefore proper precautious
are not taken. It is not unusual to find mild cases
that to the unaided eye do not present the ordinary
symptoms or appearances of diphtheria (in fact the
throat may look normal), but that are shown by bac-
teriological examination to be diphtheria.

I recall one case which two physicians saw, and
said there was nothing in the throat. It seemed
to me there was a slightly suspicious spot; I did not
call it membrane. There was not much redness ; it was
nothing like as angry a throat as you get in mild ton-
sillitis, but cultures showed the presence of the bacilli,
and the case proved to be one of diphtheria. I think
it is very important that examinations should be made
where there is the slightest symptom connected with
the throat among those who have been about a patient
with diphtheria. It is not necessary to wait until you
get symptoms of severe tonsillitis, or follicular tonsilli-
tis, or something very distressing ; but it is well to be
on one's guard, for sometimes you find bacilli when
you least expect to — at least, that has been my experi-
ence several times.

As regards the detection of these bacilli, I think in
some cases, especially early in the disease, when you
have chiefly the bacilli of diphtheria, and these are not
obscured by other organisms which develop later, they
may frequently be detected without cultures. In such
cases it is very easy to take a cotton swab, and, after
brushing it over the throat, rub it on a cover-glass,
dry, and stain with Loffler's blue solution and examine
under the microscope. lu many oases one can find the
bacilli in a few minutes. When you find them, this
method of examination is of importance ; when yon do
not, it has comparatively little weight; that is, you
cannot exclude diphtheria by means of this preliminary
examination. Of coarse, one should not rely upon
this alone ; cultures should be made as well.

As regards the method of carrying the bacilli. This
contrivance which I have in my hand is very simple.
Here is a small stick with a bit of cotton around the
end. The cotton end is brushed over the suspicious
places in the throat, and the stick is then placed in a
strong test-tube, which is stopped with sterilized cot-
ton. To prevent the specimen from drying, a small
piece of cotton moistened with water may be placed
above the stopper, and the tube may then be closed
with a cork to prevent evaporation. This contrivance,
which has, of coarse, been previously sterilized, answers
very well to carry the swab to the laboratory where
cultures 6an be made.

As regards the length of time during which the
bacilli may persist in the throat, I have in mind several
cases, some of which I have already reported. In one
case they persisted about six weeks, in another about
two months, and in another nearly three months. The
last case is interesting because the patient left thej

hospital and some weeks later had hoarseness ; and on
examining the throat a membrane was seen in the
larynx, and the bacilli were readily found, so that in
some cases the bacilli may exist in the throat a long
time. Isolation should not be terminated, although the
throat may look perfectly normal, antil the bacterio-
logical examination fails to show the dangerous bacilli
This may sometimes be weeks after the throat hiu
been clear of membrane.

Not infrequently you find diphtheria coincident with
other diseases. This is especially the case with scarlet
fever. In measles yon sometimes find diphtheritic
membrane, and it is well to remember that in typhoid
fever you may in some cases also find membrane in
the throat in which the diphtheria bacilli are present
Patients, of course, may get diphtheria or scarlet
fever if placed near those ill with either of these dis-
eases. Diphtheria does sometimes occur in patients
who have had tonsillitis or some membranous aSection
of the throat, and who have been exposed to diph-
theria. I have seen some cases of this kind. I think
the tradition that cases of tonsillitu do not acquire
diphtheria has exceptions ; it simply means that that
has not been observed; and I think, with the more
modern means at command, we shall be enabled to
detect more cases of this sort.

Db. Spbagce, of Providence: I have been very
much interested in the paper of this evening, and cer-
tainly the subject is one in which we are all interested.
My studies at the present time are more in the line of
diseases of the ear and throat, and I do not see many
cases of diphtheria ; but I meet cases in which at the
time it is impossible to make the diagnosis. In Provi-
dence our board of health has been in the habit of
making the diagnosis of diphtheria by the death-cer-
tificate and of scarlet fever by desquamation; bat
within a few months or a year, they have been going
into the bacteriological examination, systematising
things, making the work more thorough. I think
that the ground has been very ably covered by the
reader and by the discussion, and that little remains to
be said.

Db. F. C. Shattdok : Like everybody else, I suppose,
I hailed with great joy the announcement of a method
which would enable us to distinguish diphtheria from
other throat affections, because I have always felt it
to be one of the most difficult diagnoses in medicine,
to determine in certain cases whether diphtheria existed
or not. Of late years I have not seen many cases of
diphtheria. When I had a dispensary district I saw
an immense deal of it. Last winter I saw a child
with a suspicious throat. I had Dr. Stone make cul-
tures ; the Klebs-L6fller bacillas was found and the
case was treated accordingly. A few weeks later
another child in the same family came down with a
throat which clinically, macroscopically, was certainly
diphtheria. There was false membrane on the tonsils
and spreading up on the soft palate. At my request
Dr. Stone made cultures of this case. His first result
was negative. He made a second examination which
was also negative. I treated the case, however, ex-
actly as if it were one of diphtheria, and I most say
that 1 should not feel safe in following any other
coarse at present. I do not feel sure that this method
has been practised long enoagh, or that we know
enough about it to warrant us in treating throats which
look like diphtheria to the naked eye in any other way
than as if they were diphtheria. When a new method of

Digitized by

Google

Vol. CXXX, No. 5.] BOSTON MBDIOAL AND SVRGWAL JOVRJfAL.

117

diagnosis is annooDced, just as when a new drug is
brought forward, I ihiuk the tendeucj of the profession
is to be too enthusiastic at first. Perhaps I show my ig-
norance in speaking as I do ; but I shonld not feel satis-
fied in my own family or in any family to remove re-
strictions and to allow a patient to go about who bad
a throat which clinically was diphtheria, although the
'bacteriological examination was negative. I shall be
very much interested to see what ultimately comes
oat of this. If we have a sure means of differentiation
it ^111 be an immense boon. But a new terror is
added to life in the fact that patients someUmes for
fifty days after naked-eye manifestaUons have vanished,
have the bacillus in their mouths and noses or throats,
and consequently may transmit the disease to others.
In the nose there are so many hiding places for bacilli
that I cannot see how a simple little swabbing, with
negative culture results, can make us sure of their
absence.

Db. Masom: With regard to Dr. Sbattuck's re-
marks it has struck me too that some cases do not
present the Klebs-LSffler bacillus when they should
do so according to the appearances, and that has seemed
to me to {ie due rather to faulty technique or to some
ntistake than to the fact that these bacilli might not be
foaud perhaps by more prolonged search. Such a case
came under my observation not long ago in which a
^ patient had membrane in the throat — not very much,
bat there was laryngeal stenosis and tracheotomy was
, required. It was evidently a case of tracheal diphtheria,
bat the bacilli were not found at the first examination.
\ So I think that such negative results are only of value
from that point of view ; they are negative, but they
^ do not prove that the subjects do not have diphtheria.
Dk. Shattook : I do not see how greater care conld
have been taken in this case. A thoroughly competent
' man was selected who was perfectly familiar with the
appearances of the bacilli and their .manner of growth,
and at my solicitation he made two examinations with
the greatest care, the results of both of which were
\ negative.

Db. Williams : I think what Dr. Shattuck said is
very suggestive. It b a point which has been in my
mind, and in fact in a paper which I read last June
before the Massachusetts Medical Society, I said that
the caltures were not infallible. I do not think they
' are to be absolutely and entirely relied upon. I think
it is possible to have some slip so that you do not get
a growth of the bacilli, but our ability now to detect
diphtheria early is very much greater than it used
. to be, and this method is certainly a great step in
advance, and will render much service. I had a case
within a few days where examinations were made with
great care with negative results. The patient died,
and no bacilli were found in any of the parts about the
throat, tonsils or anywhere, except in the little chink
between the vocal cords. The trachea was taken out
and cat open with carefully sterilized scissors, and
a small drop of purulent matter about the size of a
pin's head was found ; cultures were made, and the
bacilli developed. I recall a case in which a child had
measles, and coughed up large pieces of membrane.
It seemed to me to be a case of diphtheria; and I
held to that diagnosis, which was based on a prelimi-
nary examination, in which the bacilli were found,
although 1 was told that the bacilli were not found in
the cnltnres. Another specimen was obtained and
another caltnre made, and no bacilli found : then an-

other specimen was taken from the throat and examined
directly in the way I have referred to for making the
preliminary examination, and the bacilli were perfectly
evident. The cases that Dr. Councilman and I studied
together last year included some which came from two
institutions of the city where there are a considerable
number of children ; and in these institutions there
happened to be during a period of about six weeks
cases of diphtheria alone, cases of membranous throats
without the bacilli, cases of scarlet fever alone, and
cases of scarlet fever with diphtheria. Similar condi-
tions must, 1 think, favor the development of these
two diseases. Let me repeat : it is well to bear in
mind the possibility of failure to find the bacilli by the
method of culture. Corrosive sublimate which is often
used as a local application inhibits the growth of the
bacilli ; one part in thousands will inhibit the growth
of the bacilli, prevent their growing at all on the
culture media; bat a pretty large proportion of the
corrosive sublimate is not su£Scient to kill the bacilli.
While speaking of corrosive sublimate I should like to
say that it does not seem to me a very serviceable
agent as a local application ; it is very irritating even
in a dilute solution if used persistently. When applied
in the strength of 1 to 2,000 or even 1 to 500 it does
not teem to have much effect in stopping the growth of
the bacilli and the spread of the membrane. 1 have
tried treating one part of the throat with corrosive
sublimate in pretty strong solution, and not treating
other portions ; and the parts treated with corrosive
sublimate did not do as well as the parts not treated.
I am very sure that corrosive sublimate as a local ap-
plication may do barm locally as well as cause poison-
ing ; but I understand from the Secretary of the Society
that the question of treatment is not so much before
the meeting as that of diagnosis, so I will not enlarge
upon the treatment of diphtheria.

THE NEW YORK NEUROLOGICAL SOCIETY.

Stated Meetings, held at the New York Academy
of Medicine, Tuesday evenings, December 5, 1893,
and January 2, 1894, Dk. M. Allen Stabb, Presi-
dent, in the chair.

GLIO-SAKCOHA OF THE BASAL GANGLIA.

Db. Fbbdbbick Pbtebson presented a specimen
of glio-sarcoma of the basal ganglion. The case was
that of a man aged fifty years, who bad been in excel-
lent health, with the exception of occasional attacks
of vertigo and slight headache, until June 8, 1893,
when he fell to the floor in his office. He had a general
convulsion, and was unconscious ten hours, in two
weeks he was well enough to return to his office from
his home in New Jersey, and to continue at work for
five days, when h'eadache and malaise kept him at
home. Four weeks after his first convulsion he had
five or six more of short duration, and rather left-sided
in character. At this time he presented the following
symptoms : left hemiparesis and hemianesthesia, left
hemianopsia, tendency to somnolence, pupils equal
and small, sometimes delirious, great frontal headache,
pulse 52 to 60 per minute, respirations slow, slight
optic neuritis. The diagnosis of sarcoma or glioma
situated deep in the brain, so as to affect the posterior
limb of the right internal capsule, was made. An
operation was out of the question. The man was on-

Digitized by

Google

118

BOSTON MEDICAL AND SUBOIOAL JOURNAL.

[Febrcabt 1, 18H

conscious during the last three dsjs of life. At the
autopsy, made just five months after the first apparent
onset of symptoms, a glio-sarcoma was found, about
two inches in diameter, occnpving the region of the
basal gangltpn, especally posteriorly, and projecting
upwards into the right lateral ventricle and down-
wards somewhat into the right crus. It was not
strictly demarcated, and there was some infiltration
into the white matter of the brain, with here and there
some areas of softened brain tissue. A secondary
tumor, the size of an almond, was found attached to
the dura mater on the right side, compressing the cor-
tex in the region of the angular gyrus.
Db. Alfred Wieabb described a case of

SUBACUTE UNILATERAL BULBAB PALST, WITH AU-
TOPSr.

The patient was a young man aged seventeen years.
Family history negative with respect to any heredi-
tary nervous trouble. Patient had always been in
good health up to two years ago, when he was taken
down with an attack of perityphlitis, from which be
recovered after five weeks of illness. About two
years ago last spring the glands on both sides of his
neck in the region of the stemo-cleido-mastoid muscles
began to enlarge. In the summer of the following
year, 1892, an abscess formed in one of these gkinds
and had to be opened. In August, 1892, the glands
on the right side, together with a large portion of the
stemo-cleido-mastoid muscle, were excised. Those on
the left side were removed the following month, and
were found to be of tubercular nature. The patient
rapidly recovered, and nothing was noticed in the way
of any disturbance of the parts which might have been
involved in the operation. In November, 1891, it was
discovered that the patient's tongue deviated to the right
side, and shortly after this he experienced some difficulty
in swallowing. He soon became hoarse, and coughed
with difliculty, and within a space of ten days the patient
developed a complete unilateral palsy of the right side
of hb tongue, soft palate, pharynx and right recurrent
laryngeal nerve. There was no disturbance of his re-
spiratory or cardiac organs, or other condition present
which should have called attention to an affection of
any other cranial or spinal nerves excepting the ninth,
tenth, eleventh and twelfth. The symptoms remained
stationary for a time ; then the patient began to grow
very much weaker; and suddenly, on March 26, 1893,
he had an attack of respiratory failure. From this he
partially recovered, and then continued in a condition
of slight respiratory difficulty. He could hardly speak
above a whisper. He had excessive salivation. On
April 11th he could barely protrude his tongue beyond
the edge of his teeth. His lips remained normal, and
could be brought into perfect apposition. The palate
and pharynx on the left side remained normal. On
April 20th he had another attack of respiratory failure,
which proved fatal.

The autopsy, made six hours after death, revealed
that the motor cortex, internal capsule, crura cerebri
and pons were normal. The nucleus of the twelfth
nerve on the right side was much diseased, while on
the left side it was diseased to a slight degree. The
nuclei of the ninth, tenth and eleventh nerves were
slightly affected, a little more on the right side than
on the left. The respiratory bundle appeared to be
completely degenerated on the right side, while on the
left, in the region of the hypoglossal nucleus, its lower

and anterior portions were diseased. In the region of
the ninth nerve a few fibres were affected. The intra-
medullary roots of the ninth vagus, vago-accessoriDm
and hypoglossal nerves were less prominent on the
right side than on the left. Otherwise, everything ap-
peared to be perfectly normal up to the exit of the
first cervical nerve in the spinal cord. As regards the
nature of the lesion, no tubercle were found, as bad
been expected, nor were tubercle bacilli found oo
microscopical examination. There was simply an
atrophy of the ganglion cells and fibres motor in func-
tion.

From a careful consideration of the preceding case
and antapsy. Dr. Wiener drew the following conclu-
sions :

* (1) That the region of the hypoglossal nucleus
gives origin to nerve-fibres which supply the tongue,
palate, pharynx and larynx on one side of the body.

(2) The column of nerve-fibres known as the re-
spiratory bundle consists of fibres from the glosso-
pharyngeal, vagus and vago-accessorium nerves; and
the lower and anterior portion of this column probably
serves as the locality for the vagus and vago-accesso-
rium fibres.

(3) That the glosso-pharyngeal nerve seems to con-
trol the reflexes of nausea and gagging in the soft
palate and pharynx, and also to send some of the
motor filaments to the pharyngeal muscles. These
latter filaments take their origin in the hypoglossal
nucleus, and ascend in the respiratory column to the
nucleus proper, and then make their exit with the
glosso-pharyngeal nerve.

(4) That the soft palate muscles are not innervated
by fibres from the seventh nerve.

THE P0H8-HSDULLA FLOCCULUS TBIANOLE AS A
TUMOB SITE, WITH PATHOLOGICAL FIMDIMaS.

Db. Bobbbt Safford Newton read a paper on
this subject, which he illustrated by the following
case:

Female, aged twenty-eight years. She entered St
Mary's Hospital July 10, 1893, complaining of a con-
stant headache for a fortnight, with morning vomiting
and sickness for seven days. No history of any
trauma ; no specific history ; family history negative.
Two days after admission she was examined, and apart
from a silly manner and a slight drawling in her
speech, she presented no symptoms. On July 20th
the patient became weak and fell to the floor. She
muttered to herself during the night, and moaned
about her head. The pain appeared to be diffuse.
She was dull and stupid. Her speech was prolonged
and tedious. At this time there was no defect of the
cranial nerves. Pulse 45 per minute. She had a
shuffling walk, with some tendency to go to the right.
The superficial reflexes were present; the knee-jerk
was increased on the right side. On July 22d the
patient became quite deaf. The headache was very
violent, keeping her awake. July 24th, patient very
feeble; deafness marked, especially in the left ear;
no tenderness nor discharge. The patient stated
that she could not see well, but the ophthalmoscope
showed no marked lesions. Upon standing up, she
was projected to the right very forcibly. The move-
ment at each trial was accompanied by a look of fear,
paling of the face, dilatation of the pupils and bathing
of the surface in cold perspiration.

From this time on the patient failed rapidly. The

Digitized by

Google

Vol.. CXXX, No. 6.] BOSTON MBDIOAL AND SUBGIOAL JOVBNAL.

119

sight became worse; the patient grew petalant and
childish ; her appetite remained fairly good. Nystag-
mus 'was present for one day only. The external rec-
tus 'was also temporarily affected. She had a transient
facial tic. The sense of smell was present to the last.
Optic neuritis first appeared in the right eye, then in
the left, and rapidly went on into total blindness. She
also became totally deaf. Her taste sense was not
appreciably affected, although she occasionally com-
plained of a hot, scalding feeling in the back of the
tongae and palate. Her pulse was slow from the be-
ginning; towards the last it dropped as low as 10, 12
and 14 beats per minute, and three days before her
death it dropped to 6 beats per minute. There was
no anaesthesia nor implication of the pain, tempera-
tare, tactile or mnscalar senses. She never had any
convulsive seizures or paralytic attacks. The weak-
ness steadily progressed ; there was loss of control of
the sphincters ; the respirations became slow, and
gradaally ceased. Just before her death she was still
able to distinguish between whiskey and milk.

The autopsy was made ten hours after death. Upon
removing the brain, an enormons tumor with a central
projection was found on the left side. The swelling
was somewhat triangular; its apex was under the
thalamas and geniculate body, its base crowding the
cerebellum off from the medulla, and its side line not
quite reaching the middle of the pons. In the central
pons region was a projecting mass, shaped like a
thumb. The bulk of the growth was a cyst. The
left half of the pons was much softened, and the me-
dulla and cerebellum were flattened. The olfactory
nerve was intact. The optic nerve was swollen on
the left side. The third and fourth nerves were intact.
The fifth and sixth also seemed to have remained uo-
changed. The seventh nerve was on one side of the
growth, the eighth on the other. The nnclei of the
ninth, tenth and eleventh nerves were pushed aside by
the change in position of the floor of the medulla.
The nucleus of the twelfth nerve was entangled in the
growth. The cyst began at the margin of the fourth
ventricle by a blocking of the channel of communica-
tion between the lateral cisternsB of the ventricle and
the cavity of the arachnoid.

STBIMOO-HTKLIA : OBNTBAL OLIOKA OF THE SPINAL
CORD, WITH BPONTANEOD8 OBMTKAL H^MOS-
BHAGB.

Db. Charles L. Dada read a paper on this sub-
ject, and narrated the history of the following case :

The patient was a man who had a central gliomatous
tumor in the lower part of the dorsal region of the spina)
cord. This tumor progressed slowly for two or three
years, causing, during that time, the symptoms of a
transverse myelitis chiefly, altbough the presence of a
spinal tumor was suspected. Among other symptoms
there was anaesthesia of the right leg extending up to
the twelfth dorsal spine, and involving touch, tempera-
ture and pain sensations. Anaesthesia involved to a
lesser extent the left leg. Just before the man's death
a large haemorrhage occurred, which was confined to
the centre of the spinal cord and which caused ex-
quisite pain ; the man, in fact, dying from exhaustion.
Upon post-mortem examination a large central haemor-
rhage, destroying nearly every particle of the spinal
cord at the level of the seventh dorsal segment was
fonnd. This haemorrhage extended up and down for
a distance of about three inches. Around the haemor

rhage and above it were evidences of a gliomatous in-
filtration involving nearly the whole of the transverse
area of the cord at that level. Very striking second-
ary degenerations, ascending and descending, were
fonnd. The case was one of glioma of the spinal
cord, without there being any cavity formed. Al-
though clinically, and in one sense, pathologically, it
would be a case of syringo-myelia, yet that name can-
not strictly be applied to it.

In commenting on this case. Dr. Dana referred to
the question of the existence or the non-existence of a
pain tract, and the advisability of our searching for it.
The psychologists seem to have come to the conclnsion
that pain is not a sensation, but a form of feeling ;
that it is not to be classed with the sensations of touch
or temperature or heat ; that it does not have peripheral
end organs and that there are no nerves in existence
which on irritation alone produce pain ; that there is
no such thing as a pain tract ; that in attempting to
locate such a tract we are pursuing a will-o'-wisp. Dr.
Dana said that after a very careful study of this ques-
tion he has been converted to the psychologist's view.
If we claim that there is a special tract for pain, we
can just as well claim that there is one for hunger and
various other sensations. If there is a special tract
for any of the common subjective sensations, there
must be a special tract for all.

Db. B. Sachs said that in former days he held to
the view that pain was nothing more than an intensi-
fication of the ordinary tactile sense ; and in the ma-
jority of cases we meet wit-h such an explanation would
hold good, and under such conditions we would not
look for any special pain tracts. The clinical facts
that have been brought out with regard to syringo-
myelia, however, do not bear out that theory. Touch
and temperature sense may remain normal, whereas
the pain sense is entirely lost. The psychologists'
view of this question is one that is rather difficult to
reconcile with the clinical facts we have obtained from
syringo-myelia. On the other hand, this disease is
very destructive and irregular in its course, and for
this reason is rather an unsafe guide for ns to go by in
trying to determine physiological functions.

Db. G. a. Hebteb said that several years ago he
hemisected the spinal cord of a monkey in the mid-
dorsal region ; he was unable to find in that case any
evidence of a loss of sensibility to pain either on the
same side as the lesion or on the opposite side. He
also performed this experiment on an opossum, with a
like result. Mott, in his experiments, cut the antero-
lateral ascending tract and was unable to find any evi-
dence of loss of sensibility to pain. The results of
experiments on animals, of course, cannot be applied
directly to man. The subject brought up by Dr.
Dana is an interesting one, and up to the present time
we have not enough cases on hand to base any definite
conclusions upon.

Db. Landon Carter Grat said that in our present
state of knowledge as regards the exact functions of
the various columns of the cord — the columns of
Burdach and Goll and the so-called column of Gowers
— and the uncertainty that exists as to the exact de-
marcation of the latter, we can arrive at no definite
conclusions as to the location of the pain tracts. So
far as clinical evidence goes, there certainly is such a
thing as a pain sense. In hysteria the tactile sense
may be preserved, while the pain sense is entirely
lost.

Digitized by

Google

120

BOSTON MEDICAL AJUD SUBOIOAL JOURS AL. [Fbbbuabt 1, 1894.

Dr. Starr said we must admit the existence of
pain sensations and of a centripetal pain tract. That
tract must necessarily go in through the posterior
nerve roots, because we have painful sensations of a
hallucinatory character in locomotor ataxia. It mnst
extend for a distance in the central gray matter of the
cord. We have now on record over seventy cases of
syringo-myelia, with aatopsies. In these cases there
is a decided loss of pain in a certain limb. If the
affected limb is an arm, then the cavity in the cord is
in the cervical region, and the pain sense is preserved
in the body and legs. Therefore these sensations,
though they may pass for a little distance in the cen-
tral gray matter of - the cord, afterward pass into the
white columns. The central gray matter contains
numerous cells, each of which sends its fibres into the
antero-lateral columns and these pass upwards. While
it is by no means positive that the antero-lateral
columns transmit sensations of pain, all the facts seem
to point to the correctness of that theory. The column
of Lissauer, to which one of the speakers referred,
can have nothing to do with the transmission of pain
sensations. It consists only of short fibres, does not
increase in size from below upward and cannot trans-
mit impulses upwards for any great distance. The
sense of hunger is by no means analogous to the sense
of pain, as Dr. Dana intimated. We must distinguish
between a common sensation and a special sensation.

In conclusion, Dr. Starr referred to a case reported
by Edinger, with autopsy, in which the lesion was
found in the parietal region on one side, and in which
the symptoms were chiefly those of intense pain radiat-
ing in the opposite side of the body. Edinger de-
scribed it as a case of central lesion, with sense of
pain.

Dr. Dana then closed the discussion. He said that
his views regarding the non-existence of a pain tract
were only arrived at after a long and thorough study
of the subject. When we come to mix up pain sense
and touch sense and heat sense, eta, we are showing a
mental confusion that is unworthy of advanced neurolo-
gists. Pain and touch are entirely different. Pain is
a subjective or common sensation. Touch is objective.
Pain is much more closely allied to hunger than it is to
touch. Pain is not a special sensation, but a modification
of it. We may have apainful pricked wound, etc., but
we do not have a simple sensation of pain. It is always
combined with something else. If we can get rid of
the idea that we must keep on hunting for a pain tract,
it will save much exertion and many futile experiments
on monkeys and men.

A CASE OF INFANTILE, CEREBRAL, SPASTIC DIPLBQIA.

Dr. F. Peterson presented the fresh brain in this
case. The patient was a female infant, aged twenty
months, with congenital diplegia ; that is, spastic pa-
ralysis of all four extremities. The child was subject
to convulsions, had enormously exaggerated knee-
jerks and ankle-clonus. Its head was exceedingly
small. At the autopsy, the skull-bones were found to
be considerably thickened, and all the sutures and
fontanelles closed and united. The dura was very
thick. There was no increased amount of sub-dural
fluid. Over each hemisphere, a large group of convo-
lutions, deluding especially the motor area, were found
wanting. The vacuum caused by this atrophy was
filled partly by sub-dural fluid and partly by the bulg-
ing of each ventricle. There was no internal hydro-

cephalus. There was no oommnnication between the
ventricles and the exterior of the hemispheres. A
microscopical examination of the spinal cord showed
degeneration and atrophy in the lateral columns.

DEAFNESS DDK TO A FOOT-BALL INJOBT.

Dr. J. Leonard Corning narrated the history of
the following case: The patient was a young man
aged eighteen years, who received a severe kick directlj
over the right ear while engaged in a game of foot-
ball. He was first seen by Dr. David Webiter, who,
upon careful examination, found that there was total
deafness on the right side ; aerial and bone conduction
were suspended. There was no trouble of the middle
ear, and the drum was in perfect condition. There
was slight bleeding of the external ear. There was
no evidence of fracture. The case was then referred
to Dr. Corning, who applied to the ear a rapidly inter-
rupting faradic current, which was allowed to pass
through the ear about ten minutes, when the hearing
was so far restored that the patient could hear the
watch at a distance of six inches. Before making the
application, the external meatus was plugged with ab-
sorbent cotton moistened in salt solution. A severe
tinnitus which existed with the deafness was also re-
lieved. Dr. Corning said he had no idea what the
lesion was, or why improvement followed the nse of
the current ; it was employed simply as an empirical
measure. The young man's hearing is now entirely
restored. There was no suspicion of hysteria. The
visual field was not tested.

Dr. David Webster said he supposed the deafness
was due to concussion either of the auditory nerve or
of the labyrinth, of which he has seen cases reported.
Temporary blindness has been produced by a sudden
blow on the brow, without ophthalmoscopic or other
lesion. Most of those cases, however, are due to
fracture of the base of the skull, involving the optic
foramen and producing nerve atrophy. He has never
seen another case similar to the one narrated by Dr.
Corning.

Dr. Stabr suggested that the case might have been
one of traumatic hysteria or concussion of the auditory
nerve. In consultation with Dr. Jacoby he recently
saw a case of total deafness in both ears, of central
origin, in which a temporary improvement in the hear-
ing was produced by tlie use of a strong galvanic cur-
rent, about six milliamperes, which is a strong current
for the acoustic nerve.

Dr. Ralph L. Parsons reported

A case of acromegaly.

The patient was a man aged thirty-six years. Family
history negative. Never had venereal disease nor nsed
alcoholic stimulants. He was in good health unUl eigh-
teen years ago, when he had an attack of malarial fever.
From this he recovered, and has had no recurrence
since. Ten years ago he was told that he stooped and
carried his head to one side. Eight years ago he
began to suffer from a pain in the back of his head.
This came on mostly at night, and not oftener than
once a week. Subsequently the headaches occurred
more by day than at night. Latterly they have in-
creased in frequency and duration, and have often been
excruciating in character. The pain was usually most
severe at the occiput, but would also involve the left
parietal and frontal regions ; the right side of the head
was unaffected. Aboat six years ago his attention

Digitized by

Google

'oi.. CXXX, No. 6.1

SOSTOh MEDIO AL AND SURGICAL JOVRJUAL.

121

/as first called to the large size of his hands. He
aen for the first time perceived that they were of ex-
ra-ordinary size. He does not know for how long a
tme this increase in size has been taking place. He
cannot say whether they have increased in size daring
he past six years.

A. careful examination of the patient was made in
[>ctober last, with the following resnit : Weight, '227
pounds. No prononnced symptoms of organic, disease.
Hair rather coarse, but natural in condition ; left ear
slightly thickened; forehead retreating; superciliary
ridges quite prominent : no exopthalmos ; malar bones
rather prominent ; cheeks appear rather sunken ; nose
broad and full at the nostrils ; lips normal ; tongne de-
cidedly enlarged, obstructing free articulation ; alveolar
processes normal; teeth not separated; chin elon-
gated ; head inclined strongly and habitually to the
left side and forwards. The hands were large and
spade-like, the right hand being decidedly the larger.
The soft tissues of the hands and fingers were firm and
reeilient, as though infiltrated by an elastic substance ;
they did not pit on pressure. Wrists rather large;
arms normal. Thorax and pelvis normal. The feet
were large, but perhaps not more so than in the case
of many men of his weight. The patient has perspired
▼ery freely for the past ten years ; of late the perspira-
tion has been decidedly offensive. Besides the head-
aches already referred to, the patient also complained
of pain in the left ear and eye, the latter coming on
after reading or using the eye in a strong light. He
does not think his eyesight has become impaired.
Appetite and thirst excessive. No marked mental
symptoms.

On the 21 St of October last, by advice of Dr. Starr,
the patient began the use of thyroid extract, five drops
three times daily. The dose was gradually increased
until he received fifteen drops three times daUy. With
the exception of touic baths, general hygienic measures
and a regulation of the diet, no other treatment was
given. At the present time the patient reports that
he ia feeling decidedly better. He is more cheerful,
and his headaches have been relieved to a very great
extent. They have not, however, entirely disappeared.
There seems to be no change in the dimensions of the
bands. His weight has increased rather than dimin-
ished. There has been a great improvement in the
subjective symptoms, bnt there is still a reasonable
doubt whether this improvement is due to the direct
action of the medicine or to the patient's mental status,
induced by the fact that something is being done for
his relief.

Dr. Cobnimo was inclined to think that the im-
provement in the condition of the patient was due to
the medication employed, rather than to the mere fact
that Bomething was being done for him. Such patients,
he thought, are usually not of a very imaginative turn
of mind.

Dr. Stabb said he was somewhat responsible for
the DM of the thyroid extract in the case narrated by
Dr. Parsons. There was nothing original in the sug-
geatioD, as this method of treatment has been pursued
io Eogland in a number of cases of acromegaly. It is
purely empirical. The supposed lesion of acromegaly
ia SD increase iu the size of the pituitary body. It is
qneationable whether it is in any way related to the
thyroid gland. The eye symptoms in Dr. Parsons's
case interested him, because in two other cases of
acromegaly coming ander his observation there Was a

concentric diminntion of the visual field, and in one
hemianopsia ; the latter symptom is quite common, and
is probably due to pressure on the chiasm by the en-
larged pituitary body. In one case of acromegaly
seen at St. Luke's Hospital last spring the patient died
of pneumonia, and at the autopsy the pituitary body
was found to be normal. There was nothing to ac-
count for the peculiar growth of the bones.

Db. Pabsons, in reply to Dr. Webster, said it is
generally supposed that there is a sort of relationship
between acromegaly and myxoedema; whether this
belief is well founded, or what that relationship is, he
does not know. While his patient was not of an imag-
inative turn of mind, still he was hopeful ; and that
element would influence his mental state and perhaps
even improve bis physical condition.

EBGOT Ur THK TBBATKBNT OF PBEIODIO NECBALOIA8.

Db. William H. Thomson read a paper on this
subject, in which he gave the histories of a number of
cases of severe periodic neuralgias in which the symp-
toms were promptly relieved by the use of ergot in
large doses. In all of these cases the disease was of
long standing, and the usual remedies had been em-
ployed without avail. Dr. Thomson said his method
of administering the ergot in migraine was as follows :
The fluid extract of the drug is employed, combined
with an equal quantity of elixir of cinchona, to obvi-
ate its tendency to cause nansea. Two drachms of
this mixture is to be taken in water as soon as the
premonitory symptoms of the headache are noticed,
and the patient is advised to lie down and keep very
quiet. If, after an hour, the headache continues, a
second similar dose is taken, and then a third in an-
other hour if necessary. As nausea is such a general
accompaniment of this affection, it is provided that if
either of the doses be vomited, it should then be taken
in an enema of two ounces of water. This medication,
the speaker said, rarely fails to arrest the attacks, even
in long-standing cases, and with a preventative course
of intestinal antisepsis in the intervals, the relief from
the malady has often proved permanent.

The following is the history of one of the cases re-
ported by Dr. Thomson. The patient was a young
man who suffered from headaches beginning at the oc-
ciput and extending to the temples ; they generally
came on about 11 a. M. daily, and gradui^ly grew
worse until they reached their acme about 4 o'clock
in the afternoon, after which they subsided, without,
however, entirely disappearing. His physician failed
to check their increasing severity, although on one oc-
casion he administered thirty-grain doses of chloral
with thirty grains of potassium bromide every two
hours for two doses, with little more effect than a slight
drowsiness being produced. The next day, the patient
becoming maniacal from the pain, sixty-five grains of
chloral, sixty of bromide and thirty of antipyrin were
given within two hours. This caused a profuse sweat-
ing and moderate sleep. The third day a consultant
was called, who recommended that quinine and War-
burg's tincture (which had been tried at the beginning
of the treatment) should be resumed in large doses.
Accordingly, sixty grains of quinine and two ounces
of Warburg's tincture were given in twenty-four hours,
with even worse afternoon paroxyms of pain than be-
fore. The next day the bromide, antipyrin and chlo-
ral were resumed, bnt no great relief was obtained. At
this time he was seen by Dr. Thomson, who recom-

Digitized by

Google

122

BOSTON MEDICAL AND SDUGJCAL JOVSNAL. [Febbuast 1, 18H

mended drachm dcwes of fluid extract of ergot every
hoar for three doses, combiniDg the first two doses with
ten grains of quioioe, aud if bis stomach rejected either
of the doses, that the medicine be given per rectum.
Soon after taking the first dose, the patient experi-
enced a good deal of relief ; the second dose was vom-
ited, whereupon it was given per rectum, and this was
soon followed by a complete subsidence of the pain,
with profuse perspiration. This medication was re-
peated for three successive days, with final cure otthe
headaches. The second ten grains of quinine pro-
duced decided symptoms of cinchouism.

Dk. Joskph Collins said that he has recently had
occasion to try ergot in several cases. In one case the
patient had been given huge doses of Warburg's tinct-
ure, quinine, bromide, and potassium iodide without
any benefit. He was then given drachm doses of er-
got, and a marvellous improvement at once followed.
This was three months ago, and the man has had no
return of the symptoms since. In another case the
patient was a lady, aged forty years, who had long
been under treatment for migraine, the pain being of
a boring character and very difiicult to relieve. In this
case the value of ergot in the treatment of this affec-
tion was discovered accidentally ; it was given to check
a menorrhagia, aud at the same time it relieved the
headaches.

Db. Thomson, in reply to a question, said our pres-
ent knowledge is not definite enough to form any idea
as to how ergot acts in these cases. He simply gave it
as an empirical remedy. Furthermore, his paper re-
fers entirely to neuralgias that are definitely periodical.
These are usually very severe, aud entirely different
from the ordinary intermittent headaches. He referred
to the fact that quinine, even in small doses, when it
ia combmed with ergot, appears to produce cinchonism
much more quickly than when given alone. In only
one of the cases reported was there any antecedent
history of malarial infection ; in that case the patient
simply gave the history of having resided in a malari-
ous district. Very likely there was a malarious ele-
ment in the other cases, of which the nervous symp-
toms were the only manifestations. Dr. Thomson also
referred to the fact that intercostal neuralgia is often
accompanied by sciatica ; also the occurrence of sciat-
ica after pleurisy. The latter combination he has no-
ticed in about twenty cases.

Xlecent Xiteratuce.

Lecture! and Estaye on Fevert and Diphtheria, 1849
to 1879. By Sib William .Jknnee, Bart., K.C.B.,
etc. New York : Macmillan & Co. 1893.
The papers which go to make up this volume were
originally published during the thirty years between
1849 and 1879 in various journals and in the transac-
tions of societies, and are now collected together for
the first time by the author.

The most interesting and important of these papers
are those early ones, published first in 1849-50-51, on
the identity or non-identity of typhoid aud typhus fever,
and on the four febrile processes — typhus, typhoid,
relapsing fever and febricula — at that time still com-
monly comfounded in England under the term con-
tinned fever. Jenner's name is associated with the
solution of this question in England, as were those of

Louis and Valleix in France, and those of Gerhard,
Jackson, Stille and Shattuck in this country. He fol-
lowed the others at a considerably later period, and
was preceded in bis own country by Stewart of E^io-
burgh. Still, when Jenner did put his hand to the
subject, his arguments were based upon a large and
careful experience, and he treated it in a thorough and
masterly manner, which finally forced the oon'viotion
of his contemporaries. It is well that these papers
should be brought together in this form, that they may
be made accessible to the present generation, who can
thus realize how slowly a scientific truth which is
to-day accepted as almost self-evident, won its way.

The well-known and excellent address delivered in
1879 before the Midland Medical Society at Birming-
ham, on the treatment of typhoid fever, is another of
these contributions. Another series is formed by the
Gulstonian Lectures for 1853, before the College of
Physicians of London, on the acute specific diseases.
The remaining pages are devoted to two lectures de-
livered in 1861 on diphtheria, and a clinical lecture
delivered in 1875 on croup.

On Contraction* of the Fingeri and on " Hammer'
Toe." By William Adams, F.R.C.S., Eng., Con-
sulting Surgeon to the Great Northern Hospital,
etc. Second edition; 154 pages with eight plates
and thirty-one wood engravings. London : J. W. A.
Churchill. 1892.

This work comprises four essays, the first of which
describes the deformity known as Dupnytreu's contrac-
tion, the second and third " hammer-toe," and the last
a method to remove or relieve depressed cicatrices.
The first edition was published in 1879 ; the text has
now been somewhat altered and new illustrations
added. There is a reeume of the work dde in Eng-
land and America daring the past ten years ; aud the
description of " hammer-toe," with its treatment, has
been introduced. The chapter describing the treat-
ment of depressed cicatrices appeared in the first edi-
tion in almost the same form as now. The present
edition, in addition to the above, includes results and
observations of the past ten years, collected not only in
the writer's individual practice but also from the work
of other surgeons. The book is well arranged and
has a good index. It is a well-written and interesting
treatise ; aud the excellent illustrations add much to its
value.

Euential* of Minor Surgery, Bandaging, and Venereal
Diteaee*. By Edward Mabtin, A.M., M.D.,
Clinical Professor of Grenito-Urinary Diseases, In-
structor in Operative Surgery, etc.. University of
Pennsylvania, etc. Second edition, revised and
enlarged, with 78 illustrations. Philadelphia: W.
B. Saunders. 1893.

This little work, which is already well known, is one
volume in the series known to medical students as the
Saunders Question Compends ; aud treats of bandag-
ing, certain details relating to minor surgical work, and
venereal diseases. The present volume is a second
edition, aud has been revised to date. The illustrations
show many changes ; and those relating to bandaging
are entirely new, the method used in the " American
Text-Book of Surgery " being followed. The value
of the volume has been much increased by its revision ;
and it contains much, in a very concise form, of inter-
est to the practitioner and student

Digitized by

Google

>x.. CXXX, N«. 5.]

BOSTON MBDIOAL AND SUROIOAL JOURNAL.

128

THE BOSTON

THURSDAY, FEBRUARY 1, 1894.

^ ^OMTNal ^JKHMoilM, amrgem^amd Allied Sotmctt,i»MitMed at
oaton, uretUy, ty <ka im<l<r«4f«e<i.

SOBaCKiPTiOH Tbbms: VB.OO^«r fear, in advanee, pottage paid,
*rth* UnUtiatatf,CemadatmdMea>ieo;9tM per year far ail for-
iyi* oamHtriti ttUmging (o the Poital Union.

All eoemnmniecMont fir Iht Sdtttr, and all bootu for review, ihonld
«adare*medlotluJMHor<tftKe Bolton Medloal and SwrfflecUJommal,
83 WaahingUm Street, Soilon.

All lettert containiiig butineu eommnnioationi, or referring to (A«
rubliaaHom, tubier^Hon, or adverOiing dcportnunf (>f tUe Jommal,
■hould be addreiied to the fuidertigned.

Jtemiittamcei ihould be made tf nunef-order, draft or regiiUred
•etter,p«ttf«Me to

DAMRELL « UPHAH,
ttS WASHnroTOn Btkxxt, Bo6ton, Mabb.

DIPHTHEItlTIC PARALYSIS.

DiPHTHKBiTic paralysis generally manifests itself

from eight to fifteen days after recovery from the local

aymptoma, thoagh it may be delayed to a later period ;

in yery exceptional cases it has been observed daring

the first week. This paralysis ezuts in one-third of

the grave cases, according to Roger's statistics ; it is

not a rare sequel of benign diphtheria. The onset is

generally slow and insidious. There is first only a

little heritation of the motor fanctions; deglntition,

walking and other movements become more and more

difficult.

The place of election of the paralysis is the velum
pendulum, where it generally begins, and where it
sometimes remains localised. A slight pallor, a little
slowing of the pulse, are the only disturbances of the
general state which are then noted. The reflux of
liquid aliments by the uarea indicates the impediment
to deglntition. Extension of the paralysis to the
pharynx generally supervenes, and the food can only
be swallowed after repeated attempts, which soon
fatigue the patient, and sometimes result in the refusal
to take nourishment. Loss of voice testifies to paraly-
sis of the larynx. The muscles of the eyes, of the
neck, of the trunk, of the upper and lower extremities,
of the rectum and bladder, even the special senses, are
taken in the more complete forms of paralysis. More
rarel; the paralysis will attack the lower limbs before
aSectiDg the larynx and the tongue; and in a few
cases it has been known to begin with the arms, then
invade the soft palate and oesophagas, to attack finally
the lower extremities.

It is a common experience to see troubles of vision
supervene which are attributed to a fault of accommo-
dation. The sight is enfeebled in different degrees,
which may vary from slight amblyopia to complete
blindness; there is hypermetropia, mydriasis, and, if
bnt one eye is affected, inequality of the pupils. Almost
all of the eye-muscles may be affected in turn.

The lower extremities generally begin to be paretic
when these ocular troubles exist The paralysis of
the lags generally assumes the form of an incomplete

paraplegia. It is announced by formication and numb-
ness in the legs. Walking becomes uncertain; the
patient has an incomplete perception of the ground
under his feet, and finds it especially difficult to go up
and down stairs, or walk in the dark. A peculiarity
of this form of paralysis is that the loss of motility in
the feet and leg^ is never complete ; the patients can
move along by dragging or sliding their feet. When
they are confined to their bed the lower limbs still
preserve considerable power of movement, but with-
out energy or much certainty. Jaccoud calls it an
ataxy of movement, rather than paralysis. These
ataxic symptoms, in conjunction with the abolition of
the patellar reflex and the eye troubles, may give
rise to a form of pseudo-tabes. Contracture is very
rare. The affected muscles present the ordinary re-
action of degeneration ; there is augmentation of the
galvanic and diminution of the faradic contractility.

With regard to the condition of the hands, these be-
come awkward and clumsy ; patients drop or upset
objects which they attempt to handle ; tremblings re-
sembling the tremors of paralysis agitans are frequently
present. The muscular enfeeblement may be so great
that the patient cannot feed himself. Paralysis of the
face is a rare phenomenon. Bourges,* who has written
a very complete description of the diphtheritic paraly-
sis, and from whom we have here borrowed, gives a
graphic account of cases which he has witnessed when
the syndrome of labio-glosso-laryugeal paralysis was
perfectly reproduced ; the tongue, lips, cheeks, larynx
being simultaneously affected.

Troubles of the sensibility are very frequent in
diphtheritic paralysis, and almost always have to do
with the regions affected with akinesic troubles. The
ordinary alteration of sensibility is ansesthesia ; excep-
tionally there is hyperaethesia which manifests itself in
the lower litAbs by numbness and formication, and
generally precedes the akinesis. Frequently the an-
SBSthesia when it exists does not extend above the
knees and elbows, but it may be general. It is some-
times accompanied with analgesia so complete that
(Bonrges says) cutting operations have been performed
without ether. The aneesthesia may affect the lips,
tongue and cheeks, and in rare cases the special senses,
hearing, smell and taste have been abolished. The
speech is often hesitating, stammering.

A capital fact in diphtheritic paralysis, says this
same writer, and one that distinguishes it from all
other paralyses by peripheral neuritis, is that there is
no muscular atrophy ; the paralyzed limbs always re-
tain their normal aspect and volume.

In very rare instances, the velum pendulum is not
affected, and the disease is located in one muscular
group or region without affecting other groups or other
parts. Such are the cases where the paralysis has
taken the paraplegic or hemiplegic form, where it is
limited to the eye muscles, to an arm, a leg, a hand,
etc. Cases complicated with diaphragmatic paralysis
are especially dangerous.

1 H. KenrgM : I« DtphtMrie, Paris, ISSS. ,

Digitized by

Google

124

BOSTON MBDIOAL AND SVB6I0AL JOXJBNAL. [Fkbbvabt 1, 1894.

In the localized and partial fonn, the paralytic acci-
dents may be transient, and disappear in a few days.
When the paralysis is general, its course is slow, last-
ing sometimes weeks and even months. Diphtheritic
paralysis generally terminates in recovery (eight times
out of ten, according to Bourges). In favorable cases,
the power of movement reappears first in the lower
limbs, then in the throat, then in the arms and hands,
the trunk, the viscera and the eyes. Generally, the
organs to be first paralyzed are the first to get well,
but there is no fixed rule even here, and it often
happens that the velum pendulum is the first part to
be afiected, and the last to resume its functions.

We have said nothing about those forms of infec-
tions paralysis in which the heart and respiratory mus-
cles are affected. These varieties are mach more
grave, for death then occurs often from syncope or
asphyxia.

These paralytic resnlts of diphtheria have been re-
produced iu animals in the experiments of Boux and
Tersin.

THE ACTION OF PEKMANGANATE OF POTAS-
SIUM IN RENDERING MORPHIA INERT.

At a meeting of the medical and surgical staff of the
West Side German Clinic, 42d Street, New York, Dr.
William Moor, one of the physicians to the clinic, re-
cently gave a demonstration on his own person of the
e£Bcacy of permangaoate of potassium as an antidote
for morphia. Against the earnest protestations of
those present, he swallowed three grains of sulphate
of morphia in solution, and immediately afterwards he
drank a solution of four grains of the permanganate
in four ounces of water. He was carefully watched,
but none of the ordinary effects of morphia on the
system were observed, and be has since stated that he
experienced no ill effect whatever from the poisonoos
dose taken.

Dr. Moor, who has made a special study of thera-
peutics and toxicology, is twenty-eight years of age,
and an Austrian by birth. He studied two years in
Berlin and one in Paris, and is« graduate of the Col-
lege of Physicians and Surgeons, New York. He
states that previous to the demonstration mentioned
he had experimented with rabbits, and also on his own
person. He at first took an eighth of a grain of
morphia, then a quarter of a grain, then half a grain,
and finally three-quarters of a grain ; and when he
took permanganate of potassium afterwards there was
no apparent toxic effect from the morphia.

In his demonstration at the Grerman Clinic he would
have been perfectly willing, he says, to take six grains
of morphia, rnstead of three. Morphine, or any of
the salts of opium, he claims, is immediately rendered
harmless by contact with the permanganate. The
antidote at once seeks the poison, passing by the other
substances in the stomach. The soluble salt is acted
upon by the permanganate 75,000 times more quickly
than albumen, and several thousand times more quickly
than ^peptone. Of course, the antidote should be ad-

ministered as promptly as possible after the morphia
is taken.

Since this demonstration it has been clumed that
the honor of the discovery is really due to Dr. Wil-
liam Condy, of London, and that Dr. J. B. Mitchell
and other writers have referred to the efficacy of per-
manganate of potassium as an antidote ; but, at all
events, it is certainly true that its action in this regard
has never been generally recognized by the profes-
sion. Lacerda recommended permanganate as an anti-
dote to serpents' poison. Experiments indicate that
it destroys the constitution of such poisons when
brought into direct contact with them, but, when in-
troduced into the general system, does not control
their action.

Dr. Moor is now engaged in making a series of ex-
periments to test the power of the permanganate as an
antidote against strychnia, cocaine aud other poisons.
In the case of the first named, its action is said to be
much slower than upon morphia.

Morphia is well known to be a powerful reduong
agent, and it is doubtless by oxidation that the per-
manganate acts. As with serpent poison, so with mor-
phia, it is undoubtedly essential that the permanganate
should enter into direct contact with it. After the
morphia has been absorbed the permanganate can have
no action upon it. This physiologico-chemical restriC"
tion necessarily limits very much any value as an an-
tidote which it may be proved that it possesses. Really,
as we have already hinted, the most surprising thing
about this incident which has attracted much attention
in the daily press, is the fact that the action upon each
other of two substances whose properties are so well
known as are those of morphia and permanganate,
should not long since have been accurately determined
and described and been generally recognized. As a
matter of fact, the usual therapeutic text-books and
toxicologies are silent on this subject.

MEDICAL NOTES.

Honors to Dr. Billings. — Dr. Billings, Sur-
geon-General of the United States Army, has been
elected an honorary member of the Royal Academy of
Medicine of Belgium, and also a member of the Inter-
national Statistical Institute, whose headquarters are
at Rome.

Physicians in the Viboinia Lkoislatdbk. — It
is a little unusual to find physicians actively engaged
iu politics ; but there are eight physicians in the pres-
ent legislature of Virginia. Seven of them are Fellows
of the State Medical Society.

Appointhbnt to the Chair of Midwifebt in
Glasgow. — Dr. Murdoch Cameron has been ap-
pointed to the chair of Midwifery in the University of
Glasgow.

Eight Imsamb Patients Bcbnbd to Dbath. —
The building on the Boone County (Iowa) Poor Farm
used as an insane asylum was burned to the ground

Digitized by

Google

Vot. CXXX, No. 5.] BOSTON MEDICAL AJ3D SURGICAL JOVRSAL.

126

Janaary 23d, mnd eight of the nine inmates were bnrned
to death. Foar of the patients were locked in their
rooms, and could not have escaped even if they had
tried. The others were not intelligent enoagh to try,
and were surrounded by fire before help could reach
them.

The Lbttsomian Lectcrks. — The Lettsomian
Lectores this year are now being given by Mr. Frederic
Treres, F.B.C.S., who has chosen " Peritonitis " as his
snbject.

" The Grand Old Man " of Medicine. — The
Medical Prat and Circular gives a new title to the
Autocrat of the Breakfast Table in the following bit of
news. It would lead its readers, however, to infer by
analc^ that Sir Spencer Wells had written the poems
of Thomas Hood.

" The ' Grand Old Man ' of Medicine seems to be
Dr. Oliver Wendell Holmes. The College Club, of
Boston, recently gave a reception in his honor, and
about five hundred persons were presented to him.
He received them as he sat ' in a laurel-decorated chair
onder a bower of palms.' During the course of the
proceedings Dr. Holmes recited 'The Last Leaf,'
'Dorothy Q.,' and 'The Chambered Nautilus,' all of
which must have been intently listened to. Truly, we
have no one in this country, of similar standing belong-
ing to the profession, who could perform such a feat.
Fancy Sir Spencer Wells, for example, reciting ' The
Dream of Eugene Aram ' at the eonvertcuione of the
Medical Society ! "

The Habtabd Mbdioai, Socibtt or New York
CiTT. — At the meeting held on January 27th, the
following officers for 1894 were elected: President,
Reynold W. Wilcox, M.D.; Vice-President, Royal
Whitman, M.D. ; Secretary and Treasurer, Dillon
Brown, M.D. ; Executive Committee, J. Winken Bran-
uw, M.D., Frank H. Daniels, M.D., and Howard
Lilienthal, M.D.

BOSTON and new BNOLAND.

Small-Pox in Boston During the week end-
ing at noon, January Slat, there was one death from
imall-pox. No new cases have occurred.

A Beqoest to the Children's Hospital or
Boston. — The will of Mr. C. C. Gilbert, of Bridge-
water, bequeaths the snm of $3,000 to the Children's
Hospital of Boston.

Small-Fox in Massaohusetts. — During the
week ending at noon, January Slst, there were re-
ported to the State Board of Health three cases of
(mall-pox from places outside of Boston, one each from
Lowell, Brookline and Worcester.

Salkm Hospital Report. — During the year just
dosed there were treated in the Salem Hospital 318
patients : 178 medical, and 140 surgical. There were
153 males and 165 females.

Ttphoid Fetbb at Lowell, Mass. — Since the
first of the year, seventy-three cases of typhoid fever
have been reported to the Board of Health in Lowell,

and during the last week many new cases have oc-
curred. The prevalence of the disease is ascribed to
the use of Merrimac River water, since in two wards
which are supplied with water from the driven wells
in experimental operation, there is scarcely any typhoid.
Those who are ill in these districts have been at work
in quarters where the river water only is supplied.

Vaccination in Vermont. — The State Board of
Health of Vermont, at its meeting in Burlington last
week, voted to recommend a general vaccination
throughout the State, in consequence of the prevalence
of small-pox in Boston and New York and the signs
of scattered infection in other New England places.

NEW YOBK.

Red Liobt on Small-Pox. — It is announced that
one of the small-pox pavilions at the Riverside Hos-
pital on North Brother Island is to be fitted up with
red-glass windows, and with red-glass globes for the
lights used at night, in accordance with the alleged
discovery that the skin of small-pox patients is ex-
tremely sensitive to the violet-colored rays of light,
and that it is these which give rise to the pitting. The
experiments which it is claimed demonstrated this fact
was made by Dr. Lindholm and Finsen, in the City
Hospital at Bergen, Norway, and was detailed in a
recent ardcle in this Journal (January 11, page 35).
New York will therefore be the first city in this coun-
try to try the efScacy of the red light, which is the
same as that used by photographers in developing sen-
sitive plates.

Small-Pox on the Increase. — Small-pox seems
to be on the increase, and several cases have recently
been reported from charitable institutions in the city
and on the islands, as well as at Charity Hospital,
Blackwell's Island.

Diphtheria. — There has been a considerable in-
crease in diphtheria this season as compared with last
year. From the 1st of January to the 24th there were
reported 767 cases as against 382 in the same period
in 1893. The mortsli^ is said to be about 33 per
cent.

A Negress who knew Washinqton. — There
recently died at tbe Colored Home and Hospital on
First Avenue a negress by the name of Sullivan, at the
extreme age of 107 years. The correctness of her age
is said to be attested by a Bible in tbe possession of
her son, who is now over 65 years old. The life of
this ancient woman is quite an interesting one. She
was the daughter of Philip Pickering, who fought un-
der Gen. Francis Marion in the War of the Revolu-
tion. She was born a slave in the Carroll family, in
1785, and in later days often recalled a visit made
with her master and mistress to General Washington,
at Mount Vernon. By the dying request of her mis-
tress, she was given her freedom, and she then re-
moved to Washington. Here she entered the service
of the Buchanan family, and on one occasion had the
honor of waiting upon the guests at a banquet given to

Digitized by

Google

126

BOSTON MEDIOAL AND SUBGIOAL JOURNAL. TFubuabt 1, 1894.

La Fftjette, who personallj complimented her. She
wu married in WaahingtoD, aud in 1829 removed to
New York. One of ber brothers fought under Gen-
eral Jackeon at the battle of New Orleant, and when
the latter became President, he gave him a position as
assistant gardener at the White House.

EXTERNAL INDICATIONS OF INHERITED
LONGEVITY.

The December meeting of the New York Academy
of Medicine was devoted to a discussion of various
factors influencing longevity, either directly or rela-
tively. Dr. Morris, in speaking of the constitutional
inheritance, said that in most cases the line of inherit-
ance could be very fairly determined by the careful
observation of certain external indications — as color,
motions and measurements.

" One of the most certain indications of long or short
life was the size of the bead, for in the brain lay the
great centre of power. A person with a head whose
diameter at the thin portion of the temporal bones
measured five and a half to six inches was almost sure
to give a longevity on the father's side of seventy to
ninety years or over. If the head measured in front
from the external auditory canal to the naso-frontal
suture as much as four and three-fourths or five inches,
we might be almost sure of long life on the maternal
side. A beard which was darker or redder than the
hair, indicated inheritance from the paternal side ; if
it were lighter than the hair, the inheritance was prob-
ably from the maternal side."

THE NEW RATIONAL WAY TO SLEEP.

Dk. Wilhelu Fischkr, according to La Mideeitu
Modtme, has recently completed some researches into
the proper method of sleeping. He says that to sleep
well, that is, to obtain the quickest and surest intellect-
ual rest, a person should lie with the head low and the
feet elevated at least to the horizontal. The ordinary
method is entirely wrong. The difficulty in becoming
used to this proper method of flushing the brain to rest
is not so very great if one has patience to begin gradu-
ally. " Each fortnight the sleeper is to discard one
pillow until he can sleep on a level." The time re-
quired for this is not stated. It must depend upon the
number of pillows started with ; aud from the manner
of mention this might be many dozen. But, to return
to the directions ; after being accustomed to the level
position, the would-be-sleeper-«oinme-t7;/at(< places his
feet each night in a higher plane than his head, increas-
ing the incline by adding the discarded pillows until
finally he slumbers peacefully with his head on the
mattress and his feet on many pillows.

This attitude has, he says, " a marvellously curative
efFect on many diseases, especially in nervous and
anaemic patients ; but its real and crowning triumph
is in the treatment of varicose veins, heemorrhoids, float-
ing kidney, basic pulmonary disease and erotic dreams."

If this highly rational way of sleeping becomes as
general as it should, we may expect to see a new style
of bedsteads put upon the market built like the kan-
garoo, with long legs at the lower end.

THE PLEASURES AND REWARDS OF A PHT-

SICIAN'S LIFE.

In his commencement address at Lafayette College
last June, Dr. William W. Keen, of Philadelphia, gave
the following picture of the pleasure and satisfaetioD
of the busy physician, which we reprint at the reqaest
of another eminent professor :

*' Sir Spencer Wells, as the net result of bis first
1,000 ovariotomies added 20,000 years to human life;
and so far has modern surgery surpassed this result
that every thousand similar operations to-day adds not
less than 30,000 years to human life ! Think what
one of these lives means, as the pale cheek regains its
color, the feeble pulse its force, strength succeeds
weakness, each day records a g^in, and finally health
is re-established. The tender father returns to hit
usual pursuits ; the adored mother once more becomes
the centre of loving care of her family ; the beloved
child is restored to the family circle with ruddy health,
rescued from the valley of the shadow of death itself.
The hushed voices, the soft tread of the sick-room have
giveq place to the laughter of health ; the mists of
sorrow are driven away ; the anxious alarms of disease
have vanished. What, think yon, can equal the joy
of the physician, as he views this happy transformation ?
Who is a dearer, more cherished, more welcome friend
than he? Who finds a* warmer place by the fireside
and in the very hearts of his patients ? No one can
adequately appreciate his profound joy, his daily delight,
his deep gratitude to the ' Giver of every good and
perfect gift.' Oh, my friends, it is a blessed profes-
sion, a divine calling, with a heavenly recompense on

earth ! "

♦

THE SOLUTION OF THE NEGRO RAPE
PROBLEM.

Tbb solution of the yearly more serious problem of
negro rape in the South is a most difllcult bat impor-
tant task. Lynching, with its attendant tortures, has
proved as useless as it is atrocious.

In the November number of the Virginia Medieat
MotUhly, Dr. Lydston strongly advised legal castration
as a remedy ; and he is supported in a more recent
issue of the Texas Medieat Journal, by Dr. Daniel.
The quieting effect of this treatment upon each crimi-
nal would, of course, be etiicient for that one man, but
it is doubtful bow far it would carry a deterrant warn-
ing to other negroes in the blinding heat of lust.

Dr. P. C. Remondino, in the January number of the
National Popular Review, urges the adoption, not of
expiatory laws, but of preventive legislation. It is
not rational, he claims, to look upon the unbridled
licentiousness of the negro as solely a racial trait.
The negro child, especially the male, is subject to
many nervous disorders from slight irritation, and this
characteristic he carries with him to adult life. Ac-
cordingly, Dr. Remondino sees in the removal of " an
irritating and ulster-proportioned prepuce " the efllcient
and gentle means of stopping the sexual crimes and
improving the moral system of the negro race. He
says:

" Although the male Jews are much given to unholy
and uuedifying carnal pursuits, and in that field make
records only equalled by the great Nimrod as a hunter,
still, we never bear of a Jewish rapist.

" From our observation and experiences in such
cases, we feel fully warranted in snggeeting the whole-

Digitized by

Google

Vol. CXXX, No. 5.] BOSTOS MEDICAL AND SVB610AL JOVRJUAL.

127

8«le eircamcisioo of the oegro race as an efficient rem-
ad; in preventing the predispogition to indiscriminate
rapiDg 80 inherent in that race. We have seen this
act as a valuable preventive measare in cases where an
inordinate and unreasoning as well as morbid carnal
deiire threatened physical shipwreck : if in sncb cases
the morbid appetite has been removed, or at least
bronght within manageable and natural bounds, we
cannot see wliy it should not — at least in a certain
beneficial dogree — also affect the moral stamina of a
race proverbial for (he leathery consistency, inordi-
nate redundancy, generons sebaceousness and general
mental suggestiveness and hypnotizing influence of an
uooecessary and rape, murder and lynching breeding
pfepuce. It would certainly be more humane for a
State legislature to pass aii act legalizing and enforc-
ing circumcision as a preventive measure, just as it
woald enforce either vaccination or quarantine regula-
tions, than to enact laws to castrate or eunucbise the
accused after his infraction of the law."

Corre^))ottliettce*

THE PREVALENCE AND KECOGNITION OF
SCABIES.

Boston, January 25, 1894.

Mb. Editor : In the Jodrnai. of September 16, 1886,
a paper entitled " Clinical Notes on Scabies," by Dr. F. B.
Greenough, was published, in which mention of the in-
creased prevalence of the itch was made, and the suggestion
offered uiat it mieht be well for boards of health to con-
dder measures looKing toward its control.

In the JouRMAi. of February 7, 1889, there appeared
an article by Dr. J. C. White, on " The Increasing Preva-
'lence of Scabies," which needs no comment.

Lastly, in the Journal of October 19, 189S, under the
heading of "The Increasing Prevalence of the Itch," the
statistics of Dr. Stelwagon, of Pliiladelphia, are quoted, as
bearing upon this point.

Since toe publication of Dr. White'* and Dr. Greenoogh't
papers, scabies has continued to present itself at the hospi-
tal clinics with great frequency, and often four or five new
cases are recorded in a single morning. In private prac-
tice also it is in no sense a rarity, and instances of its
occurrence in people of the best social class are not un-
nsoal. The importance of recognizing scabies cannot
therefore be overlooked ; and the conviction that a great
deal of annoyance and suffering, as well as in some measure
the propagation of the disease, might be avoided by prompt
treatment, has led me to add my voice to those of my col-
leaenes.

ft is true that scabies, especially in a cleanly person, may
sometimes o£fer much perplexity to the diagnostician ; yet
these cases are always in the minority, and even in them
it is usually possible to decide the question by treatment.

The point to be borne in mind, it seems to me, is that in
any itctung affection, where marks from scratching or
eczematons appearances are present to however slight a
degree, the poitibilUy of scabies should be entertained and
excluded, before the patient is allowed to go on his way
with a prescription for a mild antipruritic lotion, and per-
haps a favorite tonic internally.

The frequent failure to recognize is undoubtedly due to
the increased prevalence, and to the false presumption that
■eabies is almost unknown in cleanly people, formerly,
u Dr. White has stated, it was almost impossible to find
nfficient material for class demonstration. For these
reasons largely, this common affection is now frequently un-
recognized, and apparently unsuspected, by practitioners
of the highest medical attainments.

John T. Bowbn, M.D.

BIETEOROLOOICAL RECORD,

For the week ending January 20, in Boston, according to ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corps: —

Baro-

Thermom- Relative ' Direction

Velocity We'th'r.
of wind. •

1

meter

eter. jhumldlty.

of wind.

Date.

i

i

i

9J

a

f

M

M

a

91

M

a

a

a

1

II

1

s

00

S

00

1

•4

i

S

00

a<

s

s

00

c.

1

S..U

30.10

2Si32

18

61

SO

li«

W.

R.

14

4

o.

M..IB

80.10

36

46

28

69

77

73

8.W.

S.W.

14

:o

o.

o.

T..16

30.00

40

44

38

96

77

86

W.

n.

4

17

a.

o.

W.17

30.68

22

27

18

62

M

R9

N.

n.

14

14

c.

0.

T..I8

SO.M

28

37

18

66

78

72

N.W.

8.W.

4

10

o.

o.

F..I9

30.42

36

42

30

87

84

F6

W.

N.

10

14

o.

0.

.13

S..20

30.<3

26

32

20

62

71

62

N.W.

N.B.

9

6

0.

0.

tr

30.8S

37

24

70

1

.39

•O-.tHouOji Celewi F.,f*lri O.,toci H.,hu7i B.,
cbIdri N..inov. t IndlemtM tnm of nunlall. a^ Ilea

imok7i R..nlllt T..(l

irMt-

Ji for «Mk.

RECORD OF MOBTALITT
Fob THa Wuz bhsiko Satubdat, Jakhast 20, 1894.

1!

S3
P

1

i

Feroentage of deaths from

Ottles.

1

i§

1^

If

II

1^

New York . .

1,891,306

888

348

17.71

21.46

.60

9.46

.66

Chloago . . .
Philadelphia .

1.438,U00

_.

—

—

1,1I6,8«2

—

^ j —

_

•-.

— .

__

Brooklyn . .

978,3M

380

143 ; 11.44

31.46

.62

7.02

1.80

St. Lonla. . .

860,000

—

—

..

—

—

—

Boston . . .

«ll,387

229

74

16.84

24.64

.44

8.80

1.7«

Baltimore . .

600,000

—

— .

^

_

Wuhlngton

808,431

Ill

28

6.30 { 18.00

4.60

1.W

«.

ClnolnniiU . .

305,U0a

119

43

7.63 1 27.20

3.40

2.M

^

Cleveland . .

290,000

96

32

18.80

•iZ.]0

4.20

6.30

4.S0

Pittsburg . .

263,709

80

34

16.U0

15.00

1.26

6.00

1.26

MUwaokee. .

260,000

78

46

9.69

16.44

^

1.37

1.37

NaahvUle . .

87,764

32

12

12.62

18.78

—

3.13

Charleston . .

6S,loS

34

,

—

6.^8

—

_

Portland. . .

40,000

16

0

6.66

13.33

—

—

Worcester . .

96,217

86

18

18.9U

3U.68

—

16.12

_

FallBlver . .

87,411

V7

11

14.60

29.60

—

3.70

__

Lowell . . .

87,191

■Si

7

16.2U

37.80

5.40

_

Cambridge . .

77,100

32

18

28.17

18.78

—

12.62

16.S6

Lynn ....

62,686

*S

3

^

:!6.6«

—

^

Springfield . .

48,684

18

8

—

26.66

^

_

.^

Lawrenee . .

48,366

il

4

7.14

—

7.14

— .

_

New Bedford .

43,886

28

14

I7.t6

17.86

3.67

3.57

Holyoke . . .

41,278

.—

—

—

—

—

^

Salem. . . .

32,233

11

2

9.09

^

—

._

Brockton . .

82,140

-*

.—

—

—

_

_

Haverhill . .

31,896

8

8

—

12.50

—

—

«_

Chelsea . . .

30,264

14

8

7.14

28.66

—

_^

7.14

Maiden . . .

29,394

7

2

—

14.28

—

_

Newton . . .

27,666

11

0

tB.18

18.18

.—

_

18.18

ntchburg . .

27,146

.i!

3

—

20.00

Tannton . . .

26,972

10

1

—

20.C0

—

—

_

Qlouoester . .

26,688

2

1

—

—

—

_

^^

22,068

1»

2

22.22

11.11

.^

22.22

_

Qolncy . . .
PlttMleld . .

19.642
18,802

6
2

2
1

20.U0

20.00

20.00

—

Everett . . .

16,686

S

1

20.00

60.00

—

.^

_

Northampton .

16,331

6

1

_

40.00

—

_

__

Newbnryport .

14,073

2

1

—

—

—

—

,^

Amesbnry . .

10,920

4

1 26.00

26.00

^

"•

26.00

Deaths reported 2,399 : under five years ofage8(i9; principal
infections cflseases (small-pox, measles, diphtheria and croup,
diarrhoea! diseases, whooping-coueh,enrsipela8 and fever) 341,
acute lung diseases 066, consumption 288, diphtheria and croup
163, measles 33, typhoid fever 2!J, scarlet fever 28, diarrhoeai
diseases 23, whooping-cough 21, cerebro-spinal meningitis 17,
erysipelas 11, small-pox 11, malarial fever S.

From measles New York 24, Milwaukee 1, Brooklyn 3, Boston
and Nashville 1 each. From dlarrhaeal diseases New York 11,
Fall River 3, Boston and New Bedford 2 each, Milwaukee, Fort-
land and Salem 1 each. From whooping-cough Mew York 8,
PittsbnrgS, Brooklyn 3, Boston and Cincinnati 2 each, Brook-
line 1. From cerebro-spinal meningitis New York 8, Cleveland
4, Brooklyn 2, Worcester New Bedford and Everett 1 each,
nom small-pox Mew York 6, Boston 3, Lowell 3. From eiy-

Digitized by

Google

128

SOSTOS MEDICAL AND SDBQIOAL JOVRSAL. [FsBRUiLRT 1, 1894.

■ipelu New York 6, Boston 3, Brooklyn 2, Someryille 1. From
malarial fever New York and NashTlfle 2 each, Pittabarg 1.

In the thirty- three greater towns al England and Wales with
an estimated popnlation o{ 10,468,142, tor the week ending
January 13th, the death-rate was 28.6. Deaths reported 6,726;
acute diseases of the respiratory organs (London) 762, whooplnic-
oongh 21tf, measles 108, diphtheria 78, scarlet fever 62, fever 47,
diarrhoea 36, small-pox (Bradford 3, Birmingham 2, London,
West Ham and Nottingham 1 each) 8.

The death-rates ranged from 19.6 in Qatesbead to 60.2 in
Norwich ; Birmingham 31.6, Bradford 21.9, Cardiff 24.2, Halifax
23.0, Leeds 27.0, Liverpool 33.3, London 29.6, Manchester 30.8,
Newcastle-on-Tyne 20.7, Plymouth 66.7, ShefBeld 24.8.

OFFICIAL U8T OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SEBVINO IN THE MEDICAL
DEPARTMENT, U. 6. ARMY, FROM JANUARY 20, 1894,
TO JANUARY 26, 1894.

FiBST-LiKVT. Euclid B. Fbick, assistant surgeon, U. 8. A.,
is relieved from duty at Fort Keogh, Montana, and ordered to
Fort Townsend, Washington, for dnty at that post, relieving
Captain Robbbt R. Ball, assistant surgeon.

Captain Ball, on being relieved by Fikst-Lixtjt. Fbicx,
will report in person to the commanding officer. Fort Monroe,
Virginia, for temporary duty.

FiBST-LixuT. BlADiBoir M. Bbbwbb, assistant surgeon, will,
npon the arrival of Captain Ball, be relieved from tempoiaiy
duty at Fort Monroe, Virginia, and will retnrn to bis proper
staUon, Fort Riley, Kansas.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. 8. NAVY FOR THE WEEK ENDING JANU-
ARY 27, 1894.

J. L. Nbilsok, snrgeon, from Naval Medical Examining
Board and to Boston Navy Yard.

R. A. Mabmion, surgeon, from Boston Navy Yard and to
Smithsonian Institution.

C. U. Qbavatt, surgeon, from Smittisonian Institution and
to the " Dale."

E. H. Obbbn, surgeon, from the " Dale " and to the " Marble-
head."

A. C. H. RcssKLL, passed assistant snrgepn, ordered as mem-
ber Naval Medical Examining Board.

T. A. Bekbthill, passed assistant sargeon, ordered to dnty
at Naval Laboratory and Department of Instruction.

H. J. Babin, surgeon, ordered as member of Board of Inspec-
tion Survey.

F. L. DdBois, medical inspector, and C. A. SiBOfRiBD, sur-
geon, appointed delegates to the Eleventh International Medical
Congress to be held at Rome, Italy, March 29 to April 6, 1894.

OFFICIAL LIST OF CHANGES OF STATIONS AND DUTIES
OF MEDICAL OFFICERS OF THE UNITED STATES
MARINE-HOSPITAL SERVICE FOR THE FIVE WEEKS
ENDING JANUARY 20. 1894.

Bailbachb, p. H., snrgeon. Detailed by the president as
delegate to International Unitary Conference in Paris, France.
January 16, 18U4.

Sawtkllb, H. W., surgeon. Detailed as chairman. Board
for physical examination of officers. Revenue Marine Service.
January 19, 1891.

Austbn, H. W., surgeon. To represent the service at Inter-
national Medical Congress, Rome, Italy. December 16, 1893.

Stobbb, 6. W., surgeon. Granted leave of absence for seven
days. December 22, 1893.

Ibwuc, Faibtaz, surgeon. To proceed to St. Petersburg,
Russia, for duty. December 28, 1893. To proceed to Paris,
France, for temporary duty. January 16, 1894.

Caktbb, H. W., sargeon. To reportat Bureau fortemporary
dnty. December IT, 1893.

Banks, C. E., passed assistant surgeon. Detailed as recorder.
Board for physical examination of officers. Revenue Marine
Service. January 19, 1894.

Fbckham, C. T., passed assistant saigeou. Granted leave of
absence for seven days. January 6, 1891. Granted leave of
at>sence for six days. January 11, 1891.

Glbmnam, a. H., passed assistant surgeon. Granted leave of
absence for five days. December 20, 1893.

Bbooks, S. D., passed assistant surgeon. To proceed to San-
dusky, Ohio, as inspector. January 17, 1894.

Wbitb, J. H., passed assistant sargeon. Granted leave of
absence for thirteen days from December 18, 1893.

—— , passed assistant surgeon. Granted leave of

alwenoe for thirteen days from December 18, 1893.

Williams, L. L., passed assistant surgeon. Granted leave
of absence for fourteen days. January 17, 1894.

Bbattoit, W. D., passed assistant snrgeon. To proceed to
Wilmington, N. C, for duty. January 9, 1894.

WooowABO, R. M., passed assistant snrgeon. Granted leave
of absence for ten days. December 18, 1893. Granted leave of
absence for fourteen days. January 17, 1894.

Stombb, J. B., passed assistant surgeon. To prooeed to
Marshfield, Oregon, as inspector.

Guitbbas, G. M., passed assistant surgeon. To proceed to
New Orleans, La., for duty.

Pbbbt, J. C, passed assistant surgeon. To proceed to
Norfolk, Va., for temporary dnty.

YouNO, G. B., assistant snrgeon. Granted leave of absence
for three days. January 1, 1894.

' Bbown, B. W., assistant surgeon. Granted leave of absence
for thirty days. December 16,1893.

ROSBNAC, H. J. , assistant surgSon. To proceed to Evansville,
Ind., for temporary duty. January 13, 1891.

Oardiibr, C. H., assistant snrgeon. To prooeed to San
Francisco Quarantine for temporary dnty. December 22, 1893.

Ntdboobb, J. A., assistant surgeon. Granted leave of ab-
sence for twenty-three days. December 20, 1893.

Oaklbt, J. H., assistant sargeon. Granted leave of absence
for twenty-five days. December 20, 189S.

NoBMAM, Sbaton, assistant snrgeon. Granted leave of ab-
sence for thirty days. January 16, 1891.

Pbochazka, Emil, assistant surgeon. To proceed to Louis-
ville, Ky., tor dnty. December 26, 1898.

SOCIETY NOTICES.

BoiTOM Sooibtt fob Mbsical Obsbbvatiom. — A regular
meeting will be held at 19 Boylston Place, on Monday, Febmaty
6th, at 8 o'clock.

Dr. Charles M. Green : " Four Unusual Cases : (1) Imperforate
Hymen, with Hsmatocolpos: (2) Cysts of the Vagina; (3)
Recto-vulvar Fistula: (4) Salivation of Pregnancy."

Dr. J. E. Goldthwait : " Some Observations upon the Etiology
and Treatment of Anterior Metatarsalgia."

JOBH C. MnMBO, M.D., Secretary.

MASaAOHUSIETTS MSDICAL SOCIBTT, SUFFOLK DiBTBICT. — '

The Surgical Section will hold its regular monthly meeting at
19 Boylston Place, Febraary 7, 1894, at 8 o'clock.
Dr. Gardner W. Allen : " A Case of Litbolapaxy."
Dr. E H.Bradford: " Investigations of Fiat-Foot."
Dr. Otis K. Newell: "The Intermittent Rapid DilaUtion of
Urethral Stricture."

Ckables L. Scvsdbb, MJ>., Secretory, 1 Marlborough St

RECENT DEATHS.

Cbablbs Colbt Pikb, M.D., M.M.S.S., died in Peabody,
Mass., JannaiT 27th, aged forty-nine years. He was bora In
New London, N. H. During the war he served in the Eleventh
New Hampshire Regiment and was severely wounded at Fred-
ericksburg. After the war he went to Dartmouth College,
graduating in the class of 1869.

Qbobob Tokbbt Gbibbsuii, M.D., H.M.S.S., died In Lowell,
January 28tb, aged twenty-five years.

BOOKS AND PAMPHLETS RECEIVED.

Dr. G. Zander's Medico-Mechanical Qvmnastics; Its Method,
Importance and Application. By Dr. Alfred Levertin. With a
portrait of Dr. Zander, several explanatory illustrations and a
map. Stockholm. 1893.

Liqnor Sedans, Saw Palmetto, Damiana, PIchi and Stylosan-
tlkes Elatior; Their Uses in Nervous Diseases; Their Medico-
Le«il Relation ; Epilogue. By John J. Caldwell, Neurologist,
of Baltimore, Md. Reprint. 18M.

Descriptive Catalogue of the Anatomical and Pathological
Specimens iu the Mnsenm of the Royal College of Surgeons of
Edinburgh. By Charles W. Cathcart, Conservator, Fellow of
the College. Vol. I. The Skeleton and Organs of Motion.
Edinburgh: James Thin. 1893.

Climates of the United States in Colors. Popular edition of
Denison's Charts, with additions. By Charles Denisoa, A.M.,
M.D., Denver, Colo., Professor of the Diseases of the Chest and
of Climatology, Medical College, University of Denver; Ex-
President of we American Climatological Association. Chicago:
The W. T. Keener Co. UM.

Digitized by

Google

Ol,,

CXXX, No. 6] BOSTON MEDICAL AND SURGICAL JOURNAL.

129

XmureiEt*

LECTURES ON SURGERY.

BT DATI* W. CHKBTXB, M.D.,

Profe$$or <tf Surgtrg m Sanard IMeenUy .

XXIV.

DISEASES or TBB NOSE.

JSpittaxit. — I will speak at once of the most com-
mon affection surgically that we have to treat in the
nose, and that is epistaxis or nose-bleed. It comes
from a variety of canses. In a certain proportion of
c&ses it is wholesome and useful. It depletes very
rapidly the venous sinuses at the base of the brain.

> There is a direct communication with the veins of the
nose through the cribriform plate of the ethmoid and
^vith the base of the brain ; and in youth, in violent
exercises, in persons who are plethoric, etc., moderate

I nose-bleeds frequently are useful, and if not excessive.

. need not excite anxiety. In old age, however, in elderly

people, nose-bleed, when it amounts to anything, is

> frequently the sign of some congestion in the head
which should warn us that the patient may be in dan-

^ ger of rupturing a vessel and having apoplexy. Nose-
bleeds in old people are rather unfavorable signs as
regards the prognosis of future life. Something is apt
to take place after this warning is given ; and- we should
be very careful about the diet and exercise of such
t patients. But nose-bleed only becomes injurious in
younger subjects when they either are the subject of
, some other disease, a diseased condition of the blood or
r constitutional disease ; or else when it becomes very
' frequently repeated, apparently from the state of
ansemia, thinness of the blood and weakness of the walls
of the veins. Typhoid fever, diseases which affect the
'- blood, as purpura, or profound anaemia, are frequently
associated with nose-bleed. Occasionally, as you know,
it is merely vicarious, so to speak, occurring in the
place of habitual discharges in other directions ; espe-
cially the menstrual flow in the female is sometimes
' supplemented, or aborted, by the frequent occurrence
of nose-bleed. So also, certain patients who have trou-
ble about the rectum and bleed from piles, occasionally
have this arrested, and then have epistaxis follow.
This is not so severe, and should not be classed with
those cases which are what is called true bleeders,
where there is that peculiar constitution of the blood
that it lacks the fibrinous sticky element, and cannot
coagulate when thrown out from the vessels. These
patients may bleed from any point: from the gums;
macouB surfaces like the urethra, and sometimes from
the skin, making a bloody exudation from the true
skin. This is associated with a condition of the
blood which is usually inherited. Such cases are not
very frequent. They can hardly be classed as the
ordinary accidents of nose-bleed. Any acute disease
of the liver, which is going on to a fatal condition, is
frequently followed by hsmorrbage ; hsemorrhage by
the nose and month and bowel is one of the common
results. In typhoid fever, where the fever seems to
expend itself and its force on the head and nervous
system, bleeding from the head and nose seems to take
the place of bleeding from Pyers' patches.
Ordinary nose-bleed need occasion no alarm. It is

■ TIUM are unwritten leetores printed from the itenographert'
rapona. Verbal correoUoni are made in reviiion. bat no rnetorioal
olungea. Tbey were delivered to the third ana fnnrth tilainni as
part of tlie regular oonne.

best arrested by keeping the patient in the upright
position, applying cold, avoiding stooping over ; some-
times it can be arrested by keeping the hands above
the head a little while ; frequently by the application
of cold to the spine, or cold over the forehead, or cold,
in the form of pieces of ice held in the mouth, where
it will press against the palate process. These meas-
ures are simple ones and are generally sufficient.
When they are not sufficient, frequently the putting of
a small plug of lint in the nostril which is bleeding,
especially if it is dusted over with a little dried per-
sulphate of iron, succeeds. Syringing out the nose
with cold water is sometimes effectual. These meas-
ures are enough for simple cases ; but the cases which
excite alarm are those where the bleeding goes on al-
most without stopping, but with remission, for, perhaps,
an entire day. The patient becomes gradually quite
feeble and exhausted. The respirations are very much
impeded by the enormous clots that form in the nasal
passages, and which temporarily arrest the bleeding ;
but it keeps breaking out. If the patient lies down
from faintness, the blood goes on trickling slowly
backwards and large quantities of blood run down the
pharynx, and are swallowed. Then, after a while,
the stomach being distended by clots rejects these ;
vomiting comes on and that starts the nose-bleed again.
So in one of these bad cases, I suppose, if they went
far enough, a fatal result might ensue ; though usually
they are stopped before that result is reached.

Simple measures are of no use in these forms ; and
the most thorough way to arrest the bleeding is by
plugging the nose, the anterior and posterior nares as
well. Each nostril is a separate cavity. It is rarely
that bleeding occurs from more than one nostril at a
time : and the bleeding nostril is plugged front and
behind, and the plugs left in thirty-six to forty-eight
hours. Some surgeons advise leaving them three or
four days. The objection is that they soon become
very foul and offensive, and provoke ulceration of the
membrane covering the delicate bones inside the nose ;
and may, if kept in long enough, lead to caries of the
bone, and a chronic state of ozsena with filthy discharge.
It is always a delicate matter to decide the time when
the plug shall be taken out in a bad case ; but, as a
rule, by forty-eight, hours an attempt must be mtule to
remove it carefully ; and if bleeding occurs, a fresh
plug may be put in, which is clean and aseptic, and
may be left in considerably longer. It is perfectly
easy to plug the anterior narea. To get a plug behind
in the posterior nares is impossible without a guide.
That guide must be a thread passed through the nostril,
behind the soft palate, out of the mouth. The patient
must open his mouth widely, a gag is put between the
teeth, and the thread is carried through by a little in-
strument called Belocq's sound. The sound is threaded,
passed through the nose, and the finger passed into the
mouth catches the thread and draws it out, and the
catheter is withdrawn ; the other end is out of the nose.
We have the location we wish to plug under control with
this string. To the end which comes out of the mouth,
must he fastened another double thread, and to this a
small piece of lint or sponge, not too large. If a sponge,
it will swell to a certain degree ; but the lint will not
swell. That must be tied with a double thread, and
then passed into the mouth, and guided with the linger
behind the palate, and pulled firmly into the posterior
nares, so that it will not drop back into the throat.
Another plug is pat in front, and a string tied over it,

Digitized by

Google

130

BOSTON MSDIOAL AND StJRGtOAL JOVBNAL. [Pbbrdakt 8, 1894

so that the two are pulled together. The cayity be-
tween is gradually filled by coagula, and bleeding is
necessarily arrested. The use. of the two strings on
the back, where the plug is attached, is to leave one
coming out of the mouth, which can be fastened around
the ear, and which is a guide to the posterior plug.
This is important, because in removing the posterior
plug we wish to do it with as little excitement as possi-
ble, and if we have no guide, we are forced to take a
catheter, or something of that kind, and put it in the
nose and dislodge the plug, and catch it as it drops in
the throat; whereas if we have a string guide, we cut
the anterior string, take out the anterior plug, and pull
on the string in the back of the mouth, and easily
withdraw the plug. This may make the difference be-
tween starting the bleeding, and having to plug over
again. To our surprise we see how much suffering is
produced by this plugging in the first twenty-four
hours. At first the patient is relieved of bleeding, and
he can take nourishment and lie down and sleep ; but
he soon has pain in the nose and face and eyelids. All
the parts about the cheek begin to have an oedematous
swelling to a very marked degree ; and the skin of the
nose is largely distended by swelling, and the patient
looks as if he bad an attack of facial erysipelas coming
on. This is due to the pressure of the plugs ; and if
they are left in too long, it may be followed by septic
consequences and dangerous results. On taking out
the plugs, the swelling slowly subsides, and the case
is over.

A little rubber arrangement, which is very like what
we call the colpeurynter used to dilate the cervical
outlet, can be nsed. That can be flattened ont and
with a probe or director passed in until it projects into
the posterior nares in the throat. When it has got
fairly through the nostril, it can be blown up with air
firmly, and it makes a sn£Bcient air plug to the passage.
Of course, it adapts itself perfectly to the shape of the
nasal cavity, and makes a very ingenious and neat plug.
When we have one of these it is easier to use
and to remove than the more clumsy method of the
sponge. In many cases we shall be called to a distance,
to a case of nose-bleed, without these preparations, and
we need not wait for Belocq's instrument ; but with a
good strong elastic catheter we caaacoomplish in a few
moments the arrest of the haemorrhage.

DevieUiont of the Septum of the Note. — The septum
is partly bony and partly cartilaginous. The cartilagi-
nous part is thin and elastic, and covered with delicate
mucous membrane and vessels and nerves. This fre-
quently grows ont of place, sometimes probably in
consequence of a blow, and sometimes by a spontane-
ous deformity which pushes it to one side and gradu-
ally occludes one nostril. This condition leads to
catarrh, retention of secretions on the side where the
occlusion is, to change of the voice. When the dis-
ease goes on a little longer, and is not treated, changes
take place in the septum itself ; and as the young per-
son grows older the septum thickens and grows out
bony ridges and spurs which project on the occluded
side and still more obstruct the nose. The septum can
be broken and forced back into place in the early
stages of the affection. It will not, however, stay
there, but recoils just like a piece of birch bark. It
can only be forced to stay back by cutting through it,
and destroying its elasticity. In more severe cases it
is often best to saw off a piece of the septum with a
fine saw on the occluded side. The spurs are sawed

off, and a piece of the septum sawed off. We may
or may not go through. Sometimes we can succeed
in sawing off the spurs without sawing through into
the other side of the nose, sometimes not. If we
saw through, a small permanent opening is left. If
it is too small, it is sometimes accompanied by a
whistling sound in breathing, which is annoying. If
it is opened, it is better to make it of suflScient size,
that the air may travel back and forth without mak-
ing this sound.

The septum is the seat of ulcerations which used to
be thought to be syphilitic. . They frequently are tn-
l>erculous. The ulceration may go so far as to perfo-
rate the septum, and the patient has an opening throogb
the septum which is frequently the size of a dime or
lead pencil. It does not make any external deformity
whatever. It does not make the nose of that peculiar
shape that it does in syphilis, when the vomer is cast
off by caries. There is an obstinate ulcer, with a little
hole leading through. Local applications of varioui
kinds, and constitutional treatment, are the best things
that can be done. Usually granulations can be en-
couraged ; and if the septnm is not eaten through, the
nicer can be healed. U it is, the hole can be healed
around the margin so that it will not expand, and the
patient get along very comfortably. It is important
to recognize the fact that many of these ulcerations
are in perfectly innocent parUes with regard to either
primary or inherited syphilis ; and that they are quite
common in young and scrofulous subjects.

The cartilage will not stand any very violent appli-
cations. If you try to cauterize it, anything of that
kind, yon make the cartilage ulcerate and break down
more. Cleanliness and mild antiseptics and constitu-
tional treatment should be employed.

The turbinate bones grow out of place, grow ex-
ostoses, project into the passage and frequently obstruct
the breathing. Portions are frequently cut away with
benefit, and sometimes the trephine is used and the
turbinate bones cut through, giving the patient much
deeper breathing power. Since the use of the electric
light and the rhinoscope to look into the nose, and the
minute electric wire which can be heated as a cautery,
it is easy to bum off portions of the delicate bones of
the nose with safety and without much suffering.
Ether is not necessary. In fact that is not desirable
where the hot wire is used, because we are in danger
of setting the ether on fire. Cocaine is all that is ne-
cessary to blunt the sensibility enough to do this sort
of operation.

Foreign Bodies in the Note. — In a child with
trouble in the nose your first thought should be is there
any possible foreign body concealed in the nose. In-
fants and children are very apt to put substances up in
the nose, and those are generally of a character that
cannot be got ont easily ; beans and peas and buttons
are favorite objects. They are pushed up far enough
to get beyond the inferior turbinate bone, and are there
held ; provoke constant discharge, and other signs of
chronic ocsena, or polypus. The child is frequently
brought to the doctor with the idea that it has polypus.
Careful search will find something hard in the nose;
and the nose sprayed with cocaine and made non-sensi-
tive, the foreign body can be got out, and the case is
speedily cured.

Polypi in the Note. — Polypi in the noae are of two
forms. The common form is- a soft, gelatinous polypus
which grows from the turbinate bones, and sometimes

Digitized by

Google

Vol. CXXX, No. 6.] BOSTON MEDIOAL ASD SURGICAL JOURNAL,

131

in extreme cMea extends its growth np in little colonies

of polypi which grow as high u the npper tnrbinate
bone and even as high as the ethmoid. The ordinary
soft polyp is attached to the inferior turbinate bone,
floats or hangs in the nasal cavity, rises up and down
with the movements of respiration. If the patient
makes a forced expiration through the nose with the
moath shot the polypus can generally be brought into
light, and is seen lying as a white, soft, gelatinous-look-
ing mass a little ways up the nasal cavity. Or when
the patient inspires violently, it is drawn behind the
torbinate bone and sometimes when it is large passes
back of the posterior nares and hangs back into the
throat. In extreme cases they protrude down the
throat, and if the patient has the mouth held widely
open and raises the palate by saying the word " ah "
the polypus can be seen projecting in the throat behind
the palatine arch.

The mucous polypus can be readily removed ; but
oniortanately this frequently does - not permanently
care the affection. The tendency having been developed
to their growth, others form. They are slow to form.
They frequently do not show signs of returning for
six months, but they are apt to come back. The neat-
est way to remove them is to locate them exactly by
the ud of the mirror and remove by the snare or hot
wire. If we have not this means, we can follow up
the polyp and get hold of the stem and twist it off. It
frequently brings away a little of the turbinate bone
with it. This does no harm ; and by removing the
periosteum and root on which the polyp grows, that
particular polyp is exterminated, and has no chance of
starting again. We must not be satisfied with one
search ; bat put the forceps throughout the nose, and
frequently we succeed in extracting one large one, and
two or three small ones. After a few days, when
bleeding has subsided and the soreness gone, the nose
can again be' treated with cocaine, and investigated
carefully with the lamp and mirror, to see if any others
are left.

The signs of polyp are usually those of chronic
catarrh and obstruction. They change in their shape
and size ; swell up with fluids and collapse again ac-
cording to difierent states of the system ; and where
the patient has a slight cold and congestion, it increases
the flow of blood to the mucous membranes and distends
the polyp. A chronic catarrh running from the nose ;
sccumnlation of secretion ; difficnlty of breathing ;
snoring in the sleep, are signs of polypus. When en>
Isrged they distend the nose, but must be of consider-
kble size to do so.

On examination, the two sides of the nose do not
correspond. In extreme oases the nasal bone becomes
displaced to some degree as well as the cartilage, so
that the nose is entirely flattened out on that side.
Those are unusual cases.

Ordinary soft, gelatinous, nasal polypi then are usu-
ally removed by one of these methods. Subsequently
the nasal cavity must be treated by injections of weak
carbolic acid and by astringents. Quinine sometimes
is very useful ; and various agents to endeavor to pre-
vent the return. The milder forms of spray are the
best to use in this cavity. The nasal douche, which
is merely a repetition of the fountain syringe, is no
longer thonght to be as desirable as it used to be. It
b too violent, too forcible, has occasionally made trou-
Ue by distending the Enstacheau tubes, and has brought
OD affections in the middle-ear by being too forcibly

used. It is only in extreme cases of filthy ozsena, and
where other measures will do no good at all, that the
nasal douche is to be used. It is better to use the ap-
plications in the form of spray, applied both behind by
the throat, and forward through the nose.

The person who has once had a mucous polypus
must be on the lookout for others ; and when the slight-
est signs present themselves, he should be inspected
and the growths taken out, if possible. With the
cautery the bases from which they grow, can be thor-
oughly destroyed; and, sometimes, after one or two
operations, no more recur. Sometimes they recur
after long intervals.

The other form is essentially a fibrous tumor, and is
called sometimes the naso-pharyngeal polypus because
it affects the posterior nares and the top of the pharynx.
It grows sometimes from the edges around the nasal
cavity, the little hollow of the pterygoid process ; and
sometimes about the posterior septum of the nose; and
frequently, also, from what is called the occipito-sphe-
noid bone, the junction of the sphenoid and occipital
at the true base of the skull. This, of course, is at
the very top of the pharynx, and covered with mucous
membrane ; it is in a pouch at the top of the pharynx ;
and the fibrous tumor, we call the naso-pharyngeal
polypus, frequently has its growth there. It obstructs
the posterior nares ; and in bad cases, can be seen from
the mouth. It is not of uniform size; is generally
pear-shaped, and has a stem and a large body. Occa-
sionally the growths are broad and cover the whole of
the occipito-sphenoid bone.

These growths most often occur in young subjects,
during the period of about fifteen or sixteen to twenty-
four or twenty-five years of age. They grow very
slowly, and the patient first suspecting that he has
chronic catarrh, finally becomes aware of something
which obstructs the breathing. The surgeon, if he fails
to see anything in ordinary inspection of the throat,
can detect the trouble usually by passing a silver cathe-
ter, or elastic catheter on a wire, carefully curved, and
gently through the nares down into the throat on one
side; it will soon be found that the catheter strikes a
prominent obstruction on one side, or the other, and
the location of the trouble can be made out. With
the electric lamp in the throat and the rhinoscope the
tumor can be seen back of the palate. If we have not
this means, we can diagnosticate by means of the finger.
The patient's mouth widely open and the finger passed
in, up behind the soft palate; with this we can ex-
plore both of the posterior nares. It is a disagreeable
experience for the patient, but does not produce any
harm, and only the sensation of momentarily choking,
and perhaps a little bleeding. In that way we can
locate the growth ; determine its size ; shape ; attach-
ment; and see on which side of the posterior nares
and pharynx it lies.

Being there aud increasing, it may go on to cause a
fatal result ; leading to trouble at the base of the brain ;
to destructive changes in the pharynx ; finally hanging
down as low as the epiglottis and back into the oesopha-
gus, in marked cases ; aud obstructing swallowing,
and endangering the patient from choking while breath-
ing or swallowing. It is then evident that it is very
important, as soon as the diagnosis is made, that this
growth should be removed ; and a great many ingeni-
ous modes have been used to do it. The simplest form is
to attempt to snare it by the snare passed through the
nares, or else up behind the soft palate. If a lucky

Digitized by

Google

182

BOSTON MBDIOAL AUD SUBGIOAL JOURNAL. [Febrcart 8, 1894.

cas« with good pedicle, this may tometimea be done.
N^latOD found that the loft palate presented a barrier
to the ]a*t one-half iuch, irhich was in the way of get-
ting the snare aroand. He devised the operation of
splitting the soft palate, and passing a thread through
either tip of the avnla ; drawing it aside, and fasten-
ing it outside the mouth ; and then you gain one-half
inch or more of space by which you can get access to
the posterior pharyngeal region. Then the polypus
was removed by snare or forceps ; and the soft palate
was sewed up again.

It has been found, however, that most of the oper-
ations of this class, which merely snare off the polyp,
do not prevent its subsequent re-formation ; and that
it is essential that the base should be reached 'and
scraped away, and the periosteal layer under the
mucous membrane, be scraped away, in order to insnre
against the recurrence ; so that io order to get at this
space other operations were devised. One was to cut
a piece of bone out from the speno-maxillary fossa,
turn the bone back, and expose the whole nasal cav-
ity ; this was Langenbeck's method.

Another was to saw across the top of the antrum,
beneath the zygoma ; split the palate process, after ex-
tracting one incisor tooth ; depress and break down
one superior maxillary bone ; leaving it hinged on the
pterygoid process; then pass the finger through this
gap, push the septum to one side, and get ready access
to the point you wish. That is the operation that I
have done a number of times.

Whatever operation of this kind is done, after the
polyp is scraped away and removed, the jaw is pushed
back to place and wired, and the wound closes, and
the bone unites, as a broken jaw does, aud gives no
subsequent trouble.

When it is borne iu mind that before these operations
were devised the only other alternative to destroy
these large fibrous tumors was to excise the upper jaw,
you see how much we have gained in the point of con-
servative surgery.

The prettiest operation of all was devised by M.
OUifer of Lyons. Yon would not suppose at first it
would give the needed room, but it does. It consists
in sawing down and depressing the nose. Yon make
a cut from the centre of the forehead, down each side
of the nose, to the point where the artery goes to the
ala. Cut through the periosteum to the bone on each
side. Having made that cnt, yon take a moderately
narrow and quite flexible saw, lay it as flat as possible
on the forehead, and saw down through the nasal bone,
down to the cartilage ; upset the nose and drop it down
on the lips. The nasal cavity is fully exposed. The
vomer and septum are iu the way. They are flexible
and can be pressed over ; and yon have the means of
reaching to the growth of the polyp, which the finger
will exactly do ; and thus you can extract large polypi
by forceps, or by scissors, or by seizing them and tear^
ing them out ; and subsequently yon go in and scrape
this cavity. In these cases it is well always to operate
in the upright position ; and when any sign of choking
comes on, bring the patient's mouth well forward and
drop the jaw until they expectorate. Half etherization
is the best. Thorough etherization during the incision
through the skin and sawing the bone ; the patient
partially awake through the remaining stages. Al-
though they make a noise, they remember nothing
which has occurred ; and it is much safer to have the
patient sufficiently awake to retain a little control over

the epiglottis. Subsequently to this the nose is re-
placed. Two fine wire sotures are passed through tbe
lower angle of the nasal bone, which hold the boDs
perfectly in place. These are brought out throogh
the wound, and the wound nicely stitched. Tbe wires
must be left in two or three weeks ; two weeks iu tbe
nose, and three in the jaw. The wires loosen and ulcer-
ate ; the bone decays a little around the holes, and,
afterwards, untwisting them, they are drawn oat with
ease, and the sinus closes. Very little scar is left by
this operation on the nose. There need be do fear
that there will not be union. All the parts about the
upper jaw and nose are so thoroughly supplied with
vessels that they repair very great injuries, and always
unite.

MaUgnetHt Forms of Growth in the Now. — Theseare
sometimes mistaken for the ordinary polypus. Soft
cancerous growths occur on tbe mucous membrane of tbe
septum low down, just inside the nasal cavity. The
parts become obstructed and the patient thinks he has
a polypus. On lifting the ala and looking at this
growth, you find it is red and very vascular, with little
tuberosities on it shaped like a strawberry, or rasp-
berry. It bleeds on the slightest touch; occurs almost
always in people of middle age; and it is essentially a
soft and rapid growth of epithelioma.

This must be thoroughly removed. Usually it csd
be done by a very slight operation, by cutting around
the ala and turning it up and then the septum and the
growth may be cut away, the ala replaced and the only
subsequent deformity is the little scar on the side of
the ala. If that is not sufficient, exision of the struc-
tures inside, with portions of the jaw, must be done.
It is not very common. I will call attention to the
fact that polypus growing low down, in the elderly per-
son, prolmbly means cancerous growth. True polypi
are never, I think, attached to the septum, but always
to the turbinate bones. These malignant growths fre-
quently start from the septam itself.

Abscest of the Septum. — Abscess of the septum is a
very painful affection. You are familiar no doubt
with what is called the little boil that forms within the
tip of the nose. It is extremely painful, lasts five or
six days, finally breaks and discharges inside the nose.
It leaves no subsequent trouble.

There is another form which is more severe : abscess
of the septum. It produces a curious deformity. It
fills up the nostril completely, so that in seeing this
patient first you would suppose the whole nose was
filled with an enormous, red, malignant growth ; bat
you find the duration of the disease is not more than a
week, or ten days.' The nose begins to swell ; pain
occurs ; and this rapid ballooning out of the mucous
membrane comes on, and the nostril is occluded. You
find it is elastic to the touch.

The treatment is to make free incision and let out
the pns, which is followed by speedy care.

Mating of a New No$e. — Artificial noses of pupier
maehS, nicely colored and of a pattern to suit the taste
of the wearer, are much better than any artificial nose
made from the skin.

Am Epidrmio of Mdmps. — An epidemic of mumps
has recently occurred iu an English village, in which
96 out of the 130 children in the village were taken
ill. Many adults were also afflicted, but the number
of patients was not so carefully recorded.

Digitized by

Google

CXXX, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL.

1S8

INFECTIOUS APPENDICITIS.!

BT BOBBBT T. MOBBIS, M.D., Or KBW TOBK.

GrBNTE-BMBN: — There u only one way to prevent
Baths from appendicitis, and that ii to prevent deaths
»m appendicitis. Do you not know how? I do.
^<=> do yoa. Then let as cast the killick right here,
LEad allow the restless, changbg tides of argument to
i^aah by as they will.

We have lost enough brothers and sisters and sons

B.Kid daughters unnecessarily from appendicitis. Do

not fail to remember the word " unnecessarily," when

yon long for the " touch of the vanished hand and the

sound of the voice that is still."

For ten years we swarmed about the subject of ap-
pendicitis, trying first one hole and then another iu a
liant for rules for guidance ; but each was too small
and we left the dead outside of every hole that was
deserted. Now we are at the right place at last. There
is only one rule for guidance. You know what it is.
Those who do not accept it must lose a few cases that
they did not really intend to lose, and they must let
many trustiDg patients suffer tedious convalescence
and inconvenient exacerbation at a time when they
wonld prefer to be engaged in affairs. The troubled
families will be satisfied when it is explained to them
that these cases seem to be peculiar in their character.
I am prepared to admit that in many of the smaller
towns it is not " policy " to remove an infected appen-
dix at the very outset of appendicitis. At first I was
shocked to hear physicians say that it was better to
let a case of appendicitis run its course without opera-
tion, on the ground that the comments of rivals and of
neighbors wonld rain their practice if they attempted
to do the right thing promptly. This expression of
sentiment was so general, however, that I could not
doubt its importance. O human nature, how polyprag-
matical art thou !

Even in the large cities there are still to be fonnd
most excellent authorities who are not yet ready to
have the infected appendix removed as soon as it is
discovered. This is because they are too busy to get
out into the field and think at a mark, or because they
have not had an opportunity to see the results of the
inch-and-a-half incision and week -and-a-half confinement
in appendicitis cases. They are men who are familiar
with logic and who are accnstomed to analysis and to
rational deduction ; but they work from the wrong
set of data, and they give os a masterly impressionist
picture of strawberries among autumn leaves.

The sweet-oil and opium jugglers detained us for a
while. Did you see the Hindoo jugglers on the Mid-
way ? They put a man into a baisket and then poked
around ui the basket with a stick, and explained to the
aadienoe that the man was not there. After a while
the man came out of the basket again. The sweet-oil
and opiom jugglers tacked away an infected appendix
aod told as that infection was not there. After a while
the infection stalked out again.

Every general practitioner in this audience has in
big elietUM patients who are supposed to have recov-
ered from appendicitis ander medical treatment ; and
yet the answers that most of these patients woald
give to my questions would cause surprise. The bacte-
rium cdi communis and the pyogenic streptococci and
Btsphylococci do not leave when we shoo them off

> A iMtnre at th» New York Po«t-anKla»t« H«(UoaI School, D»-
oemtnr n, USS,

with poultices and opium and sweet-oil. They simply
run and hide. I have removed a number of appendices
in the presence of this class from patients who were
believed by good authorities to be out of danger from
relapses ; and in all of the cases we have found destruc-
tive processes iu progress. Sometimes the bacteria
were slowly destroying the adenoid layer, which had
swollen to the point of interference with its own vas-
cular supply : sometimes proliferating endarteritis was
insidiously and surely laying the way for gangrene
of the appendix ; sometimes tuberculosis had become
engrafted upon the weakened and diseased tissues;
and in every case we found appendices which were
malevolent in disposition.

Not long ago 1 quoted my statistics to an old practi-
tioner who asked, with a sly twinkle in his eye, how
many of the patients would have recovered without
operation. " I do not know," said I, " but some of
them would have died, and that settles it." Some of
them would have spent more time in bed with every
relapse than they did after the iuch-and-a-half incision
had been made; and that settles that question. I
would rather remove infected appendices at a thousand
dollars apiece from uncomplicated cases, and have all
of the patients recover, than to add op small bills for
visits to patients who died without operation, or who
are left to go through the whole performance of an-
other relapse of appendicitis after my so-called services
have been rendered.

There are many cases of simple catarrhal appendid-
tis when we fail to look at the appendices ; but when
we look at them, they are infectious, exudative cases.
If there is anything in a name, there is disaster in the
name " catarrhal appendicitis."

They have charged me with being sensational. Let
us see about that. Small-pox causes protracted suffer-
ing and death ; but many patients recover from this
disease, although the recovered ones are left with de-
fects, as a rule. We know how to prevent deaths and
defects from small-pox ; and they are consequently un-
necessary. Is there anything sensational about that
statement? No! Now, please substitute the word
" appendicitis " for the word " small-pox," and note
the effect. It is the combination of fact and date that
makes us listen cum cureetis auribus. Twenty years
from now the facts about appendicitis will ring with a
different timbre. Physicians who have not seen the
pretty modern operation for prompt removal of the in-
fected appendix are apt to draw in imagination a faulty
view of the subject. They should interrupt the patient
who is reading his morning newspaper in bed on the
second day after the operation, and have a chat with
him.

Now, look at the patient upon whom we are about
to operate. He has an abdominal scar five inches long,
and a ventral hernia. He has had one dangerous re-
lapse of appendicitis since he was operated upon ; and
the insurance companies will not risk more than three
or four postage stamps upon him. Four years ago he
had an attack of appendicitis ; and his physician in
consultation with a surgeon waited for pus to form.
Then the pus was evacuated, the appendix was left
among adhesions, and the patient recovered. Recov-
ered ! Mockery ! The surgeon who did the work
bungled it by leaving it half done ; and he is responsi-
ble for the ventral hernia and for the risk to life that
resulted from leaving an infected appendix baited and
set in the iliac fossa. / was the surgeon who gave

Digitized by

Google

134

BOSTON MEDICAL AND SOBOIOAL JOURNAL. [Fbbboabt 8, 1894

oounael and who did the work, at a time when there
was excellent anthority for doing it in that way. The
family physician, like the other physicians npoD whom
I depend, would to-day be ashamed to call me to a case
of appendicitis in which pas had formed.

This patient has given the asaal history of slight
exacerbation, of constipation and of little septic im-
pressions since the time of his first acute attack. Three
years ago he had a dangerous exacerbation, bat was
not where he could be operated upon.

The abdominal incision is now made ; and I proceed
to enucleate the appendix from a conglomerate mass
of omentum, mesentery, colon, ileum, and adventitious
tissue. The base of the appendix is ligated with fine
eye silk, and the stump is buried with four Lembert
sutures of catgut. On examinatioD of the ipecimeu,
you observe that the muscular structure of the appen-
dix is complete and hypertrophied. On inspection of
the interior of the specimen, it is seen that the mucosa
has disappeared and various tiny black or gray gangre-
nous spots are readily distinguished on the surface of
the swollen and infiltrated adenoid layer.

We have had to learn three principal things in ap-
pendicitis within the past decade: (1) that appendi-
citis is very common, and that it simulates many kinds
of abdominal disease ; (2) that we must operate for
removal of the appendix before pus has formed, if we
would prevent deaths and hernia and uncomfortable
complications ; (3) that we do not need to make much
of an incision, and that the operation is a neat and
pretty one, instead of a thing to be dreaded in itself.

NOTES ON PHOSPHATORIA.i

BY PADL THOKNDIKB, X.D., BOSTOV.

During the last three or four years the writer has
had the care of a number of cases such as are often
described and discussed in medical writings under the
name of " phosphaturia." The perplexity which several
of them caused him led to the collection of these notes
from the meagre and unsatisfactory knowledge of the
subject at our command ; and it is the object of this
paper merely to arrange these notes and present them
to the Society in a war which it is hoped may prove of
me.

Cases characterized by well-marked symptoms of
digestive and nervous disturbance, perhaps also by
neuralgic pains in the abdomen, back and loins, and
associated with a more or less persistent phosphatic
cloud in the urine, are the oues to which the writer
refers. They are common enough to be familiar to us
all, and are ofteu severe enough to make serious in-
roads upon the patient's health. The patient comes
to you complaining of a series of gastric symptoms :
distress immediately after eating, heart-burn, eructations
of gas, passage of flatus, constipation, and often of
pretty severe colicky pain in the bowels. With these
symptoms, more or less marked and pointing directly
to fermentative changes going on in the stomach, are
often associated extreme nervous irritability and some-
times indefinite but none the less annoying neuralgic
pains in the back, loins aud thighs. The urine is either

■ Read at the iiieeting of Boston Society for Medioal IniproTeuient,
Noreraber 27, ll>93.

alkaline in reaction and turbid from the cloud of pre-
cipitated phosphates, or is neutral or slightly alkaline
in reaction, clear in color, and becomes cloudy when
even very slightly heated. If the trouble has persisted
for any length of time, there is emaciation to a greater
or less degree, and due of coarse to the ingestion of
an insufficient quantity of food which is not properly
taken care of after it reaches the stomach. Let us
consider the urine of such a case for a moment, and
the causes which may bring about such a state of aStirs.

The phosphoric acid excreted in the urine is derived
from the oxidation of the waste albuminoid tissues of
the body, and also directly from the food. It is ex-
creted by the kidneys at the rate of about three gram-
mes daily, in combination with various bases, notably
potassium, sodium, calcium and magnesium. Of these
phosphates, those of potassium and sodium are very
soluble and so are never deposited as precipitates io
the urine j but the earthy phosphates (of calcium aud
magnesium) being soluble only in acid solutions, are
often deposited from alkaline or neutral urines, and
appear as a milky cloud in the urine. So it is at once
apparent that this appearance of a phosphatic cloud in
the arine has not of necessity anything whatever to do
with the amount o^ phosphoric acid which is being
excreted in the urine, aud which can be estimated only
by carefully quantitative analyses of the urine of a
patient whoso diet on successive days is carefully reg-
ulated ; but it is merely an indication of a lack of
acidity of the urine.

Now, when urine loses its acidity it does so (a)
either from the formation of ammonia due to the de-
composition of urea, that is to say, because the urine
spoils after its secretion by the kidneys, and either
somewhere in the genito-urinary tract (dependent upon
some local lesion of the organs through which it passes
or upon dirty instruments introduced into those organs)
or in the air after it has been voided ; {b) or it loses
its acidity from the constant presence in it of too great
a quantity of alkaline material which is not the result
of any process of decomposition, but is a fixed alkali
excreted in the urine chiefly in the form of carbonates
of sodium and potassium. It is with these latter urines,
those which are neutral or alkaline from the more or
less constant presence of a fixed alkali, that we are
concerned to-night. These persistently alkaline urines
seem to be associated with a series of digestive and
nervous symptoms which are of frequent occurrence
and are of enough clinical importance to demand recog-
nition as a distinct malady. It is as descriptive of this
condition that the term phosphaturia is so often used.
It would seem then that it is not the amount of phos-
phoric acid eliminated by the kidneys, but the dimin-
ished acidity of the urine and its associated symptoms,
which are of interest iu this class of cases. Many
explanations for this lack of acidity have beeu offered us.

Bence Jones thought that when the contents of the
stomach were most acid, for example, in certain dis-
turbances of digestion, the urine was least so, the one
counterbalancing the other. This explanation hardly
suffices, as it is surely evident that in such conditions
of the stomach, the excess of acid is not withdrawn
from the tissues and so kept out of the urine, but is
formed by the changes going on in the stomach.

Dr. Roberts thought the alkalinity was the result of
the increased addition to the blood of alkaline bases
from the food; but as the appetite in the condition is
much more apt to be bad than good, aud as there is no

Digitized by

Google

Vol. CXXX, No. e.3 BOSTON MSDWAl ASD StTkOtOAl JOtJtttrAl.

136

evideoce that food containing Buch alkaline bages is
either eaten or absorbed in larger amoants than usual,
this supposition does not seem of much value. What
is true is that such urines contain a surplus of alkaline
carbonates, as shown by analyses, and the alkalinity
is most probably due to the constant and excessive
elimination of these carbonates of potassium and sodium.
Kalfe says that this excessive elimination of car-
bonates may well be accounted for by three conditions :

(1) A general debility and its coincident feeble re-
spiratory acts, leading to an accumulation of carbonic
acid in the tissues. It is a noteworthy fact that in
such conditions, for example, in patients convalescing
from acute diseases, such urines are very frequently
met with.

(2) A diminished secretion of bile, the frequent re-
salt of a duodenal catarrh produced by the irritation
of the acid contents of the deranged stomach being
poured into the duodenum. The bile being the chief
secretion by which alkaline salts are excreted from the
body, any diminution of its quantity gives rise to an
accumulation of these carbonates in the blood, and
therefore to a greater elimination of them by the
kidneys.

(3) The acids formed by the fermentative changes
which go on in the deranged stomach being of the
fatty acid series, on entering the system are oxydized
into carbonic acid and unite with the alkaline bases to
form carbonates, which increase the alkalinity of the
blood and of the urine.

That the excessive elimination of these carbonates
and the consequent more or less persistent alkalinity
of the urine may be explained entirely by such diges-
tive tronbles, is not probable, for there seem to be
cases in which the phosphatic deposit is dependent
solely apoD nervous causes. In fact, cases of this sort
are by no means uncommon. For example : Two or
three years ago a middle-aged man living in Newfoand-
land, came to the writer complaining that for the last
two years he had been suffering from frequent micturi-
tion and severe neuralgic pains in the abdomen and
loins. He looked somewhat emaciated, and was ner-
vous and depressed about himself and his personal
affairs. There were no gastric symptoms, no venereal
history, and a most careful examination revealed no
lesion of the urethra or bladder. The urine was nor-
mal except for its lack of acidity and the almost con-
stant presence of a phosphatic cloud. The man said
that whenever he got into this nervous, worried con-
dition, this same set of symptoms appeared. He
was readily cured for the time being by a few hygienic
suggestions, a tonic pill and some benzoate of soda.
A second attack was brought on a year later by the
excitement and worry he went through at the time of
the great fire in St. Johns. The same treatment gave
relief very quickly. This seems to be a purely nei^
vons case, and such cases are common enough. The
writer has seen several similar cases lasting often for
months, in healthy but nervous men, after operations
apoD the penis and adjacent parts.

This deposit of phosphates has been studied by many
eminent men, both clinicians and chemists, and has
been fonnd to occur in a great variety of diseases, for
example, in acute brain diseases, acute mania, in
pleurisies and pneumonias, in rheumatic fever towards
the end of the attack, at certain periods of a typhoid
fever, etc. ; but the cases are rarely of much severity
or dnraUoD, and practically take care of themselves, as

the general nervous and physical condition improves
under proper care. That is to say, if the local cause
be removed — be it digestive or nervous — the so-called
phosphaturia disappears, as a rule ; although sometimes
it has existed long enough to leave behind it a mild
degree of inflammation of the bladder or urethra, which
may prove annoying enough to demand local or sys-
temic treatment.

There are, however, many of these cases in which
the condition persists for months or years ; the urine
gradually increases in amount and the patient's condi-
tion becomes really very serious, the general debility
and nervous depression becoming extreme and the
anaemia and emaciation marked. The general mental
and physical condition of these patients seems some-
times quite beyond any help which the physician can
offer, and the cases are most trying ones to care for.
It is when we come to a study of this class of cases
that we find the greatest 'confusion of belief in the
minds of medical men. As the disease advances it
often presents a clinical picture so similar to that com-
monly met with in cases usually described under the
name " diabetes insipidus," that confusion both as to
the terms descriptive of these conditions and of the
conditions themselves is a most natural result.

" Cases characterized by increased thirst and excessive
discharge of a watery urine of low specific gravity, free
from sugar and albumen are grouped together under
the general designation of 'diabetes insipidus'" (Rob-
erts) ; and therefore these cases should properly be
included under that definition. Other terms often used
in describing similar cases, are polyuria, diuresis, poly-
dypsia, bydruria. These terms are often carelessly
used in medical writings, without much reference to
the relationship which exists between the water and
the solid constituents of the urines in question.

Some writers, however, — notably Willis (who was
the pioneer in this direction), Tessier and Ralfe, — are
mu^h more careful in their use of terms, and have made
many attempts at classifying cases characterized or
accompanied by excessive excretion of urine, according
to the relationship existing between the solid and fluid
constituents. For example, Willis calls the cases of
excessive amount of a watery urine deficient in solids
— hydrnria ; those of excessive amount with the urea
diminished, anasoturia ; and again those of excessive
amount with excess of urea, azoturia. Several other
similar classifications have been made, and among them
one by Dr. Tessier, of Lyons, who describes a series
of cases resembling diabetes mellitus in the thirst,
emaciation, increased amount of urine, neuralgic pains,
etc., but the urine, instead of containing sugar, had
the phosphates so largely increased in amount that the
daily excretion was often as high as fifteen or twenty
grammes, instead of in the neighborhood of three gram-
mes, as it should be. To these cases Tessier gave the
name " phosphatic diabetes." Ralfe reports other
similar cases. So these writers make a distinct class
of the oases which eliminate phosphoric acid in excess.

The excessive elimination of phosphoric acid is un-
doubtedly a factor in some cases of polyuria. That it
is not present in all such cases is, 1 believe, definitely
proven by many analyses. Then, before we can rec-
ognize a definite disease characterized by this phospha-
turia, we must know in what cases of polyuria it
occurs, and must try to know the explanation of its
presence. We do not know these things. Our
knowledge of the part which phosphorus plays in the

Digitized by

Google

nt

BOSTON MSDtCAL AlfD SVRGtCAL JOtJRHAL. [FiBRtAKT 8, 1894.

body, aa well as oar knowledge of its elimination
in diseased conditions, is very small ; although during
the last twenty years good work has been done in
this direction, both ezperimeutally and clinically in
Germany and England. Dr. Goldiog Bird associ-
ated some of his spinal cases, many of which were
functional, with phosphataria. Its presence has been
noted in many cases of head-injury, in acute inflam-
mations of the cerebral membranes, in acute attacks
of mania, in anemia (and especially in its pernicious
forms). It occurs in cases of diabetes mellitus ; and
sometimes the sugar will disappear from the urine in
such cases, and be replaced by phosphoric acid. The
explanation of this undoubted fact may perhaps be that
the sugar in the tissues changes to lactic acid, which
attacks bone tissne and dissolves out the earthy phos-
phates. This is Benecke'g theory, I believe. Others
have been suggested for an explaoatton of phosphatnria
when sugar is not present in the urine ; for example,
an increased metamorphosis of nervous tissue, the
irritation of some co-ordinating chemical centre, the in-
fluence of a disturbed condition of the nervous system
upon the general bodily nutrition.

Thal> these cases of polyuria accompanied by an ex-
cessive elimination of phosphoric acid have been care-
fully and accnfately reported, is beyond question, and
therefore their existence may be taken as proven ; and
they represent the only class of cases which is entitled
to the name phosphatnria. But these cases are ex-
tremely rare, and when they do occur, present no well-
marked clinical picture which will distinguish them
from other similar cases of polyuria unaccompanied by
an excess of phospboric-acid elimination. Such a case,
then, can only be recognized by careful quantitative
analyses of the urine ; and the term phospbatnria will
have little interest for most of us in a clinical sense, as
we may never encounter such a case in the practice of
a life-time. All that we know of such cases is that
they do rarely occur, that they are generally associated
with grave physical disorder, and that they usually
accompany nervous disturbances in which the blood
and general nutrition of the patient are in bad condition.

Of the treatment of these stubborn cases there is
but little to say. Annoying symptoms must be treated
as they arise, and every efEort made to better the gen-
eral condition of the patient by careful hygienic and
dietetic suggestions and suitable tonics. Alcohol al-
ways increases the flow of urine, and should be avoided.
The administration of phosphorus or its compounds
seems of little avail as far as experience has taught us,
for as Ralfe says, " There appears to be no lack of
these constituents in the system ; the difficulty seems
rather to lie in the want of power of the tissues to re-
tain them."

To recapitulate the points which these notes attempt
to emphasize; we have considered two conditions,
both of which are commonly discussed under the name
phosphaturia :

(1) The less important class of cases of digestive or
nervous origin, in which the phospbatic cloud in the
urine is merely an indication of a lack of acidity in
the urine, which in its turn is usually traceable to some
derangement of the stomach and duodenum or to some
temporary nervous cause. These cases. have no right
to the name phosphaturia, are usually of comparatively
short duration, and are cured by the treatment of the
local cause and the consequent improvement of the
general condition of the patient, which may closely

simulate the condition we commonly speak of as diabetes
insipidus, and which should probably be classed as
cases of this disease. The fact that some such cases
are associated with an increased elimination of phot-
phoric-acid in the urine does not at present famish
sufiicient evidence to justify our making a definite
clinical condition of it and calling it phosphatnria,
phospbatic diabetes or anything else. The term phos-
phaturia, then, although perfectly proper in a chemical
sense, as descriptive of a urine which habitually con-
tains too much phosphoric acid, has in the writer's
belief no clinical significance in so far as there is no
well-marked set of symptoms constantly occurring ss
an accompaniment of this sort of urine.

(2) The rare cases of severe type and long duration
which closely simulate the condition we commonly
speak of as diabetes insipidus, and to which Tessier
gave the name phospbatic diabetes, probably because
the condition occurs occasionally in a case of true sugar
diabetes. These cases are so very uncommon, and
present such variable groups of symptoms when they
do occur, that it seems scarcely worth while to give
the name phosphaturia to any definite clinical condi-
tion, although, used as descriptive of these rare cases
when the urine habitually contains too much phos-
phoric acid, the term phosphaturia is a perfectly proper
one.

Before closing, a few words relative to phospbatic
calculi seem appropriate. In many of the long-coo-
tinned cases, the alkaline urine is often accompanied
by a more or less persistent deposit of earthy phosphates
for a period covering many months. This deposit
may be very considerable in amount ; and such patients
usually bring to yon samples of it which they have
collected from the urinary sediment. Yet primary
phospbatic concretions are by no means common ; and
snch cases often recover completely, with no further
bad result than a vesical irritability which the presence
of the phospbatic deposit in the arine has created.
This may perhaps be acooanted for by the fact that
the deposit is asuiilly a fine, powdery precipitate, non-
crystalline in 8i,ructare, and with very little tendency
to form masses or concretions of any size. Certain it
is, that most phospbatic calculi, the so-called fusible
calculi, are of secondary formation, made up of mixed
phosphates.

BIBUOOBAPHT.

Willis. Urinary diseases and their treatment. London, 1838.
Front. On the nature and treatment of stomach and urinary

diseases. London, 1848.
Benecke. Zar Physiologie and Patholofcie des Phosphors nnd

Ozalntme Kalkes. 18S0.
Boecker. Dentache Klinik, No. 33-36, 1863.
Golding Bird. Urinary deposite. Fifth edition, 1867.
Edlessen. Ueber das Verhaltniss der Phoephors&are znm stick-

stoff in nrin. Centralblatt f . d. Med. Wissensohaft, 20 Joli,

1878.
Qnthgens. Ueber den Stoff wechsie eines Diabetikert verg-

lichen mit dem eines Uesundes. Dissert., Dorpat, 1866.
Bence Jones. On the alkalescence of urine from fixed alkali in

some cases of diseased stomach. Med. Chirarg. Transactions,

vol. XZXT, p. 41.
M. Foster. Text-book of Fhysiol<wy, 1878, p. 3d6.
Lehmos. Centialblatt fSr KlDderhellkDnde, 1878, No. 19.
Zulzer. Centralblatt f. d. Med. Wissenschaft, 1876.
Tessier. Du Diabetfe Pfaosphatique. Paris, 1877.
Balfe. The Lancet, London, Febroary 26, 1876.
Balfe. Morbid urine. 1882.
Dickinson. Diseases of the kidneys. 1875.
Neubauer. Journal (iir pract. Chemie., Ixvii, p. 65.
Vogei. Vircbow's Hand, der Spec. Pathologic, Band vi, 2, p.

47H.
Parkes. Composition of nrtne In health and disease.
Ziemssen. Article on diabetes. Cyolopisdia.
Cadge. Article on ^losphaturia. Qoaln's Dictionary of Medi-
cine, 1893.

Digitized by

Google

Vol. CXXX, No. 6.]

BOSTON MEDICAL AND SURGICAL JOURNAL.

187

NATIONAL REGISTRATION A NECESSITY.*

BT SAKITBI. W. ABBOTT, M.S., BO8T0S.

In the preient paper it is my design to state briefly
some of the reasons for the adoption of a system of
registration of vital statistics in each one of the United
States — sach a system as now exists in nearly every
enlightened nation, the United States as a whole form-
ing a marked exception.

Dr. Curtis, in a very intelligent discassion of the
general subject of vital statistics, says : " A fall and
accurate knowledge of the people in every community
is an indispensable requisite for the successful admin-
ittratioD of public affairs. Such knowledge is obtained
by the pnblic authorities, from two distinct sources.
Id the first place, the enumeration of the people, by
which the population, the numbers, the ages, the
abodes, the professions, etc., of the individuals com-
posing it are ascei uined, is effected by the taking of a
eensas. In the second place, ' the movement of the
population,' under which term are comprehended the
births, marriages and deaths occurring yearly, is deter*
mined by registration." *

Dr. Ogle states the objects of registration as follows : *
"(I) There are all the legal uses, where proof of
death is required, such as the succession of property,
payment of insurance monies after death, etc. ; (2)
there is the prevention of, or interference with mur-
der, or foal play generally ; (S) the provision of trust-
worthy data for the elaboration of statistics concerning
health, disease and mortality."

The purposes of registration are manifold, and their
importance emphasizes the necessity of having this
department of statistical work conducted in the most
thorough and intelligent manner.

It serves in the first place to facilitate the identifica-
tion of individuals for the transmission of property
tod for the protection of life against crime.

Second, it affords data for the determination of. life
eootingencies, which form the basis of life insurance.
Snfficient importance has never been given to this use
of the statistics of mortality in this country. The
figures upon which this very great and important
bosiness (amounting to many millions in each year
and affording protection reckoned even by billions) is
fonnded, can only be obtained in this country from a
very small portion of the people, having registration
extending over a long period of years.

But, third, and most important of all, it furnishes to
isnitary science, and to the medical profession in gen-
eral, most valuable information regarding the public
health.

With these facts in view it is a sad comment upon
the civilization of a great nation, that sixty-five millions
of people are to-day entirely without any general sys-
tem of registration of vital statistics ; that the birth-
rste, the death-rate and the marriage-rate of this
coantry as a whole, are absolutely unknown.

There is no information to be had, for example, as
to the birth-rate or the death-rate of this great State
of Illinois, within whose limits we are assembled, the
third State of the Union in its population of more
than four millions. We have absolutely no means of
oomparing the death-rate of Chicago with that of the

J A p^>*r nad st the World'i CoBgreM of Hygiene, st CUomo,
OWobet 12, m».

' Bnak-i BTftene, toI. 11, p. 302.

, ' KTidenee before (he Parlhunentary.Oommtttee on Death UertlHoa-
>i<«,Jnie3,U93.

rural popnlation of the remainder of the State ; since,
while the former is known with some degree of cer-
tainty, the latter is unknown. There is no means of
comparing the death-rates of any of the counties of
the State (or of larger districts) with each other.

Of the foreign countries, most of the largest and
enlightened nations of Europe have had registration of
a more or less complete character for periods varying
from a quarter to a half century or more. It is a
matter of great importance in the study of nations
that their conditions and circumstances may be com-
pared with each other. But in this very important
direction we, as a nation, have no possible means for
making such a comparison. When individual States
are considered, we find a little improvement. States
embracing about twelve per cent, of the population of
the whole country have fairly complete systems of
registration ; while other States, having about as many
more inhabitants, have enacted adequate laws, but tbns
far the execution of these laws is not fully carried out.

What then is needed to introduce and perfect a thor-
ough system of registration throughout the whole
country from Maine to Oregon, and from the Gulf to
the Great Lakes ?

(1) The enactment of laws in every State providing
for the registration of births, marriages and deaths.
The more uniform such laws can be made with refer-
ence to the information to be obtained in individual
certificates, the better.

(2) The cordial co-operation of the general govern-
ment in providing a central authority for the collection
and publication of the statistical material of the in-
dividual States. Possibly grants might be made to
the younger States to facilitate the introduction of
this very important work.

(8) The necessity of awakening the interest of the
medical profession in this work and the need of their
hearty co-operation in aiding it in every possible man-
ner is apparent To this end the raising of the stand-
ard of medical education will have a favorable effect.
The teaching of vital statistics, as an essential part of
medical and especially of sanitary education, should be
urged.

(4) The placing of the work of registration in the
hands of trained medical men, who should act as
registrars. These should not only be medical men,
but also men who are experts in the subject of vital
statistics at least. This principle is recognized by all
the foremost authorities in public hygiene. No one
doubts for a moment the wisdom of the British govern-
ment in entrusting the registration of England to such
men as Dr. Farr and Dr. Ogle. And the same may
also be said of the French and German governments.
Due authority should be given to the registrars of
States and of municipalities to examine the returns of
death, carefully, and to institute inquiries in all doubt-
ful cases, especially when the certificates are signed
by unqualified practitioners.

(5) In addition to the foregoing considerations, a
revision of the nomenclature and classification of dis-
eases is demanded, which shall be in harmony with
the progress of medical science. Such revision, when-
ever it shall be made, should be uniform throughout
all countries having registration, in order to facilitate
the international comparison of the results obtained
by registration.*

While the accurate registration of all deaths em-

< See TnnascMoni of Uie Musaehuietti Medical Society, 1892.

Digitized by

Google

138

BOSTON MEDICAL AND 8US01CAL JOVSNAL. [FbbbdabtS, 1894.

braced ander the five general diviBioas or clasges of
disease is desirable, there is one class which has a
peculiar interest to the sanitarian, and that is the group
of infectious diseases, or those to which for a half-
century the name " zymotic " has beeu applied. The
diseases of this class, or at least a majority of them,
are undoubtedly amenable to those preventive meas-
ures which constitute a large share of the work of
sanitary authorities. Hence all such authorities must
necessarily recognize the great importance of having
a definite knowledge as to the mortality from infections
diseases from month to month, and from year to year.
Such knowledge can only be had ander a careful sys-
tem of registration thoroughly carried out. To this
class of diseases belong typhoid fever and phthisis,*
diseases which destroy life during its most productive
period, and hence involve a great economic loss to the
population. The steady decline in the mortality from
these diseases in cities and towns having such munici-
pal sanitation as is required, is too well recognized to
require lengthy comment here. But without a good
system of registration the question of improvement or
of retrogression could not be known with any degree
of certainty.

Legislatures are slow to act when definite, tangible
evidence or statements as to the actual results accom-
plished by sanitation are not to be bad. Hence the
importance of establishing such thorough and complete
systems of registration as shall furnish the desireid in-
formation.

The relation of the vital statistics of any community
to the public-health admiuislration of that community
is very much like the relation which the counting-
house of any commercial firm bears to its business.
The business may be great or small ; it may conduct
commercial transactions over a very large extent of
territory ; it may own property, factories or mills in
different manufacturing towns; it may employ large
or small numbers of workmen ; but, if it is desirable
to obtain any definite information as to the extent or
character of its operations, their success or failure, one
must go to the counting-house or the business-office,
where he can obtain full and accurate knowledge of
the standing of the firm, of the amount of its business,
and of its plans and methods. The assets and liabilities
of the firm are here matters of record ; and its journal
and ledger, its daily, weekly, monthly and yearly
balance-sheets tell us of the actual condition of its
business.

Applying this illustration to the operations of a
sanitary authority, the vital statistics of any community
tell us its actual progress or retrogression in the excess
of'births over deaths, or, pice vtr$a, of deaths over
births. The' changes, too, in the death-rates from pre-
ventable diseases iioth individually and collectively are
instructive, as showing to a certain extent the results
of thorough and efficient sanitary work. They con-
stitute the sanitary barometer by which not only pres-
ent conditions are known, but also with some degree
of certainty, future conditions may be foretold.

Let the following facts serve as an illustration :

Upon a comparatively large river in my own State
are some half-dozen manufacturing cities and towns.
Let these cities and towns be represented as follows :
A, the cities and small towns upon the upper portion of
the stream (embracing 300,000 inhabitants) ; B and

' Bjr almost nnirersal oonsout, phthisis sboald be Inoluded in tbe
ost«gory o( Infectious diseases.

C, two larger cities upon the lower portion of the same
stream ; D, a smaller city near its month. The entire
population upon the water-shed of this river is about a
half-million inhabitants.

The State Board of Health collects ioformstioD
weekly from the cities and towns within the limits of
the State, 'as to the mortality from infectious diseases,
including the cities and towns upon this river. It ia
also authorized by law to examine all the water-supplies
of the State, a work in which it is continually engsged.
The statutes forbid that streams used as water-supplies
shall be used for the discharge of sewage; but the
river in question is exempted by law from the oper-
ation of this statute, and sewage goes into it without
hindrance from A, B, C and D. Now B and C take
the water of this river directly and without filtration
for domestic use. Sewage from A enters the water-
supply of B ; sewage from A and B enters the water-
supply of C. As might be expected under this condi-
tion of affairs, typhoid fever has become more than
epidemic at B and C, the mortality from this cause
bearing the following ratios for the twenty years (1871
to 1890) : The typhoid death-rate of tbe State being
token as 100, that of B was 155, and that of C was
170, while in the last five years of this period the ex-
cess rate was still greater. Any slight prevalence of
typhoid fever in the sewered portions of cities and
towns included in A was pretty sure to be followed by
a greatly increased prevalence in B and C.

Up' to the fall of 1892 the water-supply of the small
city D was not taken from the river, but from a spring
upon its shore. During the dry season of 1892 this
spring became inadequate, and the water-supply which
was furnished by a private company was increased by
extending a water pipe to the river and supplementing
the supply directly from that source. In the frequent
routine examinations of the water-supplies conducted
by the State Board of Health, this fact became known
to the board, in consequence of the immediate change
in the quality of the water as shown by its analysis.
Under these circumstances the board immediately
warned the water company of the danger of using
water from a constaiitly polluted stream into which
the sewage of a population of several hundred thousand
was discharged. The company took no notice of this
communication, but continued pumping water from the
river and distributing it to the inhabitonts. What was
tbe result ? In less than two months an epidemic of
typhoid fever attacked the population using this water,
more severe in character than had beeu known in that
city for a half-century. It so happened that this event
occurred daring or at the beginning of tbe session of
the State legislature. The citizens were soon aroused
to a sense of the danger of the situation. The mayor
appealed to the legislature for sach aid as proper legis-
lation might afford ; and while the franchises of water
companies have usually beeu guarded with jealous care,
in this instance the flagrant disregard of the admoni-
tion which had been given them and the consequent
sickness and death of many citizens, which might have
been avoided, had they not neglected the advice of an
experienced authority which had thoroughly examined
the whole situation, induced the legislature to give to
the city the right to introduce an independent supply,
and at the time of this writing (October, 1893) tbe
city has, by an overwhelming majority, voted to take
this action.

I have presented this illustration, not so mach for

Digitized by

Google

Vol. CXXX, No. 6.] BOSTON MEDICAL AND SUROICAL JOURNAL.

189

the purpose of showing what might have been done in
preveDting sickness and loss of human life under cir-
cumitances of careful ob8er?ation, followed bj advice
tos responsible corporation and an obedient following of
such advice, but for the purpose of showing the nsefnl-
0661 of a careful system of vital statistics, embracing
a weekly return from the cities and towns along the
baaka of this river, of the deaths and causes of death,
by which a warning reaches the State Board of Health
and may be by it transmitted to the local boards, of
the existence of unusual prevalence of epidemic disease.

About a quarter of a century ago the death-rate of
England was constantly higher than it is at the present
day. It was noticed that this high death-rate was
mainly in the large towns and cities. Sanitary works
were introduced in these cities, embracing new water-
rapplies, systems of sewerage and disposal of refuse,
etc., and very soon the death-rate was diminished in
nearly every city in which such improvements had
been introduced.*

Now the point which I desire to enforce, is not so
much the fact of such improvement as a natural con-
sequence of thorough .sanitation, but the method by
which this fact was ascertained. The foundation or
basis upon which the general public movement for
these improvements rested, and which justified their
introdnctiou, was the death-rate of the cities in ques-
tion. The computation of this death-rate and the com-
parison of the mortality before and after the introduc-
tion of public sanitary improvements was made
possible only by the existence throughout the whole
country of a complete and accurate system of registra-

tiOD.

Again the possibility of conducting such valuable
and instructive investigations as are presented in Dr.
LoDgstaff's "Studies in Statistics," and in the older
papers of Buchan and Mitchell, is only made certain
by the existence of a system of registration.

In this connection I desire to call your attention to
one class of causes of death which is more or leu pre-
ventable, although not in the same sense and degree
as the groop of infectious diseases ; I mean the class
of deaths by violence. All measures which tend to
ameliorate the condition of man, to lessen suffering,
poverty and intemperance, to protect life and to make
it more secure from danger, will thereby diminish the
annual mortality from homicide, suicide and accident.
In the State of Massachusetts, by a statute of 1885
the registration of this class of deaths was made much
more thorough and complete than it had previously
been. At a still earlier date (1877) the coroner sys-
tem had been abolished as a useless relic of antiquity,
and an entirely new method of inquiry was introduced,
which was modelled after the better modes in operation
in ooutineotal Europe.

The new plan of procedure provides for the separa-
Uou of the medical from the legal duties connected
with the investigation of deaths by violence, the former
being entrusted to a corps of well-trained medical ex-
aminers, while the latter are performed by the district
judges. The operation of this system for a period of
fifteen years has been entirely satisfactory. It is at
once more economical and far more efficient than the
coroner system which it superseded, and no one at the
present day desires to return to the old method.

I would therefore commend this mode of investiga-
tioD, togeUier with the improved system of registration

* Mnth Baport of the PrlTj OoaaoU. Ki^land.

which now constitutes a part of the general plan, as
suited to the wants of any community comprising
either a large or a small population.

To conclude, a thorough system of registration is not
only a valuable auxiliary, but is a natural and essential
department of the work of any general sanitary au-
thority ; and in every State where no provision is
made for the collection, tabulation, and publication of
the vital statistics of the population, measnres should
be taken with the least possible delay for the carrying
out of this important public duty.

Clinical SDeiiactmettt.

TWO CASES OF HYDRAMNION ASSOCIATED
WITH ABDOMINAL DISTENTION IN THE
F0BTUS.1

BV CHABLE8 W. TOWBSKHD, M.D.

Cases of true hydramnion, where the distention is
so great as to cause morbid symptoms and the pre-
mature expulsion of the fcetus, are comparatively
rare. The causes of hydramnion are mauy ; but one
of the most common is stated to be a morbid condition
of the foetus resulting in mechanical disturbances of
the placental or umbilical circulation. Barton Cooke-
Hirst, in " The American System of Obstetrics," says :
" That increased internal pressure within the umbilical
vein will give rise to a transudation through the amnion,
has been abundantly proved by Salliuger. ... It may
be generally stated, therefore, that any condition of
the fcetus that will raise the blood-presaure in the um-
bilical vein, thus increasing the blood-pressure in the
placenta, may give rise to bydramnioo." The two
cases of hydramnion I am about to relate appear to be-
long to this class. Hirst instances, among other morbid
changes in the foetus, cirrhotic livers, and tumors which
obstruct the umbilical circulation.

The maternal histories in my cases are very much
alike. Both were patients of the Lying-in Hospital ; '
both were uncomfortably distended at the seventh and
eighth month, so as to be as large or larger than at
full term; and both gave birth prematurely (one at
seven and one-half months, the other at eight months).
A description of the labor of one of these cases will
do for both.

Mrs. S., a primipara in the out-patient department-,
seven and one-half months pregnant, was seen Novem-
ber 20, 1887. The abdomen was very large, and tense
as a drum. On external palpation no foetal parts
could be felt. The foetal heart was heard faintly.
By vaginal examination the foetal head was felt above
the brim, and ballottement could very easily be obtained.
When the membranes were ruptured a large quantity
of water came away, and the rush of v^ater was so
great after the birth of the child, which speedily fol-
lowed, that it flooded the bed down to the foot, pouring
over the edge and flowing along the floor. The labor
previous to this had been a tedious one, lasting thirty-
two hours. The child lived only forty-five minutes.

In the second case the mother was a multipara.
Here the child lived nearly an hour. Both the iufauts
were females, the sex which largely preponderates in
cases of hydramnion. The mothers in both cases
made good recoveries. In both babies the abdomen
was much distended, causing in the second case a delay
> Bead before the Obetetrioal 8<!eietT of Boston, November II, IStS,

Digitized by

Google

140

BOSTON MSDIOAL AND SUAQtOAL JOO&NAL. [ttxKOkxt 8, 1894.

in the extraction of the body. I obtained an autopsy
in each case.

Case I. Autopsy of geven and one-half months'
female foetus, weight three pounds. Circumference of
head, eleven inches ; of chest, nine and one-quarter
inches ; of abdomen, eleven inches. Abdomen much
distended, the skin tense and shining. Abdominal
cavity contained a drachm of clear serum. Liver
much enlarged, extending below the level of the um-
bilicus ou the right side and as far as the ambilicns in
the median line ; much distended with blood. Other
organs normal.

Cask II. Autopsy of eight months' female foetus,
weight nine and one-half pounds. Circumference of
head, thirteen and one-quarter inches ; of chest, four-
teen inches ; of abdomen, seventeen and one-half
inches. The abdomen was very much distended with
fluid — a fact which accounted for the weight of the
child — its superficial veins being prominent, as may
be seen by the accompanying photograph. On open-

ing the abdomen considerable clear fluid flowed out,
and there were found to be numerous adhesions among
the abdominal viscera. The liver and spleen were
normal. The fluid was not, however, the cause of all
'the distention, for a large sac was found full of fluid
extending up out of the pelvis as high as the umbilicus.
On closer examination this proved to be the vagina,
much distended with urine, the uterus being borne on
the summit of this large sac. I was unable to discover
with a fine probe any external meatus or opening to
the vagina, and it seemed probable that the bladder
emptied into an occluded vagina. The bladder itself
was slightly enlarged, but being more muscular than
the vagina was able to resist the pressure of urine,
while tbe vagina gave way. Dr. Whituey, to whom I
showed the specimen, suggested this explanation.

The association of abnormal foetal abdomens in these
two cases of hydramnion would seem to be more than
accidental. It is probable in each case that there was
increased pressure in the umbilical vein with the result-
ing hydramnion.

•

A CASE OF PDERPEEAL SEPTICEMIA.!

BY OBOBOa HATXM, If J>.

Thk following case of puerperal septicsemia is, I
think, Bufiiciently interesting from a bacteriological
standpoint to justify the time which I shall occupy in
reporting it to this Society.

The patient was delivered at the Boston Lying-in

Hospital. Dr. J. L. Morse has made cultures from

> Read before the Olwtetiloal Society of Boeton, November 11, 1893.

the patches which were found in the vagina and on
the cervix, and will speak of the result of bis research
after I have reported the case.

B. W., dissipated history, entered the hospital August
29, 1898, in labor, membranes ruptured. She had been
examined before entrance by some unknown person.
She was delivered after a very long second stage by
high forceps and axis traction. Twelve hours after
d^ivery she had a chill, and the temperature went up
to 104°.

August 81st. Lochia was very foul. Dr. C. W.
Townsend, in whose service the case was delivered,
found the vagina covered with whitish-yellow deposits,
which could not be scraped o£F. The uterus was
washed out with corrosive and carbolic. The pulse
was weak and rapid ; pain and tenderness were present
over the uterine area. Epsom salts were given until
she had free movements. She also had brandy and
egg-nogs.

I examined her on September 1st, when my tarn of
service began at the hospital. Condition about the
same as at last examination. Dr. Morse removed
sufficient of the membrane to«make cultures. The
uterus was washed out with corrosive and peroxide of
hydrogen. An iodoform pencil was introduced into
the cavity of the organ, and iodoform powder dusted
into the vagina. She had at this time a diarrhoea,
probably septic. Nourishment was pressed as much as
possible. She was given champagne in place of brandy,
as the former nauseated her.

September 2d, she was feeling slightly better. Her
condition remained about the same up to the 9th of
September, when she complained of pain over the
uterus. A flaxseed poultice gave her some relief.
There was a slight trace of albumen in the urine, also
a few hyaline casts.

September 25th, she was much better.

September 27th, she had a very severe headache,
which did not yield to treatment, and made me think
there was a distinct renal element in the case. She
was given digitalis and acetate of potash. The urine
contained a large trace of albumin, as well as many
granular and hyaline casts.

On. September 28th she had a convulsion, and was
comatose after it. She was given croton oil and a hot-
air bath. A movement occurred about midnight, but
the skin remained perfectly dry; and she died at
5.40 A. M., September 29th.

This was a case where, if the kidneys had remained
normal, recovery would have been possible. As it
was, she died of uraemia. The kidney lesion may pos-
sibly have been secondary to the septicsemia, but was
probably present when she entered the hospital. The
rapid and violent development of her septicsemia (twelve
hours) makes it almost certain that she was septic when
admitted.

BACTERIOLOGICAL CULTURES FROM A CASE
OF PUERPERAL SEPTICEMIA'

BT J. L. HOBSB, II.D.

Befokk the employment of cultural methods for iso-
lating micro-organisms, various observers found chains
of micrococci in the tissues of women dead of puerperal
fever. Mayrhofer, in 1865, was the first to pnblisb
such an observation, and was rapidly followed by
> Bead before the Otatetrioal Soeietr of Boston, Norember It, M"-

Digitized by

Google

^OL. CXXX, No. 6.] BOSTON MSDliJAL AifD SVkCfiOAL JOVMUfAL.

141

others, among whom may be mentioned Rindfleiscb,
Recklinghausen, Klebs, Orth and Doleris.

Pasteur, in 1880, was the first to cultivate the
streptococcus from the organs of women dead of puer-
peral fever. Similar results were obtained bj Frftnkel,
Bamm, Winter and many others, so that at present
there can be no doubt that the streptococcus pyogenes
stands in a causal relation to a very large proportion
of the fatal cases of puerperal disease. Widal found
streptococci in nearly every case in which he performed
an autopsy, and also demonstrated that the most
divergent forms of puerperal affection, for example,
endometritis, peritonitis, pysemia and even phlegmasia
alba dolens, could be traced to streptococcus infection.

Streptococci are not the sole cause, however, for
organisms that lead to wound-infection elsewhere can
also give rise to puerperal wound-infection. Brieger
was the first to show that the staphylococcus could
cause fatal puerperal fever, and his statements were
soon verified. They, however, rarely cause the more
severe forms, but are often combined with strepto-
oood.

Kr5nig ^ has recently demonstrated that gonococci
may occasionally be the cause of some of the milder
cases of puerperal disease.

Von Franque,' in a recent article, reports a case of
moderate severity, in which be found a pure culture
of the colou batullns in the uterus, unaccompanied by
any other organism. A pure culture from this case
readily killed guinea-pigs and rabbits. As far as 1
kaow, this is the first and only reported case of puer-
peral infection due to this bacillus. It is not to be
lurprised at, however, when we consider the proximity
of the rectum and the frequency with which the colon
bacillus is found in purulent affections of the abdomen,
especially appendicitis.

It is probable that other organisms may cause the
trouble, either alone or in combination, notably the
bacillus protens.

In the case in question a sterile swab was introduced
into the interior of the uterus and another into the upper
vagina under aseptic precautions. Cultures of both
were made on Loffler's blood-serum mixture, and
ihowed a pure growth of a short bacillus. Agar
plates were made from each of these tubes, and showed
a pare culture of colonies resembling in their growth
the colon bacillus. This bacillus, when cultivated on
the various media, correspouded in every way to the
bscillas coli communis, that is, grew on nutrient gela-
tine without liquefaction and with the formation of a
few gas-bubbles ; formed gas in sugar agar, acidified
and coagulated litmus milk ; showed a profuse, moist,
jellowish growth on potato; was motUe in hanging
drop of bouillon culture ; and gave the indol reaction
in Dunham's solution.

A NOTE ON THE USE OF ICHTHYOL.'

BT A. D. B»CI.AI>, H.D.

I WISH to say a few words about the drug ichthyol,
which has come to rather extensive use of late, espe-
cially in Germany, but not used as yet to any great
extent in this country. Some observations, however,
published from time to time in the journals, have

■ Baad before the Otwtetrlcal Society of Boston, November 11, 18SS.

■ ErOBto: Centnlbl. f. Oyn., 1893, 151.

' VoDnaDqne: Zelt. f. Qeb. n. 07i).,lg83, zxt, 2TT.

given a favorable impression of its value in the treat-
ment of various conditions of the system, local and
constitutional.

Ichthyol is an exudation from strata of rocks in the
Jura, which abound in fossil fishes. It is of a tarry
consistency. Less than a dozen years ago this sub-
stance was brought to the notice of chemists in Ham-
burg, 1 think, who analyzed it. At all events. Pro-
fessor Unna, the famous dermatologist of that city,
was the first who brought it to the knowledge of the
medical profession by the report of cases of certain
cutaneous affections successfully treated by its use.
This exposition led to further elaboration of the sub-
stance by the chemists, Cordes, Hermanin & Co., of
Hamburg, who have made a variety of combinations
of the original product with ammonium, sodium and
zincum, each of which is supposed to possess — and
some to my certain knowledge have — distinct in-
fluence therapeutically. Pills and capsules of the
same are also made by them, and are beautiful speci-
mens of pharmaceutical art. The liquid preparations
of ichthyol exhale a strong sulphide-of-ammoninm
odor, which, however, soon passes off on exposure,
and need not be, as some have written, prejudicial to
its use as a drug to be used in one's consulting-room.

I shall now give in a few words my own experience
of the use of ichthyol since I first had it brought to my
notice in March, 1891, and will anticipate by stating
that its moat characteristic effects, when applied locally
in certain affections of the pelvic viscera, are anodyne
and eutringent.

I have had many opportunities to test the value of
ichthyol in congested states of the pelvic organs of
women with various dilutions of the above-named
preparations, but have arrived at a point where I think
I find the best result from a fifty -per-cent. with glycerine.
This strength of the drug has been used by me in
numerous cases of recent and chronic congestions of
the reproductive organs, as well as those of the vagina,
urethra and rectum.

In prescribing ichthyol, the druggist will always
dispense the sulpho-ichthyolate of ammonium, as this
is the most known preparation. The combination with
sodium 1 have not tested, but that with zinc is remark-
ably astringent, and its effects in ce/tain conditions, to
bo arrived at by experience in the use of this medica-
ment, are a little surprising. I have not had a single
bad effect in the use of preparations of ichthyol, al-
though I have applied them many hundreds of times.
I therefore, from my experience of their effects in cer-
tain conditions in the practice of minor gynseoology,
would recommend a trial to those who have never
used them, and a more extended application by those
who have already tried them.

I have in these short remarks confined myself to
the use of ichthyol in congestive and chronic inflamma-
tory states of the pelvic organs, but could say some-
thing favorable of it in the treatment of dyspepsia,
chronic diarrhoea and erysipelas.

The Effects of Medical Leqislation. — At
the last meeting of the State Board of Medical Ex-
aminers of the State of Washington, held in Seattle,
there were twenty-two applicants for a license to
practise, of whom twelve failed to pass the required
examination and were rejected. The Board now re-
quires a general average of 75 per cent, on all
branches. — Medical Newe.

Digitized by

Google

142

BOSTON MEDICAL AilB StJBOIOAL JOJJRHAL. ft ebruabt 8, 1894.

lEleportj^ of j^ocietie^.

THE OBSTETRICAL SOCIETY OF BOSTON.

CHAKUtS W. TOWJISCIID, 1I.I>., SKCBKTABV.

Beoular Meetiug, Novembor 11, 1898, the Presi-
dent, Dr. Charles M. Green, in the chair.
Dr. George Haven reported

A case of FGERPERAL SEPTICjBMIA.'

Dr. J. L. Morse ihowed

BACTERIOLOGICAL CDLTURES FROM THE ABOVE
CASE.*

Dr. Edward Retnolds said that he saw the case
reported by Dr. Haven on the fifth day, for the first
time, and was impressed with the fact that it was dif-
ferent from most cases of puerperal septicemia.

Dr. J. G. Blake thought that the great rapidity in
the .spread of the pseudo-membraue was very inter-
esting.

Dr. C. W. Townsend said that he was astonished,
on first ezamining the case, about twenty-four hours
after labor, to find the whole vagina from the cervix
to the vulva covered with an extensive pseudo-mem-
brane. He had uo doubt but that the patient, who
had been leading a dissipated life, and who was unable
to give a clear account of herself, had been in some
way infected before entrance to the hospital.

Dr. G. Haven said that the patient had recov-
ered from the septicaemia, but died of renal disease.
Whether this was induced by the sepsis he was unable
to say.

Dr. C. M. Green said that a number of septic cases
at the Boston City Hospital have nephritis, although
this lesion is also sometimes entirely absent.

Dr. J. L. Morse suggested that this nephritis, in sep-
ticsmia, was similar to the nephritis in scarlet fever.
The only other case of puerperal septicaemia in which
the colon bacillus was present, recovered.

Dr. C. W. Townsend reported

TWO cases of hydrahnion associated with ab-
dominal distention in tbe foetus.*

Dr. J. G. Bla^e mentioned a case of enormous
distention coming on suddenly. Notwithstanding this,
the patient went on to full term, and gave birth (to-
gether wiih a great flood of water) to a living child.

Dr. a. D. Sinclair had had a case of extreme
hydramnion where the child was aneucephalic, and he
asked whether, in these cases, hydramnion was apt to
occur.

Dr. E. J. FoRSTER had had but one case of aneu-
cephaius without hydramnion.

Dr. Edward Reynolds had seen two cases with-
out hydramnion.

Dr. C. M. Green had seen one case without it, and
he did not think there was any necessary connection
between the two. Anything that interfered with the
umbilical circulation, whether by disease of the liver
or abdominal tumors of the foetus, as in Dr. Town-
send's cases, or by twisting or knotting of tbe cord,
might cause hydramnion. The cause is sometimes to
be found in disease of the placenta or decidual tissues.
Oftentimes, however, it is difficult or impossible to find

> See page 140 of tbe Joaraal.
* See page 140 of the Journal,

> See page 138 of the Journal.

a cause. These points he had brought out in a paper
on hydramnion read to the Society some ten years ago.

Dr. Townsend, in closing, said that it was diffiralt
to draw an exact line between hydramnion and an
amount of liquor increased within normal limit. Cases
of true hydramnion, however, rarely went to full term
on account of the extreme distention, and often gave
rise to morbid symptoms. In both of his cases tbe
association of abdominal distention in the fcstns, which
might result in interference in the placental cirenla-
don, suggested strongly the origin of the hydramnion.

Dr. a. D. Sinclair read

A NOTE on the use OF ICBTBYOL.^

Dr. J. 6. Blake had recently used ichthyol, and
considered it a valuable drug. In the vaginal pmritis
of pregnancy he had used it with great relief, combined
with lanolin ; and he found it much better than strong
solutions of cocaine. In the case he mentioned the
mucous membrane of tbe vagina was very raw and
painful. Carbolic acid, previously used in this case,
had failed. One objection to ichthyol is its odor.

Dr. Sinclair spoke of its use in the pruritis of
diabetes. The form usually dispensed is the sulpho-
ichthiolate of ammonium, and it is generally diluted
fifty per cent, with glycerine. The zinc compound is
much more astringent.

A BABE FOBH OF THE HTHEN.

Dr. F. W. Draper reported an instance of abnor-
mally-formed h^men which had recently come under
his observation. The subject of the anomaly was an
unmarried woman, twenty-five years old. The hymen
presented the following characteristics: From the
middle point of the free edge of a moderately thick,
crescentic, membranous curtain at the posterior segment
of the ostium vaginae there projected forward and up-
wards a thin band or bridge about one-sixteenth of an
inch in diameter, composed of tissue that was quite
elastic and not tense, and having its anterior insertion
just below the meatus urinarins. This band divided the
vaginal outlet into two symmetrical orifices, oval in
shape, each of a size to admit the tip of the index
finger. The vaginal canal, above this unusual curtain
at its entrance, was entirely normal.

Dr. Draper remarked that the possessor of this
peculiar arrangement of the hymen could offer it as
very strong presumptive evidence of her chastity and
virginity.

BOSTON SOCIETY FOR MEDICAL IMPROVE-
MENT.

J. T. BOWBX. M.D., BBCBBTABT.

Regular Meeting, Monday, November 18, 1893,
the President, Dr. C. F. Folsom, in the chair.

REMOVAL OF FOREIGN BODY FROM THE ANTERIOR
CHAMBER OF THE EYE.

Dr. 6. Hay : 1 wish to speak briefly of a case of
foreign body in the anterior chamber of the eye,
which I removed recently with a magnet. The foreign
body did not project from the cornea. It bad passed
into the anterior chamber, but the anterior extremity
was lodged in the cornea, and just appeared on a level
with the outer surface of the cornea : possibly it pro-

* Be* page Ul of til* Jonmal.

Digitized by

Google

I.. CXXX, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL.

143

icled sligbtlj, bat not enough to grasp it with forceps.
tie foreign body was a very narrow piece of iron,
ce the end of a needle, about one-tenth of an inch
ng. Xhe inner end touched the iris, and it bad been
Cbe eye about two weeks when the man came to
i^> Xhe history was that, while he was hammering,
snoething struck the eye. Some one in the room re-
>a.i*ked that there was blood in the eye. I suppose
tksit the iris must have been wounded. When I saw
ilm the blood had disappeared, and you saw this
ioveign body, the end of which was on a level with the
>'ater surface of the cornea. I knew that an attempt
to remove it by the point of the narrow knife would
be daDgerons, since one is liable to push the foreign
body io, and might be obliged to do iridectomy, and
might even then not be able to get the foreign body.
While I was thinking how to remove it the man said :
*' I>on't they sometimes use a magnet ? " I had a
magnet, which I prepared and carefully applied. At
first it produced not the slightest result. The cornea
was BO tightly around the iron that it produced no
effect. After two or three attempts, it occurred to
me to cat with a very sharp-pointed knife where the
bit of iron showed itself, in order to loosen it. I cut
as carefully as I could on two opposite sides of the
iron, and in so doing I noticed that the anterior
chamber began to leak. This is what would be ex-
pected if I had attempted to pry it out ; I should have
opened the anterior chamber. It occurred to me that
there would now be a better chance of pulling it out.
I applied the magnet again, and it came out very
readily.

The case did perfectly well. It is not a new case at
all, and is only interesting on account of the way in
which the piece of iron came out, and as an instance
of a comparatively new method of treating an accident
which formerly might have resulted disastrously.
Db. M. H. Biohardson showed a

LABOK DIFFUSE FIBROUA OF THE BRBA8T, WITH
SPOT OF MEDCLLART CARCINOMA.

This specimen is interesting from the fact that it
shows a cancerous degeneration in a large fibroma of
the breast. I have frequently advised patients with a
simple fibroma of the breast not to have any operation
performed; that the tumor is not dangerous; that it
simply interferes with the comfort of the patient from
its sice. I have never before seen a benign tumor of
the breast which has taken on malignancy. In several
cases of intracanalicular fibromata there have been
sDgpicioaa spots found somewhere in the disease. This
ia the first case of its kind where there has been a
marked malignancy both in gross appearances and his-
tory, and in the microscopic examination.

The patient, a woman of tbirty-four, single, is a
stitcher in a shoe shop. In her work the shoe is
brought constantly against the upper part of the breast.
Her attention was called to the breast for the first time
last Jane. She felt a hardness there. There was no
family tendency to cancer. She has always been well
and strong, I found a large tumor occupying the
whole left breast. In the lower and anterior quadrant
the skin waa distinctly infiltrated. The axilla contained
aeveral large glands. There was no evidence of in-
ternal metastasis. It was impossible to remove the
breast without sacrificing all the skin over it. I took,
in addition to the skin over the breast, a circular mar-
gin of about an inch in all directions. This method

left an enormous wound to be filled by granulations.
Without cutting away the breast, I carried the dissec-
tion along the edge of the pectoralis major and the
anterior axillary border until the last of the glands had
been dissected ont. The breast and axilla, therefore,
came away in one continuouB mass. The operation
was performed on Saturday — the day before yester-
day — and thus far the patient is making very good
progress.

It is always desirable in these operations to take a
broad margin of skin. Recurrences in the scar always
seem to me an evidence that not enough has been taken.
The error in removing breasts generally consists in
trying to shave the tumor too closely in order to get a
first intention. The most important thing is to get
the disease out, then we should, for the first time,
think how we are going to close the wound.

EXCISION OP THE ELBOW-JOINT.

Dr. Richardson also described a case of chronic rheu-
matic arthritis of the left elbow, with excision of the
joint, which was shown. The patient, a woman of
forty-seven, had, seven years ago, pain in the right
shoulder, supposed to be rheumatic. About five years
ago the left arm began to trouble her. Six years ago
she bad some rheumatic trouble in the feet. There is
no consumption in the family at all except one aunt.
The pain has been so great in the left elbow during
the last six years that she has been disabled most of
the time. Finally, it was put up in plaster-of-Paris
by the attending physician Dr. McCollester, of Wal-
tham. The immobility resulted in some alleviation of
pain, bat not complete. Meantime the left elbow has
become more or less anchylosed. On careful examina-
tion there was undue prominence on each side of the
olecranon. This soft swelling did not seem to be ten-
der. Movements of the elbow were extremely pain-
ful, especially extension. I have had this case under
observation since the 10th of May of the present year.
During this time there has been no improvement what-
ever in the subjective signs. The elbow has been
almost entirely disabled and there has been a great
deal of pain. After very carefnl deliberation I decided
to try forcible extension to the movements of the joint.
Five or six days ago, under ether, [ broke up the
adhesions and extended and flexed the elbow, and at
the same time rotated the forearm. This was followed
by a great deal of pain. Dr. Warren saw this case in
consultation during the an«stbeaia, and we both thought
that there was probably a tubercular element in the
disease. Whether tubercular or not, it seemed best
to excise the joint, not only to relieve the pain, but to
give a more useful joint than the one she had. The
bones were excised on Saturday in the usual manner.
I did not use any efforts at bsemostasis. I did not use
the Esmarch bandage or tourniquet. It seems to me
better to stop the haemorrhage as we go in operations
of this kind, because we tbereby avoid in the best
manner subsequent oozing and extension of fiaps.
Patient to-day is sitting up, and there is no pain.

Excision of the elbow is justifiable for simple an-
chylosis at a right angle, because after an excision the
joint is more useful than a stiS elbow. It is also
justifiable for pain. If there is any suspicion of tuber-
cular process it seems to me that the operation should
be performed as early as possible, and that it is not
wise to wait until the bones have become extensively
disorganized.

Digitized by

Google

144

BOSTON MEDICAL AND SUBGICAL JOVBNAL. [Fbbku^t 8, 1894.

Bboulab Meeting, Monday, November 27, 1858.

NOTES ON PHOSPHATURIA.'

Db. Paul Thobmdikk presented a paper with the
above title.

Dr. £. S. Wood: I am very glad to have been
able to hear Dr. Thorndike's paper. I thoroughly
agree with him that the first class of cases to which he
referred, the milder cases of phoephataria, really is
not entitled to the term phoephataria. It is not the
condition of thiogs which at all affects the quantity of
the phosphoric acid eliminated, bat simply the pre-
cipitation of the earthy phosphates due to a change in
the reaction of the urine, and a good deal of distinction
should be made between the temporary and permanent
condition. As we know, temporary phosphatnria is
physiological and not pathological. It is of very fre-
quent occurrence in the urine of perfectly healthy
persons after the ingestion of a good deal of vegetable
food or vegetable salts. The permanent condition,
however, which results in the permanent alkalinity of
the urine by a fixed alkali is dependent apon jast the
conditions which Dr. Thorndike has mentioned, dis-
turbances of digestion, nervous disturbances ; and such
cases used to be treated sometimes by the antacids
simply for the purpose of changing the character of
the reaction of the urine, an erroneous treatment, un-
less with the idea of giving the mineral-acid tonics,
which prove generally of very excellent service, but
not by virtue of their antacid effect, only by virtue of
their tonic effect. The quantity of the earthy phos-
phates which may be precipitnted from the urine under
such circumsCanceB may be made to vary a good deal
with the character of the food. Lime salts and waters
containing lime will prevent, to a certain extent, large
quantities of earthy phosphates in the urine, for the
reason that chalk when united with phosphoric acid in
the alimentary canal will pass through without being
absorbed. The form Dr. Thorndike has spoken of
under the head of phosphoric diabetes I was glad to
hear him mention because those cases are in my ex-
perience exceedingly rare, and it is, I think, largely on
account of their rarity tliat they cannot be classified
under any special set of clinical conditions. In all
my experience in urinary analysis I have never met
with but one case of what should be considered, I
think, true phosphaturia, or what has been spoken of
ns phosphatic diabetes. This term was given by
Tessier, I think, because it had sometimes alternated
with the saccharine diabetes ; and the explanation was
given which Dr. Thorndike has mentioned. That
class of cases is always characterized by polyuria and
polydypsia, with various symptoms referable to the
nervous system and other organs in the body. One
class of symptoms reported by Tessier was in the early
stage of phthisis where there was an immense amount
of earthy phosphates in the urine, with polyuria and
polydypsia ; the explanation is given by him that the
earthy salts are derived largely at the expense of the
pulmonary tissue. I have tried to find similar cases,
and have received the co-operation of a number of
clinicians ; but I have never been able to duplicate
any of Tessier's cases. I have never in early phthisis
been able to find a polyuria with a large excess of
earthy phosphates. The only case of true phosphaturia
which I have met with since I have been connected
with the Medical School was in the case of a genlle-

> S»e page VH oC the Jourukl,

man whose urine I had examined from time to time
for a good many years ; and in 1879 a large number
of an^yses of his urine showed this condition. I never
saw the patient himself, and do not know the symp-
toms. February 25, 1879, my record shows four
quarts of urine passed in twenty-four hours, containiDg
9.6 grammes of phosphoric acid, the average being 3
to 8.5 grammes. The urine on March 7th was 3,500
c.c. ; between three and four quarts on four successive
days ; and the amount of phosphoric acid on the 12tb
of March was 7.4 grammes, and the amount of urine
8,700 c. c. ; no albumen and no casts. There was a
little evidence of some irritation about the prostatic
region which was easily explained by the age of the
patient. That condition lasted but a comparatively
short time, perhaps two months, and then disappeared.
The polyuria continued, but the phosphoric acid fell
to its normal quantity. A year or two later examioa-
tion showed, instead of phosphaturia, decided oxaluria ;
large quantities of calcic oxalate were found in the
sediment, and albumen and casts appeared later. Those
have continued, and the condition of the urine at the
present time is that of chronic nephritis of the inter-
stitial type, which must have begun somewhere in
1879 or 1880. That is the only case in which I have
ever been able to And those large quantities of phos-
phoric acid in the urine, with polyuria and polydypsia,
where it was not due to the ingestion of phosphoric
acid or phosphates.

One class of Tessier's cases is given as a purely
nervous disease ; and be considers that the nervous
tissues which are rich in phosphorus are undergoing
an unduly rapid metabolism, which accounts for the
excess of the earthy phosphates in the urine. In all
of these cases the excess of phosphoric acid is in the
form of the earthy phosphates, and not in the form of
the alkaline phosphates.

Db. R. T. Edks : I was rather glad to find from
the remarks of Dr. Thorndike and Dr. Wood that the
notion of the relation of phosphates to the disintegra-
tion of the nervous tissue has been exploded. There
used to be a good many stories in the books. One of
them is quoted by Dr. Holmes in one of his non-medi-
cal works, to the effect that a clergyman used to pass
a large quantity of phosphates every Monday morning;
that probably bad more to do with the Sunday dinner
than with the sacred exercises in which he participated.
A number of years ago 1 made some observations on
myself, taking some days when I was as lazy as I
could be, and others when I was busy ; and I could
not see anything decisive in the quantitative changes.

Db. Thorndike : In protesting against the use of
the term phosphaturia, I only meant to find fault with
it as descriptive of a well-marked clinical condition,
such as one commonly reads of in books, and might be
led to suppose occurred as commonly as albuminuria,
for example. I did not mean to say that there was
no such thing as true phosphaturia, of course.

A Hospital While You Wait. — The Metro-
politan Asylums Board of London, to provide for the
rapidly increasing number of fever patients, recently
haid a hospital built in nine weeks, with wards all
complete and with accommodation for 40U patieuts,
40 "charge" nurses, 50 assistant nurses and 76 female
servants, every hygienic and sanitary appliance, corri-
dors, kitchens and consulting-rooms.

Digitized by

Google

oi— CXXX, So. 6.)

BOSTOit MEDICAL AND SURGICAL JOnRNAL.

146

THE BOSTON

ictetifcal anD ^utgical iouvnaU

Thursday. February 8, 1894.

M J^otamal cififed%eine,8wrgerii, and Allied Seiemeet.publitkediMt
tomton, noeekly, by the undenigved.

StTBSCRiPTiOH Tebms: tt.OO pcT y«<tr, in advanee, poilage paid,
'or the United States, Canada amd Mexico; f6.S6 per year far all for-
tigi* co^ntriet beUmging (o the Pottal Uniim.

ji.ll contmiuttcaMoiw for tke Editor, and eUl boots for review, shotUd
be atldreooedtotheSditoroftlie BosUmMediceUandSnrgiealJownal,
283 fToMhington Street, Boston.

^11 letters containing business aonanmieaHons, or referring to the
publication, subscription, or advertising department of (M* Journal,
MhotUd be addressed to the undersigned,

Rensittarues should be made by mouey-order, draft or registered
letter, pat/able to

DAMBBLL * DPHAM,

28S WASHniOTOH Stbxxt, Bostok, Mam.

THE CONTAGIUM VIVUM OF VACCINE AKD
OF SMALL-POX.

SoMB recent iiivestigatioDS nndertaken to ascertain
the nature of the germs of raccioe, by Battersack, at
the Imperial Hygienic Institute of Berlin, were de-
tailed by him at a meeting (December 15, 1893) of
the Society of the Physicians to the Charit^, and are
of interest.*

All pathologists are agreed that the specific microbes
of vaccine must exist in the clear lymph of the vesicle,
and that these micro-organisms are the agents of the
vaccinal infection .The experiments of Straus, Cham-
bou and Menard (1890) have proved that the lymph
when filtered through a plaster filter loses entirely its
properties,' so that its virulence is due to the figured
elements which it contains. Various bacteria have, it
is true, been found in the vesicles and pustules of vac-
(unia (bacterium termo, proteus vulgaris, staphylococ-
cus pyogenes aureus, cereus albns, etc., also peculiar
cocci discovered by Hallier, Quist, Voigt, Glarr^, and
others), but none have yet been proved to possess the
peculiar properties of vaccine.

Battersack bases his investigations on the assump-
tion that the real germs are in the lymph of the vesi-
cles, but are invinbU, and that any microbes hitherto
fouDil there are simply accidental, unessential, or ac-
cessory. The vaccinal lymph is clear and transparent ;
the elements which it contains must then have the same
index of refraction as the liquid itself. If this were
otherwise, the lymph would be turbid, and the more
so the greater the number of elements in it not trans-
lucent. Now, in order that microscopic elements may
remain thus invisible in lymph, whose index of refrac-
tion is about 1.34, it suffices that the difference of their
indicei of refraction from that of the liquid which con-
tains them shall be 0.1 or a little more. This differ-
ence is inappreciable to ordinary sight, especially if
the observer is looking through the microscope, and
the object is unknown. Even for an object that is
known and not of microscopic dimensions, a difierenoe

1 DeatMbe Hed. Wooh., Mo, SI, 18S8 ; MMe<>ii>« Modeme.
> Vkaroot : Tr>at« de MMlelne, t. U, p. m.

of index equal to 0.05 between it and the liquid in
which it exists, assures its complete invisibility.

It is, then, because both the liquid and the germs re*
fract alike that the latter are invisible in the lymph.
To render visible the germs, it would be necessary to
examine preparations of lymph in a medium with re-
fractive index widely different from the ordinary. The
air, whose index of refraction is one, can be utilized
for this examination, and in slides of dried lymph ex-
amined without any refractive medium but the air, a
method already employed by Koch to reveal the cilia
of certain bacteria that do not stain, Buttersack has
been able to detect a certain number of formed ele-
ments. To test the value of this mode of mounting,
Buttersack first tried it on blood globules and certain
bacteria of known species. All these bodies appeared
in these preparations with contours incomparably more
clear and well-defined than when seen in water.

The germs of vaccine, according to this authority,
are not merely distinguished by their peculiarity of re-
fraction ; they are also very small, and have little ten-
dency to aggregation in masses. Vaccinal lymph, as
is well known, remains active under great dilution.
The vaccinal corpuscle, moreover, seems to have dif-
ferent chemical properties from those ascribed to other
known germs, and this explains the failure of attempts
to stain it. In short, this germ is presumed to be
small, pale, and unsusceptible of staining.

Buttersack has studied the lymph of the vesicles of
children, recently vaccinated. This lymph, taken when
perfectly clear and dried on the cover glass, is gently
washed in water and fixed to the glass slide with a
couple of drops of wax and examined by means of
apochromatic objectives. In these conditions, Batter-
sack has seen corpuscles in great number, very small,
pale, always of equal size, sometimes grouped in chains.
In continuing the examination, he perceived an ex-
tremely fine network constituted by pale filaments.
These could always be followed to a considerable ex-
tent, and contained in their meshes an abundance of
the little corpuscles above described. These filaments
were preponderant in pustules, growing and completely
developed, while the corpuscles preponderated in pus-
tules in process of retrocession.

Buttersack's investigations have included one hun-
dred vaccinated children, and always gave the same
results. The slides invariably contained corpuscles
and filaments iu varying proportions. Control experi-
ments were made with dried fluid obtained from phlyo-
tensB in different stages, from the pustules of acne,
from various transudations and exudations, from nor-
mal lymph, but there was entire absence of the char-
acteristic vaccine corpuscles and filaments.

From the point of view of culture, there was not
much to expect of the ordinary media which have thus
far proved refractory under the manipulations of other
experimenters. Battersack has attempted preferably
the culture of the germs in the living animal. He in-
troduces under the skin of a calf a capillary tube filled
with vaccine lymph. At the end of three or four days

Digitized by

Google

146

BOSTOlr MSDlCAl AUD SVJtGJCJl JOVJlIiJl. [PibHUART 8, 1894,

there appears at the site of inocalation an intense infil-
tration, the liquid of which contains filaments. This
liquid by inoculation in other animals and in children,
gives rise to typical vaccine vesicles. Buttersack an-
ticipates the objection that these filaments may be
nothing bat fibrine. The vaccine filaments are every-
where of uniform thickness ; not so with fibrine fila-
ments. Moreover, the former cross and intercross
with a clearly defined angle, and without fusing to-
gether, in this respect markedly differing from fibrine.
Fibrine takes certain staining fluids ; the vaccine fila-
ments do not.

Lastly, the elements of vaccine undergo a certain
biological process of development, as Buttersack's ex-
periments show. The principal of these experiments
consisted in the. introduction of sporiferous lymph in a
deep cutaneous wound of the forearm ; six boors after-
wards he found several isolated filaments in the serum
of the wound ; at the end of twelve hours, they were
much more abundant ; twenty-fonr hoars after, the
complete network was formed, and on the third day
spores luxuriated, and became predominant.

Hence, then, the constant presence of these elements
on vaccinal lymph, their absence in other affections,
their biological evolution in harmony with the clini-
cal syndrome, lastly, their transmission by inoculation
tend to prove their importance in the act of vaccina-
tion.

It remains to be established whether these elements
exist also in small-pox. Some researches undertaken
on some small-pox patients at three different towns,
incline Buttersack to believe that they do. In recent
cases, he has observed the filaments, and in advanced
cases the spores accumulated in the pustule and in
the lymph of the neighboring cutaneous region. The
variolous substance inoculated in calves, furnished the
same infiltration with the same filaments and spores as
when ordinary vaccine lymph was the infectaut ma-
terial.

A fuller, illustrated report, of these observations
will be issued in an early publication of the Imperial
Hygienic Institute. In this connection our readers
will recall the report of the work done in this direction
by the late Dr. S. C. Martin, of Brookline, published
in this JooBNAL, December 14, 1893.

PROPOSED LEGISLATION CONCERNING CAP-
ITAL PUNISHMENT IN OHIO.

The Ohio Legislature is to have under consideration
this session a bill to substitute physiological experi-
mentation for capital punishment, or rather to make
the criminal subject first to experiment and then to exe-
cution. The proposed bill, which is offered as an
amendment to the present act dealing with capital
punishment, provides :

(1) "That all persons sentenced to death by any court
having jorisdiction in the State of Ohio, shall be held as
subjects for experimental research ; that snch experiments
shall be conducted in the interests of science and society,

and shall be regulated by approved rules of humane trest-
ment to avoid all unnecessary pain ; that in the prepara-
tion for such experiments, where pain would be occasioned,
anesthetics shall be administered to the extent of complete
insensibility to pain, and during the progress of the experi-
ment narcotics shall be judiciously used to allay any pain,
and the condemned person shall not be maltreated in any
way ; that after the conclasion of such experiments the crim-
inal shall be again anesthetized and put to death while in a
deep sleep and entirely insensible to pain ; that the execu-
tioner shall be an expert physiologist duly appointed and
authorized by the State, and that such appointments to ex-
ecute and conduct such experiments shall be vested in the
Grovernor, and shall consist of one executioner and five as-
sistant physiologists, with a like number of deputies, who
shall hold their office for the term of good behavior, except
upon proof of incompetency ; and no one so appointed shall
be removed without sufficient cause, which shall be left to
the discretion of the Governor, and that all appointments
to fill vacancies caused by death, resignation or removal,
shall be made as prescribed in the foregoing.

(2) " All executions of the death penalty, according to
the provisions of this bill, shall take place within a building
provided for that purpose, and so constructed as to safdy
and comfortably lodge all capital criminals nntil the com-
pletion of the execution ; that such criminals shall be in the
custody of a warden or deputy warden and board of man-
agers, who shall provide for their safe and comfortable
keeping ; that the execution of the sentence shall commence
on the day fixed by the judge passing the sentence, unless
a suspension of execution be ordered by the Supreme Court
or two judges thereof.

(8) " That no one shall be present at experiments and
executions except the warden or deputy warden in charge
of the prisoner, the executioner, assistants, and deputies,
and those who have duly qualified themselves to compre-
hend the experimental work ; that such qualifications shall
be determined by a board of examiners, who shall issue a
certificate which shall admit the holder to witness the ex-
periments and executions ; that at the conclusion of each
execution a written report shall be required of the body of
physiologists which shall contidn a correct account of the
result of the experiment and execution, and that such a re-
port shall be made within thirty days from the infliction of
death, and recorded in the arctiives of the institute."

It has often been suggested, with some degree of
reason, that criminals condemned to death be allowed
reprieve on the condition of subjecting themselves to
experiment; but certainly to pass a law that such
persons shall be used for vivisection and then executed
even while still ander ansBsthesia, is as far beyond all
bounds of Intimate action as it is abhorrent to the
sense of humanity.

Before the same Legislature we understand another
bill has been introduced, prohibiting the performance
of circumcision. Are these proposals to be classified
under tragedy or under comedy ?

MEDICAL NOTES.
SoMK Vacoinatiom Statistics. — The offiraal re-
port of the epidemic of small-pox which occurred in
the borough of Halifax, Nova Sootia, between the
middle of March, 1892, and the end of September,
1898, shows that there were 513 patienU admitted to

Digitized by

Google

CXXX, No. 6.J BOSTON MEDIOAL AND SUROIOAL JOURNAL.

147

' hospital, 44 of whom died, a mortality of 8.5 per
'*.x>, 'Phe vaecinated cases numbered 425, with 8
ft.tba, or 1.8 per cent, mortality ; the unvaccinaUd,
« ^ith 36 deaths, or 40.9 per cent, mortality. There
»re two cases in revacoinated persons, one having
e*i " revacdnated ineflSciently five years ago," the
ber ** revaccinated thirty-fonr years ago."

To Pbbpbtdatb Dk. Blanchk's Memobt. —
be City of Paris has changed the name of the Rue
aa Foutes to Rue Blanche, in honor of Dr. Antoine
!^aail Blanche.

A Gift fob a Vibginia Hospital. — The Shelter-
ng Arms Hospital at Charlestown, W. V., has received
• gift of seventeen thousand dollars from the widow of
£x-Goveruor Olden of New Jersey.

Dbaths fbom Cabbolic Acid in Enoland. —
Between February. 1892, and November, 1893, there
were two hundred and thirty deaths in England due
to taking carbolic acid. One hundred and seventy-fonr
of them were suicidal.

Examination fob the Makinb-Hospital Sbb-
VICE. — A board of medical officers will meet, Mon-
day, April 16, 1894, in Washington, D. C, for the
purpose of examining candidates for appointment to
the grade of Assistant Surgeon, in the Marine-Hospital
Service. For further information address the Super-
vising Surgeon-General, U. S. Marine-Hospital Service,
Washington, D. C.

Chehistbt and Rbadino Notices. — 0*"' esteemed
contemporary The Lanctt has started a department of
Analytical Records, which to Americans who are sup-
posed not to have a very keen medico-ethical sense
seems very strange. It has equipped a laboratory,
and everything is grist to the scientific mill therein.
We find The Lancet publishing analyses of champagne,
lager-beer, bon-bons, cigarettes, malt, wine, tea, gin,
etc Curiously enough everything analyzed and re-
ported apon is found to be good ; so that the state of
mind of Tht Lanett't chemist is very suggestive of
that deicribed in Grenesis at the end of creative work.
— Nme York Medical Record.

BOSTON AND NBW BNOLANO.

Small-Pox in Boston. — Two new cases of small-
pox have been reported to the Board of Health during
the week coding at noon February 7th. There have
been no deadis. There are at present nine patients in
the hospital, all of whom are doing well.

AcDTB Infectious Disbases in Boston Dar-
ing the week ending at noon February 7th, there were
reported to the Board of Health of Boston the follow-
ing Dumbera of cases of acute infections disease:

scarlet fever, 47 ; diphtheria, 41 ; measles, 7.

Thc Public Health Coumjttbe or the Lbqis-
LATORE. — The Public Health Committee of theMas-
tschosetu Legislature for the present session consists
of Seostora E. B. Harvey, M.D., of Worcester County,
£. 6. Frothingham, of Essex County, E. A. Besson,
of Essex County, and Representatives Crane, of Som-

erville, Tuttle, of Boston, Mahoney, of Boston,
Johnson, of Lynn, Harvey, of Springfield, Fisk, of
Dennis, Goodell, of Brookfield, and Marsh, of Han-
over. It gave a hearing yesterday upon two proposed
measures — one a bill to provide for medical regis-
tration, and the other for the State ownership of vac-
cine farms.

The Ltuan Pbizb. — The Lyman Prize estab-
lished for graduates of the Boston City Hospital, of
not more than three years' standing, by Mrs. George
H. Lyman, in memory of her husband. Dr. Greorge
Hinckley Lyman, who was a member of the medical
staff of the hospital for many years, has been awarded
this year, in two equal parts of $150 each, to Dr.
John Lovett Morse, of Boston, for an essay entitled,
"A Bacteriological Study of Four Hundred Cases of
Infiammation of tlie Throat in Diphtheria and Scarlet
Fever, with Special Reference to Pathogenesis," and
to Dr. Arthur Howard Wentworth, of Boston, for an
essay entitled, "A Study of the Blood in Early Life."
The usual prize is $150, but no prize was awarded
last year.

A Bequest to a New Hatbn Hospital. —
The will of Mr. Andrew L. Kidson of New Haven,
Conn., bequeaths five thousand dollars to the General
Hospital Society of New Haven.

The Boabd of Medical Exauinebs, M. V. M.
— By a recent order of the Commander-in-Chief, the
Board of Medical Examiners, M. V. M., is now con-
stituted as follows : Lieut-Colonel Freeman C. Hersey,
Medical Director Second Brigade, President; Lieut-
Colonel Edward J. Forster, Medical Director First
Brigade ; Major Otis H. Marion, Surgeon First Regi-
ment Infantry, Recorder. Brigadier-General Herbert
L. Burrell and Major Charles C. Foster are relieved
from further duty on the Board by the same order.

The Alleged Deaths fbom Vaccination in
Lowell. — The two deaths in Lowell week before
last which were reported in the daily papers with much
heading as due to vaccination, were due to other causes.
From official sources we learn that the death returns
gave " tonsillitis " and " bronchitis " as the causes.
The several cases of " bad arms " which came to notice
were " considered due not to impure vaccine, but to
the introduction of foreign micnM>rganism8 by faulty
technique."

NEW tobk.

Insanity Statistics. — The annual report of the
State Board of Charities, submitted to the legislature
February Ist, shows a total increase in the number of
insane in the institutions of the State from October 1,
1880, to October 1, 1893, of 8,842. The increase in
population from 1880 to 1892 was 28 per cent., while
the increase of the insane in the institutions was 83
per cent. A part of this increase, it is stated, may be
accounted for by the greatly increased accommodations,
by means of which many insane had been taken from
their homes to institutions. Besides, the better care
of the chronic insane has doubtless considerably pro-

Digitized by

Google

U8

SOSTON MEDICAL AND SVMOIOAL JODSXAl. [FebbcabtS, 1894.

longed their liveg. Still, the Board believes that the
increase is not wholly accoonted for by these caoses.
The Dumber of patients in the Tarious State hospitals
for the insane on October 1, 1892, was 7,484; the
namber of admissions during the year ending Septem-
ber 30, 1893, was 2,586, and the total namber under
care during the year, 10,070, as against 9,435 the pre-
ceding year. The number of insane in the county
and city poorhouses and asylums of the State, exclu-
sive of New York and Kings C!ounties, October 1,
1893, was 610, as against 857 October 1, 1892. The
number of admissions to the asylums of New York
City during the year ending September 1, 1893, was
1,699, as against 1,592 admitted the previous year.
Overcrowding still continues in the asylums of New
York, The one on Blackweli's Island, with a capacity
for 1,110, has 1,762 inmates, and that on Ward's
Island, with a capacity of 1,620, has 2,349 inmates
Other buildings however are to be fitted up on Ward's
Island which will accommodate 1,200, and thus re-
lieve the overcrowding in these institutions.

MoBTALiTT. — The general health of the city, as
indicated by the mortality reports, continues very fair
for the mid-winter season. During the week ending
February 3d, there were 848 deaths. Of these, 13
were from influenza, a decrease of six from the pre-
cedlLg week. The contagious diseases in general,
however, show some increase, and the deaths from
measles amounted to 28. Diphtheria continues to be
the most prevalent and serious, and shows a mortality
of 58 for the week. The deaths from scarlet fever
numbered 20. During the week an unusually large
namber of births were reported, 1,187. As a rule, a
large namber of births are left unrecorded by physi-
cians and midwives, and of late the Board of flealtb
has been making a house-to-house canvass of the city
in order to ascertain approximately the namber of
births which occurred in 1898.

CREMATION IN PABIS.>

In November, 1887, a law was passed allowing the
French citizen to dispose of his dead by cremation in-
stead of burial, if he so chooses. All such cremation
is carried on under the control of the Board of
Health and under the surveillance of the municipal
authorities, who issue permits for incineration only
upon a written request from the legal representative of
the family, accompanied by a certiGcate of the cause
of death from the attending physician and the consent
of a sworn medical official appointed to verify the
cause of death in such cases. The ashes after crema-
tion may not be placed, even temporarily, in any but
regular places of sepulture.

At the present time Paris is the only French city
possessing a cremation establishment. Previous to the
law of 1887 she had obtained the permission of the
government to build a crematory to dispose of the ha-

> La HMecine Hoderne, 1893, 103.

man remains from the medical and anatomical schools ;
and this plant served for the first incinerations.

The law prescribes most minutely the details of the
procedure and the preparation of the body. The
ashes are placed in an am paid for by the family. If
the urn is to be placed in a private tomb, it may be of
any design ; but if it is to be put in the mnoicipsl
columbarium, it must have the following dimeDsioDs :
height 28 centimetres, length 48 centimetres, width
28 centimetres. Urns containing funeral ashes may
not be made part of any monument, but may be buried
if the grave is marked by a stone.

The charge for cremation varies according to the
convoy, the services being free. The cost runs from
50 to 250 francs. The expense of private cremations
has been much reduced by the fact that the city is
obliged to maintain a cremation furnace in constant
operation day and night, in order to dispose of the re-
mains of the 2,000 iMdies annually received from the
dissecting-rooms. There is only one columbarium,
which contains 354 cases.

The statistics of cremation in Paris up to the first
of last November are as follows :

Inoin«ratioiu Bamatn* at Bmbtra*

at reqoMt bodies (ram ondar (our

of family. hoapitalt, eta. monUu.

ta 483 3IT

121 2,IK8 l,OiS

134 2,3S> 1,238

1S9 2.3»8 1,426

ISO I.MS 1,IS4

188S . . . .
1B80 ....
1891 ....
1882 ....
18S3,toO«toberSlst,

«13 t.414 6,ltl

In spite of the advantages from a sanitary point of
view, and of the ease and cheapness of procariag
service, cremation has won favor but slowly in Paris,
and even more slowly in the rest of France, The
government has done much to extend the use of in-
cineration, but with very little eSect. Two facts have
especial bearing on this : the publicity attending cre-
mation and the religions repugnance of a Roman

Catholic people.

•

WHAT "MENTAL CURE" IS.

In a recently published volume entitled " The PhUot-
of Mmtal Healing" the author, Mr. L. E.

hippie, gives the following definition of what mental
healing is in the minds of those devoted to that science :

" Mind is the intelligence of the body. Mind thinks ;
its thought is registered on the body in physical ele-
ment. The thought is a model of the idea ; the body
and its conditions are a constructed copy of the model.
When the model changes the copy correspondingly
changes. This rule holds good with regard to every
part of the system, but is especially true of the most
finely constructed parts, because these are subjected to
the quickest changes. In the finest nerve mechanism
important changes frequently occur instantaneously,
while in the coarser structure of bone, cartilage and
ligament they take place more slowly. The instant
the mental cause ceases its disturbing vibrations, nature
begins natural restorative activity in every part of the
physical system ; this is as certain as that water will
run down hill. . . . When these truths are intelligently
comprehended the fact becomes evident that disease —
whatever its name or nature — must originate in some
mental activity afterwards registered in the body, where
that mode of action is outwardly expressed. Knowl-
edge of this fact is the key to accurate diagnostication,

Digitized by

Google

Vol. GXXX, No. 6.] BOSTON MEDICAL AUD SVMGICAL JOISHAL.

149

and a sure gaide to adequate mental therapeutic*. . . .
Thorough knowledge of the natural lawn of human ex-
iitence, based upon intelligent understanding of the
fandamental principles of spiritual life, each thinking
mind has power to reverse every wrong mode of action,
and to establish right conditions. Exercise of this
power in removing disease is a legitimate mental cure.
Us nature is metaphysical.

OBITUARY.

MEMORIAL OF HOWLAND HOLMES, A.M.,

M.D., OF LEXINGTON, MASS.

At a meeting of the Middlesex East District Medi-
cal Society held at Wakefield, Mass., January 24,
1894, the following memrrial and resolution was pre-
sented and adopted :

The members of this Association desire to place upon
record their high appreciation of the life, character, per-
gonal and professional worth of our late associate-fellow,
Uowland Uohnes, A.M., M.U., of Lexington, Mass., wboss
sadden death has brought grief to us all.

Dr. Holmes was born in Halifax, Plymouth County, Jan-
nary 16, 1815, and was a lineal descendant on his mother's
nde from John Alden, the Pilgrim, and on his father's side
&om John Hohnes, who was in Plymouth in 1632. He
was fitted for college at Bridgewater, Mass., and Exeter,
N. H., and took his degree of A.B. from Harvard in 1843,
A.M. in 1846, and that of M.D. in 1848. Dr. Holmes was
made an associate member of this Society soon after its
organization, and so long as he lived was a constant and
interested attendant upon its meetings, endeavoring always
to contribute his full sliare to their interest and profit.

From this time forward his genial presence wul be sadly
missed. He closed a long, a useful, an honest, and an
honorable life in a moment. The swift-winged messenger
of death met him while returning to his home from one of
hii accustomed errands of mercy. That messenger came
to him unheralded, and in a twinkling he left us and was
gone.

We tender our heartfelt sympathy to his afflicted family
in this great trouble, and point them to the consolation to
be derived from the knowledge of his long and useful life,
aad that he was spared the mental and physical infirmities
of old age.

Dr. Holmes was distinguished in a marked degree for his
deameas of perception, the firmness of his convictions, his
eonrage in expressing them, and his geniality of manner.
He was highly social in bis nature, and, aside from his
own domestic circle, enjoyed the society of none more than
that of his professional brethren. We knew him long and
knew him well.

J. M. Harlow,)

W. S. Brown, >■ Committee.

J. S. Clark, )

THERAPEUTIC NOTES.

Tbbbb Cobtza Prescriptions. — In a recent dis-
eossion before one of the Parisian medical societies,
the three following prescriptions were given, as hav-
ing been found of value. M. Grellety advised the
free use of this powder, especially in the early stages :

Bi B«tal SJlgnunmM

Menthol 0.26gnunm«s

Cocaine OJSO graiuni«t

Powdered bantooffee 1.S grammes H.

H. Huchard recommended a snuff containing less
cocaine:

B BiimathU snbnltratla ... 15 grammes

OunpborB 5 grammes

anas b7drooli)orMls . 0.06 grammes H.

M. Julien preferred an ointment to a dry powder :

K Vaselloe 30 grammes

Aoidt. tmral 6 grammes

Menthol OS to 20 grammes M.

A Rkuedy for Trigeminal Nbdralgia. —
Ntegely * recommends the following method for quiet-
ing the paroxysms of trigeminal neuralgia, hemicrania,
globus hystericus. The great horns of the hyoid
bone are pressed by the two thumbs of the patient or
physician up against the larynx for a minute or ninety
seconds. While he cannot give an explanation of the
action, he has found it effective in many cases.

Gastric Neurasthenia. — Bummo and Braocini'
recommend the following combination of the zinc salts
in acute neurasthenia, especially when attended by
gastric symptoms :

£ ZincI phosphidt 0.1 gramme

ZInoi >>romidl 1.0 "

Quinlnao bromohjdrat. . . . l.S "
£zt. nucia Tomlcs .... 0.18 "
Mlsce. Ft. pil., Mo. zzz. Sig. One three times a day.

Albuminuria and Phosphaturia. — In a com-
munication to the Academic de Medecine, M. Robin
gave the following outline of treatment for cases of
phosphatic albuminuria : The first point, in importance,
is to combat the nutritive disturbances, and the batabol-
ism which leads to an undue elimination of phosphorus.
Following this the attention should be given to pre-
venting the destruction of the blood globules and to
controlling the albuminuria. The hygienic treatment
consists in moderate exercise, massage and complete
intellectual rest. The diet should contain, above all
else, vegetables, rich in phosphorus and potassium, sa
beans and lentils; white flour and sugars which
retard oxidation are contraindicated. Beef, mutton
and shell-fisb are allowable, but meats rich in gelatine,
and fish are to be forbidden. As medicinal treatment
the following are especially commended for the nutri-
tive troubles : arseuiate of soda, cod liver oil, the
golycero-phosphates, hypophosphites, sulphate of qui-
nine. Iron, arsenic and strychnine combat the destruc-
tion of the blood globules ; while gallic acid, and the
iodo-tannic preparations give good results in control-
ling the albuminuria.

THE EXPERIENCE OF TWO WOMEN PHYSI-
CIANS WITH SMALL-POX.

Boston, February 3, 1894.

Mr. Editor : — Dr. White'* personal experience with
small-pox, related in the Boston Mtdical and SurgictU
Journal recently (January 24, 1894), recalls our own vivid
acquaintance with the same disease.

In the summer of 1870, we were visiting hospitals in
Paris, being, with Dr. Mary Putnam Jauobi, the only medi-
cal women there. We were in good health, and full of en-
thusiasm about our work, but were also intensely interested
in the Franco-Prussian War, which was then in progress.
Since the 7tb of August, Paris had been declared in a state
of siege, and its bombardment was only a question of time.

Small-pox was epidemic in the city, the mortality from
the disease averaging about four hundred deaths a week.
There seemed to be no public or private precautions taken
against its spread, and no special hospitiils devoted to the
care of its victims. A personal friend of the family with
whom we boarded, died of confluent small-pox, and his
friends watched with him several nights before his decease.

> Mercredi MMicsle, 1893, Mo. 31.

> Stmalue Mcdioale, 1893, M.

Digitized by

Google

150

BOSTON MEDWAL AND SURGIOAL JOURNAL.

fFKBBUABT 8, 1894.

He had a public funeral in one of the churches to which
written inntations were sent, according to the custom there.

Naturally we were free from fear or apprehension of the
disease, bo that when we decided to follow the service of
Dr. H^rard, in the old Hotel Dieu (the new one was not
then ready for occupancy) the fact that one of his wards
was devoted to small-pox, did not serve to deter us from
our plans. We took tue precaution to be vaccinated, how-
ever, for the first time since infancy. It was hot weather,
and it was found months later that the virus had been kept
some days, and was probably inert. At all events, the vac-
cinations did not take, and in consequence we considered
ourselves safe from infection.

Our first visit with Dr. H^rard was September 2d. At
the close of the regular visit we accompanied him to the
small-pox ward, which contained twelve bedfi, all occupied.
The instant we entered the ward, we noticed the peculiar
musty, sickening odor, which seemed characteristic of the
disease. That day there were no cases of unusual severity,
but on later visits, we saw cases both confluent and hsemor-
rhagic, extremely repulsive to look at, with faces swollen
beyond recognition. Stupor or delirium fortunately made
these patients partly oblivious to their sufferings. Very
little treatment seemed to be given, and in no cases were
the faces protected in the slightest degree. Therefore all
we gained, was some knowledge of the appearance of the
disease in its successive stages.

We had decided to remain in Paris during the si^K,
under the protection of the American minister. The Re-
public had been proclaimed September 4th, the city was
being provisioned, troops were arriving from the Provinces
for the defence of Paris, and were being quartered on the
inhabitants. We were well and anxious to stay, when
on the ISth of September, there appeared in the papers a
peculiarly strong appeal from General Trochu, the Military
Governor of Paris, in which he implored all foreigners and
those not absolutely needed, to leave the city at once, as
the difficulty of pro>iding food would be so great that " use-
less mouths " must go.

The following day we went to the American Embassy
and were advis^ to leave the city that evening. Realizing
that as soon as the city gates were closed, we should be cut
off from communication with the outside world, we at last
relactantly resigned ourselves to going in the last train that
would be allowed to leave the city. The Prussians were al-
ready in Versailles, and the shorter routes to England had
been destroyed by blowing up the bridges. .Therefore we
were obliged to go by the way of Dieppe and Newhaven.
Since we were allowed to carry only hand baggage with us,
it became necessary to pack and store all our belongines.
This, with other matters, kept us very busy during ue
hours that remained before our departure, so that, when
we took our places in the crowded train at six o'clock, we
were thoroughly tired out.

We reached Dieppe at one a. h., and drove to the boat
in an omnibus. It was three hours before we started, and
the wait was very tiresome. The boat was small and un-
comfortable, and so overcrowded that it was impossible to
find proper accommodation, so we were obliged to lie in
cramped positions on seats next the outside rail on deck.
The night was damp and raw, and we could not obtain
extra coverings, so we alternated with cold and heat all
through that wretched night. The passage took seven
hours, nearly twice its usual time. We finally landed in
Newhaven, about eleven a. m., with excruciating headaches,
vertigo and fever, and aching all over. We secured com-
fortable seats in a compartment of the train in waiting, and
bonght some biscuit and fruit, as we felt unable to take a
breakfast at the hotel near bv.

London was reached in about two hours, and we drove
at once to the hotel. We retired early, but were burning
with fever or in profuse perspiration all night, while our
headaches were constant and severe. We had no lumbar
pain, however, but a bruised feeling all over. In the morn-
ing we wondered that we felt no better, but were inclined
to attribute our discomfort to the fatigue and excitement
of the few previous days. We felt that quiet and rest for

a time would restore us to our wonted health. Neither of
us suspected we might be suffering from premonitory symp-
toms of small-pox.

Throughout the day following our arrival, September
l$th, we were never free from chilly sensations and high
fever, with a sense of extreme prostration, headache, and
complete anorexia. No relief followed the taking of hot
baths, hotpunch and Dover's powder ; indeed, we felt even
worse. The following day, all our symptoms became in-
tensified. We remained in bed, and concluded we mast be
in for something serious.

Up to this time we had done what we could for ourselves,
and kept our real condition as far as possible from our
friends, bnt we knew they felt very anxious about us, and
so we decided to call a physician.

Accordingly, a note was written to Miss Garrett, M.D.
(now Mrs. Garrett-Anderson) the only woman phyrfcian
in London. She was the only woman graduate of Apothe-
caries' Hall in London, the doors being closed to other
women after she obtained her degree. Later she had taken
a degree at the ficole de Mddecine in Paris, being its first
woman graduate. We already had a letter of introduction
to her, which we enclosed in the note asking her to visit us
professionally. She promptly responded to the call, and
found us with temperatures of 104° and 105" rcspectivelpr,
with pulses to correspond, but reserved her diagnosis.
Cooling draughts and quinine were prescribed, but with
little relief.

The next day, September 18th, the temperature had les-
sened slightly, bnt the lassitude was still extreme, and there
was a peculiar feeling all over, as if one were incased in
India rubber half an inch thick. We were obliged to stay
in bed all day, too wretched and miserable to care for any-
thing. All through that night, the one who later had the
most eruption complained of a peculiar taste in the mouth
and throat, with considerable soreness, and both were con-
scious of an odor which for the first time made us think of
" small-pox." The feelinw of shot under the skin of the
forehead was marked. We mentioned to each other oar
suspicions that we were suffering from small-pox, and anxi-
ously waited for daylight to confirm the diagnosis. In the
morning faces and parts of the body were seen to be covered
with blotches like measles, and Hie fever and discomfort
had moderated somewhat.

Naturally our friends were much alarmed, and thought
of small-pox at once, as they knew it was in Paris. We
persuaded them to keep away until after the doctor's visit.
The moment she entered the door she exclaimed, " Why,
is it possible you have the measles ? " Bnt as she approached
nearer, she added, "Oh I 1 am afraid it is the small-pox."
A close inspection proved the correctness of the diagnosis,
and then we began to consider what we should do. At that
time there was no good small-pox hospital in London,
though one was built soon afterward. No hospital would
take us, the hotel proprietor was in despair at having such
a dreaded disease in his house, and naturally eager to get
us away at once, while we were equally eager to depar^
but in a quandary where to go. ftliss Garrett was full of
sympathy, and said she would see what could be done, and
meanwhile would send us at once a nurse with directions
ahont our care. Our friends were banished from our room,
and all vaccinated as soon as possible.

An hour or two of waiting intervened, when a tap at the
door was followed by the entrance of a good, motherly- /
looking nurse who had received instructions what to do for
us. In a short time we were dressed and thickly veiled, put
into a cab, and carried to a private house not far away,
where we were put into comfortable beds in a large room
on the top floor. The occupant of the house had been
away on the Continent for some weeks, and the oppor-
tunity had been taken to have a house-cleaning. The two
upper floors were thoroughly dismantled, with carpets up,
so they were in the right condition for our reception. _ -W
one was on the floor with us but our good nurse. Antisep-
tic precautions were instituted at once. , ,

With the exception of our banker, who had been a^J^J'"
of the disease in Paris, our friends were not allowed to

Digitized by

Google

Vol. CXXX, No. i.] SOSfOH MkDlCAl Atfi) SVJtGlCJl JOURNAL.

IM

know of our whereabouts, although they were kept ac-
quaiated with our progress. We had the best of care, and
every reason to be thankful at our good-fortune.

The partial remission of symptoms the day the eruption
appeared, was of course, but temporary, and fever appeared
with renewed energy that evening. The fever and restless-
ness caused by ihe discomfort and excessive itching was so
great that the temperature rose again to 1 05° in one case,
and continued at that height several successive days. The
eruption rapidly extended over the body, and to the feet
which were much swollen and painful. Sleeping-draughts
were a necessity, and the feet were wrapped in soothing
lotions, kept constantly wet. The oiher case was milder,
though the temperature frequently rose to 104°.

Our room contained two large windows), which were
kept open continually, but darkened by heavy curtains,
while a constant fire was kept in the open fireplace for
ventilation. A feeble light was supplied by a lighted candle
placed behind a screen. In this way the light was kept
from our faces, and Uke air was kept out by toe manner in
which they were treated. Our faces were bathed with a
solution of aromatic vinegar, which allayed the itching, then
glycerine applied with a soft brush, and finally a covering
of soft linen with apertures for the eyes, nose and month.
This process was repeated frequently, and undoubtedly
was of benefit. Every day a large portable tub was wheeled
into the room, and each in turn carefully lifted into it and
bathed in tepid water containing oatmeal and a disinfectant.
This was accomplished by squeezing the water from a
sponge over the surface of the body, which was afterwards
dried by patting gently with soft warm towels. Then we
were wrapped in soft old linen sheets. This daily bath and
change of linen was very cooling and refreshing, and added
very materially to our comfort. It was supplemented by
■ponging surfaces where the eruption was thickest p. r. n.

AU clothing, bed-linen, and towels were daily placed in a
tab, and disinfected with Condy's solution before being sent
to a special woman who did no other washing. All hooks
and papers we handled until well, were either burned or
disinfected by baking after we had used them. All letters
we wrote when convalescent, were also baked before mail-
ing them. No one contracted the disease from us, which
was a comfort. ■

The papules on the face rapidly developed into vesicles,
and those on the body followed more slowly. The burning
and itching, especially in the face and feet, was intense, and
the bands were kept tied up in linen to prevent scratching.
The second week the eruption began to dry up, and the
iwelling and heat to subside.

Uur treatment medically was quinine in an effervescing
mixture with carbonate of ammonia, sedatives as needed,
chiefly chloral or morphine, stimulants, and a nourishing
diet Milk was chiefly depended upon at first on account
of the soreness of the mouth and throat. Neither case had
troable with the eyes. Indeed, it looked peculiar to see a
clear circle around the eyes free from eruption, as if pro-
tected by glasses. The scalp was not so free from invasion,
however, and later the hair fell out, but was rapidly renewed.

The milder case was confined to the bed about ten days
after the eruption appeared, and the other two weeks, but
was forced to return to bed again for three days on account
of an nnosually severe attack of pleurodynia contracted by
sitting too near an open window the first day she sat up.
The third week both began to drive out a little, and in
three weeks we joined friends in Scotland. Strength re-
turned rapidly ; and on our return to London a fortnight
or so later, our physician could hardly recognize us. The
diiease left no marks, only discolored spots that were notice-
able for Eome months, and eventually disappeared entirely.
It was rather remarkable that we had the disease at the
lame time, the eruption making its appearance on both the
same day. We considered it very fortunate, and it did
much to keep up oar spirits, as we were companions in
nisery. During convalescence we entertained ourselves
by counting the crusts on each other's faces, one having
over two hundred and fifty, the other not half aa many.

E. F. P. and C. A. P.

HETEOROLOQICAL RECORD,

For the week ending January 27, in Boston, according to ob-
servations furnished b; Serjeant J. W. Smith, of the United
Statei Signal Corpa: -

Baro-

111611110111- BelatlTe

Uireotion

Velocity; We'tti'r.
of wind. •

1

meter

eter. huraldity.

of wind.

Uats.

i

i

a

*

f

i

i

a

*

a

i

a

1

- 1

29:35

23

■*

ft.

00

1

76

8

OD

•<
1

a.

9&

4

S

1
o.

§

S..21

30.22

63 89

N.W.

N.W.

7

•T

o.

M..22

so.oe

41 en 32

S7 BS

71

W.

W.

12

;s

c.

0.

T..23

30.44

34 37 131

68 73

69

N.W.

S.K.

6

6

o.

0.

W.24

30.10

44 , 66 3'i

% 91

91

K.

8.W.

I«

28

o.

B.

M

T..28

30.33

26 i 31 1 20

41 63

4;

N.W.

N.W.

14

12

0.

0.

.84

•F..28

30.94

26 32 19

.12

6fl

flO

N.W.

B.

10

21

T.

o.

S..27

30.08

24 28 19

m

»7

92

N.

N.W.

21

5

N. 1 O.

.80

tr

r; 1

1

1.31

•0..alowl7i Celtwi F..t*iri 0.,t(l>; U.,liuqP| S..
•nlBKi (l..niaw. « IndlntM mm «f Tdntell. wrHm

lowkyi Il..mlBi T..ttarMl-

n forwMk.

RECORD OP MORTALITT
Fob thb Wan aiiDiNO Saturday, Januabt 27, 18M.

Otttes.

New York . .

Chleago . . .

Plilladelidila .

Brooklyn . .

St. Louts . . .

Boston . . .

Baltimore . ,
Wachlogton

GlnoinDatl . .

Glevelaud . .

Pituburg . ,

Milwaukee . .

NaahTlUe . .

Charleston . ,

Portland . . .

Worcester . .

Fall RIvec . .

Lowell . . ,

Cambridge . .

Lynn . . . .

Sprlngfleld . .

Lawrenee . ,
New Bedford

Holyoke , . .

Salem , . . ,

Brockton . .

Haverhill . ,
Chelsea . .
Maiden . .

Newton . . .

Fttohbnrg . ,
Taunton . ,

Oloaoester . ,

Waltham . ,

Qalnoy . . ,
Pittsileld .

Everett . . ,

Northampton ,

Newburyport ,

Ameabnry . ,

it

k a

Is

r

Per

sentag

eof d<

11

5

»attufrom

§1

r

u

r

S u

o «

II
11

1,881,306

U2

340

lfi.4« 22^

1.20

M

».n

1.438,000

827

124

10.60

13.]£U

1.20

—

tM

1.118,862

888

189

9.18

23.40

.61

2.jSt

4.14

978,894

—

—

—

—

—

—

—

860,000

-..

—

—

—

—

•^

—

467,897

222

68

lOJIO

26.10

—

^

6.88

800.000

—

—

._

—

—

—

—

308,431

94

26

12.72

16.96

3.18

1.06

8.30

3O8,UO0

108

—

12.88

22.08

4.60

4.60

2.76

290,000

81

38

8.61

18.46

1.23

1.23

3.69

263,709

100

89

16.00

17.00

.40

.60

280,0(10

87

36

20.23

13.09

1.19

2.88

8.83

87,764

25

»

—

20.00

—

— >

— '

8S,1«>&

26

8

4.00

12.00

—

4.00

..

40,000

23

6

8.70

4.36

—

4JI6

^

96,217

39

16

VIM

33,^

-_

—

*M

87.411
87,191
77.100

88

19

IM

18.90

5.67

—

—

27

11.10

18.80

.

.^

8.78

62,666

i;

8>8

23JM

^

^

^

48,684

._

14.28

^

-.

^

48,366

^

14,28

9.62

9.82

4.76

•^

43,88«

11.76

11.76

—

^

—

41.278

18.18

63.63

^

^

9.08

32,283

—

9.09

—

—

—

32,140

6.66

33.33

^

—

6.66

S1.396

9.09

27.27

—

—

—

30.264

18.78

26.00

6.28

^

29,394

14.28

14.28

—

^

._

27,886

28.00

—

—

*.

UM

27.146

—

20.00

— .

^

—

26,972

6.28

87.60

—

—

_

26,688

—

—

•^

—

i_

22,068

16.66

16.86

—

—

—

19,642

—

—

—

—

18,802

40.00

40.00

20.00

_

20.10

16,686

28.00

26.00

—

—

...

16,331

—

83.33

—

^

14,073

—

i6.ce

—

_

10,920

2

80.00

—

—

—

80.00

Deaths reported 2,828: under five years of age 975; principal
infecttotis diseases (small-pox, measles, diphtheria and cioap,
dlarrhceal diseases, whooping-coueh, erysipelas and fever) 348,
acute lung diseases 683, consumption 323, diphtheria and croup
171, typhoid fever 36, diarrhoeal diseases 31, measles 31, scar-
let fever 22, whooping-cough 19, cerebro-spinal meningitis 16,
erysipelas 12, small-poz 6, malarial fever 2.

From measles Mew York 20, Milwaukee 4, Philadelphia 8,
Chicago 2, Worcester and Fall iBiver 1 each. From scarlet
fever Boston ti, Chicago 8, New York 4, Pittsburg and Cambridge
2 each. New Bedford, Chelsea and Newton 1 each. From
whooping-cough Pittsburgh 4, Bo&ton and Washington 3 each,
Philadelphia and Milwaukee 2 eacb, New York, Cincinnati,
Cleveland, Somervllle and Taunton 1 each. Fromcerebro^apiiial
meninsitis Chicago and Worcester 8 each. New York, Philadel-
phia, Cleveland, Milwaukee, Portland, Lynn, New Bedford,

Digitized by

Google

162

BOSTON MSDtCAL AJSL SURGICAL JOURNAL. [^bbsoart8, 1894.

Holyoke, Chelaea and Everett 1 each. From erysipelas Phils'
delphla B, New York 1, BostoD, Haverhill aod Waltbam 1 each.
From small-poz Chicaf^o 4, New York 2.

In the thirty- three greater towns of England and Wales with
an estimated jwpalation of 10,408,442, for the week ending
January 20th, the death-rate was 23.2. Deaths reported 4,SMi
aente diseases of the respiratory organs (London) S47, whoopiog-
congh 191, measles 84, diphtheria 74, scarlet fever 46, ferer 43,
diarrhlBa 40, small-pox (Birmingham G, Bradford 4, Bristol 3,
West Ham, Leeds and Hull 1 each) 16.

The death-rates ranged from M.'l in Halifax to 42.4 in Nor-
wich; Birmingham 2M.», Bradford 22.1, Cardiff 21.4, Gatesheaxl
18.4, Leeds 21.1, Leicester 15.7, Liverpool 2tj.0, London 23.7,
Manchester 21. U, NewcaKtle-on-Tyne 20.7, Nottingham 18.7,
Plymouth 38.0, Portsmouth lli 6, Sheffield 19.1, West Ham 21.0,
Wolverhampton 24.6.

OFFICIAL UST OF (MANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEFART.MEN1 . U. S. ARMY, FROM JANUARY 27, 1894,
TO FEBRUARY 2, 1894.

CoLONCi, JosKPB R. Smith and Colonbl Bbbnakd J. D.
Ibwin, assistant surgeon-generals, U. S. A., are detailed to
represent the Medical Department of the Army at the Eleventh
International Medical Congress to be held at Rome, Italy,
March 29 to April 5, 18H4, and will proceed to the place desig-
nated at the proper time.

LiBCT.-CoL. Francis L. Town, deputy surgeon-general, U.
8. A., is relieved from duty at Fort Porter, New York, to take
effect on the expiration of bis present sick leave of absence and
will report in person to the commaudlDg general. Department
ot the Missoari, for temporary duty in the office of the medical
director of that department.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. 8. NAVY FOR THE WEEK ENDING FEB-
RUARY 3, 1894.

T. H. Stbbets, surgeon, from U. S. 8. " Bennington " and to
U. 8. 8. '• Detroit."

0. T. HiBBBTT, snrgeon, from U. S. S. " Detroit " and to U.
8. 8. " Bennington."

J. W. Ross, snrgeon, ordered to the U. S. Receiving-ship " In-
dependence."

F. W. Ou;oTT, passed assistant surgeon, ordered to the Naval
Hospltel, Brooklyn, N. Y.

L. W. Spbatlino, passed assistant surgeon, from Naval
Hospital, New York, and wait orders.

SOCIETY NOTICE.

Boston Socibty fob Medical Impbovbmbnt. - A regular
meeting of the Society will be held at tbe Medical Library, No.
19 Boylston Place, on Monday, February VI, 1894, at 8 o'clock,
r. M.

Dr. H. L. Bnrrell : " The After-treatment of Appendicitis."
Dlscnssion opened by Drs. G. W. Gav and M. U. Richardson.

Dr. J. G. Mnmford: "Compound Fractures." Discussion
opened by Dr. A. T. Cabot.

Directly after the Secretary's report. Dr. W. T. Councilman
will show a specimen of " Peritonitis Due to Embolism of the
Mesenteric Artery."

Members are requested to show interesting cases and patho-
logical specimens.

John T. Bowkn, M.D., Secretary.

RECENT DEATHS.

Abthub Rataba, M.D., surgeon to the King of Portugal and
to tbe San Jos^ Hospital of Lisbon, died recently from tbe
rupture of an aortic aneurism while be was examining a patient
preparatory to operation.

Paul Diday, M.D., one of the leading surgeons in France,
died in Lyons, January 8th, aged eiglity-three years. He had
been a pupil of Dupuytren and was one of the founders of tbe
Lyvn Mtdical. He was the author of several books on syphili-
tic and venereal diseases.

BOOKS AND PAMPHLETS RECEIVED.

Tbe Treatment of Diphtheria. By F. E. Wazham, M.D.,
Denver, Colo. Reprint. 1893.

How Shall We Make Our Homes Healthy? By Benjamin J.
Portugaloff, M.D. Chicago. 1893.

Fifteenth Annual Report of the State Board of Lunacy and
Charity of Hassacbasetts, January, 1894.

Mensuration in the Physical Diagnosis of Pulmonary Phthisis.
By George A. Evans, M.D. Reprint. 1893.

Marine sanitats ordnung. III Bands, Berlin, 1803. Ernst
Siegfried Mittler and Sohn. Konigliebe Hofbnchhandinng.

Some Reasons for the Performance of Circumcision on ill
Male InfanU. By Alex. L. Hodgdon, M.D. Reprint. 1893.

Report of tlie Kensington Hospital for Women (Non-Sectarian)
from October 10, 189i, to October 9, 1893. Philadelphia. 1893.

The Snoceasf nl Management of Inebriety Without Secrecy in
Therapeutics. By C. H. Hughes, M.D., St. Louis. Reprint.
1894.

The Johns Hopkins Hospital ReporU. Vol. Ill, Nos. 7, 8, 9.
Report in Gynecology, II. Baltimore: The Johns Hopkins
Press. 1894.

Venereal Memoranda, A Manual for the Student and Practi-
tioner. By P. A. Morrow, AM., M.D New York: William
Wood b Co. 1894.

Transactions of the American Association of Obstetricians
and Gynecologists, Vol. VI, for the Year 1893. Philadelphia:
Wm. J. Dornan. 1894.

The Modern Climatic Treatment of Invalids with Pulmonary
Consumption In Southern California. By P. C. Remondino,
M.D. Detroit: George S. Davis. 1893.

Announcement and Catalogue ot tbe National Medical Col-
lege, Medical Department ot the Columbian University, Wash-
ington, D. C, for the Seventy-second Session. 1893-1894.

The Necessity of Special Institutions for the Consumptive
Poor; The First Step Toward the Complete Eradication of
Tuberculosis. By U. Longstreet Taylor, A.H., H.D., St. Paul.
Reprint. 1893.

How to Use the Forceps, with an Introductory Acootut ot the
Female Pelvis and of the Mechanism of Delivery. By Henrr
G. Landis, A.M., M.D. Revised and enlarged by Charles H.
Bushong, M.D. Illustrated. New York : E. B. Treat. 1894.

Autobiographical Sketches and Personal Rooollections. By
Geo. T. Angell, President of the American Humane Education
Society, the Massachusetts Society for tbe Prevention of Cruelty
to Animals. Boston : The American Humane Education Society.
1894.

A Practical Trentise on Nervous Exhanstion (Neurasthenia),
Its Symptoms, Nature, Sequences, Treatment. By George U.
Beard, A.M., M D. Edited with notes and additions by A. D.
Rockwell, A.M., M.D. Third edition, enlarged. New York:
E.B. Treat. 1894.

Antiseptics in Midwifery. By Robert Blozall. H.D., CanUb.,
M.R.C.P., Lond., Assistant Obstetric Physician to, and Lecturer
on Practical Midwifery at the Middlesex Hospital : Formerly
Physician to the General Lying-in and Samaritan Free Hospi-
tal. London: H.K. Lewis. 1894.

A Synopsis ot Clinical Surgery during the Serrice of Samuel
H. Pinkerton, M.D., Snrgeon to the Holy CroM Hospital; by
Franklin A. Meacbam, A.B., M.D., Assistant Surgeon to the
Holy Cross Hospital, Salt Lake City, Utah, for the Year 1892.
Salt Lake City : Tribune Co. 1893.

Tbe Technique of Post-Mortem Examination. By Ladwig
Hektoen, H.D., Pathologist to the Cook County Hospital,
Chicago; Professor of Pathologic Anatomy In the College of
Physicians and Surgeons of Chicago. With forty-one illustra-
tions. Chicago: The W.T. Keener Co. 1894.

Relation d'une Epidemic de Cholera ^tude cliniqne et Ezp^ri-
mentaie. Par MM. A. Mairet, Professeur de ciinique des mala-
dies mentales et nerveuses, et F. J. Bosc, chef de cliniqae des
maladies mentales et nerveuses a la Faculty de M^ectne de
Montpellier. Avec four Planches et eleven TracA dans Is
Texte. Montpellier: Charles Boehm. 1893.

The Relations of Urinary Conditions to Gynecological Sur-
gery. Report of Two Years Work in Abdominal Surgery at tbe
Kensington Hospital for Women, Philadelphia. Report of a
Year's Work In Minor Gynecological Surgery in the Kensington
Hospital for Women, Philadelphia. The Causation of the Dis-
eases of Women. By Charles P. Noble, M.D., Philadelphia.
KeprinU. 1893.

A Clinical Text-book of Medical Diagnosis for Physicians and
Students, Based on the most Recent Methods of Examination.
By Oswald Vierordt, M.D , Professor of Medicine at the Uni-
versity of Heidelbeiig. Authorized translation with additions
by Francis H. Stuart, A M., M.D. Third revised edition with
one hundred and seventy-eight Illustrations, many of which are
in colors. Philadelphia: W. B. Saunders. 1894.

Dissections Illustrated; A Graphic Hand-book for Students
of Human Anatomy. By C. Gordon Brodie, F.C.R.8., Senior
Demonstrator of Anatomy, Middlesex Hospital Medical School;
Assistant Snrgeon, Northwest London Hospital. With plates
drawn and lithographed by Percy Hlghley. In four parts.
Part I. The Upper Limb. With seventeen coloredplates two-
thirds natural size Part II. The Lower Limb. With twenty
colored plates two-thirds natural size and six diagrams. Lon-
don and New York : Whittaker ft Co. 1894.

Digitized by

Google

Vol. CXXX, No. 7.] BOSTON MBDIOAL AND SUBOIOAL JOOBNAL.

168

RECENT OBSERVATIONS ON THE FUNCTIONS
OF THE THYROID GLAND; AND THE RE-
LATION OF ITS ENLARGEMENT TO
GRAVES'S DISEASE; ALSO REMARKS ON
THE THERAPEUTIC USE OF SHEEP8 THY-
ROIDS AND OF OTHER ORGANIC EXTRACTS.*

BY JAMBS J. ptnrx^ii, 1I.I>.,

Pntftuor nf Diteatei of the Nervout Sytttm, Marvard Medical

School.

The object of this paper is to call attention to the
present state of our knowledge as to some of the func-
tions of the thyroid gland, and certain disturbances of
nntridon doe to its atrophy ; and as to the relation of
goitre to the nervous symptoms met with in Graves's
disease and analogous states. I shall also speak of
the therapeutic action of thyroid extracts in conditions
other than myzcedema, and as to the use of some
other organic extracts as therapeutic agents.

The dramatic history of the discovery of the relation
of thyroid disease to myxoedema, cachexia strumiprivi,
cretinism, and the so-called foetal rickets, is now, in
its broad outlines, familiar to every physician, so thor-
ODghly has public attention been aroused by the de-
velopments of the past few years. As long ago as
1856, Schiff had noticed the fatal effect of thyroidect-
omy in dogs ; and even earlier than this Sir Astley
Cooper and one or two other physiologists had made a
few experiments in the same line, with varying results.
Id 1856 Curling described a few cases of sporadic cre-
tuism as occurring in England ; and in 1871 Dr.
Hilton Fagge described others, and noted that they
were characterized by atrophy of the thyroid. In
1874 Sir William Gull read his paper on " The Creti-
noid State in Women " ; and two years later, Dr. Ord
gave a full description of myxoedema, and christened
the symptom complex with its present name. He also
remarked on the clinical relationship between these
cues and those which had been described by Curling
sad Fagge, and noted that the atrophy of the thyroid
made a pathological bond between them.

In 1884 came the remarkable observations of. Rever-
dm, of Greneva, and Kocher, of Berne, who found that
the thyroidectomy with which their experience in the
goitrons districts of Switzerland had made them famil-
isr, was often followed by a strange cachexia. Kocher
at first thought this to be due to laryngeal asphyxia,
bnt Reverdin a few months later recognized it as
essentially identical with myxoedema. The flood-gates
of physiological research were then opened, and a
mass of observations began to pour in, which I have
00 space even to summarize.' Dr. Felix Semon, rec-
ogniziDg the extreme interest of the new discoveries,
at once proposed the appointment of a commission of
inquiry from the Clinical Society of London, the re-
port of whose labors, finally published as a separate
rolome in 1888, will always be referred to as a treasure-
hoDse of facts upon this subject.

Even before the publication of this report, came
the scarcely less valuable review by our own colleagues,
Dn. Hon and Prudden, based on one hundred and
fifty cases, and giving the details of two thorough and
important autopsies. Finally, in the winter of 1891-

■ Bead before tbe SeetUm tor Cllnloal Medlelne, Pathology and
Hjglene of the Snflolk Oiitriot Medical 8oolet7 at the meeting,
DtoanberiOth.

' See a rerleir. with original oDwrratloni, by Dr. F. P. B^lnnlontt,
Hev York Uedloal BeeordTxllT, p. MS.

1892, Mr. Horsley, of London, whose name is identified
with the best original research with regard to this
matter, published in Virchow'a Denkiekrtft and in tbe
BritUh Mtdical Journal (January, 1892), a compre-
hensive and masterly analysis of all the facts which
were at our disposal up to that time, relating to the
physiology of the thyroid.

Most of Horsley's conclusions have been confirmed
by subsequent research ; and it is now accepted by
every one that the thyroid is an organ of immense im-
portance for nutrition. A few of his views will, how-
ever, DOW bear revision ; and a few important discov-
eries are to be added.

The history of the therapeutics of myxoedema was
sketched anew by Dr. F. C. Shattuck at a recent
meeting of the Medical Improvement Society ; and I
have nothing to add to his interesting remarks except
to call attention to the fact that many cases of cretin-
ism have been greatly benefited by thyroid feeding,
even those where the disease bad existed up to adult
life. Two or three of these cases have been under
the care of Dr. Osier,* of Baltimore, to whom we also
owe an in\^tigation into the frequency of sporadic
cretinism in America, showing that it is a disease of
rare occurrence among us.

It is probable that the thyroid is not, as -Horsley
thought it was, a hsemapoietic organ of real significance
(Gibson * and others, and among recent observers, De
Qnerrain * ).

It is practically certain that the functions of the
thyroid are not related to those of the spleen (De
Qnervain * ). Later observations have indeed made it
more and more probable that it is not safe to regard
secondary enlargement of an organ following thyroid-
ectomy as a sign of compensatory activity. This is
especially important as regards the pituitary body,
since this is probably or possibly related to the thyroid
in function. It does frequently enlarge after removal
of the thyroid and so does the thyroid sometimes en-
large after removal of the pituitary body ; but Vassale
and Sacchi,' who have beeta most successful experi-
menters with regard to the pituitary body, do not
believe that the enlargement or the increase of colloid
which accompanies it, necessarily means an increase
of functional activity.

The interesting experiments by Breisacher [v. Hors-
ley] with regard to the action of animal food in in-
creasing the cachexia from removal of the thyroid have
been confirmed, with slight modifications, by De Quer-
vain,* in a very recent research.

This latter observer was unable to confirm the state-
ment of Bogowitsch, Capobianco, and others' that
constant demonstrable changes occur in the central
nervous system after thyroidectomy.

It is not impossible that a repetition of the fatigue
experiments of Professor Hodge, of Clarke University,
would show that anatomical changes could be more
easily induced in animals suffering from cachexia than
in normal animals, and that, for this reason, anatomical
changes would sometimes be present which at other
times were not found. Piseuti ^ has recently observed

' Traoiaotloni of the Aiaooiatloo of Ameriean Physlolans, 18S3.

• British Uedieal Jonmal, 18S8, 1, p. 14.

• Vlishow's Arohlv, US8, M. 13S, Heft 8.

• See also Qley and other authors elted by him In the Aroh. de
Phys. n. et p.. im, p. SOT.

< Ardh. lua. de Biol., 1893, t. xrlU, p. S8S.

• VIrohov's ArohiT, IStS, Bd. 133, Heft 3.

> See a paper by the writer, on oases of myxoedema, eto., In the
Amerloan Journal of Medical Salenoes tor September, 1B83.
u Olted by Oley, Areb. de Phys. n. et p., ISM, p. 187.

Digitized by

Google

164

BOSTON MSDIOAL AS1> SVMGtOAL JOVRHTAL. [Fbbrcabt 15, 1894.

the formation of imall oBTitiM, apparently of Taacnlar
origin, in tlie spinal cord of doga who had ■nnrived
thyroidectomy for a nnmber of months.

The thyroid gland ii fonnd in all vertebrate animals."
It is formed by an invagination of the pharyngeal
wall, and is believed by most embryologists to serve
as a digestive gland, even in the lowest animals where
it exists. I mention this point because a recent
writer ** has proposed the view that its functions are,
in a broad sense, respiratory, and that this is indicated
by its anatomical relations to the branchial clefts. It
is supposed by him that its secretion in some way
assisto the oxygenation of the tissues. I am not able
to say whether there is any real foundation for this
theory or not, but Poehl ** who has for several yean
been studying the chemistry and physiol(^ of spermin,
finds that this, too, has a powerful influence on oxida-
tion, so that it is a constituent, not only of Brown-
S^nard's testicular emulsion, but also of many glands
and organs, and among them the thyroid.

The ^and shows itself at an early period in the homan
embryo and, according to Horsley, it probably begins
its secretory functions by the sixth or seyenth month
of fcBtal life. It is not known upon what principle the
efficiency of the secretion depends ; and the fact that
it remains active after it has passed through the walls
of the stomach, as well as after precipitation by
alcohol, has not as yet cleared up the mystery, though
it indicates that the active principle is a sort of ferment.
The adnlt gland is made up of spaces containing colloid
material and lined with epithelium. It is, however,
doubtful whether the colloid is more than a vehicle
for some more active agent. CerUinly its chemical
structure may ehange somewhat without iu efficiency
being destroyed. It has been clearly shown that when
the gland is injared ^* or undergoes such changes as are
seen in Graves's disease and even in phthisis " there
is a strong tendency to a modification of the gland-
structure, with arborescent arrangement of the tissue,
higher, cubical epithelium and without colloid.^* Yet
myxoedema does not necessarily or even usually come
on under these circumstances.

We cannot say with confidence that the gland thus
altered remains in all respects as efficient as before,
but even a very small part of an altered goitre is
enough to ward oS cachexia of serious amount. A
number of cases are on record, one of which was ob-
served by myself, where goitre with nervous symp-
toms passed over into myxoedema. It is a curious
fact that the outbreak of the myxoedema, in my case,
was attended by an enlargement and hardening of the
altered thyroid, and that these peculiarities diminished
during improvement, and increased again daring a re-
lapse.

Greenfield," who has recently studied the subject,
regards this tendency of the gland to change its strno-
tnre in Graves's disease as an evidence of increased
glandular activity in that affection. But in view of

" Sm W. K. Brooka, Johns Bopkiiu BnUettn, Hay, 1888.

u Aodriecen: Biitlah Medloal Joonwl, 1883, 11, p. 878.

u Beil. Kl. W. sohr. 1888, No. St.

u H«l»t««d and Welob: IHHonlon on Myxoedsma, Transaotioiii
AwoolmtiOD of Amerloan Phjnieluu, 18)13.

Oantsuro: DentiolM Hed. Woeh., 1882, p. 184.

u Defkneamberge, eited br Honley, loo. olt.

u araenfleld (British Hedleal Joornal. Oaaember 8, 1888) w.j» that
the Moratlon In exophthalmic nrftra 8omattB«8 bsoomea maalnoid in
oharaotar. He aaiamea that the diaappeatmnoe o( the oolloid Is doe
to more aotire abeorption aaoomptuiTina aotlTe leeretloo.

Fntnam: The Treatment of Orave*'* Diieaie b; Thyroideotomj,
Journal of Kerroni and Mental DIaeaoeo, December, 1882.

" Oroanlleld : Britlah Medieal Joomal, December 8, li>83. Bee alio
Stewart and Gibson: Brltlih Medical Journal, 1888, il, p. ers.

the fact that a very similar, if not exactly the same
change occurs as a result of injury and disease (phthisii)
the assumption cannot be accepted as certain. The
fact that this change oocnrg after removal of part of
the gland (Halstead) suggests that it means increased
activity, but in Caniazero's experiments the gland was
injured but not mutilated, yet a similar change occurred.

Another fact, which is important in this same connec-
tion; is the following : It was at first thonght that rab-
bits were less susceptible than the carnivorous animals to
the bad effects of thyroidectomy ; but the regearches of
Gley showed that their survival after operation was dae
to the fact that in these animals (and, as it seemg, in
many others as well), besides the main body of the
gland, accessory glands or "glandules" are present
which had commonly been overlooked when the mun
body of the gland was removed. The literatare of the
" glandules " is already a large one, and I will here
refer to only one point concerning them. These
glandules have an embryonic structure ; and although
they grow larger after removal of the thyroid and to
some extent seem to ward off the threatening cachexia,
yet their strncture does not necessarily change to that
of the adult gland.*'

If this observation is correct, the statement which
has been made that the embryonic nodules found even
in the adult human thyroid (Wdlfler) develop nnder
certain conditions into a more highly differentiated
structure, may need revision.

Although it has been proved that the myxoedema-
touB cachexia does not occur after partial thyroidectomy,
provided about one-quarter of the gland is left behind,
yet it is not to be assumed that even this incomplete
removal of the gland is of indifference as regards the
nutrition of the organs and tisanes of the body. This
is a subject of practical interest, and some important
experimental evidence has been brought forward in
remrd to it since Horsley's paper was written.

It has been found that the preservation of the
glandules of Gley, though it usually prevents the
worst forms of cachexia, does not prevent the gradual
development of a series of changes affecting the bones,
the skin, the ovaries, and many other organs, especially
if the animals operated on are young (Hofmeister,'*
De Quervain). Gley and Rochon-Duvigneaud *° have
recently studied with care a serieg of changes occurring
in the eye, under these same conditions. The practi-
cal question is this, To what extent most the thyroid be
mutilated, or atrophied, or diseased before some of the
nutritive effects due to lack of ,its influence begin to
make their appearance? A partial answer to this
question is perhaps furnished by the fact that there
are disturbances in nntrition, not identical with myx-
oedema but presenting one or another symptom anal-
ogous to those met with in that disease, for which
thyroid treatment seems to be useful. It is needless
to say that this reasoning should be used only with
caution, and that no positive conclusions can be drawn
as to the real value of these preparations, either as
means of treatment or as pointing to a deficiency of
the normal thyroid secretion.

The first person to use the thyroid of animals for
other affections than myxoedema, so far as I know,
was Dr. Barron of Liverpool, who, noting the fact
which must have impressed every one, that patients

u See dlMunlon between Oley and Monuo, Comptea B«ndas,
Soolite de Biologie, 1883.
» FortMhritte der Med.. 1882, p. 81.
» Aroh. de Phys. n. et p., 18»t, p. 101.

Digitized by

Google

ToL. CXXX, No. 7.] BOSTON MEDICAL AND SUBOIOAL JOURNAL.

165

reeovering from myzaBdema frequently lose weight
iritli extreme rapidity, the logg going even beyond the
limit of health in some cases, suggested the employ-
meat of thyroids in ordinary obesity. I am not aware
whether be has continued his investigations or not,
bat in a private letter, received in May, 1893, he
stated that he had used the treatment in five cases,
and in three of them with marked effect.

Acting on this suggestion, I have tried the same
treatment in several cases during the past year, with
the following results : One (Mtient lost 33 pounds in
three months, falling from 270 to 287, but here the
influence of the treatment seemed to cease. When it
iras suspended for a month he regained seven pounds,
which he again lost on resuming the treatment, but I
have not been able to reduce his weight below 237
pounds even by giving fifteen grains of the thyroid
daily. No change was made in his diet or habits.
His general health showed a marked gain during the
thyroid treatment.

A female patient, treated by Dr. Coggeshall, at
the Boston Dispensary, lost 47 pounds in four months.
On the other hand, a female patient of my brother,
Dr. C. P. Putnam, who weighed 240 pounds at the
beginning of the treatment, after losing five pounds
the first week, seemed to be no longer affected ; and I
have had three or four other patients in whom only a
temporary loss of weight (up to fourteen pounds in one
case), or none at all, has occurred. Possibly, larger
doses might have had more effect.

It seems clear from the many experiments which
have now been tried, that healthy persons are not so
easily affected in an injurious way by the thyroid
treatment, though certain symptoms, especially an in-
crease in the pulse-rate, occur with considerable regu-
larity.** It would seem that we do not yet know the
eondidona which make one person a suitable subject
for this treatment and another not so. It will be in-
teresting if it turns out that the loss of weight, even
when it occurs, cannot be made to go on indefinitely.

Another therapeutic use of thyroid preparations is
in the treatment of diseases of the skin, especially in
psoriasis, ecsema, and xeroderma. The first of these
cases was brought forward by Dr. Byrom Bramwell at
the annual meeting of the British Medical Association,
August, 1893;** and the photographs which be there
showed were very impressive. Unfortunately, one of
these cases afterwards relapsed, and not all the more
recent observers have been equally successfnl, even in
their primary results. Dr. Hartley " obtained favor-
able effects, and Dr. Arthur T. Davis ^ likewise,
while Talfourd Jones '* experimented on a case of
psoriasis, with the apparent result of making the dis-
ease spread. Lesley Phillips ** obtained improvement
in a case of xeroderma but none in three oases of
psoriasis and one of ecsema. It may turn out that
the remedy is useful only in a certain class of these
cases, or that it acts indirectly by exerting a psychical
influence.

The history of therapeutics shows that new remedies
sometimes have a mysteriously good effect. It is
highly probable that these effects do not occur through
mere coincidence, and are not wholly to be explained

>■ See, Bmong other papers, Greesfield'a Bradiduiw Leotare, British
Medieal Journal, Deoember 9, 1S9B.
" British Medical Journal.
" Ibid., ISM. ToL U, p. W.
" lUd., p. 474.
* Ibid.. VMt. It.
» IbkL, Hovember, 1803.

by the assumption that the most favorable resolta are
the first to be made pablic The researches of the
past few years have taught at that psychical influences
can be counted upon to affect the nutrition to a degree
formerly not dreamed of, and the effects of the new
remedies must be studied anew from this standpoint.
It is noteworthy that eczema has been favorably in-
fluenced by hypnotism pure and simple, and that good
results have followed injections of testicular fluid in
eczema, leucoderma, icthyosis.*' Ecdes*' has used
spermin in similar cases with favorable effects.

Finally, Yermehren, of Copenhagen, has made an
interesting series of experiments with- thyroid prepara-
tion, in various conditions of impaired nutrition, with
the special view of testing their action on some of the
changes of old age.** He first treated three cases of
myxcadema with thyroids, and gave also measured quan-
tities of food, and followed the urea excretion. This
increased in the course of the first five days in all three
cases, finally reaching twice or three times the amount
noted for the period before the experiments were be-
gun. In one case it then remained at the maximal
point during the continuance of the treatment, so long
as the experiments lasted. In the other two cases it
fell rapidly, after the first rise, but in one of these it
rose again at a later time. A small part of this in-
creased excretion of urea was found to be probably
referable to an increased absorption from the intestine.
The patients also lost fat largely, but the rate of loss
was not estimated.

The non-myxoedematoos patients experimented on
were : (1) A boy of seven years, with fracture of the
tibia ; (2) a girl of seven, greatly emaciated and per-
haps infected with tuberculosis ; (S) a woman of
twenty-eight, with chlorosis and gastric catarrh ; (4) a
man of fifty-two, but very old for his years, with
chronic alcoholism ; (5) a man of sixty, also old for
his years, with chronic bronchitu ; (6) a man of sixty-
two, with varicose ulceration of the leg.

The study of the urinary excretion seemed to the
author to warrant the conclusion that in the cases of
the young persons the only positive effect of the thy-
roid treatment was a moderate diuresis, while with
the elderly patients changes occarred like those seen
in myxoedema, though to a less degree. It is obvious
that more experiments are needed before this conolu-
sion can be accepted as of general significance ; bat it
is certain that slight degrees of myxoedema occurring
in the period of involution are liable to be overlooked.
I have recently observed and shown a patient *° whose
case was perfectly clear on close study, but whose ap-
pearance alone would not have attracted notice as ab-
normal. The case of an elderly gentleman recently
described by Dr. F. C. Shattuck, is important in this
connection, and not less so for illustrating the liability to
the persistence of the ill-effecU of thyroid medication,
— when such effects occur at all — long after the treat-
ment has been stopped.

THEBAPEUTIC ACTION OF OTHER OBQANIO BXTBACTS.

It was impossible that the wonderful discoveries
with regard to the effects of thyroid extracts in myx-

" Honnet : Journal of Ontaneow and Qenlto-Urinary DUeuai,
Tol. Iz, 188S.

» British Medical Joomal, 18SS, Tol. ii, 4T4.

» StoffweohsclnntersacbiuiEeii oaah Bahandlang mit Olandnla
Thjrroidea an IndlTidnen mft n. ohne^yxcBdema, Denteohe Med.
WoCh., I8t4. See also, in thJi oonnectiOB, Ord and White, British
Medical Jonmal, July 28 and Deoember 9, ISS3.

*> Boston Medical and Surgical Journal (Society tor Medical Im-
proTement), 18S4.

Digitized by

Google

166

BOSTOJf MEDICAL ASD SUBGJOAL JOUSSAL. [Fbbruabt 15, 1894.

aedema shoold have failed to renew the intereat in the
use of the other organic extracts (of teiticle, brain,
tpinal cord, etc.) saggeated by Brown-S^qaard and
D'Arsonval,*" by Babes,** and by Althans.**

The subject is large enongh for a whole evening's
discussion, and I cannot pretend to do it justice here.
The many observers who have obtained good results
from these remedies bring forward an astounding and
impressive array of facts in support of their view.
Poehl** shows that similar results may be obtained
with his tpermin, a definite compound obtained from
the testicles and the ovaries, and from other glands as
well, and adduces evidence that a part of these results
are due to increased oxidation occurring under special
conditions. It is obvious that all these observations
are not to be treated with ridicule, and especially not
from an a priori standpoint.

What one may and must say, however, is this, that
the case for testicnline and cerebrine and myeline in
neurasthenia and tabes, and the like, rests on a wholly
different basis from that of the case for the use of thy-
roid in myxoedema. It is not as if we were attempt-
ing to cure by injections of spermatic fluid a series of
clear and invariable results following castration, though
this would be a highly interesting and important ex-
periment. It is a much more diflScult matter to decide
whether the improvement which takes place in various
diseases, even diseases characterized by gross structural
changes, like locomotor ataxia, is due to the remedy
whi<£ has been given.

Explain the fact as we may, the value of all but the
clearest therapeutic experiments is enormously vitiated
by the fact that mental influences which we cannot
^uge are capable of profoundly affecting the result.
The powerful phantom of suggestion stands behind the
physician's chair, unseen both by him and by the pa-
tient, and the influence of the unwelcome intruder is
often increased by the very effons that are made to
exorcise him. Altbaus, the latest experimenter, re-
cognises this general fact, but thinks that hia observa-
tions are free from suspicion on account of the intelli-
gence and mental balance of his patients, and because
no attempt was made to impress their imagination.
But, the very use of this reasoning indicates a failure
to grasp the true significance of the ducoveries of the
past few years as regards the relation of psychical in-
fluences to nutrition. It is not necessary that the pa-
tient's imagination should be impressed, in order that
results may be produced due to what — for lack of a
better name — we must call " suggestion." In hyp-
notic suggestion the imagination can hardly be said to
enter as a factor at all ; and even in the many forms
of waking suggestion, there is often no conscious
stimulation of the imagination. It is, of course, not
always easy to say why one drug or treatment should
have a markedly greater effect than another ; but two
causes suggest themselves as often effective. One is
the influence of the physician's own feeling of hope or
interest, which be may try in vain to conceal,** and by
which the patient may easily be impressed without
being himself aware of the fact ; the other is the influ-
ence of an interest previously stored in the patient's

« Arch. Physiol, norm, et path., tor the put threo jttn ; OomptM
Bandns 800. d« Blol. ; British Medtoal Journal, June, IMS, ate.

M Conttuitin Paul, Soo. de Th&-apaatiqae, Senlon of February 24,
ie»2.

» Lanoet, Deeember 2, 1893.

M Berl. UlD. Woah., 1891 and 1S93.

» The obserratloiu on " maaole-readtiic " shoold be borne In mind
in this oonneotion.

mind by hearing or reading of the remedy or the
method, but perhaps wholly forgotten so far as con-
scious memory is concerned. The phenomena of
" crystal vision," and a host of kindred facts show how
potent such " forgotten " cerebral impresaions may
continue to be. Within certain limits these inflaencei
would be all the more active if the patient was intelli-
gent and a person of wide reading and quick instincts
of observation.

The admissibility, to say the least, of this explana-
tion of the action of injections of organic extracts is
shown by the success which has attended the substitu-
tion, under certain precautions, of inert fluids for the
testicular or nerve extracts. A large number of control
experiments of this sort have been made by other
observers,** and one or two by myself.

One general fact is noteworthy in connection with
this branch of the subject, and that is that cures of
tabes or locomotor ataxia are perhaps more numerous
than any others except neurasthenia, it is, now, well
known — in spite of Charcot's " Quand on gn^rira le
tabes it fera chaud " *' — that amelioration of some of
the symptoms of locomotor ataxia has been brought
about, here and there, by several different remedies,
such as suspension, injections of phosphate of sodium,
and by hypnotism (Moll) as well as by the organic
extracts. Moreover, it was noticed long ago, by West-
phal and his colleagues, that in cases when the lesions
of tabes were combined with those of cerebral degen-
eration, the ataxia of motion was apt to be much less
prominent than where the mental condition was sound.
Finally, it is well known that the symptom of pain is
pre-eminently susceptible to hypnotic and to waking
suggestion ; and that persons in a state of somnambu-
lism exhibit an unusual fineness of muscular sense, or
sense of position.

It is admissible, I think (though, of course, not
obligatory), to read the signiflcance of these facts as
follows : that patients with locomotor ataxia are better
subjects for psychical treatment than patients with
many other an^ogous forms of disease, because (1)
their pain is susceptible of relief in this way. and (2)
the aggravation of their ataxia coming from misdirected
conscious efforts can be relieved by influences which
shunt out the consciousness of their disability in a
measure. Perhaps the relief of these symptoms tends
also towards a real nutritional improvement in the
nerve-centres. Certainly, the reverse is often true,
namely, that organic lesions are unfavorably affected by
the influence of the symptoms to which they give rise.

Locomotor ataxia seems, again, to be one of those
affections where the symptoms may subside ip spite of
the persistence of the lesions, provided (probably) that
the disease is not actually progressing. The important
case, with autopsy, by F. Schultze *' published in 1882,
affords strong evidence for this view.

My own experience with the testicular and cerebral
extracts extended over about a year, during which time
I used the injections in a good many cases, but only
in nine or ten with a persistence to justify a use of
them for clinical inferences. These cases comprise
three of locomotor ataxia, and six of what I nuay call,
with sufficient accuracy, neurasthenia. Besides these

M Hassalongo : Le Injedonl di Liquids Testlo. dl Brown-S^nard,
etc., un NaoTO Capltolo di Therapeotioa Snggsstira. Kltorma Med.,
February, 1893.

Stookwell : Medical News, Angnst 26, 1883.

» Qauted by Althans. loo. olt.

- Zor Prac* T.d. Heilbarkelt der TidMS, Aroh. fUr Psyoh. n. N.
heilk., vol. iu, p. S3S.

Digitized by

Google

Vot. CXXX, No. 7.] BOSTON MEDICAL AND SVROIOAL JOURNAL.

157

I have the notes of the treatment of a case of chronic
myelitis which Dr. Coggesball kindly allovs me to
report with the rest. I have also, as a control experi-
ment, treated, for about a month, a case of locomotor
ataxia by the injection of a simple mixture of glycerine
and water. Daring part of the time I used testicular
flaid obtained from Paris through the kindness of Dr.
Brown-Sdqnard, but the greater part of the extracts
were made at the Pasteur Inscitute of New York. The
habitual dose was about two or three grammes. In
their naost recent publications Brown^S^quard and
D'Arsonval advocate a dose larger than this.

The summary of the results of my own experience
is as follows : In one of the tabetic cases an ap-
parent improvement was shown, not only in a most
gratifying general gain (by relief from pains and in-
crease in strength), but also by the apparent cure of
one of the gastric crises. The subsequent history of
this patient is, however, very significant. At a later
period injections of glycerine and water seemed, also,
to help him very much, but after this even testiculine
failed to prevent a rapid prostration. Another tabeUc
patient who was treated with testiculine for about a
year, with gain as regards relief of pain and general
sense of well-being, was attacked with tubercular lar-
yngitis towards the end of this period, and shortly
afterward died. This is noteworthy because Dr. Brown-
S4qnard has claimed that tuberculosis also is favorably
influenced by the remedy. The third patient thought
* bis pain relieved, but there was no marked or perma-
nent improvement in the course of two or three months
of treatment.

In Dr. Coggeshall's case of chronic myelitis, the pa-
tient received three injections of three to four grammes
each, of testiculine, every week, and at the end of seven
weeks had gained greatly in every respect. In this
case there was a history of syphilitic infection fifteen
years before, and the final symptoms were of nine
years' duration. Under the injections the improve-
ment began at the end of two weeks. After five weeks
of treatment there was a marked gain in power of
muscular endurance, a gain of weight of four pounds,
an increase of half an inch in the girth of the calves,
and of one inch in the girth of the thighs. The grasp,
as measured by the dynamometer, increased from 60
to 110. Unfortunately, even while the treatment was
still in progress, the patient began to relapse, and had
soon gone back nearly or quite to his earlier state.

As an offset to these cases, I will briefly report the
case of tabes treated by injections of glycerine and
water. The patient was a married woman about thirty
years old, and there was reason to think that she had
been inoculated with syphilis by her husband. The
tabetic symptoms, which were of several years' stand-
ing, consisted in severe characteristic pains ; ataxia of
both arms and legs ; Argyle-Robertson- pupils, with
irregularity in outline ; loss of the knee-jerk ; and im-
purment of control of the bladder. I had intended to
treat her with testicular fluid, and gave one injection
for that purpose. At the next visit, however, happen-
ing to be out of the fluid, and not wishing to disap-
point her, I gave an injection of glycerine and water.
At the oext visit she was better, and so I thought I
would continue the glycerine and water, experinwnti
emud. This u now two months ago, and she has con-
Unned steadily to improve in most respects. The
ataxia of the bands is no better, but the gait has im-
proved so much that, whereas at first she had to bring

a companion with her, she now comes alone. The
pains, also, have left her, and in her general health and
feeling there is a distinct gaiii.**

Of the six neurasthenic patients who remained un-
der treatment long enough to make their histories of
value, three were men, three women.

Of the men, one was a gentleman past middle life,
eminent for scientific training and powers of observa-
tion, who had been for some little time in a nervously
debilitated condition, owing to stress of work and other
causes. The injections were begun by Brown-Sequard,
and continued for a time by me, eventually by himself.
The treatment was marked by steady improvement,
and ended in complete recovery.

The second case was that of a typically neurasthenic
patient, an intelligent physician, rather below middle
life, and of good nutriiion. The symptoms consisted
mainly in an incapacity for application without great
mental effort and distresB, so that steady work, espe-
cially of a literary kind, was well-nigh impossible.
Temporary improvement of a very marked sort oo-
curred during the first week of the treatment, and
recurred to some extent when the treatment was re-
sumed after an interval of cessation. In the end, how-
ever, in spite of thorough and persistent efforts, no
permanent benefit was obtained.

With both of these cases one interesting symptom
showed itself a few times, when the treatment was first
begun, namely, a tendency to erections on the night
following the injections. This has been noted also by
other observers, but is not regarded as due to the
specific character of the fluid, and does not, it would
seem, imply that the treatment is especially effective
against impotence. In one case of this sort, of purely
neurasthenic character, a few injections bad no effect.

The third case was that of a young man in a typi-
cally neurasthenic state, with morbid fears and marked
loss of endurance, due, apparently, to sunstroke. The
improvement was steady, but as it had begun before
the injections were used, under the influence of encour-
agement, electricity, etc, and continued after the ces-
sation of the injections at the same rate as before, I
did not feel that a large share of the result was to be
ascribed to them.

The first of the female cases was that of a young
girl with infrequent attacks of epilepsy, and great de-
bility. The improvement during the use of the injec-
tions was very great, as regards the debility. The fits
were too infrequent to warrant conclusions about them.

The second case was that of a lady past middle life,
in a condition of slight mental deterioration of unknown
origin. The use of the injections, which were faith-
fully given for many weeks, afforded her encourage-
ment, but brought no real improvement.

The third patient was a woman with mild hysteria,
or neurasthenia with hysteroid symptoms of sensory
character. Not many injections were given, but after
each one she felt distinctly better. In this case the
gain was undoubted, but a similar gain and one equally
great fcdiowed each of many applications of static elec*
tricity, and I was inclined to attribute it in both cases
to the encouragement attendant on systematic treat-
ment.

I do not maintain that these few observations are in
the least conclusive in either direction ; but while it is

•• Some montba have paued since this itateinent was written, but
I hare not seen tba patient thii winter, and do not know ber later
history.

Digitized by

Google

168

BOSTOlf MSDWAL AND SUSGIOAL JOURNAL. [Pebboaet 15, 1894.

true that all which has been claimed for the organic
extracts may have been claimed with jastice, yet it
should not be forgotten that the claims of hypnotism
in similar lines are equally far-reaching, and that what
hypnotic suggestion can accomplish it is also possible
for waking suggestion to accomplish, under sufficiently
favorable conditions.

I will now ask your attention to the consideration
of another class of affections associated with diseases
of the thyroid, those namely, of which Graves's disease
may be taken as an extreme type.

This subject is not yet ripe enough for definite con-
clusions ; and a discussion of the points involved, to
be adequate, would necessarily be long. I shall there-
fore content myself with referring to a few prominent
considerations.

In the first place. What is the probable relationship
of goitre to the other symptoms of Graves's disease ?
The following answers, no one of which seem to me
wholly satisfactory, have been offered in reply to this
question ;

(a) Graves's disease is made up of a collection of
conditions, part of which are due to the irritation of
nerves ramifying in the enlarged thyroid or lying near
it, while part are due to an altered thyroid secretion,
which acts as a poison. The cardiac symptoms may
also be in part explained by disturbance of respiration,
as in ordinary goitre.

(J>) The whole symptom-complex of Graves's disease
is of toxic origiu, and due, directly or indirectly, to an
increased amount of thyroid secretion or an alteration
of its quality.

(e) Thyroid enlargement has no causal relation to
the other symptoms of Graves's disease, but like them
is due to a disturbance of the nervous system, the
exact seat of which is unknown, but which probably
consists mainly in a disturbance of some of the func-
tions of the meduUa-oblongata.

(d) Finally, the enlargement of the thyroid may be
partly a cause, partly a symptom of the Graves's dis-
ease complex.

Without attempting to take a positive position in
favor of either of these views I will call your attention
to a few salient facts.

(1) Quite a large number of cases have now been
published in which the partial removal of the enlarged
thyroid has led to great improvement and even cure of
Graves's disease. I have recently collected fifty-one
cases of this sort, in all but a few of which, substantial
improvement was obtained by operation. Since I
made my collection still others have been reported.*"
At the same time, the results have not been uniformly
good. A case which I have carefully followed was
operated on by Dr. J. C. Warren nearly a year ago,
and of late even the remnant of the thyroid has nearly
disappeared. Nevertheless, the improvement in the
patient's condition, though satisfactory in some respects,
has not been marked by any permanent change in the
exophthalmus or the uchycardia.

(2) Although typical Graves's disease is not com-
mon in goitrous districts, yet it is common for patients
with ordinary goitre to suffer from some of the symp-
toms of Graves's disease, especially dyspnoea, palpita-
tion and dysphagia. (Mueller,** Maude, Wette,**

« Mainly collected by MoBbiun (Schmidt's Jabrb., 1893). See alio
Maude: Lancet. 18ii3. 11; Freiberg: Medical News, August 2<t, 1893.
<i Dealjcbes Arcb. fur )l\\i\, Med,, 189;i.
« Arch, fttr klin. Chir., 1892, vol. 44.

Schranc,** etc.) It is in fact for these symptoms that
patients with goitre usually present themselves for
operation, and it is not difficult to give a fsirly satis-
factory explanation (Wette) of the way in which the
enlargement of the thyroid might lead to them. The
following condidons are often met with ; (a) PaUeots
with large thyroids, without other symptoms of any
kind ; (h) patients with large thyroids and symptoms
referable to the respiration and pulse. Occasionally
slowing of the pulse is seen (Wette) ; («) patients
with these symptoms, and in addition, perhaps, ex-
ophthalmus and some general nervous disturbance;
{d) the same, with the addition and other disturbances
frequently met with in connection with Graves's dis-
ease.

(3) Some of the symptoms of Graves's disease are
occasionally excited by some cause apparently wholly
independent of the thyroid. This is true, for example,
of exophthalmus, which seems to be sometimes due to
disease in the nasal cavity and to sympathetic irrita-
tion.

(4) Graves's disease sometimes comes on with great
rapidity under emotional excitement, so rapidly that
it hardly seems possible that the thyroid secretion
should have become increased, although it might have
become altered in quality.

(5) There is no good reason for characterizing
Graves's disease as a cachexia.

(6) The Graves's disease complex strongly suggests ,
the symptoms met with in conditions of extreme ex-
citement, as in fear or in anger, that is, it occurs as a
quasi-physiologioal complex.

(7) Operations on goitres are sometimes followed
by sudden death or by extreme disturbance of the heart
and respiration; and no satisfactory explanation for
this has yet been given, though several of great inter-
est and importance have been suggested. One that
has not been suggested, so far as I know, and which
may be worth considering is, that if a large amount of
thyroid secretion is poured out from the cut surface
of the gland into an open wound it must be rapidly
absorbed. Against this view, however, is the fact
that these serious symptoms do not always occur.

(8) Improvement may be brought about in cases of
Graves's disease by various influences, both general
and reflex, tending to quiet a disturbed vascular excite-
ment of the gland or of the heart.

(9) The symptoms of Graves's disease bear a certain
resemblance to the nervous symptoms of the first stage
of cachexia strumipriva. But this resemblance is not
a close one, nor is the contrast which has been sug-
gested as between myxcedema and Graves's disease,
more than superficial.

(10) Although the histological characters of the en-
larged gland in Graves's disease are altered, and the
secretion of colloid is apparently deficient, yet the re-
moval of the greater part of such a gland does not
lead to myxcedema.

(11) On the other hand, myxcedema occasionally
follows Graves's disease in the same patient, or the
two diseases are seen indifferent members of the same
family ; and in the same family ordinary goitre may
be met with.

We have no right to assume that goitre was the
original cause of the symptoms which are cured
through its removal.

The recent view that the symptoms of Graves's

o Ibid., 188«, vol. 34.

Digitized by

Google

Vol. CXXX, No. 7.] BOSTON MSDIOAL ASD SUttGIOAL JOtmtfAL.

169

diieaie are dae to excess of thyroid secretion, altbongh
supported by some evidence, has not been fully estab-
lished, and is strongly controverted by a recent case in
which the disease was cured by sheep thyroid taken
by the stomach.**

THREE CASES OF SALPINGITIS OF UNUSUAL
EXTENT.*

BY MAUKICB H. KICHAKDBOS, M.D.

Bb-

I. DoDBLB Pto-Salpixz ov Tubkbcclab OKiatM

MOTAi.; Bbcotkbt.
n. DouBLB PTO-SAiraix, Pbobablt Tubbhculab ; Bb-

iiovAj.; Local PJcbitokitu; Bbcotkbt.

ni. DovBLB Pto-Salpixx ot Sbptic Obioin; Bbmoval;

Dbath.

Thk following cases are unusual because of the
extraordinary size of the tubes. They are interesting
also from their etiology. In the first case the question
of diagnosis was a conspicuous feature ; the tumors,
from their sise and apparent solidity, with their in-
timate connection with the uterus, having deceived
every one who examined them. Apparently the growth
was a lobnlated fibroid. The diagnosis seemed so clear
that a sonnd was not put into the uterus ; yet it does
Dot follow that because a uterine sound doea not enter
ao abnormal distance that the uterus is not enlarged.
In the second case the diagnosis was easy. The source
of the trouble, however, was not so clear. It was im-
possible to exclude a tubercular element in this case.
The possibility of an infection through the uterus was
also considered. Whatever may have been the cause
in this instance, the great size of the tubes, their
outline and their situation made the case one of un-
nsnal interest. In the third case a history of a direct
infectioa through the vagina and uterus made the eti-
ology more positive. The methods used and their
results justify certain oonolusions of value to me in the
fature management of similar cases.

Case I. N. Q., aged twenty-four, single. Entered
the Massachusetts General Hospital July 5, 1892.
There was a family history of consumption. The pa-
tient has never been sick. One year ago she began to
have pain in the back, which of late has been less
severe than at the first. For some time she has noticed
a swelling in the lower abdomen on the right side.
Of late the pains have been referred to the thighs and
have been sharp and shooting. Catamenia regular
ddUI last month, when they were absent. She had
always had dysmenorrh<Ba. There has been a slight
vaginal discharge. She has lost thirty pounds in
weigh^ in the last year. Her appetite is gooid. Urine
nohnid. She is not confined to the bed.

Below the umbilicus the abdomen was enlarged,
and contained a mass about the size of a six months'
foetus, with two prominent tumors. The mass of both
tumors was somewhat to the right of the median line
and was slightly tender and movable. The uteras
moved with the movements of the tumor. The uterine
Mund was not passed. A large mass could be felt
io the posterior cul-de-sac. She was examined by
Mveral of the staff, and the diagnosis of a uterine
fibroid was made. Thia case was carefully studied
DDtil the 15tb of July, when a median laparotomy was
performed. As soon as the abdominal pressure was

■ Btad \Mtvn tbe Obstotrieal Sooiaty of Boston, Deoember 9, 18S8.

' Ovan: Brittah UadtoiU Journal, Uas, U, p. ISll.

relieved by delivery of the tumors, both stood upright
in tbe wound, presenting the very extraordinary ap-
pearance of two convoluted masses, perfectly sym-
metrical, attached one to each cornu of the uterus,
like enormous spiral horns. Both tumors extended
deep into the pelvis and were attached by adhesions so
easily separated that the continuity of the tubal wall
was not broken. The peritoneum was studded with
miliary tubercles ; — tubercular salpingitis was evident.
The patient made an uninterrupted recovery. A small
portion of the omentum was removed for microscopic
examination.

Dr. Mallory's report is as follows : Nodules miliary
tubercles. The tubes are eighteen and nineteen centi-
metres in length, circumference twenty-four centimetres
eaoh, weight one oaid one-half pounds tach. Thin
walls filled with thin, greenish-yellow pas ; peritoneal
surface studded with gray miliary tubercles.

The patient came to the hospital to have this opera-
tion performed so that she could get married. I dare
say that she has carried out this intention. This case
is an extraordinary one from the great size of the
tumors, and is interesting from the difficulty met with
in diagnosis and from the glaring error made by every
one. Tbe necessity for the operation was apparent,
even with tbe incorrect diagnosis of fibroid. The
shape of the tumors was characteristic of the large
dilatations of the Fallopian tubes. The great lengthen-
ing of the tube which accompanies the increase in
lumen gives a spiral shape to the tumor. This ap-
pearance was well marked in the other cases. As a
rule the distal end of the tube becomes rounded and
projects into the pelvis, where it becomes adherent.
In the present instance the enormous double enlarge-
ment was so great that the pelvis could not hold the
mass. The tumors were not so deeply attached and
firmly adherent as in Cases II and III. Separation
was therefore accomplished so easily that no fluid
escaped.

Casb II. Massachusetts General Hospital, August
26, 1898. Eunice G., aged twenty-six, married five
years ago, has always been well. One miscarriage
four years ago. Catamenia have been irregular, sev-
eral periods having been missed without pregnancy.
Four years ago, after being sick in bed with pain in the
right side, the doctor lanced an abscess in the vagina.
A year later a lump was noticed in the right side of
the pelvis which has lasted ever since. Two weeks
before entrance, she was taken with chills, fever and
great general tenderness.

General condition poor ; facies " peritoneal " and
anxious. Marked swelling in the lower abdomen over
right tube, with increased resistance and ill-defined
dulneas. Great tenderness at this point ; whole abdo-
men somewhat tender. Constitutional symptoms severe.
By vagina a bulging mass was felt on both sides of the
uterus, which was firmly fixed in the centre.

The question of supra-pubic operation presented
itself. The fluctuating tumor felt by the vagina invited
drainage in that direction ; but the unsatisfactory results
that follow vaginal and rectal drainage in pelvic
abscesses; the brilliant recoveries which take place
after abdominal section, with the immobility and sharp
definition of the tumor that presented in the abilomeu,
decided me to take the abdominal route.

In the extensive tubal disease found in this case ab-
dominal section is much better than vaginal drainage,
in my experience. Recovery is much more rapid and

Digitized by

Google

160

BOSTON MXDICAL AND SUJtGtCAL JOV^NAL. [Fibhdirt 16, 1894

complete. Moreover the mortality is do greater, con-
■idering the complicatioDS that may attend the pro-
longed convalescence of the latter method, the insoffi-
ciency of the drainage at times, and the not infrequent
involvement of the bladder. To have seen a few
women slowly waste away and die after the failare of
rectal and vaginal incisions, to have seen the greatly
increased dangers and difficulties of the abdominal
operation after the failure of the vaginal, to have
watched the progress of intestinal, vesical and other
fisiulae — to have seen a few of these deplorable con-
ditions, makes one hesitate in adopting the so-called
safe operation of dependent (always septic) drainage.
Not that vaginal drainage should never be employed.
It can do no harm when an abscess is clearly pointing,
for, by the supra-pubic, rectum drainage will have to
be established, and probably vaginal also. Bot in
conditions in which complete extirpation of the dilated
tubes and their contents is possible, there is no argu-
ment of weight in favor of the vaginal, much less the
rectal incision.

On the 28th of August a median incision was made,
with the patient in the Trendelenberg posture. The
abdominal cavity was thoroughly protected from possi-
ble extravasations by means of gauze barriers. The
light tube was found to be as large as two fists, and
everywhere adherent. The whole tumor was freed
from its adhesions and delivered from the abdominal
wound. The uterine attachment was tied clode to the
uterns. On the left side, also, a tumor was found —
not quite so large as the one in the right. In free-
ing the adhesions on this side the abscess was rupt-
ured, and at least four ounces of what seemed to be pus
escaped. In spite of every precaution, the intestines
were somewhat contaminated by this fluid. The tube
was delivered and tied near the uterus with silk. The
contents of this tnmor, like that of the right, seemed
to be purulent. It was greenish-yellow and odorless,
thick and tenacious. The intestines that presented
were carefully wiped with sterile gauze ; the abdom-
inal wound was closed without drainage.

The patient's temperature rapidly fell to the normal
line, and she improved very much. In the course of
a few weeks, however, she began to get hectic. A
mass could be felt both by vaginal and by abdominal
palpation. I was on the point of incising the posterior
cul-de-sac several times. Finally, however, there was
an abundant discharge of pus with a small piece of
gauze from the rectum. Through this spontaneous
opening the finger could be introduced into an abscess
cavity situated behind the uterns. The convalescence
from this time was steady, and she is now in excellent
condition.

The dangers by the intra-abdominal method of treat-
ment in cases of this kind may be very great. Safety
to the patient depends upon causes beyond the control
of the surgeon, if he selects this route. It is beyond
human skill in many cases of this kind — in which
the tubes are enormously dilated and presumably ad-
herent, to remove the tumor without rupturing it.
Notwithstanding all precautions, the extravasated fluid
will contaminate the peritoneum more or less on all
sides. In spite of irrigation, of wiping out with gauze,
of thorough disinfection — of every thing that we can
do in those instances in which the fluid contains the
more septic micro-organisms — the dangers of a gen-
eral and fatal peritonitis are very great In this case,
the abdominal wound was closed. We knew nothing

as to the septic or aseptic qualities of the fluid when
the peritoneal cavity was sealed. We were very for-
tunate, therefore, that there was not a general septic
peritonitis and death. The accidental presence of the
gauze would have had nothing to do with the sepsis in
the absence of a septic element pre-existing in the fluid,
for I have often left gauze-padding much longer than
this without symptoms. Unless we can demonstrate
on the spot, by some of the rapid methods of stain-
ing micro-organisms, the absence of these bodies, we
have no right at present to close the abdominal
wound. We must give the patient the benefit of the
doubt, and provide for drainage in every instance.
Not that drainage is sure to prevent a general septic
infection — it will not do this invariably ; but if by
means of tubes or of gauze, or of both, the toxic pro-
ducts of germs can be removed as fast as they form,
the prospect of recovery is much better.

Case III. Sarah H., aged forty-five. Boston.
Admitted to the hospital October 1, 1893. Menstrna-
tion regular, slightly painful, not profuse, for thirteen
years. Married twenty-seven years ago. No chil-
dren. Second marriage four years ago. No children.
Pregnant once at nineteen, and some sharp instrument
was nsed to produce abortion. Has never been free
from pelvic trouble since. During the last twelve
years has had various disorders — pneumonia, conges-
tion of the lungs, nervous prostration, eta Last sum-
mer a tnmor was discovered in the left ovarian region.
Six weeks before entrance to the hospital, while doing
her housework, during her catamenia, pain to which
she had been subject off and on for years, became
worse than usual, and she had to go to bed. In the
coarse of two days an ulcer broke in the womb, and
thick, greenish matter escaped. Has been in bed ever
since. There have been severe spells of vomiting,
lasting a day at a time. Micturition has been frequent
and difficult. Yesterday and to-day has had chills and
fever for the first time.

Face pale and pasty ; valvular disease of the heart ;
abdomen very fat, and somewhat tender all over, espe-
cially above pubes and to the left, where a round mass
about the size of two fists or larger, dull on percussion,
could be indistinctly felt. In addition to the tumor
on the left, another could be felt less distinctly on the
right ; both were fluctuating, and seemed unattached
to the abdominal wall.

At my first examination (without ether) it seemed
to me that the operation would consist simply in inci-
sion and drainage, either through the abdominal pari-
etes, to which the tumor on the left seemed then
adherent, or through the vagina, or by both«routes.
As soon as the patient was etherized, however, the
unattached condition of the tumor on the left and the
presence of another on the right could be clearly
demonstrated. I therefore made the median incision,
the patient having been prepared for laparotomy.
The right tube was enlarged to about the size of two
fists, or a little smaller; it was adherent deep in the
pelvis, but not attached anteriorly. The adhesions
were separated carefully, and the whole mass was
delivered without rupture. A ligature was applied
does to the uterus; and the whole tnmor removed.
There was no escape of fluid during this procedure. The
left tumor, which was considerably larger than the
right, was next isolated, as far as possible, by separating
the recent adhesions. The undelivered extremity of
the tube, pointing downwards and forwards to the left

Digitized by

Google

Vol. CXXX, No. 7.] BOSTON MBDIOAL ASD SUBOIOAL JOUBNAL.

161

of Donglaa poach, was so intimately adherent in the
dq>tbs of the pelris, that I found it impossible to sepa-
rate the mass without rupture. There was a very
Urge escape of foul fluid, apparently pus, which con-
taminated everything in the vicinity. All the intes-
tines and the lower part of the abdomen were bathed
io this fluid, in spite of all efforts, either by the inter-
position of gauze barriers or by rapid irrigation. The
pelvis was cleaned as carefully as possible, by the use
of both boiled water and sterile g^auze. A small gauze
drain was placed in the pelvis, and the incision was
closed with silkworm^ut sutures. The operation was
a very rapid one, but the amount of shock following
was considerable. Her condition, however, which even
before the operation was very serious, slowly im-
proved. There was no vomiting.

On the following day there was moderate staining
from the drain. The temperature and pulse steadily
roae. Salines were given in drachm doses every hour.
On Monday, the 9tb, the bowels moved freely. Large
quantities of gas also were passed. Her condition was
very poor, and steadily getting worse. There was no
pain in the abdomen — which was distended — and no
vomiting. Her general conditipn was very bad. Dur-
ing the day she gradually failed, and died early on
Tuesday morning.

This operation differed in no respect from that in the
preceding case, except in that the patient soon showed
evidences of septic absorption. Though a general
peritonitis did not develop, yet there was sufficient
poison in the localized peritonitis that did follow to
produce a fatal septicsemia. An examination of the
flaid showed the presence of the streptococcus py-
ogenes, with some of the less virulent micrococci.

This case shows the importance of early opera-
tion in Sonne forms of salpingitis. While in the first
case the symptoms were in no way so severe as would
be expected in tubercular abscess, yet in the second
there were more or less serious constitutional disturb-
ances. Bat even in the second case there were no
elements present which were likely to produce serious
local or constitutional disturbance. In the third case,
on the contrary, there was a mass of fluid likely at
any moment to break into the peritoneal cavity, and
to virulent in its micro-organisms that death followed
in less than three days, through the local infection
alone. Her extreme prostration undoubtedly opposed
but feeble barriers to the septicemia, and death in spite
of free catharsis was probably due to a very moderate
absorption.

It is an interesting question to differentiate these
conditions, and it does not seem especially difficult to
do so in the later stages. Unfortunately, in delayed
cases, the prognosis is much more serious. It does
not seem reasonable to allow tumors of the Fallopian
tabes to attain such a size as these specimens show
— no matter what the cause of the process may be.
The operations for the removal of tumors may not
be especially hard. They may present, of course,
great difficulties ; — their removal may even give rise
to some of the gravest emergencies in surgical pro-
cedures. But the chief danger in the late operation
lies in raptare of the dilated tube with unavoidable
peritoneal infection. Though in none of the above
eases were the adhesions impossible of separation, yet
the tumor might have been so intimately attached
that enocleation wonid have been out of the question.
Not infrequently the bowel has been torn open in

forcible attempts at separation. In early extirpations,
most of the above dangers are avoided.

These cases certainly indicate a much earlier oper-
ation in salpingitis than was performed. If we can
demonstrate, by bimanual palpation, the existence of
tubal inflammation so extensive that there is no reason-
able hope of cure, either by natural processes or by
drainage through the uterus, then we ought to interfere
surgically in every case in which there is no contra-in-
dication in the condition of other viscera. Not only by
the experience gained in these cases, but also by that
met with in much less extensive forms of salpingitis,
am I inclined to favor early interference when the
tubes are distinctly diseased. I would not advocate so
severe an operation as an abdominal section, however,
unless the progress of the disease was distinctly un-
favorable ; unless the local evidence was marked ; and
unless, under palliative treatment, there was no distinct
progress toward permanent disability. The results in
my operations for this disease have all been, almost
without exception, very gratifying when recovery has
followed. In the third case reported, and in another
similar one drained some years ago by abdominal sec-
tion, death took place. All the others recovered.
The number is not great, — probably not over fifteen or
twenty. I would not be willing to say that the mor-
tality is nU; still in cases that have not advanced to
any great degree of local or general infection, I regard
it as 80 inconsiderable that the outlook — not only for
immediate, but for permanent cure — is very gratify-
ing.

The prognosis in uncomplicated cases in which the
tubes are not greatly enlarged an^ can be tied and re-
moved without infecting the peritoneum, is very much
like that after removing the appendix in the interval
between attacks. The operation is very similar, and
the danger of haemorrhage or infection not unlike.

In all cases of pyo-salpinx, as well as in all cases of
suppuration elsewhere in the abdominal cavity, exces-
sive care is necessary in the evacuation of pus, or of
what seems to be pus. In many instances the fluid
contained in the Fallopian tube is sterile, but it is clearly
impossible by the naked eye to tell whether a given
fluid is septic or not. Our techniqne must be so carried
out that all contamination shall be avoided as far as
possible. In hospital as well as in private practice,
it is extremely desirable to have slide preparations
examined on the spot by an experienced bacteriolo-
gist, while the process of cleansing the abdominal cav-
ity is going on ; for the method of treating the wound
depends upon the results of such examination. If no
pathogenic bacteria can be found by snch a method of
rapid staining, for example, as that just described in
the JoOBNAL of December 7th by Mr. Barney, irri-
gation may be dispensed with and the abdominal wound
may safely be closed. If, on the other hand, the
streptococcus or other pathogenic micrococci are pres-
ent, or the fatal colon bacillus, we should make re-
newed efforts at cleansing and disinfection ; we must
not, under these circumstances, close the abdominal
wound without providing free drainage, by the use of
either gauze or a tube, or both.

Philadklphia Advbbtising. — A Philadelphia
firm of truss-makers has sent out a circular to physi-
cians offering commission in the following bold man-
ner: "If you will send us your patients, we will
reciprocate W>tb » check by return mail."

Digitized by

Google

162

BOSTON MEDICAL AUD SUMfBIOAL JOVMXAL. [Fkbbcabt 15, 1894.

A BACTERIOLOGICAL STUDY OF FOUR HUN-
DRED CASES OF INFLAMMATION OF THE
THROAT, OCCURRING IN DIPHTHERIA AND
SCARLET FEVER. WITH ESPECIAL REFEK^
ENCE TO PATHOGENESIS.!

BT JOBS LOVSTT IIOBSX, A.M., 1I.D.

Wk owe the first description of diphtheria to BretoD-
neaa. He regarded the preseoce of a pBeado-mem-
brane in the pharjnz and upper air-passages as its
characteristic feature. The infectious nature of the
disease was first recognized in 1860 by Trousseau,
who considered the local manifestations as compara-
tively unimportant. As the disease became more
prevalent, more and more attention was directed to its
clinical characteristics, and the presence of a pseudo-
membrane in the throat was again regarded as its
diagnostic feature. It was not^, however, that the
membrane varied in different cases. In some it was
removed with diflSculty and left a raw, bleeding sur-
face ; in others it proved to be a mere exudation, and
left an intact surface after its removal. It was also
found that a fibrinous exudation, taking the form of a
membrane, anatomically indistioguisbable from that
found in diphtheria, could be produced in a number of
ways, as by wounds and irritants of various sorts. This
same pseudo-membrane was also found to be produced
in other portions of the body by the same irritants.
A pseudo-membrane was also noted in scarlet fever,
measles and typhoid fever. The discovery of these
facts resulted in great confusion and accurate diagnosis
was impossible. Every man had his own standard
and no one could prove whether he was right or
wrong.

Much of the confusion arose from the fact that men
failed to recognize that a diphtheritic inflammation is
essentially an anatomical process and does not neces-
sarily have any connection with the infectious disease,
diphtheria. Any inflammation characterized by a
fibrinous exudation forming a membrane on the in-
flamed surface is a diphtheritic inflammation, however
it may be caused. The diphtheritic membrane, is due
to a combination of necrosis and inflammation with
fibrinous exudation. The essential factor is a necrosis
of the surface epithelium. This necrotic tissue supplies
the fibrin ferment, and fibrin is formed from the serous
exudation which comes in contact with the necrotic
tissue. The membrane itself is found on microscopical
examination to consist almost entirely of fibrin and of
necrotic tissue which has undergone fibrinoid meta-
morphosis. The tissue beneath shows evidence of the
most intense inflammation. It is infiltrated with in-
flammatory exudation, the blood-vessels are dilated
and pus cells are found in the vessels and in the Ussue.
The necrosis is not limited to the surface but extends
irregularly into the tissue below, often passing beneath
the unchanged epithelial surface. It is here also ac-
companied by the formation of fibrin, the fibrin in the
tissue below often connecting with that on the surface,
causing this to adhere more strongly. Confusion has
also arisen from the so-called diphtheroid affections of
the throat. In these inflammations we may have
masses of detritus, consisting of cast-off epithelium,
mucQs and masses of bacteria, collected on the sorface
of. the mucous membrane and frequently extending

' A oontribatlon, ander dirsoUon of Dr. W. T. OonnaUnuui, from
the Pathologleal Deputmeat to the forthooming Medioal and Sorgi-
esl Beport of the Boaton City Hospital. Awarded one of the Lyman
prlMB for 18S3.

into the follicles. These masses can be removed Id
more or less adherent flakes. Under the microscope
they are often found to be composed almost entirely
of mucus, epithelial and pus cells, and bacteria of
various forms, which evidently find a favorable caltnre
medium in the collections of mucus and cast-off epithe-
lium. These deposits are sometimes accompanied by
marked signs of local inflammation as well as by con-
stitutional disturbance, due to the absorption of chemi-
cal products.

The diaoorery of bacteria and their relation to dis-
ease, however, offered a aolution for the problem.
After years of careful investigation by many observers
the bacillus causing the disease was isolated and its
pathognomonic character demonstrated. Klebs (1)
in 1888 found that a bacillus, always the same mor-
phologically, was constantly present in the pseudo-
membrane of cases of epidemic diphtheria. Loffler
(2) in 1884 investigated the subject still farther and
found that this bacillus was pathogenic in certain ani-
mals, and produced, on inoculation, a pseudo-membrane
on the surface inoculated. The whole subject has
been carefully gone over by numerous investigators
since that time, noUbly Lfiffler, Roux and Yersiu (27),
Babes (8), Welsh and Abbott (4). Pseudo-membranes,
paralyses and organic lesions, similar to those in man,
have been produced in animals by inoculation and a
toxine has been isolated, which produces, when inocu-
lated, the same results as the pure culture, with the
exception of the pseudo-membrane (5, 6, 7). This
toxine is probably due to a ferment produced in the
membranes by the bacillus, which is absorbed and
forms poisonous albumins and an organic acid in the
body (7, 8). Hence we now consider only those
pseudo-membranous inflammations as diphtheria, in
which this bacillus, known as the Klebs-Loffler, is
found. Therefore, no diagnosis can be made, which
can be regarded as more than probable, without the
bacteriological demonstration of this bacillus.

The Klebe-Loffler bacillus is a small organism not
much larger than the tubercle bacillus. Its most
striking feature, morphologically, is its variation in
form and its irregularity in staining. The ends of
the organism are frequently clubbed, sometimes one
and sometimes both ends, and in most cases when
stained it shows a series of clear spaces along with in-
tensely stained particles. The form and size vary
greatly under various circumstances. In different
cases it appears in some much larger and more irregu-
lar than in others, and in the same preparation great
irregularity may be seen. It grows readily on a variety
of culture media and most readily on the modified
blood serum first introduced by Loffler. When culti-
vated on potato it is much larger and more irregular
in form than when grown on any other medium. The
organism is pathogenic for a number of animals, espec-
ially for young cats and guinea-pigs. In guinea-pigs
the most virulent form of the organism will prodnce
death in from thirty-six to forty-eight hours. Like
some other organisms, there is a marked difference m
its virulence. While cultures from some cases will
always produce death in thirty-six hours, in others
death will not take place for several days; and in
others, again, the animals may survive the primary
inoculation, and afterwards die of paralysis after an
interval of three or four days. Again, in still other
cases, no results may follow the inoculation (9).
Numerous cases of psendo-membranons inflammar

•Digitized by

Google

Vol. CXXX, No. 7.] iOSfOOf MEDICAL AND SURGICAL JOURNAL,

16S

tion of the throat are met with, however, which are
doe to other bacteria than the Elebs-L&fQer bacillas.
These cases are absolutely indiatinguiahable clinically
from those dae to the action of the Elebs-Loffler ba-
eiilos, and may be precisely the same anatomically.
As a rale they are associated with streptococci, as is
notably the case in scarlet fever and measles. More-
over, the Klebs-Loffler bacillus and the streptococcus
are often found together or accompanied by staphylo-
cocci and other organisms. A differential diagnosis is
itnly possible by a carefal bacteriological examination.
Tbe futility of clinical conclusions has been shown by
namerous investigators. In 1889, Prodden (10) in-
vestigated twenty-four fatal cases which bad been
diagnosed clinically as diphtheria. In several of these
cases scarlet fever and measles were also found. The
Elebs-Loffler bacillus was not found in one, but the
streptococcus in all but two. Baginsky (11), in one
hundred and fifty-four cases diagnosed clinically as
diphtheria found the Elebs-Loffler absent in thirty-
foar. Martin (12), in two hundred suspected cases of
diphtheria found no Klebs-Loffler in seventy-four.
Park (13), in one hundred and fifty-nine cases of
pseado-membranons inflammation, found the diphtheri-
tic bacillus in only fifty-four. In every one of the
remainder streptococci were the most abundant bacte-
ria, and often the only ones. Koplick (14) found the
streptococcus alone in eleven cases of clinically pure
fibrinous diphtheria. Jauson (28), in one hundred
cases of pseudo-membranous angina, met with the
Klebs-LiSffler bacillus in only sixty-three.

As the prognosis, contagiousness, and hence the
necessity for isolation, varies greatly with the form of
bacteria present, the necessity of an accurate and
early diagnosis is evident. This can only be obtained
bacteriologically. By the examination of a cover-slip
preparation, prepared directly from the throat, the
presence of the diphtheritic bacillus may often be
demonstrated immediately. This method is fortu-
nately most valuable early in the disease (29) (15).
The presence of the bacilli is positive evidence, their
absence only negative, and in these cases further ex-
amination by means of cultures is necessary. In fact,
it is advisable to examine all cases by cultures as well,
which requires only twenty-four hours for the deter-
mination of the presence of the bacteria.

The main objects of my work have been to deter-
mine by the examination of a large number of cases,
in which diphtheria had been diagnosed clinically, or
at least strongly suspected : (a) the proportion in
which tbe Eleba-Loffler bacillus was present; {b)
whether or not, and if so, in what way, the prognosis
was altered by its presence; (c) in what way the
prognosis was altered by the presence of other organ-
isms in combinadou with the Elebs-Ldffler bacillus;
(<Q what these organisms were and how often they
were fonnd. During the course of my investigations
many other points have come up which seem worthy
of special note, particularly the results bearing on tbe
length of time which the bacillus remains in tbe throat
and nose after convalescence is established.

The method employed was essentially the same in
tl\ cases. Swabs are made by winding absorbent
cotton tightly on the end of a piece of stiff wire five
inches long. These are put in cotton stoppered test-
tubes, and sterilized by dry heat. The swab is rubbed
thoroughly over the throat, and put back in the test-
tobe. In tbe laboratory the swab is carefully rubbed |

over the surface of a slant tube of Loffler's blood
serum mixture. A platinum loop is run over the sur-
face of this tube, and then smeared on a second tube ;
this procedure is repeated on a third tube. The cul-
tures are left in the thermostat at a temperature of
Sb" C. until the next day and then examined micro-
scopically. The colonies on the third tube are usually
discrete enough to admit of a differential diagnosis of
the organisms present. The diagnosis has been made,
as a rule, on morphological appearances, although in
many cases the cultural peculiarities have been inves-
tigated and animals inoculated. In one series of
twenty-five cases, which will be given in detail later,
the various organisms were isolated in pure cultures
and accurately differentiated on the various media.
The blood serum was prepared according to Loffler's
well-known formula, solidified slowly in the dry steril-
izer at 75°-80° C, and then sterilized in Arnold steam
sterilizer at 100° for one-half hour on three successive
days. This method is much simpler than the one in
ordinary use, saves all the media, and is entirely satis-
factory in every way. The organisms grow as rapidly
and as vigorously as on blood serutn prepared by the
old method. The time and trouble saved in this way
is evident. Ldffler's methylene blue solution was or-
dinarily employed in staining. Four hundred cases
have been investigated in this routine way. • All of
them were examined after admission to the diphtheria
ward of the City Hospital, or were cases in the scarlet
fever ward whose throats were suspicious.

These cases, as a rule, come from the tenements
house districts in the thickly-populated portions of the
city, the North End, about Dover Street, and South
Boston. A few, however, come from the outlying dis-
tricts, as Brighton and Roxbury. It is safe to say that
a very large portion of them live in improper hygienic
surroundings, and are in poor condition to resist so
severe a disease as diphtheria. Moreover, many are not
brought to the hospital until they are in txtremU, and
die within the first twenty-four hours. The proportion
of adults is very small, only seventeen per cent, of the
present series being over fifteen. All these factors
have an important influence on the statistics and make
tbe percentage of mortality appear far worse than it
would in other circumstances.

DIPBTHBBIA, SOABLET FKYEB.

The presence of the Elebs-Loffler bacillus was dem-
onstrated in two hundred and thirty-nine, that is, in
sixty per cent, of all suspicious cases. There were three
hundred and one cases in which scarlet fever was not
present, not excluding, however, those cases in which
it may have occurred earlier or later. Of these, the
Klebs-Loffler bacillus was present in two hundred and
seventeen, or seventy-two per cent. These results cor-
respond pretty closely to those obtained by other in-
vestigators, Baginsky (1) having found the Klebs-
Liiffler bacillus in one hundred and twenty cases out of
one hundred and fifty-four, or seventy-eight per cent. ;
Martin (12), in one hundred and twenty-six out of two
hundred, or sixty-three per cent. ; Park (13), in fifty-
four out of one hundred and fifty-nine, or thirty-four
per cent. ; and Janson (28), in sixty-three out of one
hundred, or sixty-three per cent.

One hundred and thirty-six of the four hundred cases
examined died, giving a general mortality of thirty-
four per cent. Of the two hundred and thirty-nine
cases containing the Klebs-Loffler bacillus ninety-nine

Digitized by

Google

164

BOSTON MEDICAL AND 8VSOIOAL JOURNAL. [FsBBUARt 15, 1894.

died, that is, forty-one per cent. Of the one hnndred
and sixty-one in which it was not present, thirty-seven
died, or twenty-three per cent. The general mortality
of the three handred and one cases not complicated
with scarlet fever was tbirty-six per cent. Eighty-nine
of the two hundred and seventeen cases in which the
Elebs-Loffler bacillus was present, died, that is, forty-
one per cent. ; in the eighty-four in which it was
absent, twenty-one, or twenty-five per cent. died. Of
the remaining ninety-nine cases in which the diagnosis
of scarlet fever or scarlet fever and diphtheria was
made, twenty-six, or twenty-six per cent. died. The
Elebs-LSffier bacillus was demonstrated in twenty-
three, ten of which died, or forty-three per cent. Of
the seventy-six cases in which it was absent, only
sixteen, or twenty-one per cent. died.

MortaUty In four hnndred oaaet 84%

" In all caMe containing K. L. 41

'• in all oases Titboul K. L 23

" in all oases ancompllcated bjr soarlat feTer . , .96

" In these oases whioh oontained K. L. . . . .41

" In these oases whioh did not oontain K. L. . . .IS

" in all ouea oomplioated b; scarlet ferer . . .36

" In these oases containing K. L 4S

" In these oases not containing K. Ii, . . . .21

These figures go to prove that the mortality in
pseudormembraneous inflammations of the throat is
nearly twice as great in those in which the Klebs-
LSffler bacillus is present as it is in those in which it
is absent. Somewhat similar results have been ob-
tained by other observers. Park (13) records a mor-
tality of -forty-six and one-half per cent, in true diph-
theria. Twenty-five per cent, of Janson's (28) series,
in which the Klebs-LSffler was found, died, while all
the other cases of angina, uncomplicated with scarlet
fever, recovered. In Baginsky's (11) series, thirty-
eight per cent, of those with Klebs-Loffler died, com-
pared with eleven per cent, of those without. Heubner
(15) fonnd a mortality of sixty per cent, in seventy-
seven cases of true diphtheria.

Of the sixty-two adults, Elebs-Lofiler was present in
thirty-eight, absent in twenty-four. The general mor-
tality was nine per cent. ; that of those in which the
Elebs-Loffler bacillus was presen.t, thirteen per cent. ;
of those in which it was absent, four per cent.

IIBA8LB8, 80ARLBT FBTER.

A mild epidemic of measles occurred in the scarlet-
fever ward during the course of this investigation. Six
cases had measles and scarlet fever together. All re-
covered, and the Elebs-Loffler bacillus was not found
in any. Streptococci were present in five ; stapbylo-
cocd in two, and the diplococcus lanceolatus in three.
Four cases of measles with severe throat symptoms,
giving rise to the clinical diagnosis of diphtheria, oc-
curred. One contained a few Elebs-Loffler bacilli and
many staphylococci and recovered. The others were
practically pure cultures of staphylococci, and all died,
one, however, of scarlet fever contracted while conva-
lescent. These cases, as far as they go, show that the
Elebs-Loffler bacillus is certainly a very rare accom-
paniment of the throat complications of measles. The
literature on this point is very scanty. Hofmann (16)
and Escherich (17) claim to have found the pseudo-
diphtheritic bacillus in several cases of measles.

TYPHOID FBTEK.

Four cases of typhoid fever with throat complica-

tions have been examined, and seem worthy of sepsp
rate consideration.

L. F., for some time a patient on the surgical side,
developed a sore throat. Bacteriological examination
showed a few Elebs-Loffler bacilli. She was trans-
ferred to the diphtheria ward, where a few days later
the diagnosis of typhoid fever was made. She ulti-
mately recovered. A guinea-pig, inoculated with a
pure culture of the Elebs-Loffler badllus obtained
from her throat, died.

E. W. entered the hospital after a sickness of a
week. The diagnosis of typhoid was made, bnt she
was pat in the diphtheria ward because of her throat.
Examination showed a few Elebs-Loffler bacilli, many
staphylococci, and a few streptococci. Her throat was
clear in five days, and she was soon after transferred
to a medical ward, where she recovered.

F. D. was ill with typhoid in a private room. A
nurse, several days after leaving the scarlet-fever ward,
had a sore throat, and was put in the same room over
night. On the discovery of the Elebs-Loffler bacillus
on the next day she was transferred to the diphtheria
ward. Four days later F. D. developed a sore throat
with membrane. The presence of the Elebs-Loffler
bacillus was demonstrated, and she was also transferred.
The next day a typical scarlet-fever rash developed,
which was followed by desquamation. Her throat was
clean in ten days, and she ultimately recovered. <

Isabella N., nineteen, was admitted to the medical
wards of the Boston City Hospital on October 27th, at
about the middle of the first week of typhoid. She
was a large, well-built girl, in very good condition.
A faint systolic murmur was noted in the heart at both
base and apex. Although her temperature ranged
high, she did very well until November 4th, when she
became delirions and her pulse more frequent. She
slowly lost ground, and on November 11th it was no-
ticed that swallowing was painful. Examination of the
throat showed both tonsils and pillars of &aces covered
with a dirty-white membrane, which extended all over
adjoining parts of soft palate and uvula. The posterior
pharyngeal wall was not seen. She was immediately
transferred to the diphtheria ward. Cultures from
swabs made on this day and the next showed strepto-
cocci and staphylococci, but no diphtheria bacilli.
Blood-serum tubes made from swabs of November 14th
showed almost pure cultures of the Elebs-Loffler
bacillus. She was able to take but little nourishment,
and remained semi-unconscious and delirious. Her
pulse gradually failed, and she died on November 17th.
Her throat had begun to clear op during the last two
days. The autopsy was performed by Dr. Councilman
thirty hours after death.

Body. — Large, well-built, tolerably well-nonrished.

Shin. — Grenerally pale and anaemic. Mucous mem-
branes pale. Posterior surface of body slightly con-
gested. No eruption. Subcutaneous fat medium in
amount.

Abdomen. — Moist and peritoneum smooth, save
over spleen, where there is a sligbt fibrinous exudation.
Both liver and spleen free from connective-tissue adhe-
sions. Along course of ileum and colon areas of con-
gestion. Diaphragm in nsaal position. Anterior
mediastinal glands slightly enlarged and reddened.

Lung$. — Bemarkably free from pigment. Both
slightly adherent by old adhesions. The entire poste-
rior part of right long congested, oedematoas, and
slightly consolidated, the consolidation generally Iaz>

Digitized by

Google

7oi. CXXX, No. 7.] BOSTON MEDICAL ASD SUROIOAL JOVUNAL.

165

with here and there areas of more distinct consolida-
tioD about the bronchi. The entire plenral snrface of
this portion of the long covered with a slight fibrinous
exndation, more marked between the lobes. The
parietal plenra congested. Abundant muco-pnrulent
secretion from t£e bronchi everywhere in the lungs,
particularly in the posterior parts. In the left lung
there area few areas of consolidation about the bronchi,
bat the consolidation is everywhere less well-marked
than in the right. The bronchial glands distinctly en-
laieed, reddened, and slightly pigmented.

Heart. — Medium size. Both layers of pericardium
smooth. The myocardium generally pale without any
appearance of faded leaf. In the right ventricle there
are fresh clots. In the left there are old thrombi
covered with adherent fresh clots along the musculte
trabeculse of the septum and the apex of the ventricle.

lAver. — Large. Surface pale, markings somewhat
obecore. Gall-bladder distended, bile-ducts free. On
section, liver pale and somewhat cloudy.

Spleen. — Seventeen by ten by five centimetres.
Weight three hundred and forty grammes. Surface
covered with a slight fibrinous exudation. On section,
comparatively firm, homogeneous, of a dark-red color,
small dark-reid points of hemorrhage scattered through
it. Neither Halpighian bodies nor trabecules visible.

Kidneyt. — Of ordinary size. Surface smooth and
capsule not adherent. The lobules very evident. On
section, cortex pale, markings faintly visible, the laby-
rinth clondy. On the surface of the right kidney
there is a slightly elevated, soft, nodular mass, one and
a half centimetres in diameter. On section the cortex
at this point is soft, pale, with opaque white streaks
and points scattered through it ; where it extends into
the pyramid, it has a reddish color.

MtMenterie Glandt. — Both of the mesentery and
mesocolon are enlarged, deeply injected, and soft. The
post-mesenteric are also enlarged and reddened.

hUestinet. — In the intestines there are numerous
ulcers. There is one low down, almost in the rectum.
Throughout the large intestine there are numerous
ulcers with sharply circumscribed edges and perfectly
clean base, extending down to the muscular coat, one
of them extending through this to the peritoneum.
In the small intestine also there are ulcers of the same
general character as those in the large. Higher up in
the intestine are some with sloughs in the base.

Adrenal Glande and Panereat. — Normal. The pan-
creas large and firm.

Pharynx and Larynx. — Mucous membrane of the
pharynx covered with an extensive muco-purulent mass.
The tonsil on left somewhat enlarged and covered with
a whitish deposit, which is easily scraped away, but does
not wash off. On removal of this there is an epithelial
lose of substance. There is an extensive formation of
the same substance on the lateral wall of the pharynx
opposite to the larynx. In the larynx there is an ir-
regular nicer on each side along the posterior portion
of the Tocal cord. The edges of the ulcer have a gray-
ish film over them ; the base also. All of the cervical
glands are enlarged, softened, and reddened. The
trachea is intensely congested.

ANATOUIOAL DIAON08I8.

Typhoid Fever. — Ulceration of ileum and colon.
Diphtheria.
Heart thrombus.
Benal Infarction.

Congestion, fledema, pneumonia, and bronchitis in
the lungs.

Acute swelling of spleen.

Diphtheritic ulceration of larynx.

Diphtheritic pseudo-membranous inflammation of
pharynx.

Hyperplasia of lymphatic glands.

Acute parenchymatous degeneration of liver, kidneys
and heart.

BACTERIOLOGICAL EXAMINATION.

liung. — Pure culture streptococci.

Tonsil. — ' Numerous streptococci and other cocci,
with a few Elebs-Loffler bacilli.

Traehea. — Mainly streptococci and Elebs-Loffier
bacilli.

Traehtal Gland. — Negative.

BUe. — Typhoid bacilli.

Spleen. — Typhoid bacilli.

Metenterie Gland*. — Bacillus coli communis.

Pleura. — Streptococci.

Bronchial Gland*. — Streptococci.

Heard Mood. — Negative.

Heart* Thrombi. — Typhoid bacillus; streptococci.

Kidney Jhfarction. — Typhoid bacilli ; streptococci.

Kidney. — Typhoid bacilli ; streptococci.

Liver. — Streptococci.

One of the two pigs inoculated with the pure culture
of the Elebs-Ldffler bacillus, obtained from the trachea,
died in forty-eight hours with the pathological lesions
of experimental diphtheria. The bacilli, however,
were not found at the seat of inoculation. As far as
I know this is the first reported autopsy of a mixed
case of typhoid and diphtheria. It proves conclusively
that certain of the inflammations of the throat occur-
ring in typhoid may be due to a mixed infection with
the Klebs-Lo£9er bacillus. The other cases cannot be
considered as more than suggestive. Wagner, who
has given the most accurate description of the angina
accompanying typhoid fever, calls attention to the
greater frequency of pseudo-membranous affections
when diphtheria is prevalent.

The bacteriological examination of the tissues of the
case show that three different infections have taken
place. One by means of the typhoid bacillus ; one by
means of the Klebs-Loffler, and one by a streptococcus,
which probably found its point of entrance in the tis-
sues from the lesions in the throat. Evidences of these
three different infections were present in the tissues.
The general lymphatic hyperplasia was due both to the
typhoid and diphtheria. The lesions in the lung and
pleura were due to streptococci coming from the throat,
and from here the general infection of the body may
have taken place. Streptococci were found in the
thrombus in the left side ol the heart, and on section
of the tissue beneath the thrombus there was a slight
endocarditis with streptococci in the superficial layers
of the tissues. The embolus which produced the in-
fection of the kidney came from the heart thrpmbns
and produced a circumscribed purulent infiltration of
the kidney in the place of a simple infarction. No
effect seems to have been produced on the intestinal
ulcers by the other infections. They had the typical
appearance of late ulcers in the beginning of healing.
The presence of the streptococci in the acute fibrinous
pleurisy shows that they may produce in the pleura as
typical a fibrinous exudation as is found in the pleurisy
accompanying an acute croupous pneumonia.
(Z\» b4 BonHmml.)

Digitized by

Google

166

BOSTON MiDlOAL AND SVBOIOAl JOVRBAL. [f urcabt 1$, 1894.

Clttttcal S)e|iartm(ttt.

A CASE OF ACUTE INFECTION SIMULATING
ACUTE YELLOW ATROPHY OF THE LIVER
IN A PREGNANT WOMAN: AUTOPSY."

BT SAXCltl. OKOWSLL, M.D., DOBCHB8TBB, IfA88.

Jaundicb and a sudden suppreBsion of urine in a
pregnant woman, lasting eight days and ending in
death, is the story in a nutshell. We will go into the
clinical history of this interesting case, however, more
in detail.

Near midnight of November 15, 1893, I was con-
sulted by a husband seeking aid for his wife, who was
suffering from pain in the back and stomach. She
was a primipara, at about the sixth month, age forty-
two. She had always enjoyed the best of health, and
had been entirely free from the many ails accompany-
ing pregnancy. She attended a lecture in town that
very evening, retired for the night in her usual health,
but shortly afterwards began to complain of this pain,
which no domestic remedy seemed to relieve.

November 16th. 1 was sent for in the early evening
to see the patient. The quarter-grain of morphine of
the night before had relieved the pain, and it bad not
recurred. The patient was bleeding from the gums,
and had been spitting and wiping blood from her lips
all the afternoon. The face, eyelids, lips, hands and
feet were swollen. Headache, and vomiting of all
nourishment taken into the stomach, had existed all
day. On inquiry it was found that not a drop of urine
had been passed for the twenty-four hours. The pa-
tient was about the house doing her work. At my
request, she passed four ounces of bloody-looking
urine, containing a large amount of albumen, granular
and hyaline casts, renal epithelium and a few blood-
corpuscles.

November 1 7th. I saw the patient in the morning
by daylight. She was deeply jaundiced. This jaun-
dice I believe to have been present from the first, bnt
just when it appeared it was hard to say, as no one
had noticed it, and the gaslight would have hidden its
presence the night previous on my visit.- She had
vomited everything but cream-of-tartar water. The
headache was less, she did not complain of it again
until twenty-four hours before her death. The skin
was moist from the attempts made to sweat her. The
bowels had moved slightly from a dose of ol. Tiglii,
and there was only two ounces of urine to show for
the twenty-four hours' excretion of the kidneys.

November 18th. Ck>Ddition the same ; mind dear ;
no urine for twenty-four hours. Ten grains of calomel
had produced one watery discharge.

November 19th, Condition the same; no urine.

November 20th. Condition the same ; no urine.

The temperature taken at the time of my visits was
generally normal, twice I found it 99°. The pulse
ranged about 76 per minute.

November 2lBt. Condition the same; no urine>
In the morning I started up labor with a bougie.
The uterus responded, and in the evening I took away
a macerated foetus at about the sixth month. The
patient's condition was good. There was no flowing
connected with the miscarriage and practically no dis-
charge afterward.

November 22d. Condition the same ; no urine. I

> Baad by InriUtlon before the Obatetrioal Sooiety at Boston, !>•-
«wnber 8, 188S.

drew, with the catheter, five ounces from the bUdder.
In the afternoon a convulsion occurred lasting ten
minutes, followed by delirium, requiring two to hold
her in bed, and an intense headache and pain tbroogh
the right eye. The tongue became thick and swollen,
and the features expressionless. In the early evening
she had a second convulsion of about the same dora-
tioD. This was followed by delirium alternating with
short lucid spells during the night, and ending in death
at eight a. h., November 23d, on the eighth da; of
the disease.

At the autopsy made five hours after death, the heart
and lungs were normal. No fluid in the serous cavities.
Liver not descended below the ribs. It extended well
over to the left side of the body, and seemed somewhat
larger than normal. It was firm and smooth. The
gall-bladder was not distended.

Specimens were sent to Dr. W. T. Councilman for
examination. His report reads :

" There was brought for examination a portion of
the liver, one kidney, spleen, a portion of the heart and
of the uterus.

" The portion of the uterus brought bad about the
thickness and consistency of the uterus at the end of
pregnancy. It was rather soft and of a pale-yellowish
color. On its internal surface there were some adhe-
rent clots.

"The liver microscopically was of a dark green
color. The bile-duct was not occluded at the autopsy.
The kidney was very large, of a pale-yellowish color,
with a distinct greenish tinge. The cortex was
smooth. No appearance of haemorrhage. On section,
the cortex enlarged and pyramids congested. Mark-
ings obscure. On section, the cortex had the same
greenish appearance as the surface. Cultures made
from the organs gave pure cultures of streptococci in
all of the organs. They were most abundant in cul-
tures made from the uterus and spleen. The cultures
from the liver and kidneys gave only a few colonies.
The streptococcus found belongs to the general type
of the streptococcus longus. It grew out in long thin
chains, and the opposing surface was flattened.

" Microscopic examination of the tissues was made
both in the fresh state and after hardening in various
media. At the fresh examination a considerable
amount of bile pigment was found in the kidney, with
well-marked fatty degeneration, principally confined
to the collecting tubules. Sections of the hardened
organ showed a considerable degree of acute nephritis.
The glomeruli were but little altered. The only
change noticed was that the capillaries were somewhat
thickened and indistinct. The epithelium of the con-
voluted tubules was swollen, fatty and in places dis-
tinctly necrotic. Accumulations of round ceils and
leucocytes were found in various parts of the paren-
chyma. Numerous casts were found in the collecting
tubules. The liver showed, both fresh and hardened,
an injection of the smaller bile-ducts with inspissated
bile. There was marked fatty degeneration of the
cells, and in places the cells were necrotic No change
was found in the heart other than a very slight fatty
degeneration.

" The case appears to be one of general infection
with streptococci proceeding from the uterus. The
condition of the kidneys is probably to be referred to
this. The jaundice and the lesions in the liver may
have been due to other causes."

The autopsy is of great value to us in making the

Digitized by

Google

CXXX, No. 7.] BOSTON MEDICAL JJfD 8UBGI0AL iOVBNAL.

167

Li^^^Kiosis, though it does not throw all the light we
iTMKkt ; it fails to explain the jaundice. Without its
ksaistsDce one would not be far out of the way in
Dock'kixig a diagnosis of acute yellow atrophy of the
li'vex-, brought about by the general infection from the
at^rns, and especially aided in its development by the
kidneys, except that percussion of liyer dulness was
tA>o great.

Jaandice in pregnancy is of rare occurrence, and

abonld always be looked upon as a grave complication,

tbireateniug the life of both mother and child, especially

tbe life of the child, even where the jaundice is of

Itenign origin.

^cute yellow atrophy of the liver is considered to
be the cause of jaundice in a large proportion of the
cases, though jaundice may be produced by the same
causes as in the non-gravid state.

It is also stated that the pressure of the gravid
n torus upon the liver is a cause of jaundice. This
t]>»ory seems to me hardly tenable, when one considers
the innumerable pregnancies where the liver must be
greatly pressed upon without jaundice, and the few
caaes where it occurs are in those months of pregnancy
before the uterus has attained sufficient sise to cause
pressure.

A CASE OF MTXCEDEMA TREATED BY THY-
ROID EXTRACT.!

BT W. S. COWUCS, K.D., ATEB, KASS.

Im view of the prevailing interest in the subject of
myxcedema and allied affections, I have prepared a
report of the following case :

Mrs. S., aged forty-two years, is the oldest of a
family of five children. Her mother, a brother, and
three sisters are living and in good health. Her father
died two years ago at the age of sixty-six years, after
a long illness accompanied by gangrene of one foot.
For many years previous to hisdeath his eyes presented
a bulging, staring expression, so marked as to attract
the attention of all who saw him. He was of an ex-
citable disposition, and his ability to work was limited
by what his family called " nervousness and heart dis-
ease." His family physician says he had an excitable-
heart. There is no history of thyroid enlargement.
A. photograph of this man taken just before his last
illnesa shows the characteristic facies of Graves's disease.
My patient, Mrs. S., has always been well until her
present trouble began. Menstruation has always been
regnlar except when interrupted by pregnancy. i$he
is the mother of five children, three of whom are liv-
ing. About seven years ago, soon after the birth of her
yoangest child, the patient noticed that she was getting
bulky in body and awkward and weak in her move-
meots. The trouble increased at a variable rate until
July, 1893, when her condition was as follows :

The body bulky ; the face, hands and feet distinctly
swollen, the swollen surface not pitting on pressure.
The skin was dry, harsh, thick, and always cold to the
touch. There was a pale-yellow tint of the, surface,
saggestive of slight jaundice. Scaling of the epidermis
was noticeable over the greater part of the body. The
skin of the ends of the fingers was thick and cracked,
and the nails seamed and brittle. The hair had a dry
aod broken appearance. The tongue was unusually
broad and thick. Speech was slow and thick, as if the

> Bmd before the Section of Clinical Medlolne, Patholoiy and Hj-
glnie, ol the Suffolk Dl«tilot Hedioal Soelaty, DeoemlMT SL ''

tongue were too large for the mouth. There was ap-
parent mental sluggishness, with an inclination to
melancholy ideas. The temperature was always sub-
normal, 96° to 97° F. in the mouth. The thoracic and
abdominal viscera appeared to be normal. The thy-
roid gland could not be felt. The patient complained
of great weakness, of being easily tired, of shortness
of breath on exertion, and of a constant feeling of
coldness. She had noticed a lack of perspiration, even
in hot weather. The urine collected for several days
in succession in July, 1893, amounted to about two
pints in twenty-four hours. Specific gravity, 1,024
to 1,026; color, pale; reaction, acid; sediment, nor-
mal ; no albumen or sugar found.

On September 8th, Mrs. S. began taking dessicated
sheep's thyroids, in doses of one-third of a gramme,
three times a day.

Her condition at the time was practically the same
as in July. Weight, 204 pounds ; temperature, 96.4° F.

After three or four days of treatment the patient
complained of severe pain in the lower extremities.

September 18th, the patient's weight was 192 pounds,
the temperature 96.5° F. The amount of the remedy
administered was reduced one-half, on account of
severe pain in the lower extremities.

September 26th, weight, 190 pounds; temperature,
96.5° F. ; no pain or discomfort of any kind. The
remedy was increased to one gramme daily.

October 2d, weight, 186 pounds ; temperature, 97.5°
F. Severe pain in head and left shoulder. Dose of
the extract again reduced to half a gramme daily.

October 7th, weight, 188 pounds ; temperature,
98.2° F. The dose of dessicated thyroids was again
increased to one gramme daily, and continued at that
amount without further discomfort.

October 14th, weight, 182 pounds; temperature,
98.4° F.

November 12th, weight, 172 pounds; temperature,
98.6° F.

December 20th, no further change in weight. The
patient's appearance has wonderfully changed. The
swelling of the face, hands and feet has literally melted
away. During the first six weeks of treatment there
was marked anaemia, as shown by pallor of the mucous
membrane. That condition is gradually giving place
to a ruddy, healthy appearance. There has been a
considerable desquamation of the skin, especially upon
the hCbds and feet. The surface is warm to the touch.
The yellow color has disappeared. The perspiration
has retured. The condition of the nails and hair has
improved, but is not yet normal.

A record of a number of urinary examinations made
during the first two months of treatment shows an in-
crease in amount to about four pints in twenty-four
hours ; specific gravity, 1,018 to 1,022, with no marked
departure from a normal quality.

Quick movements, rapid speech, and an animated
manner have taken the place of former slowness of
speech and action, and stupid appearance.

This case appears to be especially interesting on
account of the probable occurrence of exophthalmic
goitre in the father of the myxcedematous patient,
Mrs. S.

A HEHBER of Sorosis says that every young girl
should read Naphey's " Physical Life of Woman," a
book called " Tokology," and Cook's " Mothers and
'^■•"hters,"

Digitized by

Google

168

BOSTON MBDIOAL AND SURGICAL JOURNAL. [Fxbbuabt 15, 1894

Vjvf^wt^ Of jftoctetie^.

MASSACHUSETTS MEDICAL SOCIETY.
SUFFOLK DISTRICT.
SECTION FOR CLINICAL MEDICINE, PATHOL-
OGY AND HYGIENE.

HBNBT JA.CKSOK, M.D., SBCBBTABT.

Rgocljir meeting, Wednesday, December 20, 1893,
Db. F. C. Sbattdck in the chair.
Db. J. J. Pdtna^m presented a paper on

THB FDNCTION8 A.ND TBK THBBAFECTIO USES OF
' TBB THTBOID OLAND.*

Dr. W. N. Cowles reported

A GASB OF HTXCEDEHA TBEATBD BT THTBOID EX-
TRACT.*

Db. J. C. White : I have not uted this substance
in the treatment of skin diseases, bat judging by what
I have read, it follows the rule of many new remedies
in cutaneous therapeutics, that do not seem to produce
in the hands of subsequent experimenters the results
produced in the hands of those who published the first
accounts. I should like to ask some of the gentlemen
who speak of its action upon the growth of the hair
in myxoedema, whether they noticed it produced sacb
astonishing results in male patients. If it would make
the hair grow in male patients, it would be quite dif-
ferent from making it grow in the female patient.

Db. Pctnau: Most of the cases have been in
women. I cannot answer from memory.

Db. F. C. Sbattuck : Of my four cases two have
been in males and two in females. In one male, a
man of sixty-nine, the beard is distinctly thicker than
it was before he took the thyroid extract. I think
there is more change in the hair of the beard than in
the hair of the head. My other male patient has been
under treatment too short a time to give opportunity
for observation in this respect. With regard to the
loss of weight, which seems to be so common a feature
in the treatment of myxoedematons patients, and which
has led to the employment of the drug for obesity with
good results apparently, it is interesting to note that
in one of my cases there was a gain of twenty pounds
in weight, coincident with great improvement; and the
weight has been properly distributed. The waist and
the neck have got smaller, and the legs of proper
shape, which they were not before. That, as far as I
know, is rather unusual. It hag always seemed to me
that this Browu-Sequard treatment by testiculin is by
no means analogous to the use of thyroid. We call
both the testicle and the thyroid, glands ; but, physio-
logically, they have nothing in common. I was a good
deal interested in a patient of mine at the hospital this
winter, as vigorous, fine-looking a man as one could
wish to see, who was castrated several years ago for
some disease of the testicles without the slightest
change of appearance, up to the present time at any
rate.

Db. Glabk : In regard to a possible relation of the
spleen to the thyroid gland, I think some recent exper-
iments of Zanda are interesting. This observer per-
formed thyroidectomy on dogs without any evil results
in cases where the spleen had been removed at least a
nonth before. He concluded from this that the thy-

1 See page 163 of the Journal.
* See page 167 of the .Journal.

roid probably neutralizes some toxic principle, appa^
ently a prodact of tissue change sent into the Uood by
the spleen.

Db. Pdtnah : I did not speak of the therapeutics
of myxoedema, because Dr. Shattuck recently read an
interesting paper on that subject.* 1 should like to add
the fact that quite a large number of cases of cretinism
have been published as much benefited by thyroid ex-
tract even where the disease had persisted to adnit life.
Two or three of these cases have been under the care
of Dr. Osier, of Baltimore.

There is another interesting point that I meant to
refer to, which has been made the subject of a good
deal of experimental work, namely, the relation of
animal food to thyroidectomy. It was first observed
by Mank that some of his animals died after they
swallowed lumps of meat; and that was thought to
strengthen his theory that the result was due to injury
of the nerves of the neck, but it was observed that if
the extractive matters were removed from the lumps
of meat by boiling that these results did not occur. On
the other hand, it was found that if the animals were
fed with strong beef broth that they apparently did die
sooner, and experiments of this sort form a part of this
recent series to which I referred, as having been just
published in Yirchow's Archiv.

Db. C. B. Pobteb referred to the question of preg-
nancy. It was observed quite early that daring preg-
nancy some of the symptoms of myxcedema seemed to
grow less severe, and Dr. Murray suggested that the
thyroid of the foetus might be doing duty for the lack-
ing thyroid of the mother. Some doubt, however, is
thrown on that by certain observations I have read.
It was found by Coiztisni, that if rats were pregnant,
they seemed to suffer more from thyroidectomy than if
not pregnant.

It is also an interesting fact, to which Dr. Porter
referred, that occasionally the cachexia does not seem
to follow thyroidectomy, and that has been reported,
I think, after complete atrophy of the thyroid in
Graves's disease. It would seem that sometimes this
may be 'due to the fact that accessory glands exist, but
it does seem as if a person could get accustomed to do
without the thyroid.

Reports indicate that not all observers find the same
improvement in the use of these preparations of the
thyroid in healthy persons. It would also seem that
in persons in health the effects of the thyroid were
temporary, that loss of weight only went on to a cer-
tain point, or was fluctuating.

A case reported by Dr. Bramwell and one or two of
Vermehren's cases would seem to indicate that the
improvement as regards the skin and nutrition at
large, was not necessarily lasting.

The Smithsonian Institute has received from the
Peruvian Army Surgeon-General nineteen crania of
pre-historic character. They are of interest because
they show that in that far-off age the skull was tre-
phined. In one instance the patient survived the re-
moval of a fragment four inches long and one and
one-quarter inches wide ; the cavity was covered with
silver. In one case the patient survived two trephin-
ings, but died after the third. The instrnmenta used
were flint. — Medical Standard.

• To be published In the Joomal of February itad.

Digitized by

Google

ox.. CXXX, No. 7.1

BOSTON MEDICAL AND SURGICAL JOURNAL.

169

THE OBSTETRICAL SOCIETY OF BOSTON.

CHABI.B8 W. TOWMSBSD, II.P., SBOBBTABT.

^MEbktino, December 9, 1893, the President, Dr.

aA.Ri.KS M. Gbeen, in the chair.

I>R. S. Cbowell, of Dorchester, reported, by in-

tation,

CA.8B OF ACCTB INFEOTION StMTJLATINO AOUTB
TRLLOW ATBOPHT OF THB LIYBB IN A FRRONANT
'WOMAN: ADTOP8T.*

Dr. C. £. Stbdhan regarded the case as ooe of
lecaliar interest from the fact that the patient secreted
luly eleven ounces of urine in eight days, three of
hese being days of complete anuria. Daring the
^eater part of 'this time the patient appeared fairly
veil.

Dr. C. G. Couston said that the endometrium's well-
cnown ability to absorb would account for this case of
general infection.

Db. Wh. Inoalls tbooght it was a very curious
Eact that the patient was in such good health previous
to the attaclc. The case would suggest some ante-
cedent cause.

Dr. M. H. Bichabdson thought the case was an
extraordinary one and that its true origin was not yet
foand. The unusual points were the sudden onset,
and the absence of marked constitutional disturbances.
One would suppose that the pulse, at least, would be
affected by the streptococcus infection.

Dr. J. G. Blakb would agree with Dr. Richardson
that the case was certainly very obscure and not thor-
oughly understood.

Db. £dw. Bbtnolds said he believed a great
advance was being made in our understanding of sepsis
by the aid of bacteriology. Clinical experience had
taught him that the sense of smell might be of little
use in these cases, that severe sepsis might exist with
absence of odor in the uterine discharges.

Db. M. H. Richabdbon said that there was often
no odor from pure cultures of certain septic bacteria,
but that the degeneration of the tissues which followed
with the addition of other bacteria resulted in the foul
stench.

Db. C. M. Gbbbn saw the patient two days before
death. From the appearances alone at this time one
would wonder why it was necessary to keep the pa-
tient in bed. He had learned to believe, however,
that in sepsis a sense of comfort and well being on the
part of the patient was often of serious import. As to
the odor this was not infrequently absent in cases of
true sepeis.

Db. M. H. Richabdson reported

TBREB CASES OF SALPINGITIS OF UNUSUAL EXTENT,'

and showed the specimens.

Db. 6. Hatbn mentioned reported cases where a
preliminary operation was done in order to examine
the contents of the tabes. He himsielf had operated
some twelve or fourteen times with good recoveries in
aU except one who died of embolism on the ninth day.
He tboDgbt that one could not operate too early.

Dr. J. 6. Blake would take issue with the treat-
ment of the second case by laparotomy. Why not have
draiued through the vagina which would have been a
perfectly safe operation. ^He has been treating cases
m thii way for thirty years. A case he had treated

< 8m pige 167 of the Journal.
■ 8m ptge 160 o( tb« Jonroal.

in this way for a double abscess two years ago, gave
birth to a child a few nights ago. He remembers an-
other case where the abscess was very large and where
the patient has had several babies since. Of course,
the risk in opening the abdomen nowadays is very
slight, but still there is some risk. Hence he would
prefer to evacuate the abscess per vagina whenever that
is possible.

Db. S. Crowell referred to an abscess in the
posterior cul-de-sac of the vagina which was opened
through the vagina, but pointed later in the left iliac
region.

Dr. C. G. Cumston, late of Geneva, Switzerland,
showed some instruments. •

Dr. G. Haven reported a case of rapidly growing
fibroid of the uterus and showed the specimen. The
patient, a woman of forty, had been examined within
six weeks and nothing found. Since then the fibroid
had rapidly developed and she had lost much blood
during menstroation. The tumor was removed and
the patient has made a perfectly good recovery.

Dr. M. H. Richardson showed a pregnant uterus
removed for cancer of the cervix.

Vittmt literature.

A Manual of Praetieal Hygiene. Designed for Sani-
tary and Health Officers, Practitioners and Students
of Medicine. By W. M. L. Coflin, M.D., and
D. Sevan, M.D. With an introduction by H. A.
Hare, M.D. 140 illustrations. Philadelphia: P.
Blakiston, Son & Co. 1898.
Great improvement has taken place in the past five
years in the character of works pertaining to practical
hygiene ; and this book offers no exception to this
statement. Its excellent treatment of the subject will
make it a valuable hand-book for reference.

The general character of the book may be under^
stood from the following list of subjects treated:
Causes and Prevention of Disease, ludividaal Hygiene,
Clothing, Food, Water, Air, Climate, Soil, Habita-
tions, Sewage, Disposi^ of the Dead, Technic. The
chapters on Climate and on Habitations are especially
full and complete.

The following extract from the introduction sets
forth the general scope of the book : " Heretofore the
busy practitioner has often neglected hygiene, in its
relation to private life, because the reliable books
were, most of them, based on military needs. The
architect has found that too often the stated scientific
facts clashed with the utility of his building, and, as a
resnit, in many instances serious hygienic sins were
committed. It is to meet such cases that this book
was planned and written; and that its objects have
been accomplished will be evident to any one who is
wise enough to study this important branch of knowl-
edge in its pages."

Di$eaie in Children. A Manual for Stndents and
Practitioners. By James Cabuichael, M. D.,
■F.RC.P. (Ed.), Physician Royal Hospital for Sick
Children, University Lecturer on Disease in Chil-
dren, Edinburgh. New York : D. Appleton & Co.
This handy little book takes up briefly the whole
subject of paediatrics, and finishes with an excellent
appendix, containing directions for making the simpler
dietary of children. It should meet with much favor.

Digitized by

Google

170

BOSTOJf MEDICAL AND 8VMG1CAL JODBJ/AL. [Fxbbdabt 15, 1694.

THE BOSTON
THURSDAY. FEBRUARY 15, 1894.

A Jowmal tifMedieUu, Stirgerf, a»a AtUtd 8cieneu,imbU$hed ol
BotUm, tMeily, ty IA« timdtnigntd.

SUBSCBIPTIOH Turn : 98.00 ptr near, i« aHvamet, poitag* paid,
f&rtlu VtMtdStatf, Qmada amd Maeioo ; 9tM per ytar fl>r all for-
tign coamtrU* bekmgiiig to the Pottal I7itiom.

All oomtmmieatioiu for the Editor, and all bookt forrtirtt»f,$houU
beaddretttdtotheKdilorqfthe Boston Medical aadSturtloalJomnal,
88S Waihington Street, Soibm.

All Uttere eontaimiag friuitwM oommmueatione, or refarimg to the
pnUiooMon, Kibietiptlim, or advertising departmaU qf fMj Jomrmai,
ihoald be addreued to the tmdereigned.

Jiemittamoe* ehould be made 6y money-oriicr, draft or regieterod
letter, pavable to

DAHSKIjL * UPHAM,
28S WASHmOTOX 8TBUT, BOITO>, KJLU.

SANITART INSURANCE: A SCHEME.

Undbr this bead, Dr. 6. Walter Steeves writes in
the January Nineteenth Oenturg magazine, taking for
his text the proposition that " thousands of deaths
annnally resnlt from diseases which are in the most
absolute sense preventable."

The complaint which be has to make i> that under
the existing social arrangements, there is no sufficient
guaranty to the purchasers or lessees of tenements as
to the perfect sanitary condition of such dwellings.
It frequently happens that the first intimation of a
sanitary defect in a house is an outbreak of a prevent-
able disease, or one of those infectious maladies classed
under the generic term " zymotic," such as diphtheria
or typhoid fever. It is an acknowledged fa6t that
people are living at the present day in habitations
whose condition of healthiness is only tested by the
sudden advent of an infectious disease, and it is equally
true that a house is usually considered healthy till
found unhealthy. If the wealthy may indeed carefully
select their dwellings, the time has certainly not ar-
rived in any civilized country when sanitary surround-
ings are a $ine qtut non with the masses ; and the
majority are only induced to inquire into such matters
after serious illness has occurred, or some marked in-
sanitary condition has been pointed oat.

Despite the fact that the Health Department is a
prominent feature with all our municipalities, that
there are Local Boards and State Boards well equipped
and that all our universities have departments for the
study of hygiene and laboratories for bacteriological
research, and that grand results have been accomplished
by all these instrumentalities — it would appear from
mortality statistics that the public are not yet suffi-
ciently protected against insanitary dwellings and snr>
roundings.

Dr. Steeves dtes instances like the following, which
seem to settle the question of the tenant's protection
— such instances can be paralleled in the history of
many municipalities :

Mr. A., a prosperous draper, with a family of yonng
children, elects to lease a house in a presumably
healthy suburban district ; be himself is quite ignorant
of sanitary matters, bat is naturally anxious to be on
the safe side ; consequently, as soon as he has taken
possession, he communicates with the Health Depart-
ment, asking for an inspection. He is surprised to
find that as he cannot complain of any nuisance, the
services of the Board's officials are not at his disposal.
He is next advised to call in a sanitary engineer, who
may or may not be associated with some sanitary as-
sociation, to make an examination of the premises.
This time he is successful; he is satisfied with the
report, pays his fee, brings his family from town, where
they have always enjoyed good health, and settles
down at his new fireside with a feeling of relief. Six
months elapse, when suddenly one of his children com-
plains of sore throat ; the doctor is sent for, and to the
horror of the parent, the patient is declared to be saf-
tering from diphtheria. The doctor now notifies the
local Board of Health ; and the main drain of the
house, on being carefully tested by the officials, ie
found faulty — cracked by the sinking of one of the
walls of the house, or one of the joints underground
has been badly cemented. A further examination re-
veals the fact that the earth in the immediate vicinity
is sewage soaked.

If such an incident as the above were to be taken as
a statement of sober fact, it would teach either that
the engineer who made the first report was careless in
his inspection, or that the drain had subsequently be-
come defective; in any case the necessity of frequent
sanitary inspections of premises is apparent. Dr.
Steeves's especial contention is that the existing pro-
tective associations, while doing much good work,
have not gone far enough. As for property that has
been standing twenty or thirty years, inspections with
the necessary testing, should be scrupulously con-
ducted three or four times yearly.

The "scheme" which this writer proposes, is as
follows (how far it is practicable we must leave to our
readers to judge) : It is proposed that any city or dis-
trict may organize for itself a sanitary protective and
insurance association founded for the purpose of pro-
viding the public with a source of protection against
unsanitary dwellings and surroundings. The definite
objects would be:

(1) To examine into the sanitary condition of any
building previous to tenancy, or after, and to afford
skilled advice on hygienic matters or appliances,
either on existing premises or on the plans of proposed
arrangements of new buildings.

(2) To issue certificates respecting the sanitary con-
dition of dwelling houses and buildings.

(8) To provide the means by which a cleanly and
wholesome state of dwelling bouses and premises may
be mainfauned..

(4) The sanitary registration of dwellings.

(5) The insurance of buildings against a defective
sanitary condition.

Digitized by

Google

ox.. CXXX, No. t.] iOSTOHr MEDICAL AND SUROWAL JOUANAL.

171

It will be 8een fram the above statement that sach
.n aasociatiou would have for one of its principal
luties to keep yards clean, hoase-draina flashed,
rallies cleared oat, and all refuse promptly removed.
Landlord and tenant would thus be relieved of need-
ess worry.

Tt is a part of this scheme to insure dwellings against
preventable diseases; it does not seem probable that
this writer would advocate the indemnification of per-
sons in the case of illness, for this would open the
door to exorbitant claims. Nor is it quite clear on what
principle damages could be assessed.

His notion is that dwellings are to be kept in sani-
tary repair by his hypothetical association in consider-
ation of an annual premium paid by the owner, tenant,
or both. In order that any property should be ac-
cepted by the association as a risk, it woald be sub-
jected to a stringent examination by both engineer and
medical ofBcer. Before this inspection could be made,
a written permit must be obtained from the owner.
The report with fall details shall then be submitted to
the members of council, who, with all the facts before
them, assisted by the advice of their officials, would de-
termine on an acceptance or rejecUon, as the case might
warrant. When once the dwelling is insured, it will
be the doty of the association to see that it is kept in a
' healthy condition. It is obvious that such a house would
be snbjected to frequent inspections, and minor defects
would be at once corrected ; it is also evident that all
work (plumbing, etc.) would be performed by skilled
and trusted workmen.

The review writer thinks that builders and land-
lords would favor this scheme, (1) because they would
have an opportunity of having their property certified
and registered; (2) they would be free from petty
annoyances and frequent demand from tenants on ac-
count of unsanitary conditions arising from faulty traps,
house-drains, etc. ; (S) where the property was of such
a high order as to warrant its acceptance by the asso-
ciation as an insurance risk, the owner would practi-
cally be rid of all responsibility.

The Boston Board of Health at the present time
will, upon application, send one of its inspectors to
examine-the plumbing in a house or tenement where,
on account of sickness or for other reason, there is
cause to suspect an unsanitary condition — more than
this cannot be undertaken without greatly increased
resources. In other and smaller cities of this State a
similar provision prevails, though the ability to re-
spond to such demands is even less in proportion to
the populations. The New York Board undertakes to
do there about what the Boston Board does here.

Snch an incident as the following, however, is not
unheard of. In a large building, rented for industrial
parpotes, complaint is made by the occupants that the
plambiog is defective. Inspection by the Board of
Heslth shows that the complaints are well-founded,
and that the defects are both grievous and dangerous
to health. The owner is notified. Plumbers are em-
ployed, and several hundred dollars are expended.

Their work is approved by an inspector of plumbing
in the department of the inspector of buildings. Upon
re-examination, the Board of Health finds the condition
of the plumbing as faulty as before, but the work
having been accepted and approved by the inspector
of the other department, the Board is powerless to
take farther action, the owner's money has been
wasted, and the occupants are still exposed to the
same danger and inconvenience.

It is not a new proposal to undertake the sanitary
inspection of dwellings and of buildings as a private
commercial enterprise, but we donbt if it hitherto has
been successful from a financial standpoint There is
no doubt, however, that of two dwellings offered for
lease or for sale, one of which carried a guarantee of
its sanitary condition and the other not, the former
should, and we believe would, command a better price
than the latter.

SURGICAL TREATMENT OF CRIME.

In the last issue of the Jodbna^l, editorial reference
was made to a curious bill lately presented to the
Ohio Legislature for the treatment of condemned crim-
inals by using them as material for physiological ex-
periment, and then potting them to death under ether.
This may be called the physiological treatment of
crime.

We have, before this, on several occasions referred
to a proposition which is not new, but which seems to
commend itself to members of the medical profession
in our Southern States, namely, that criminals should
be reformed and held in check by castration, instead
of by imprisonment and hanging. A correspondent,
Dr. Bishop, of Smithsburg, Md., sends us his views on
this subject, which are not without originality as set
forth before the Medical Society of Washington
County, under the title of " Surgical Treatment of
Crime."

Dr. Bishop is impressed with the feeling that law
is a curious business, and that lawyers are curious
people, hut he thinks there might be hope of improve-
ment if the legal mind would give its attention to
medical methods. This idea he develops as follows :

" If a case comes into court (the hospital for the care of
social maladies being bo called) for treatment for curative
or preventive results, and a remedy should be proposed
altogether rational and promising, its use is not permitted by
the learned judge until a precedent for it has been discov-
ered. Then the counsel in the case turn over the pages of
legal lore to the times when people did not seem to know
much of their own affairs, and if they find something like
the case in h^d (like it, because it is not like anything
else), then they employ it as a remedy, — not otherwise.
Under such circumstances it is hardly matter for wonder
that the disease keeps ahead of the remedy, or that the
law's delay should be a proverb and a threat against hon-
est business. It is not so in medicine. If a physical mal-
ady occurs, all scientific methods are at once invoked to
ducover its nature and an efficient remedy and preventive.
Clwmistry, microscopy, physiology, are all employed. The
profession everywhere is enlisted in the investigation.

Digitized by

Google

172

BOSTON MEblCAL AtfD SVttGJCAL JOVHHAl. [pEBBtiBt l4, 1894,

One doctor is never employed by anybody to defeat the
honest efforts of another.' Under such conditions it is
hardly marvellous tliat there should occur marvellously con-
trasting results. In court, in equity cases so-called, the
chances are largely with the rogue."

Returning to the subject of surgical treatment of
crime, he says :

"Crime of all kinds is on the increase; our jails and
almshouses and other asylums are filled with its products.
Lynch-law cases (the signal-Ughts of lost confidence in
courts of justice) are flashing everywhere every day, and
everyday business transactions are largely based on indi-
vidual integrity.

" On the other hand, it need only be mentioned that the
average of human life' is being gradually raised. Not only
that, however, but all the deadly diseases of the past are
under virtual control.

" Population is no longer decimated. People no longer
fly in insane fear from house and home at the approach of
cholera or yellow fever where medical men hold sway.

" Seeing that these things are so, would it not be wise
for the one profession to borrow the methods of the other ?
Nay, would it not be even better to profit by both their
example and assistance?

" The medical profession have long since shown that
criminals are of germ origin, some peculiar character or
condition of the spermatozoon resulting inevitably in the
production of a criminaL The saying, 'Naseitur turn Jit,'
is as true, therefore, for the criminal as it is for the poet.
Now, the doctors have found that the true way to prevent
diseases of germ origin is to prevent the germ ; and if the
law wants to prevent criminals, the sure way to do it is to
sterilize the parent criminal, and the only way to do that is
to castrate him. Of course there will be a thousand ob-
jections urged against the remedy, only two of which will
be worth answering. One will be cruelty, the other danger
to life, both of which are already negatived by anesthesia
and asepsis. Doubtless there will also be the epithets ' un-
civilized ' and ' unchristian ' applied to such treatment.
But how will prevuling methods of treating criminals com-
pare with this? Now they are penned up together to
fester and ferment into more and more repulsive and dan-
gerous criminal forms, — the petty thief emerging in form
of a daring robber and the robber in the shape of a mui^
derer.

" The practical effect of it all is the production of mur-
derers by cultivation and breeding and the subsequent
slauglitering of them by hanging. The thief, especially
a bank thief, is imprisoned until the baby is weaned ; but
the spots of the leopard change not and the thief remains
a reproducing thief in spite of legal punishment. How
simple and how clean and how effectual the germicide
metitod 1 You destroy the germ factory of the thief and so
reform the thief himself more sorely and effectually than
all the prayers of the righteous would do it and prevent the
production of thieves. If you do not breed thieves yon will
not have them.

" We owe it to the old English custom of hanging thieves
that we are now as well rid of them — more than we owe
it to moral suasion.

" One curious result of the treatment would be the set-
tling of the race problem.

" Castration would hardly be a hardship to the negro.
It has been practised upon members of the race from all
time.' The harem of the Turk is always supplied with

1 Exospt In clTlng expert teatlmonr.

* Uutii tbey UTe become quite nsed to it.

negro eunuchs. Why they were selected we may never
know. Possibly it was because there were hidividiuls who
could be restrained in no other way. Of course a law
declaring all crimes not punishable by death shall be pan-
ished by castration would not be tolerated by the Consd-
tution as it is now written. But a law could be enacted
punishing all slighter crimes by an exceedingly severe flog-
ging, but releasing the criminal upon producing proof of
recent castration. There is a Japanese law which secures
the destruction of State offenders by restoring to the fam-
ily the estate if they could prove that the offender bad
committed suicide. Truly wonderful is aseptic surgery : it
enables us to literally obey the Scripture which enjoins ns
to cut off the offending member. It is, of course, taken as
understood, that lady criminals are meant also, it being as
easy to cure one as the other."

DISSECTION IN THE PUBLIC SCHOOLS.

It seems to be dawning apon the minds of some of
the members of the Boston School Committee that a
foolish thing was done when the Committee passed a
vote recently, prohibiting all dissection of animals in
the public schools. The idea apparently was that, if
zoology could not be taught withont dissection, so
mach the worse for zoology. Some members of the
Committee, however, have now sufficiently recovered
their mental equilibrinm to admit that a cold-blooded'
animal, a fish or an oyster, for instance, may be dis-
sected, but a warm-blooded animal may not.

This somehow suggests the art-oodo of members
of oar common council, that little boys in diapers or
panties may be done in stone, bnt little boys without
may not.

At the last meeting, on Wednesday evening, it was
voted, after a sharp discassion, that dissection of ani-
mals be allowed in the public schools, and so the ques-
tion retnrns to the itatus quo <mte. We are not by
any means enthusiastic that zoology should be tanght
in the public schools — certainly not in the grammar
grade ; but if it is to be taught at all, there is but one
way to teach it — thoronghly, by means of dissection.

MEDICAL NOTES.

A Special Vaccination Train. — The Pennsyl-
vania Railroad Company has sent oat a special train
with two physicians, who are to go over the whole line
to Chicago and vaccinate at each station all the switch-
men, section-men, gate-keepers and other enotploy^s.

The Medical Societt of the District or
Columbia. — The Medical Society of the District of
Columbia will celebrate the seventy-fifth anniversary
of its organization in Washington, on Friday, Febru-
ary 16th.

A New Medical Qcarterlt. — Dr. Joseph M.
Matthews, of Louisville, Ky., has issued the first num-
ber of his new quarterly journal devoted to the diseases
of the rectum, gastro-intestinal diseases, and rectal and
gastro-intestinal surgery.

Digitized by

Google

Vol. CXXX, No. 7.] BOSfOlf MM)I0AL AtfJb St/AGlCAl JOtJRNAL.

173

A Nbw Italian Joubnal. — Guido Baccelli, M.D.,
Minister of Public Ingtraction in the Italian Cabinet
and Director of the Medical Clinic in Rome, is to edit,
with the association of Dr. Durante, a new Italian
medical journal, II Polielinieo, a periodical of medi-
cine, surgery and hygiene.

Tbk Academt of Medicine Bubbau of Nubses.
— The New York Academy of Medicine has estab-
lished a bureau of nurses which was opened February
5th. Each nurse is charged a registration fee of two
dollars ; and a complete record of ail her cases is kept
on file, with the report of the attending physician as
to her work. It is hoped to have the bureau open
both by day and night as soon as it is sufficiently or-
ganized.

The Sbobxtaet of the Wisconsin State Boabd
OF Health.— U. O. B. Wingate, M.D., M.M.S.S.,
of Milwaukee, has been elected Secretary of the Wis-
consio State Board of Health, to succeed J. T. Reeve,
M.D., who retires June Ist next, after serving in that
capacity since the board was organized, nineteen years
ago. Dr. Wiogate's term of four years as Commis-
sioner of Health of Milwaukee, expires in April next ;
about two years ago he was appointed on the State
Board of Health for a term of seven years by Grov-
emor Peck.

The Photkctite Influence of Vaccination.
— The report of the medical superintendent of the
hospital-ships of England is strongly corroborative of
previously recorded experience as to the protective
iofloence of vaccination in safeguarding nurses and
members of the staff of small-pox hospitals against an
attack, and more especially a fatal attack, of that dis-
ease. Of 1,201 persons employed on the staff of the
hospital-ships during the years 1884 to 1892, only six,
or one-half per cent., contracted small-pox, and all of
those attacked recovered.

The Intebnational Medical Conobess. — The
Minister o( the Treasury of Italy has awarded the
ram of 80,000 lire ($6,000) from the reserve fund of
the treasury, toward the expenses of the Eleventh In-
ternational Medical Congress of Rome. This is given
as a temporary instalment pending the meeting of
parliament, when a special bill for an adequate con-
tribution from the State will be presented by the
ministry.

The Intebnational Sanitabt Confebbnce at
Fabis. — The International Sanitary Conference which
was to have met in Paris during the last week in Janu-
ary for the consideration of measures to control the
cholera in the Red Sea and Persian Gulf in connec-
tion with the Pilgrimages to Mecca, was postponed by
the French Grovernment owing to incomplete arrange-
ments made by other countries, especially Turkey
which appointed no delegates. The postponed meet-
ing was opened on the 7th of February, and the mem-
bers were received by President Carnot, who welcomed
them to the warmest hospitality in the name of the
Republic.

Pbbliminabt Pbooramme of the Congress of
Ahebican Pbtsicians and Suboeons. — At the
Congress of American Physicians and Surgeons to be
held in Washington May 29th, SOth, 31st, and June 1st,
the following subjects have been selected for discussion :
By the Association of American Anatomists, " Mor-
phology as a Factor in the Study of Disease " ; by the
American Climatological Association, " Sewer Gas " ;
by the American Dermatological Association, " The
Distribution and Control of Leprosy in the United
States " ; by the American Association of Genito-
urinary Surgeons, " Nephritis iu its Surgical Aspects " ;
by the American GyBcecological Society, "The Con-
servative Surgery of the Female Pelvic Organs " ; by
the American Laryngological Association, " The Sur-
gery of the Accessory Sinuses of the Nose " ; by the
American Neurological Association, "The Influence
of Infections Processes on the Nervous System."

BOSTON AND NEW ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon, February 14th, there
were reported to the Board of Health of Boston the
following numbers of cases of acute infectious diseases :
diphtheria 24, scarlet fever 44, measles 10.

Rbpobt on State Contbol of Vaccine Fabms.

— At the next meeting of the Section for Clinical
Medicine of the Suffolk District Society, Wednesday,
February 2l8t, Dr. D. D. Gilbert, of Dorchester, will
give the report of a Committee appointed by the Nor-
folk District Society to investigate the various vaccine
farms with reference to State control. The Commit-
tee was appointed to act with the aid of the Suffolk
District.

The Massachusetts General Hospital. — At
the meeting of the Corporation of the Massachusetts
General Hospital last week, the following officers were
elected : President, Charles H. Dalton ; Vice-President,
John Lowell ; Treasurer, Franklin Haven ; Secretary,
Thomas B. Hall ; Trustees on the part of the Corpora-
tion, Arthur Astor Cary, Edmund Dwight, Samuel
Eliot, William Endicott, Jr„ Thornton E. Lothrop,
Nathaniel Thayer, Henry P. Walcott, Roger Wolcott.
The Governor has sent to the Executive Council the
following nominations as trustees of the hospital on
behalf of the State : Charles T. Bemis, of Medford ;
David P. Kimball, Thomas E. Proctor, and William
S. Bigelow, M.D., of Boston.

Cost of the Suall-Pox Epidehio in Lowell.

— There were eight cases of small-pox in Lowell dur-
ing the recent epidemic. Their occurrence cost the
city nearly $7,000. This sum includes the hospital ex-
penses and the cost of the free public vaccination.

NEW TOBK.

Cbildeen in Factobies. — The State Factory In-
spectors, in their annual report, transmitted to the leg-
islature on January 31st, state that the number of chil-
dren under sixteen found employed during 1893, was
a fraction under 84 in each 1,000 persons, as against

Digitized by

Google

174

BOSTON MSDlOAL AMD aUnotOAL JOVMNAl. fl^BUABT 1$, 1894.

88 daring 1892, and 112 in 1887; showing a decrease
of about 10 per cent, over 1892 and of 70 per cent,
over 1886, when the law restricting the employment
of children went into effect.

A Reception to the Suroeon-Gbhbbal. — On
Tuesday evening, February 6th, Mr. William Wood,
the publisher, gave a large reception at his residence
on 63d Street in honor of the new Snrgeon -General
of the United States Army, Dr. Greorge M. Sternberg,
at which there were present a representative gathering
of the medical profession of New York and a number
of other guests.

A FiRB AT the Mbmobial Hospital in Bbook-
LTN. — On the evening of February 5tb there was a
serious fire at the Memorial Hospital for Women and
Children in Brooklyn, which broke out in the operat-
ing room. All the patients, however, were soecessfnlly
removed to the nnrses' dormitory. The hospital is a
three-story frame building, and it will be some time
before the damage inflicted can be repaired. A
longer and more substantial building is now in process
of construction, and funds, are being raised for its
completion.

Transfusion of Blood in Asphyxia fbom Illc-
MiNATiNO Gas. — In the case of a woman asphyxiated
with illumiaating gas recently admitted to the Long
Island College Hospital, Brooklyn, all other remedies
having failed to relieve the patient, transfusion was
resorted to, and the blood for the purpose was gener-
ously supplied by the house-surgeon, Dr. Franklin W.
Kemp. There was some temporary improvement after
the operation, but she died the following day. A
young girl, seventeen years of age, who had slept in the
same room with this patient and had also been over-
come by the gas, was successfully treated by the ordi-
nary means.

Small-Pox. — During the week ending February
10th, 28 cases of small-pox were reported, with 9
deaths, against 22 cases and 4 deaths the previous
week ; and 594 cases of measles, with 19 deaths,
against 554 and 20 deaths the previous week. The
other contagious diseases showed a decrease. There
were reported 129 cases of scarlet fever, with 16
deaths, against 151 cases and 20 deaths the previous
week; diphtheria, 190 cases and 59 deaths, against
197 cases and 58 deaths. The total number of deaths
in the city was 868, an increase of 20 on the week
ending February 3d.

philadelphia.

Pboteotion of Wateb-Sdpplies in Pbhnstl-
YANiA. — A conference of county and other local
boards of health of the State of Pennsylvania was held
at Harrisburg during the week ending January 29th.
The preservation of the water-supplies of communities
from pollution was discussed, and a resolution adopted
pledging all boards of health in the commonwealth to
do all in their power to prevent contamination of the
inland waters of the State. In a paper read by the
Health OfiBoer of Philadelphia the work done by the

Woman's Health Protective Association in stimnlst-
ing sanitary reforms, such as keeping streets clean, re-
moving nuisances, and improved household hygiene
was referred to in the higheat terms of approbation.
The communications read were generally of a very
practical and useful character. It was decided to form
a permanent organization, which is to hold annasl
meetings at Harrisburg. The name adopted is " The
State Association of Health Authorities of Pennsyl-
vania." All persons officially connected with boards
of health of this commonwealth shall be members, and
honorary members may be elected from those who
have rendered distinguished services to sanitation.
Committees on Legislation and on Publication were
provided for, besides an Executive Committee- The
following officers were elected for the ensuing year:
President, Hon. Robert E. Pattison (the Governor of
Pennsylvania). Vice-President, Major Moses Yeale,
Philadelphia; Hon. Thomas P. Merritt, Beading; J.
H. McClelland, M.D., Pittsburgh. Secretary, Wm. B.
Atkinson, M.D., Philadelphia. Treasurer, Jesse C.
Green, M.D., West Chester. At the first session, Dr.
Walter Wyman, Snpervuing Surgeon-General United
States Marine-Hospital Service, and Dr. J. H. Baoch,
of the Illinois State Board of Health, were elected
honorary members of the Association. This recent
development in public health work is principally due
to the zeal of Dr. Benjamin Lee, the secretary of the
State Board of Health.

THE STUDY OF PEDIATRICS.

Db. W. S. Cbbistopher^ makes an earnest plea
for the more general and thorough study of the dis-
eases of children. As it is the most immature depart-
ment of clinical medicine, so it offers one of the richest
fields of work for the student and pioneer. '< Internal
medicine," he says, "is taught almost universally
from the standpoint of the adult, and pediatric mani-
festations of disease are only incidentally referred to.
The consequence is that the new graduate la afraid of
a baby, readily accepts the diagnosis of the grand-
mother, and not infrequently follows her treatment."

Another important factor in the retardation of the
study of infantile disorders is the inherent difficulty of
diagnosis. While the infant has not the power of
speech, yet it does possess a very distinct and quite
full language, the acquirement of which, however,
demands faithful and persistent efEort on the part of
the practitioner. This language is quite as diflScalt to
acquire as the manual skill needed iu so many of the
mechanical departments of the profession.

The foundation of the new work lies in the study
and appreciation of the normal processes of growth,
and of the development of functions which at birth and
in infancy are so immature as practically to be non-
existent. The anatomy and physiology of infancy and
childhood are as much a part of pediatrics as ia their
pathology.

The great importance of environmental factors in

> AmwlMn Journal of OtMtetrioi, ItaoMrj, UM.

Digitized by

Google

OK.. CXXX, No. 7.3 BOSTON MEDICAL AND SVSOJOAL JOURNAL.

175

le child's deTelopment is to be boroe in mind : both
■e natritive, the ssDitary and the peychio. All are
* l>e considered. Infant-feeding is not the whole of
ediatrics, though, from the clinician'* standpoint, it is
ke most important single factor.

1''be advantage gained from this systematic study of
isease in children is not the child's alone. Mach
igfat will be thrown apon disease as it occurs in adults,
,nd a keener appreciation of many conditions will be
>088ible. The study is important for the great light
irbich it will shed upon the diseases of adults, for the
better alleviation of the sufferings of the helpless little
ones, aud for the broader and nobler, because farther-
reacbiog, purpose of improving the race.

ConrejBt)ionDence*

SIR ANDREW CLARK ON OCCUPATION.

In the course of a most interesting lecture on the
treatment of fibroid phthisis,^ Sir Andrew Clark
makes the following observations on occupation, which
show clearly the peculiar quality which gave him his
wonderful control over his patients. After speaking
of the prime importance of proper food, clothing and
exercise, he says :

"Another point about the management of those
cases is occupation. If people are wonderfully well
off in life, and a member of the family falls sick or be-
comes delicate, they are disposed to take him away
from work on the ground that work is bad for him. I
do not agree with them at all. I think that is about
the biggest mistake that you will have to encounter.
Labor vitee vita ett. Labor is the life of life ; and es-
pecially is it the life of life to ' the delicate. And
when any organ is sick it is then truer than in health
that even in sickness and delicacy it is better for the
organ to do what work of its own it can, provided it
can do it without injury. And I can say to you from
a considerable experience of tuberculous pulmonary
disease, I can say with perfect confidence, that those
who have done tJie best have usually been those who
have occupied themselves the most. . . . Then
comes tranquility of mind. Yes, labor is life, but
worry is killing. It is bad management that kills
people. I am frequently told that such and such a
man has overworked himself. Nature will let no man
overwork himself unless he plays her false — takes
stimulants at irregular times, smokes too much or
« takes opium. If he is regular and obeys the laws of
health and walks in the way of physiological righteous-
ness, nature will never allow him or any person to
work too much. I have never yet seen a case of
breaking down from mere overwork alone; but I
admit that it is necessary above all things to cultivate
tranquility of mind. Try to help your patients to
exercise their wills in res;ard to this, for wills count
for something in securing tranquility — to accept
things as they are, and not to bother about yesterday,
which is gone forever ; not to bother about to-morrow,
which is not theirs ; but to take the present day and
make the best of it. Those affectionate women who
will cootinually peer into what lies beyond never have
any present life at all — they are always grizzling
over the past or prying into the future; and this
blessed to-day, which is all that we are sure of, they
never have."

> iMttt, Juawucj S, 1894.

THE VERMIFORM APPENDIX.

Clinton, Iowa, February 10, 1894.

Mr. Editor: — Recent articles on appendicitis have
suggested to my mind that if the vermiform appendix is of
no use to its possessor from his birth to his death, it follows
that its period of usefulness must have preceded his birth.
In that case It must be a remnant of the umbilical cord,
and should have been removed at birth, as is the custom,
beyond a doubt, among the brute creation. The depression
of the human navel, as compared with the smooth cicatrix
of the brute, indicates a different condition of the interior
of the abdomen of the one as compared with that of the
other.

My belief that animals remove this from the body of their
young at birth, rests on the fact that I have witnessed the
operation. Over a dozen years ago I befriended a little
female dog in her hour of travail, and, instead of concealing,
she seemed to take pains to make evident to me what ser-
vices she rendered her }'0ung. Cautiously, with the points
of her teeth, she made an incision around the umbilical
cord about an inch from the body. This incision disclosed
an inner membrane sheatlied within the outer one. Grasp-
nig this inner membrane with her teeth and pushing with her
forepaws on the little body, she pulled vigorously at the mem-
brane, withdrawing quite a quantity through the umbilical
orifice and out of the body of the pup. When she had re-
moved all that would yield to her efforts, she bit it off and
carefully and neatly chewed together the severed edges of
the part that remained. Then commencing at the hind
quarters of iJie little thing, which was lying limp and help-
less, she cave it a vigorous licking with lier tongue. Every
sweep of ner tongue seemed to give it life, and also to raise
it slightly, when it would fall back again. She persevered
and soon had it nearly upright, stsnding on its head and
shoulders ; but she did not leave it till slie had thoroughly
licked it all over and had brushed every hair into its proper
place.

I have reason to believe that this custom prevails among
all animals, though they perform the operation in a manner
to defy the curiosity of man. The instinct of the brute
prompts her to devour ravenously, everything; ejected with
her young. Having consumed all that is visible, she pursues
the invisible, whicli she extracts by suction, while ostensi-
bly she is merely licking her offspring. The ripples that
pass through the little one, and the contortions it involunter-
ily undergoes, testify, however, to some change which is
occurring within, such as, possibly, the removalof a sepa-
rate tissue enveloping each individual organ.

If, as the Scripture teaches, our first parents were created,
not born, and created in the image of One who was not
born, there could be no raison d'etre for a navel-. On the
other hand, if mankind is an evolution from the animal,
why did his reason bid him discard a practice which he had
followed with success as a brute ? We seem to hold a chain
which stretches back, link by link, through past generations,
till we reach a point coeval with the Fall of Man« Is it a
cause or a result?

Looking forward, however, what might be the result if
man would learn of Nature from the brutes around him ?
To the infant, immunity from pain, a life as healthy as any
little animal ; to the woman, a vast decrease in the pains of
gestation and parturition ; to mankind at large, less liability
to hereditary disease and a freedom hitherto unknown from
those unnatural appetites which sink man below the level
of the brute, and lead to insanity and suicide.

Certainly, the subject is well worthy of investigation ; .
and the solution of the problem would tend to raise man to
a plane far above his present level ; and the generations
of the future, by avoiding the mistakes of their forefathers,
would attain the perfect type of the human form divine.
Very truly yours,

Marqarkt C. Hates.

Digitized by

Google

176

BOSTON MEDICAL AND SUR6IOAL JOURNAL. [Fkbbuabt 15, 1894

HETEOROLOOICAL RECORD,

For the week endine Febrnaiy 3, in Boston, acooidinf: to ob-
servationB furnished by Sergeuit J. W. Smith, of the United
States Signal Corps: —

Baro-

Thermom-I Relative

Direction

VeloeltylWe'th'r.

1

meter

eter. hnmlditT.

of wind.

of wind.

•

Date.

i

e

1 J ii ■

i

i

a

>i

i

a

a

a

a

a

i

£•'1-2

i it ' 5

Sis

•

S

0.

S

S

a.

8

S

a
2

Q

OSS

oc !od

c

00 1 00 .^ 00

00

«

«0

8..28

30.38

26 32 19

eo! 66 58

w. ; W. 1 W 1 8

0.

C.

M..2S

30.10

28 36 19

73'l00 86 N.W.

N.E. 5

28

o.

N.

0.36

T..30

29.08

31 138 23

100: 70 85; N.

W.

!T

25

N. C.

0.74

W.31

29.88

32 38 25

60; 601 60 w.

W.

15

13

0.

C.

T.. 1

29.96

27 3023

60| 6(1] 60 N.

N.W.

9

8

<).

U.

P.. 2

30.17

23 30 ! 16

83' 47 66 W.

S.W.

10

10

(;.

0.

8.. 3

29.80

32 41 23

81, CO

70 S.

W.

12

9

0.

O.

tr

1 ■ 1

1

*0.,oloii(l7; C, clear; F., 'ftfri U., foffi IlMhmzyi 8..imnky! R..niiii T..thr««t-
Milngt N. . IDOV. t iBdicfttM trmc« of nunfall. a^ M«»n for vcek.

RECORD OF MORTALTTY
Fob thb Wbek skding Satubdat, Fkbbuabt 8, 18M.

li

■

Percentage of deaths from

J .a

•o ►• . •

•■e.

Oltlet.

¥.

J^

°£ If

n

«S

i

p

l,t<9l,306

2,"

848

■3 9»

1 i'

i^

|i

¥

1

New York . .

344 19.06

21.00

8.62

2.40 S.36

CbJoago . . .
Philadelphia .

1,438,000

— — . •

—

_

1.116,662

462

144 9.90 20.24

6.60

.66

.44

Brooklyn . .

978,394

3116

16J 1 12.26 ; 25.26

8.00

1.60

.60

St. Loula . . .

6«U,U00

—

—

^ —

_

Boetou . , .

4K7,397

220

69

12.16 22.05

7^0

iM

_

Baltimore . .

BOU.OOO

—

—

_ 1 _

—

__

Washington

808,431

95

35

11.66 ' 19.95

6^

_

1.0ff

Olnelnnatl . .

305,000

Ub

42

10.44 24.36

3.48

_

Cleveland . .

290.000

87

23

13.09 16.47

5M

,_

i.to

PItUburg . .

263,709

87

41

20.23 —

5.95

9.62

Milwankee . .

260,000

83

42

22.80 13.20

9.G0

1.20

4.80

Nashville . .

87.764

26

9

— ; 20.00

—

Charleston . .

65,105

87

13

6.40

28.80

—

2.70

Portland . . ,

40,000

14

3

—

7.14

—

—

— .

Worcester . .

96,217

31

13 19.38

26.t4

16.10

—

FallKirer . .

87,411

31

11

9.69 . 32.30

—

8.23

_

Lowell . . .

87,191

36

8

17.10 14.26

—

2.86

Cambridge . .

77,100

37

lU

— 32.4V

__

._

Lynn ....

62,666

14

0

7.14 7.14

—

^

..

Springfield . .

48,684

IV

2

6.>8 17.64

—

—

_

Lawrence . .

48,366

10

0 10.00

■ —

—

10.00

—

New Bedford .

45,886

19

6 1 6.26

21M

^

—

^

Uolyoke . . .

41.278

8

3 ! 12.60

MAO

—

^

__

Salem ....

32,233

14

4 . 21.42 21.42

—

Brockton . .

82,140

1

0

14.k8

14.28

~-

.._

^

Haverhill . .

31.396

12

I

16.66

8.33

16.66

_

_

Chelsea . . .

30,264

t

0

14.28

14.28

—

_

Maiden . . .

29,394

6

1

—

—

_

—

Newton . . .

27,686

12

2

16.66

8^

16.66

__

_

Fitohburg . ,

27,148

—

— 1 ~

—

—

—

Taunton . . .

26,972

r;

2 , —

29.40

—

—

_

QlouceBter . .

26,688

10

4 .20.00

20.00

—

.^

Wallham . .

22,068

0

0 —

_

_

Qniucy . . .
PitMlIeld . .

19,642

6

» -

._

—

_

18,l>02

2

0 —

—

—

—

Everett . .. .

16,6*6

5

I — 20.00

—

—

..

Northampton ,

16,331

6

1 . - 20.00

^

_

Newbnryport .

14,073

6

2 16.66 I6.C6

—

_

—

Amesbury . .

1(1,920

2

1 50.00 —

^

~~

Deaths reported '2,811 : under five years of age 1,000 ; principal
infectious diseases (small-pox, measles, diphtheria and croup,
diarrhceal diseases, wboopiDg-cou^h, erysipelas and fever) 377,
acute lung diseases 4t>7, consumption .SOO, diphtheria and croup
190, scarlet fever 47, measles 39, typhoid fever 28, diarrhoea!
diseases 2(>, cerebro-spinal meningitis 18, whooping-cough 18,
erysipelas 10, small-pox 6.

From typhoid fever Philadelphia R, New York, Cincinnati aod
Lowell 4 each, Brooklyn 3, Cleveland and Pittsburgh 2 each,
Boston, Milwaukee aud Springfield 1 each. From diarrboeal
diseases New York, 13, Cincinnati 4, Brooklyn and Milwaukee
3 each, Charleston, Fall Kiver and Somerville 1 each. From
cerebro-spinal meningitis New York 8, Cleveland 2, Brooklyn,
Washington, Worcester, l.ynn, Holyoke, Chelsea and Amesbury
leach. From whooping-cough Boston 4, New York and Wash-
ington 3 each, Philadelphia and Milwaukee 2 each, Cincinnati,

Cleveland and Fall River 1 each. From eiystpelaa New York 5,
Philadelphia 2, Boaton, Pittsburgh and Lowell 1 each. From
small-pox New York 4, Brooklyn and Boston 1 each.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,468,142, for the week ending
January 2Tth, the death-rate was 20.7. Deaths reported 4,166;
acnte diseases of the respiratory organs (London) 422, whoopinK-
oongh 1U2, diphtheria 80, measles 73, fever 42, dtarrhma 42,
acanet fever 3S, small-pox (Birmingham 7, Bradford 3, Bristol
2, London, Nottingham, Liverpool and Halifax 1 each) 16.

The death-rates ranged from 14.8 in Derby to 31.1 in Nor-
wich ; Birmingham 26.6, Bradford 19.6, Croydon 17.7, HalKax

18.5, Hull 18.6, Leeds 18.8, Leicester 14.9, Liverpool 24.6, London

19.8, Manchester 23.8, Newcastle-on-Tyne 19.9, Nottingham

18.9, Portsmouth 16 8, Salford 30.1, Sheffield 19.7, Sunderland

16.6, West Ham 16.0.

OFFICIAL U8T OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE BfEDIGAL
DEPARTMENT. U. S. ARMY, FROM FBBRCARY 8, 18M,
TO FEBRUARY 9. 1891.

The following named officers of the medical department are
relieved from dnty in this city, to take effect upon the comple-
tion of the nreseut course of instruction at the Army Medical
School, and are assigned to duty at the stations hereinafter
designated: Fibst-Libut. William W. Qdintom, assistant
rargeon. Fort Riley, Kansas ; Fibst-Luut. Thokas S. Bkat-
TOM, assistant surgeon. Fort Niobrara, Nebraska; Fibst-Ludt.
Dkakb C. Howabd, assistant surgeon. Fort Bnford, North
Dakota; Fibst-Libut. Albxandbb S. Pobtbb, assistant sur-
geon. Fort Keogh, Montana ; Fibst-Libut. William H. Wil-
son, assistant surgeon. Fort Leavenworth, Kansas.

Leave of absence for two months, with permission to go be-
yond sea, is granted Hajob Robxbt M. O'Rbillt, surgeon,
U. 8. A.

FiBST-LiKUT. Bbnjahim Bbookb, assistant surgeon, is re-
lieved from duty at Fort Leavenworth, Kansas, to take effect
upon the arrival of Fiest-Libut. Wm. H. Wilsok, assistant
surgeon, at that post and ordered to Camp Pitot, Butte, Wyo-
ming, for duty.

OFFICIAL LIST OF CHANGES IN THB MEDICAL CORPS
OF THE U. S. NAVY FOR THB WEEK BNDING FEB-
RUARY 10, 1894.

Frank C. Cook, assistant surgeon, ordered to the Naval
Xjiboratory and Department of Instruction, New York.

SOCIETY NOTICE.

MA88ACHIT8KTT8 MbDICAL SoCIBTT, SUITOLK DISTBICT. —

The Section for Clinical Medicine, Pathology and Hygiene will
meet at 19 Boylston Place, on Wednesday, Febraary 21st, at 8
o'clock.

Papers : Dr. D. D. Gilbert, of Dorchester, will give the report
of a committee appointed by the Norfolk District Medical So-
ciety, to investigate the production of " Vaccine Virus."
Dr. A. P. Chadbourne will read on " Fibroid Phthisis."

F. C. Shattuck, M.D., Chairman.
Hbnbt Jackjk>n, M.D., Secretarj/.

RECENT DEATH.

Thbodob Billboth, H.D., professor of surgery in the Uni-
versity of Vienna, died at Abbazia, in Austria, February 6Ui,
aged sixty-fonr years. He was born on the Island of Rogen, in
the Baltic, aud received his education in arts and medicine at
Gottingen, Berlin and Vienna. In 185S he was assistant to
Langenbeck at the clinic. In 1869 he was made professor at
Zurich, but returned to Vienna in 1867 where be haa since re-
mained. During the Franco-Prussian War he had charge of the
military hospitals on the Rhine. In 1881 he performed snocess-
f ully the first operation of pylorectomy for cancer of the jstom-
ach. Of his numerous writings bis work on " Surgical Pathol-
ogy " is probably the best known.

BOOKS AND PAMPHLETS RECEIVED.

Anger; An Analysis of the Words of Jesus Christ Concerning
Anger, as Given In the Sermon on the Mount. By Aaron M.
Crane, Boston,

Trephining in Its Ancient and Modem Aspect. By John
Fletcher Home, M.D., D.Sc. (Hon.), F.R.C.8., Ed. London:
John Bale & Sons. 1894.

Treatment of the Diseases of the Stomach and Inteetinea. By
Dr. Albert Matbien, Physician to the Paris Hospitals. New
York : William Wood & Co. 1894.

Digitized by

Google

toL. CXXX, No. 8.] BOSTON MEDICAL AND SUR610AL JOURNAL.

177

Original %xtxt\t^,

FOUR CASES OF MYXEDEMA TREATED BY
THYROID EXTRACT.

BT rSBOKlUCK O. 8HATTDCK. M.D.

Tbk evolution of onr knowledge of the functions of
the thjroid gland and the interdependence of atrophy
of the gland and the disease which, following Ord, we
call myxoedema, will constitute, I think, one of the
most interesting chapters of the medical history of our
time. Cretinism, endemic and sporadic, had long been
known when the late Sir William Gull, just twenty
years ago, published his paper on " A Cretinoid State
Sopervening in Adult Life in Women." The next
important step was taken when the Swiss surgeons,
Eocher and Reverdin, recognized the identity in symp-
toms of the cases described by Gull and certain cases
in which total extirpation of the thyroid gland for goitre
hadbeen practised. Then came the confirmatory experi-
meotal evidence derived from extirpation in animals,
notably dogs and moukeys, and complete demonstration
that the thjroidgland plays an extremely important rdle
in the economy, profoundly influencing the nutrition of
the central nervous system, and through it of the skin
sod its appendages in particular. Antiseptic surgery
rendered the next step possible — the transplantation
of the thyroid gland. Temporary improvement fol-
lowed this procedure: but it was only temporary, as a
rale, inasmuch as the gland underwent absorption in-
stead of rooting itself and persisting as such. The
disease thus remained of great clinical and pathological
interest, but was considered practically not amenable
to treatment. For instance. Osier's " Practice of Med-
icine," the prefatory note of which bears the dale Jan-
nary 1, 1892, says : " Unfortunately, no satisfactory
treatment is known. The patients suffer in cold and
improve gradually in warm weather ; they should
therefore be kept at an even temperature and should,
if possible, move to a warm climate in the winter
months." How differently would this passage have
been worded January 1, 1898 !

To Dr. Greorge Murray, of Newcastle, England, be-
longs the credit of the practical introduction of our
present brilliantly successful treatment. In 1891, he
began the hypodermic injection of a glycerine extract
of the sheep's thyroid. The obvious dangers and in-
conveniences of this method led to the attempt to
attain the same good results by the feeding of the
raw gland, finely minced, to myxosdematous patients.
MirabiU dietu, gastric and intestinal digestion were
loood not to impair the efficacy of the gland, and it
was proved to be still active even when moderately
cooked. Under these circumstances it is not to be
wondered at that dried or liquid extracts of the gland,
which offer convenient modes of administration, are
foood to be thoroughly effective. We are still much
in the dark as to exactly what the gland does in the
economy and bow it does it, and we must probably
look to physiological chemistry for the answer to these
qaestions. The interest of the subject is so great that
I have not been able to refrain from these iotrodactory
remarks to a brief report of four cases in private prac-
tice which I have thus far treated by thyroid extracts.

Case I. This is, as far as I know, the first thus
tKsted in this country, and presents some points of

' ttmi before the Boeton SooletT for Medloal Improrement, De-

special interest. Miss A, twenty-nine years old, first
consulted me April 21, 1892. Her maternal great-
grandmother and great-aunt and her paternal grand-
mother died of cancer ; otherwise the family history is
unimportant. The catamenia appeared during the
thirteenth year, and were regular. She was well
until she reached the age of seventeen, when she left
school on account of frontal headache and nervous-
ness. For the next five or six years she was antemic
and lacked strength. The catamenia diminished in
amount and she had lencorrhoea ; but she did much as
other girls, nevertheless, and was fond of dancing, in
which she excelled. In 1885, much arsenic was found
in the cretonne and wall-paper of her room. These
articles were removed, and she improved somewhat ;
but remained physically below par. In October, 1890,
she took carbonate-of-iron pills, and by January 1,
1891, considered herself perfectly well. In January,
1891, normal menstruation appeared; February was
skipped ; in March, May and June there was a slight
flow; but the period has been entirely absent ever
since, nor has there been any return of the leucorrhcea.
In February, 1891, she began to gain weight, and
since then had put on twenty pounds, especially about
the face and bust. The complexion, which was for-
merly fair and delicate, had become coarse and red,
and her appearance had so changed that she was often
not recognized. Within a few months the palms of
the hands in particular, but also the soles of the feet
and portions of the integument covering the neck and
trunk, had acquired a peculiar yellow color. This
could also be detected on the mucous membrane of the
inner surface of the lips. The skin was generally
rather coarse and rough, but was deeply fissured and
cracked toward the finger-tips. The coloration of the
fingers, combined with the roughness, led Dr. Osier,
who saw her with me, to compare the skin to the cov-
ering of a goose's foot. The nails were brittle and
uneven, the hair thin and dry. The patient herself
questioned whether the color of the fingers could be
attributed to oranges, of which she had eaten many of
late ; but she observed that she could not wash or
scrub the color off, and that it did not disappear when
she temporarily omitted this fruit. She stated that
three years ago, and several times since, she had
awaked in the morning to find blisters (herpes ? ) on
her nose. Lately she had had two small red bunches
on her eyelids. One was removed by Dr. Cheney;
the other disappeared spontaneously. Later she had
another which I saw, and which looked like a stye,
though it did not suppurate. Within two years a
vaginal examination had been made by a competent
hand, which discovered nothing amiss. In past years
she had consulted specialists for her hair, and a throat
specialist, and had been under the care of several phy-
sicians one after another.

Visceral examination was negative and the tempera-
ture normal. There was no mental or physical slag-
gisbnesi ; indeed, subsequent evidence would suggest
that she was at this time mentally elated rather than
depressed or indifferent. She was not strong; but
complained chiefly of her changed appearance, coarse
complexion and unevenly distributed gain in flesh.
Perspiration was slight or absent. Her appetite was
very large, digestion good, but sleep very poor, not
more than four hours a night. I examined the blood,
though I made no regular count, nor did I estimate
the haemoglobin. I considered it practically normal

Digitized by

Google

178

BOSTON MEDICAL AND SUJtGIOAL JOVSNAL. [fsBBUART 22, 1894

as did Dr. Osier some weeks later. The urine was
uormal in amount and not very significant. It con-
tained constantly a very faint trace of albumen, uric-
acid crystals, once a few hyaline casts, and a trace of
arsenic (" A small trace in comparison with most cases
of arsenical poisoning,'' Dr. Wood reported to me).
Sapraclavicular pads were present.

Suspecting myxoedema, though the case differed
decidedly from those I had seen or read of previously,
I sent her to Dr. J. J. Putnam, providing that he
should not know my opinion before he stated his own.
He was inclined to call it obesity with menstrual dis-
turbance, rather than myxcedema. A few weeks later
Dr. Osier saw her, and concurred in my diagnosis. I
then began injections of a glycerine extract of sheep's
thyroid prepared for me with every precaution by Dr.
A. C. Jelly, who visited the abattoir weekly himself,
and kindly took infinite pains, thanks to which no un-
desirable local symptom was ever produced. The ex-
tract obtained from one gland was injected every week
in three doses for about three months by myself and
Dr. Charles Folsom, who kindly assumed charge of
her during my vacation.

For the last year she has not been under my care,
as she lives out of town and has been unable to come
in. During this year she has taken the dried extract
of Parke, Davis & Co., and is now taking the New
York glycerine extract by the month. At first, there
was improvement in the condition of the skin, but I
now believe that was attributable to the warm weather
rather than to the treatment, which has been of no real
benefit to her. About the middle of May an ecchy-
mosis appeared on the right thigh as large as a small
lemon. She had received no blow or injury so far as
she knew, and the injections were all made in the
back. In August, 1892, she began to be depressed
mentally, and several times tried to end her life ; in-
deed, for the last year she has been watched inces-
santly. The chief effects attributable to the thyroid
administration seem to be loss of flesh, strength and
appetite. A number of months ago a swelling near
the left angle of the jaw appeared and discharged
pus.

Dr. Cutler, of Waltham, under whose care she now
is, kindly writes me that the left cheek is riddled with
sinuses, and new abscesses occasionally form. He
also says : " There is no violence, and apparently no
hallucination or delusion, unless it may be a delusion
when she says she cannot possibly move while almost
in the act of walking. She is much depressed, and
indeed quite desperate often, for she is certain she
shall never be better. She has an intense prsecordial
distress often, which I judge to be the prsecordial pain
of melancholia. The hair is still falling, but new is
growing. The skin and nails are still dry and rough.
Speech is slow, but perfectly rational. She probably
still retains her suicidal inclination, but does not mani-
fest it in any way except in an occasional doubtful
word."

Her mother writes under date of December 8, 1893 :
" There are black and blue marks on her legs, which,
indeed, are so thin that they look like two sticks.
Her face is swollen, also her waist, but the chest is
hollow. The eyelids are swollen ; the eyeballs often
protrude. Her weight, which was 135 pounds when
she first consulted you, is now less than 99. The
under eye-lashes have gone. In July, 1892, her bust
measured 40 inches ; in October, 1893, 36 inches. In

July, 1892, her waist measured 88 inches ; in October,
1893, 29 inches."

I permit myself a few I'emarks on this case here, as
it is sharply contrasted with the others which I am
about to report I confess that the failure of the ap-
propriate treatment is a point against the correctness
of the diagnosis of myxcedema in this case. If it be
not myxoedema, I am at a loss what to call it. Dr.
Mitchell Clark * reports two cases of failure, the only
two I have been able to find in which treatment has
been ineffectual. The treatment lasted two months
and six weeks respectively. The use of these different
thyroid preparations in my case, one after another,
shows that the failure is not attributable to inertness
of the remedy.

Case II. Mr. B., sixty-nine years of age, consulted
me first March 26, 1898. He has had many attacks
of rheumatic iritis, and been quite deaf for a number
of years. He at first dated his symptoms from about
December, declaring that he had been perfectly well
the previous summer. Later he, and especially his
wife, felt sure that the symptoms were of older date,
and had been gradually coming on for at least a year,
though more rapidly of late. He said he was suffering
from " a dropsical tendency," and wished relief for
two symptoms, — a nearly constant watering of the
eyes and serous running from the nose, and an unsatis-
factory condition of the bowels which moved onoe
daily, the dejections being small and watery. I found
that he was notably weak, so much so that he had not
for some weeks made his accustomed daily visit to his
club, only a few steps from the house. He bad be-
come very sensitive to cold, and would sit before the
fire with his feet in a foot-muff and in a temperature
of the room which was trying to his family. A sensa-
tion as if the lining membrane of his mouth and throat
were swollen was also mentioned. Perspiration was
absent. The skin of the hands was very dry and
rough, the nails brittle; and he said his hands felt
stiff when trying to grasp anything. The integument
generally was dry and harsh, though far less so than
the hands, and his skin had previously been unusually
soft and smooth. There was pallor of the face and
slight puffiness about the eyes and cheeks, suggestive
of Bright's disease except for a translucency of the
little folds and wrinkles revealed by close examination.
The lips seemed swollen, and the lower was everted
and somewhat pendulous. There was slight oedema of
the ankles. His wife had noticed no mental change.
Supraclavicular pads were not marked. In the
median line of the neck, extending for perhaps two
inches above the thyroid cartilage, was a scar, the
result of an operation for the removal of a tumor by
Dr. Hodges some twelve years ago. Dr. Hodges
states that this was a deep-seated lipoma. The texture,
color and thickness of the hair had shown no change ;
pulse 64 ; temperature 97.5 ; and the temperature was
subnormal whenever taken during the few days which
elapsed before treatment was begun. Physical exami-
nation, including the blood, gave negative results ex-
cept as above stated and hsemoglobia 60 per cent.
The urine was only 740 c. c. in twenty-four hours ;
specific gravity 1,020 ; albumen very faint trace ; urea
nineteen grammes to the litre ; sugar absent ; a few
medium-sized hyaline casts and abnormal blood cor-
puscles.

The signs and symptoms seemed to me the same in

> British Medioal Jonmal, Aogost S7. Ita2, p. »l.

Digitized by

Google

Vol. CXXX, No. 8.] BOSTON MEDICAL AND SURGIOAL JOURNAL.

179

character as those of myzaedema, though they were
leu in degree than in any case which I had ever seen
or read of ; and I had no hesitation in making this
diagnosis, in which Dr. J. J. Putnam concurred. Dr.
Patoam was so kind as to let me have some of Parke,
Davis & Co.'s dried extract of thyroid gland, which
had not yet been put on the market ; and from April
]8t to April 5th, inclusive, fifteen grains, the eqaiva-
lent of one lobe of a sheep's thyroid, were given twice
daily. April 6th, fifteen grains were given once.
Before April 6th he complained of pains in the limbs
and back. April 10th, seven and a half grains once.
The remedy was then omitted nntil May 5th. After
dioner on the evening of April 10th, I was sent for,
and fonnd him with severe pain in the cardiac region,
resembling that of angina, with quick pulse and tem-
peratore slightly above normal. Morphia was given
nnder the skin. Fur the next two to three weeks
now he kept his bed. The attacks of pain tended to
recur toward evening, and were always accompanied
bj marked increase in the pulse-rate, though irregu-
larity and intermittency were never observed. With
the subsidence of the pain, either spontaneously or
after morphia, the rate promptly fell again. Nitro-
glycerine had no control over the pain. Repeated
and most carefnl examination of the heart itself failed
to detect any change in the size and sounds. He is a
conrageous man, whose iritic attacks have taught him
what pain is, and he is reasonably tolerant of it ; but
this anginoid pain was so severe as to necessitate
morphia hvpodermically in one-half-grain doses. Two
nights, at least, four of these were required to give
relative comfort. The whole cardiac area was tender
to pressure or touch, and a very limited spot just out-
side of the left nipple was exquisitely so. The neces-
sity for hypodermics ceased April 28th. Gradually
the attacks of pain diminished and disappeared ; as
did the tenderness, though more slowly. Meantime
the myxcedematons symptoms showed marked im-
provement. The urine more than doubled in quantity,
and April 13th was 1,028 specific gravity, with a very
faint trace of albumen and forty-six grammes of urea
to ihe litre, the sediment remaining the same. As he
lay in bed now, he kept his arms out, covered only by
his night-shirt, and desired only a sheet and one blanket
as covering instead of a thick layer as before treat-
ment. Desquamation took place as freely as after
scarlet fever, affording the patient much occupation.
The skin came off a toe like the finger of a glove.
The watering of the eyes and running at the nose
diooinished materially. May 5th, one-grain doses of
the extract every second day were given ; May 18th
to June 8th, one grain daily ; June 9th to July 5th,
two grains daily; from July 6th to the present time,
foar to eight grains duly. In June he felt better than
for a year or two, in fact, perfectly well ; and he has
since so remained, though with the advent of cold
weather the symptoms seem inclined to return in a
measure. He has been remarkably free from head-
sches, to which he was formerly much subject. His
weight has not varied materially.

Cask III. Mrs. C, thirty-four years old, consulted
me at my office in March, 1898. Her family history
was good, except that an uncle was ill for years with
"deathly pallor and bloating." The catamenia ap-
peared at fourteen and were regular until her marriage
at twenty. Ten oMoths later she was confined, and
has never since been pregpf^nU The patamenia have

recurred every five to seven months, painlessly and
otherwise normal in every way. For at least ten
years she has been notably pale, more or less " bloated,"
sensitive to cold, perspiring but little if at all, better
summers than winters. Six years ago she was oper-
ated on for laceration of the cervix, with some subse-
quent gain in strength. Her urine, she thinks,- has
not been scanty. She has been supposed to have
firigfat's disease. She thinks her memory is less good
than it was, but recognizes no other mental change.
The facies was strongly suggestive of nephritis, but
the urine was negative. Unfortunately the urea was
not quantitated. There was some swelling of the
legs without distinct pitting. Visceral and blood ex-
amination gave negative results. The temperature
was normal. The skin and its appendages were not
notably changed except for swelling and pallor.
Supraclavicular pads not marked. At her first visit I
was not inclined to think her the subject of myxoedema ;
but was led to reconsider the diagnosis after my ob-
servation of Case II, which came to me soon after. I
therefore sent for her and gave her at first seven and
a half grains of the dried extract every third day,
after three weeks every second day. There was no
unfavorable symptom except some palpitation ; later,
pains in the limbs were complained of, but they passed
oft entirely. Improvement was prompt, and has been
very marked. The swelling of her face and her girth
diminished. There was desquamation of the skin and
increase in strength. Early in June she reported that
she perspired as she had not done for a long time, and
said that all her friends were congratulating her on
her changed appearance. One grain of the extract
was ordered thrice daily, and this dose has been main-
tained ever since. I saw her a few days ago ; and
she then said that she felt better than for years, and
has regained her natural shape, though her weight has
gone up nearly twenty pounds. Her dressmaker states
that her neck measures one-half inch less, her bust
three and a half inches less, than last winter. The
swelling of the legs has disappeared. The flesh in
general has become natural in consistency ; there is
color in the lips and cheeks. She volunteered the
statement that last winter she was not comfortable if
the temperature of the room was less than 80° ; and
now she objects to a temperature above 65°.

Cask IV. Mr. D., of Missouri, visiting friends in
the £ast, was sent to me by Dr. Gage of Lowell,
November 17, 189S ; fifty-two years of age, banker.
Until five years ago his occupation was a very active
one ; since then has been sedentary. Family history,
previous history and habits good. He never had
malaria. For the past two years he has been less
strong. The past two winters his hands especially
have been very rough, and he has not perspired. Last
winter and spring his friends began to notice a change
in his color and appearance. Kest and change of
scene was advised ; but the panic came, and he had to
stay at home. He lost his appetite ; bowels became
constipated; sexual desire was lost. He was weak,
and very sensitive to cold. Some weeks ago he left
home and went to some iron springs and then came
East. He has gained fifteen pounds in flesh, with in-
creased appetite and strength since leaving home ; but
bis hands and appearance do not change. His eyes
water easily, and his tear-ducts were dilated last sum-
mer with some relief. His former weight was 205 ;
present, 180. The face presented a dirty pallor, with

Digitized by

Google

180

BOSTON MEDICAL AND SUBGIOAL JOURNAL. [Febbuakt 22, 1894.

slightly puffj and translaceot lids ; no swelling of the
lips. The skin generally was harsh, especitJly the
hands and feet. The hair dry ; sopraclavicalar pads
marked ; temperature 96.5° ; pulse 60 ; heart soands
weak, otherwise not remarkable ; lungs and abdomen
clear ; knee-jerks present. Blood negative except for
dimiuished hsBmoglobin. No enlarged glands ; no
oedema of the legs ; feet objectively very cold. Novem-
ber 17th, the daily amount of urine was about 40
ounces ; specific gravity 1,015 ; an accident prevented
the estimation of urea. November 24th, specific grav-
ity 1,020. November 29tb, specific gravity 1,025;
albumen slightest possible trace; a few casts. Decem-
ber 6th, specific gravity 1,027 ; albumen slightest
possible trace ; an occasional hyaline cast. The pa-
tient reports a distinct increase in the flow of urine,
but the amount has not again been measured. One
grain of the thyroid extract twice daily was ordered,
and November 29th four grains a day. November
29th, temperature 97.5° ; less watering at eyes ; sweat
some yesterday after exertion. Some pain and ten-
derness on right elbow. Increased thyroid extract to
six grains a day. December 6tb, pulse 72 ; tempera-
ture 97.4° ; skin about the same ; color better ; less
sensitive to cold ; eyes distinctly less watery ; is less
hoarse than for six months, and sang last Sunday for
the first time during that period. The duration of
treatment in this case has been very short; but its re-
sults confirm the diagnosis. I have learned to push
the remedy caatiously.

Cases II, III and IV are unquestionably cases of
myxcedema, and can be added to the rapidly lengthen-
ing list of cures. Dr. Kinnicutt* collected 49 cases
up to May 1st, treated by thyroid extract ; aad Dr.
B. C.'Cabot has kindly collected 68 cases published
since May Ist. As before stated, two showed no gain
under the treatment. Two of Dr. Murray's* died
suddenly while under treatment, the symptoms having
markedly improved. One was known, the other sus-
pected to have an unsound heart Dr. Cabot has found
two other fatal cases. In one diarrhoea set in after
the first dose, and death was speedy. In the other,*
figured in Plate III, in Byrom Bramwell's " Atlas of
Clinical Medicine," marked improvement in the myx-
oedematous symptoms had taken place. January 6,
1892, the patient had an attack of angina, took the
last dose, and died seventeen days later. Myocarditis
was found at the autopsy. In the 68 cases collected
by Dr. Cabot the only other untoward symptoms which
occurred often enough to make them especially sugges-
tive were : faintness and headache in six cases, nausea
and vomiting in four cases, pain in the back in four
cases.

There has been so much written on this subject of
late, and it is so prominently before the profession,
that I shall not go into statistics or any general con-
sideration of the disease and its symptoms ; but there
are several points illustrated by my cases to which I
wish to ask your indulgent attention.

In the first place, we must recognize the fact, that,
as in all other ailments, there are here differences of
degree. Naturally the extreme cases were the first
to be recognized, and to these alone does the descrip-
tion as now laid down in the text-books closely apply.

• TranBaotions of the Auoclatlon of American Physloians, vol.
TlU. 1883, p. 332.
< Britlah Medloal Journal, 1S92, II, p. 4S0.
> Edlnbargh Hedloal Journal, May, 1893, p. lOU.

Total inactivity or loss of the gland is one thing ; par-
tial inactivity or loss another. It is highly probable
that the latter does not necessarily lead to the former ;
at all events, a long period of years may elapse before
the mild passes into the fully developed disease. The
symptoms in Case III were of ten or twelve years'
duration ; and yet 1 at first crossed out myxcedema in
my differential diagnosis. Now that our attention is
awakened and we are on the lookout for cases, I am
convinced that we shall find them to be pretty commoD.
Case IV, the mildest I have seen, I am sure I should
not have recognized a year ago, although I was then
watching for cases. Case II illustrates the power of
the remedy and the dangers of overdosage. Dr. Put-
nam and I decided on the initial dose in that case, as
he had been giving that dose for some time to another,
but an extreme, case with great benefit and no unto-
ward result. The anginoid attacks caused me great
anxiety. I can now see that it was unwise to fail to
appreciate therapeutically differences in degree and
duration, but I did not see it then. It may be stud in
extenuation that knowledge of the safe dosage of the
remedy was then very slight and that experience had
to be gained. Similar anginoid attacks have been
noticed by other observers, and constitute the most
important untoward symptom likely to be encountered
during treatment Pains in the limbs and back have
also beeu noticed in some cases, and were complained
of by Case II before the appearance of the anginoid
pain. They were also present in Case III, and the
pain and tenderness of one elbow in Case IV may be
of neuritic nature.

It seems probable that the use of the remedy must
be persisted in through life, and that larger doses will
be required during the cold than during the hot weather.

Diagnosis should seldom offer any special difficulty
at present. Grave anaemias and Bright's disease are
readily excluded, as a rule. I say, " as a rule " ; for
we must not forget Starr's ' case, which had been diag-
nosticated as Bright's by eminent authorities and so
treated for years. But the albumen and casts disap-
peared entirely under thyroid extract.

SECOND ATTACKS OF TrPHOID FEVER IN
ADULTS, TWO CASES.»

BT A. L, lUaoH, M.D.,
VUiHftg Phgiieian, Botton CUy HbtpitcU.

OcoASiONALLT a patient with typhoid fever says
that he has had it before ; but ou further inquiry this
statement can rarely be verified, on account of the
lapse of time and memory, and the absence of accurate
data regarding the previous illness, the history, charts,
etc. Therefore the two following cases, which came
under my care during both the primary and the second
attacks, with an interval of two years in each case, are
recorded as being somewhat exceptional. In Case I,
that of a nurse, it seems not improbable that the dis-
ease was conveyed to her directly by the patients she
was nursing.

Case I. — First Attack. Hospital nurse, aged
twenty-four, after five days of prodromal malaise, Sep-
tember 7, 1890, was admitted to Dr. Rotch's service
with typhoid fever. She came under my care October

1 From the forthcoming Medical and Surgical Report of the Boe-
ton City UoBpltal.

• Transactions of Asaoslatiou of American FhyalcianB, 1881.

Digitized by

Google

Digitized by

Google

■<7°

1.05°
fe'04«

Bioa°
3 101 =

S ''°
5 «°

r *'

CABX L lOttT Attack.

.

Rr.u«s.

Chut /

=^

H 1

M 1

r.

M ■

M I

M 1

11 B

Jl_

M ■

m" K

M K M K

M 1

M K

il

ii

/9\ao

S-13-i

21

«9

JH.Af

m >{■• •

*±.

m ■

^

2°

3/_

M B

13

^B

3-V

«-B

35;

M K

36

5— M

1?.

3^
S-.

39

H B

^1^

~'i

—

—

1

—

—

—

—

~

—

—

__

1

/

1 ,

1

/^

ivi—

/

V

^

s/

u

/

^;\-

y

/

<■

./J

L/1

;

V\ y

I

^/^

y

iH

/

^

y

—

—

^

^

\/

. i

/v

"

V

v^

i^

Vi

:^

^

P"

i

^

/

^:t

—

—

—

—

—

—

/

—

V

1

^L /

w

\/

y

iJ

n

_..

..

—

—

vr_.

V

-..

V.

i:.

—

—

—

—

—

—

^^

—

-

—

—

—

--

1

—

—J

.^

_

F—

^_

__

.^

^_

^^

.B.

1 1

^B,

,,.l, 1

l_

_

CASE L SscoXD Attaox. Oitft f

107 =

/6

M M.

11

/9

M B

20

M B

M B

22

M B

£3

M B

—

M B

M I

£6

M ■

£7

M B

£8

kli' B

29

m 1

30

M B

M B

3»

33

M 1

M B

i

3,0,0
• 1040

—Si,

s?

V\

-/^

~~r

'~~.

--

—

/^

—

—

/\

/

y

-lojO
J10.0

!,oi°

i 97°

r

V

1/

1 /l\

L

1/

V

I /

—

—

—

—

rr-

L

~

—

—

V

\/

\^

/

!

~

-

If

~

V^

\l.

kb

- «°

_

__

...

-I

!™o

i «'°
1 0°

F ««'
U «°

5 ,40

i ,30

a ,„

|:

64

M 1

M 1

if

M S

1l

67

M B

8>

M S

com

M B

.7

> A

M B

M B

K.

M B

11

M 1

_R

TV

M S

KLAi

7£

H 1

M I

11

M 1

-0

hut

21

M B

3

H B

4

J

^

^

_

5^

1

r

i

—

/-

/

u

U

t

k

A

—

1

V:

^

^

1^

S^,

;^

b

"-

X

—

^

—

'-^

^

^

—

CASE U. SzoovD Atmoil Chan S. |

as;:

■07°
5>o6°
g,05»

= 101°

p »»=

L ISO
E 14°

i si!

M B

i5-!|Sj

> •

/5-

M 1

/r|/£ /£

M B

a.1
s— ,

H B

M 1

£1

M 1

M 1

H B

;?7

M I

52

M B

-

;2

^b<i

^

e

' 1

'^

~

—
t

I-. _

1
1

—

V

^

4._

\/

v-

.,

^

-

^

^

—

— :

2^

^

&

^

1

1 1
"illiZ?

—

1

-1

—

—

—

—

—

rA~

j

^^^v^

A

/■

V

/ \

"S

A

<-^

!

v

^"v

t^

'V'

1 1 1 (

V

\f'

sr

_~T.

— 1

— '

—

—

^

—

—

—

Digitized by

Google

OK.. CXXX, No. 8.] BOSTON MEDICAL AND SURGICAL JOURNAL.

181

It, in the later stages of a typical attack, which had
sen characterized by much abdomiDal pain and tym-
Any, and was attended by a relapse, as is shown by
le appended chart Daring convalescence the pulse
'as high, 100 to 112, and she remained in hospital
ixty-five days. (See Chart 1.)

Case I. — Second AUaek. October 10, 1892, the
Ekme patient was admitted to my service on the siz-
eenth day of her second attack. On the 23d of August
be had gone to the country to nnrse a patient with
■yphoid fever, and, after remaining there for a month
iix constant attendance, she contracted the disease her-
self. I saw her a few days later at home, when the
Bymptoms were general malaise, insomnia, bad head-
ache, fever and diarrhoea, bat the knowledge of her
severe attack two years before led me to doubt whether
she bad typhoid fever a second time. On admission
to the hospital, rose-spots were abundant, the spleen
was enlarged, anorexia and vomiting were troublesome.
Xhe urine was albuminous. The disease ran a longer
course than before, defervescence taking place at the
end of the fifth week, and the pulse then falling to 80.
(Chart 2.) She got up on the fifty-seventh day, but
from the sixty-fourth to the seventy-ninth day conva-
lescence was interrupted by a recurrence of febrile
symptoms and severe pain in the right iliac fossa, re-
quiring morphia for relief. She left the hospital on
the ninetieth day. (Chart 8.)

Case II. — Fir$t Attack. A male cook, aged twenty-
one, entered the service of Dr. Rotch, September 22,
1890. He had been ill ten days and complained of
the usual prodromal symptoms of typhoid; malaise,
pains in the limbs, headache, and nose-bleed. The
bowels were constipated. In the second week splenic
enlargement and rose-spots were noticeable ; later the
abdomen was swollen and tender. The fever abated
at the end of the third week. As the patient appeared
to be entering upon his convalescence, however, a re-
lapse occurred which delayed his recovery for another
month, and he remained in the hospital until the sixty-
fourth day. (Chart 4.)

Cask II — Second Attack. March 19, 1892, the
same patient re-entered my service with a history of
malaise and debility for the previous three weeks. He
had lost his appetite, slept badly, and felt chilly and
feverish by turns. Eight days before admission he
gave up and went to bed. Epistaxis had been frequent.
In the second week the symptoms were bronchitis, ab-
dominal pain, splenic enlargement, and an abundant
eruption of ro8e-«pots. Diarrhoea ensued, with tympany ;
epistaxis recurred, and during the third week typhoidal
stupor was very marked, as was also sensory deafness.
There was no otitis. In the fourth week a laryngitis
began and lasted two weeks. The right submaxillary
gland became swollen to the size of an hen's egg, red
and tender, but subsided without suppuration. During
convalescence there was a peripheral neuritis affecting
the feet and legs, and the patient was not discharged
until the sixtieth day of his illness. There was no
membrane in the throat at any time, and the laryngitis,
glaodalar swellings, and neuritis were thought to be
poBt-typhoidal. (Chart 5.)

Remarkt. — The rare recurrence of typhoid fever in
persons who are protected by a previous attack has
been pointed out by many writers, but there is some
diSerflDce of opinion as to the degree of immunity
which is thus conveyed.
Nathan Smith, in his " Medical and Surgical Me-

moirs," says : " My own personal experience is strongly
in favor of the non-liability of the same individual to
a second attack of typhus ; for daring the twenty-five
years since I first attended patients in this disease, and
in that time I have visited many hundreds, and have
witnessed its prevalence several times in the same
village, I have never known nor heard of its recur-
rence in the same person."

This accords with the researches of Gendron in his
" M^moire sur les epidemics des petites localites." *
He mentions several instances of this immunity, among
them the following : The village of Petit-Gdnes had
fifteen inhabitants, of whom twelve had typhoid fever.
Of the three others two had had it before. Three
years later, in a second epidemic, the disease attacked
five persons only, who had come there since the previ-
ous outbreak.

Chomel, at the Hdtel Dieu, among one hundred and
thirty typhoid patients, found no one who had previ-
ously had the disease.

On the other hand, Alonzo Clark, in his " Lectures
on Fevers," ' mentions two epidemics of typhoid as
occurring in Richmond, Massachusetts, in which Dr.
Jennings attended two patients with second attacks,
of whom he had also taken care during their fevers
two years before. Sixty persons were attacked in
each epidemic, but no details of these cases are given.

Fiedvache* relates the case of a girl who had a
severe attack at the age of ten, and a second one eight
years later. Michel ' had met with three cases ; and
Paul,* one in which a second attack occurred after
three years.

Trousseau,' with his long hospital experience, saw
but one case at the Hdtel Dieu, where a woman under
his care had typhoid four years after an attack of the
same disease in the wards of Professor Bostau, where
she had remained four months. Trousseau in his
private practice also met with one caae : a girl twelve
years old took typhoid fever in a severe form. The
illness lasted fifty-seven days. In the following year
she had another characteristic attack fifty days in
duration.

Liebermeister ' says that this disease confers a cer-
tain immunity, but not as complete as is the case with
variola, measles and scarlet fever. He alludes to re-
current cases at the Basle Hospital, but gives no details.

Murchison (third edition, 1884) says : " It is gener-
ally believed that one attack of enteric fever confers
an immunity from subsequent attacks." After recount-
ing in brief the observations of Gendron, Piedvache,
Bartlett, and others above-mentioned, he states that
several cases had come under his notice in which two
attacks had occurred in the same person after puberty,
and that four similar cases were observed by Dr.
William Budd (1859).

StrtimpeU's opinion (American edition, p. 4) is that
" it does seem to be certain that the occurrence of ty-
phoid fever gives very probable though not absolute
immunity against any later new attack."

Pepper, in " The American Text- Book of Theory
and Practice," * states that he has atteuded several pa-
tients through two characteristic attacks of typhoid

> Journal dea Connklasanees Medioo Chlrargloalai. Par M. Gen-
dron, 1B34.

> Mew York Medical Beeord.vol. xlU, 1818.

* Fiedrnche, p. lOii, 18S0.

• Michel, p. 297, 1859.

• Paul : L'Unlon MMloale, 1870, 1, 687.

' Trousseau, vol. ill, p. CO. Sydenham translation.

* Zlenuaen's UyclopBdia, vol. i, p. 75.

> Ibid., Tol. i,p. lC6,ia93.

Digitized by

Google

182

BOSTON MEDICAL AND SUBGIOAL JOURNAL. [Fkbrcabt 22, 1894

fever, and has had more than one apparently reliable
account of three distinct attacks at intervals of several
years. The same author says that a study of six
hundred cases by Eichborst showed the occurrence of
a second attack twenty-eight times, or in 4.7 per cent. ;
and that recurrences are more common in men than
in women, and milder than the original attacks.

Moore, of Dublin, in his recent work on " Eruptive
and Continued Fevers," '* gives a " Case of Recurrent
Enteric Fever followed by Relapse," in full detail,
with charts of both attacks, and also contributes a re-
port of the same case to the Dublin Journal of Medical
Science, April, 1892.

From the foregoing citations and cases, it appears
probable that physicians who see many cases of typhoid
fever may, in the course of years, meet with a few re-
current attacks in their own practice. Therefore I
made inquiry on this point of most of my past and
present colleagues at the City Hospital, who have all
had exceptionally large experience in this disease.
The mere statements of patients that they had had
tyflhoid fever more than once were not regarded as
sufficiently conclusive, but cases corroborated by re-
cords, charts, or the remembrance of professional ob-
servation, were sought for. None were found.

Dr. Robert T. Edes, who paid much attention to
this disease, and whose paper on " The Cold Water
Treatment of Typhoid Fever," by bathing, appeared
in the City Hospital Reports, Second Series, 1877,
replied to my inquiry as follows : " I do not think I
ever saw a case of typhoid fever in a person who, to
my knowledge, had had it some months or years
before."

Dr. C. Ellery Stedman, whose published "Notes on
Typhoid," based on an analysis of 1,188 cases at the
City Hospital, are contained in the '' Reports," Third
Series,. 1882, answered that be bad " formed the opin-
ion that one seldom had the fever, really, twice." He
had no proofs of recurrent attacks, in the way of charts
and records.

Dr. C. F. Folsom writes : " I have never seen re-
current typhoid fever which I knew to be such. A
few patients stated that tbey were suffering from sec-
ond or recurrent attacks."

Dr. T. M. Rotch says : " I do not recollect any
cases of recurrent typhoid."

Replies of similar tenor were received from Drs. J.
G. Blake, Geo. B. Shattuck, E. J. Forster, and other
members of the hospital staff with long experience.
In an analysis of G76 cases of typhoid admitted to the
hospital in 1890 and 1891, after careful examination
of the records, I found no recurrent cases."

Therefore the two instances recorded above, with
their histories and charts, are the only ones I have
been able to verify, as having occurred in this hospital,
in which the same patient has been admitted twice for
typhoid fever. One other case came within my own
knowledge in which a recurrent attack was fatal after
an interval of thirty years.

Although the negative results of such an inquiry
must be to some degree inconclusive, and a few authen-
ticated cases indicate the probability of a still greater
number which fail of positive proof, 1 think it may be
assamed that the immunity afforded by an attack of
typhoid fever is as complete as in the case of the exan-
themata, except, perhaps, small-pox, in which it is said

10 Moore, p. 3St, Wm. Wood & Co., 1892.

■1 See Boston Medical and Surgical Jourual, April? and 14, ISSSt.

that less than one per cent, of recurrences occur," al-
though Sir Thomas Watson states that a few instances
are recorded of three attacks of this disease in the
same person.'*

A BACTERIOLOGICAL STUDY OF FOUR HUN-
DRED CASES OF INFLAMMATION OF THE
THROAT, OCCURRING IN DIPHTHERIA AND
SCARLET FEVER, WITH ESPECIAL REFER-
ENCE TO PATHOGENESIS.!

BT JOHH lOTSTT MOUSE, A.II., M.S.

(Consluded trom Mo. 7, page ISS.)
HIXBD IMFKOTIONB.

The pseudo-membranous inflammations of the throat
occurring in scarlet fever are always accompanied by
cocci, usually streptococci. The presence of the Klebs-
LoiHer bacillus, means association with diphtheria as
the result of a mixed infection. Janson (28) in seven-
teen cases of scarlet fever found streptococci alone or
associated with other cocci. Baginsky (11) did not
And the Elebs-Loffler bacillus in scarlet fever, and
thinks that it disappears in cases of diphtheria when
an eruption similar to the scarlatinal fever is developed
and gives place to cocci. Park (13) found streptococci
in seventeen cases of scarlet fever, and Sorenson (18)
in thirteen cases of scarlatinal diphtheria found cocci
and other organisms, but never Klebs-Loffler bacilli.
Booker (19) has made a special study of the forms of
cocci found in the scarlatinal pseodo-membranoaB
angina, but does not find the Klebs-Loffler bacillas in
them. Escherich and Bourges, however, have found
them in the throat affections appearing in the course
of scarlet fever.

In ninety-nine cases of scarlet fever with simultane-.
oas pseudo-membranous inflammation of the throat,
the following bacteria were found :

Casei.

Klebe-LSffler baellU alone 3

K. L. and gtreptoooocl 1

K. li. and Btaphyloooool 10

E. L. and atreptocooci and staphylocooel . . . S

Streptococci alone 4

Staphylococci alone 12

Streptococci and itaphjlooooci 23

Btreptoooocl, staphylococci and others .... 34

Other bacteria 3

That is, there were twenty-three cases of mixed in-
fection, or nearly twenty-five per cent. Streptococci
were present, alone or associated, in seventy-one cases,
or in seventy-one per cent.

This tremendous proportion of cases of mixed infec-
tion can be accounted for in a number of ways. In
the first place, the scarlet fever and diphtheria wards,
although isolated from the rest of the hospital, are in
charge of the same house-officers and visiting physi-
cians. They are constantly going from one ward to
another, and, although always wearing gowns in the
wards and disinfecting their hands on leaving a ward,
are probably responsible for a large number of the
mixed forms. Various other persons, not directly
connected with the care of the patients, also enter both

1 A contribntlon, under direction of Dr. W. T. Councilman, from
the Pathological Department to the forthcoming Medical and SnrKt-
oal Report of the Beaton City Hospital. Awardod one of the Lyman
prizes for 1893.

" See Reynolds' System of Medicine, TOl. I, p. I3S.
" Watson's Principles and Practice of Physic, toI. il, p.<84,4Ui
edition, ISST.

Digitized by

Google

Vol. CXXX, No. 8.] SOSTON MSMOAL AUD SUBGIOAL JOVH^AL.

183

wards. The possibility of the direct infection with
Klebs-Loffler bacillus by physicians, nurses, and con-
valescent patients must also be considered, as it is un-
doubtedly a fact that a person with a very slight sore
throat, without visible membrane, due nevertheless to
the Klebs-LufBer bacillus, may infect others with a
severe form of the disease. It is also a fact that the
bacillus remains for a long time in the throats of con-
valescent patients, retaining its virulence, and render-
iog them a source of danger to others. Escherich (17)
found the virulent diphtheria bacilli in cases in which
the clinical picture of diphtheria was wanting. He
thinks that these persons are immune towards the
toxine, while there is no limitation to the growth of
the bacillus. In one case a nurse in a hospital had the
bacilli in her throat and, without being diseased herself,
gave the disease to the children intrusted to her care.
Feer (20) reports five cases in children in which the
diphtheria bacilli were found on the tonsils without
there being a trace of membrane. Koplick (14) has
also proven the existence of similar cases. A certain
namber enter'the hospital with a mixed infection, as is
shown by bacteriological examination. As there is at
present no separate ward for such cases, they are nec-
essarily placed in one of the present wards. Although
tbey are isolated as far as possible in separate rooms,
they are undoubtedly the source of a certain number
of other mixed cases. I think, moreover, that the
diagnosis of scarlet fever is often made on insufficient
grounds. The existence of scarlatiniform rashes and
erythema fogax in diphtheria is well recognized (21
and 22). Steam and rough clothing next to the skin
are also very likely to cause an erythema, which is
often quite lasting. Drug exanthems may also give
rise to error. These mistakes in diagnosis are espe-
cially liable to occur in cases which survive but a short
time, thus not allowing opportunity for the recognition
of the fleeting nature of the eruption. That these
mixed cases do originate in the hospital is shown by
the fact that during the period covered by this study
aixteen cases developed scarlet fever in the hospital at
an average time of nearly two weeks after entrance.
Moreover, seven cases of scarlet fever developed in-
flamed throats during convalescence, in all of which
the Elebs-Loffler bacilli were then demonstrated, al-
though tbey had been absent previously. Under the
present conditions these secondary infections are un-
avoidable, although every possible precaution is taken
to prevent them. With the completion of the new
wards for contagious diseases, however, which are now
io process of erection, the conditions will be radically
improved and all opportunity for such cases removed.

BACTERIA OF THE HDUAN UODTB.

Very extended researches (34) have been made
with reference to the bacteria in the human mouth,
which show that numerous species are constantly
present in the buccal secretions and upon the surface
of the moist mucous membrane. Some are occasional
and accidental, while others appear to have their nor-
nial habitat in the mouth, where the conditions as to
warmth, moisture, and«organic matter are extremely
favorable for their development. Up to the year
1885 Professor Miller, of Berlin, had isolated twenty-
two different species from the human mouth — ten
were cocci; five short bacilli; six long bacilli, and
oae a spirillum. He later cultivated eight additional
species. Yignal has isolated and described seventeen

species obtained by him in pure culture from the
healthy human mouth ; most of them are bacilli.
Miller, who found micrococci to be the more numer-
ous, supposes the difference in results to be due to the
fact that many of the cocci do not grow on nutrient
gelatine, which was the medium employed by Vignal.
Among the species we find two of the most common
pus cocci, namely : the staphylococcus albus and
aureus. Very diiferent results have been reported by
different observers as to the frequency with which
these pathogenic cocci are found in the buccal cavity.
Black, in the saliva of ten healthy individuals, found
the staphylococcus pyogeues aureus seven times, the
staphylococcus albus four times, and the streptococcus
pyogenes three times. On the other hand, Netter
found the staphylococcus aureus only seven times out
of one hundred and twenty-seven persons examined.
Vignal, in the course of his researches, did not find
the streptococcus pyogenes at all. Experiments made
by Sternberg, Vulpian, Fraeukel, Nutter, and others,
show that the diplococcus pneumoniae is frequently
present in the mouths of healthy individuals. Netter
found it in fifteen per cent, of one hundred and sixty-
five cases. Several other species have also been iso-
lated by late observers. Sanarelli has also shown that
the normal saliva has the power to destroy the vitality
of a limited number of certain pathogenic bacteria,
among them the staphylococcus aureus and strepto-
coccus pyogenes.

BELATIYE FREQDENCT OF MICRO-OROANiaHS.

The small number of organisms found in the course
of this study is probably because many do not grow on
the media employed, and because others do not develop
in the short time allowed before the cultures are ex-
amined.

The organisms most commonly met with, either
alone or associated with the Klebs-Lofller bacilli, were
streptococci and staphylococci. Diplococci were found
in a number of cases and various forms of bacilli met
with from time to time.

Streptooocol ooourred In 191 cuei .... 48%

Btaphjloooool ocourred In 28fi ooMa .... 74

Dlploooool ocourred in U oases IS

BaoUli occarred In 87 cues 22

HORTALITT.

Id this routine work no attempt was made to deter-
mine the nature of these bacilli, although several of
them were carefully worked out in a shorter series to
be reported later. The diplococcus lanceolatus was
also noted in nine cases. As has already been stated,
the mortality in cases containing the Klebs-Loffler
bacillus was forty-one per cent, against twenty-three
per cent, in cases in which it was absent. How the
mortality was influenced by the presence or association
of the various bacteria is shown in the following
table:

K. L. alone in 46, of whleb 20 died .... 49%

K. L. with streptoooool in 21, of whloh 6 died . . 2S

K. L. with Btaphylooocot in 93, of whioh 43 died . . 4S
K. L. with atreptoooocl and staphyloooooi in 77, of whioh

29 died 38

K. L. with others in 3, of whioh 1 died .... S3
Streptocoeoi alone In tS, of whieh 1 died . . . S

Sta^ylooocol alone In 27, of whioh IS died ... 40

Staphyloooooi and streptoooooi 99, at whioh 19 died . 19

OtbMsinS.ofwhlohSdled 40

These figures show that the mortality is about twice

Digitized by

Google

184

BOSTON MEDICAL AND SURGICAL JOVttSAL. [Febbcabt 22, 1894.

M great in those pseudo-membraootM iuflammatioDs of
the throat in which the Klebs-LSffler bacillas is pres-
ent as in those in which it is absent. They also show
that the mortality is not appreciably altered by the
presence of other bacteria in association with the diph-
theria bacillus. This result is somewhat at variance
with those obtained by other investigators, several of
whom have done special work with regard to the in-
fluence of other bacteria on the virulence of the Klebs-
Loffler bacillus. Roux and Yersin (27) made injec-
tion experiments on guinea-pigs with mixed cultures of
LSffler's bacillus and erysipelas. The animals experi-
mented on died in forty -eight hours, while other
guinea-pigs, which were inoculated with pure coltores
of the same diphtheria bacillus, did not die. They
also foand certain products in mixed cultures which
were not present in the pure cultures of either organ-
um.

llie toxic albumens obtained from the mixed cultures
were much more virulent than those from the pure.
Those of pure cultures of diphtheria bacilli killed
guinea-pigs in thirty-six hours, while those from mixed
cultures killed them in ten hours. Janson (28) thinks
that the prognosis is worse when the bacilli are asso-
ciated with a streptococcus. Heubner (15) found that
sixty-six per cent, of the cases in which the bacilli
were found alone died, and fifty-five per cent, of those
in which they were associated with other cocci. Mar-
tin (23) found that in all cases of diphtheria where
the streptococci were present there was a more fatal
course than in those where only simple forms of cocci
were found. He thinks that the presence of strepto-
cocci, either with or without the bacillus, materially
complicates the prognosis. Goldscheider (24) found
that the cases in which streptococci were present ran a
more severe course, and lasted longer, and thinks that
they may play a very important role in diphtheria.
Gottstein (25) thinks that the streptococcus symbiosis
may cause an increase in the virulence of the bacilli.
Ba'rbier (26) thinks that the diphtheritic infection may
have a much more malignant character when it is en-
grafted on a streptococcus inflammation. He is in-
clined to believe that there are two forms of diphtheria
to be separated from one another, one the pure form,
and the other mixed with streptococcus. The latter
corresponds to the form which is known as septic
diphtheria.

The general opinion thus seems to be that other or-
ganisms, especially streptococci, in connection with the
Klebs-Loffler bacillus, render the prognosis more grave.
It would seem from my figures, however, that they
have little or no influence. It would also seem that
staphylococci, either alone or iu combination, were
more fatal than streptococcci.

A series of twenty-five cases, uncomplicated by
scarlet fever and containing the Klebs-Loffler bacillus,
were examined more carefully. Agar plates were
made from the first slant tube of blood serum, and all
the organisms present isolated in pure cultures. Pure
cultures of all the Klebs-Loffler bacilli were obtained
upon blood serum, of the streptococci on glycerine
agar, and of the staphylococci on blood serum or agar.
"Hie staphylococci were also further differentiated by
growth and liquefaction in gelatine stick cultures. The
other organisms met with were studied as to their cul-
tural peculiarities on the various media and inoculated
into animals. The following table shows the results
obtained:

No. Nuna. Dlag. Baetaria. B«ralt

1 M. B. D. K. L. ftreptoeoool D.

2 B. C. D. K. L. streptoooo«l : staphjloooooni slbos. D.
S D. P. D. K. L. strsptoooeoi : ftaptaylooocel auniu, W.

4 P. K. O, K. L. itraptoooool . . D.

5 A. O. D. K. L. •Upyloooeeus albas . . . . W.
« C. K. D. K. L. ■traptooocol W.

7 S. O. D. K. L. atreptoaoool : staptayloeoconi albu,

itaphjloooooiu anreiu . . . D.

8 S. M. D. K. L. ■troptooocfll W.

9 M. D. D. K. L. atraptoooccl D.

10 P. R. D. K. U baeiUiu ooll oommnnls (1) . . D.

11 P. H. D. K. Ij.«treptoooool: ■taphylococsaaanreii*, D.
\i S. R. U. K. L. streptococci W.

13 W. M. D. K. L. strcptoooeel : diplo-baeiUtu (2) . D.

14 V. E. D. K. L. itreptoooeol W.

U A. A. D. K.L. itreptococcl: ■taphylococeos anreiu, W.

18 B. W. D. K. L. ttreptooooel W.

17 O. T. D. K. li. staphTlooooons albas . . . D.

18 F. H. D. K. L. staphylococaoB aureus . . . D.

19 J. H. D. K. L. itreptocoocl V.

20 V. P. D. K. L. laise dlploooooni (3) . . . . W.

21 L. B. D. K. L. ttreptooooel, large dlploeocaus (3) . D.
2-J £. M. D. K. L. streptocooei, diplo-baolUua . D.

23 O. T. D. K. L. ttreptocooel, abort bacillus (4) . V.

24 T. K. D. K. L.(traptoeoeel: ataphylococcat aureus, D.

25 B. H. D. K. L. ■taphyloooocua albus, stapbylococ-

oua aureni. D.

(1) Bacillus Coli Commonis.

Diagnosis made on following peculiarities : Short,
thick bacillus with rounded ends, often resembling a
coccus. Acidified and coagulated litmus milk. Formed
gas in sugar agar. Did not liquefy gelatine. Gave
moist, distinct, yellowish growth on potato. Slightly
motile in hanging drop of bouillon culture. Grave in-
dol reaction in Dunham's solution.

(2) DipIoBacillus.

A diplo-bacillus with lancet-shaped ends. Morpho-
logically always the same. Stains readily with the
aniline dyes. Grows freely in white colonies on blood
serum and glycerine agar. No growth in gelatine.
Invisible growth on potato. Does not form gas in
sugar agar. Does not coagulate or acidulate litmus
milk. Whitish growth at bottom of bouillon. Non-
motile in hanging drop of bouillon culture. Non-
pathogenic for guioeapigs. Resembles more nearly
the Imcillus septicus acuminatus of Babes than any
other, but is probably not the same. Was found in
two cases of this short series and observed a good
many times in the long series, although its cultural
characteristics were not studied at that time.

(3) Large Diplococcus.

Colonies on agar plates. White, homogeneously
granular, with well-defined edges. Grows rapidly.
Profuse white growth on glycerine agar; removed
from surface with difficulty. Grows freely on blood
serum. No growth in gelatine. Slow growth at
bottom of bouillon. Non-motile in hanging drop of
bouillon culture. No growth on potato. Non-patho-
genic for guinea-pigs.

(4) Short Bacillus.

A small bacillus, not forming spores. Stains with
aniline colors. On gelatine plates deep colonies show
coarsely-granular, sharply-defined centre with finely-
granular, outer layer having well-defined border.
Liquefy plates in 24°-48''. Stick cultures in gelatine
tubes show profuse white growth, liquefying surface
and extending in pyramidal shape downward. Profuse
growth on blood serum which it liquefies. Moist,
yellowish growth on potato. Profuse white growth
on surface of sugar agar, but no gas formation in stick
culture. Gives marked white cloudiness in bouillon
culture, and after a few days forms a white pellicle on
surface. Motile iu hanging drop of bouillon culture.

Digitized by

Google

7oL. ex XX, No. 8.]

BOSTOIf UEDIOAL AND SURQIOAL JOURNAL.

185

Does not coagulate or acidify litmas milk. FrofuBe
creamy-colored growth on glycerine agar. Non-patho-
genic for goinea-pigs.

These two last forms do not correspond to any de-
scribed by Sternberg. This may be either because
they have not been met with before, or if so, imper-
fectly described.

Of course, statistics compiled from so small a num-
ber of cases are of little value, but I nevertheless give
them for what they are worth.

Kleb«-L6ffler twoiUiu not {ound alone.

Streptococci in 19 76%

8ta|dijlococet In 10 40

K. Ij. and utreptooocci In 9 86

K. L. and lUphjlocoool In 4 16

K. L., itreptocoed and ataphyloeoect la t . . .24

General mortality 58

Mortality, K. I^ with atreptocoeoi alone ... 83

" K. L. with staphyloeoool alone ... 66

" K. L. with atreptooooel and ataphylooooei, 66

Thus this series, as far as it goes, also seems to
prove that staphylococci are more fatai in combination
with the Elebs-Loffler bacilli than streptococci. It
most be remembered, however, that in both series bao-
teriolo^cal results have alone been considered. It is
very probable that an explanation for this excessive
mortality in connection with the staphylococci would be
found in the other pathological conditions, other fac-
tors, possibly severe lung complications, being present
to account for the fatal termination.

Streptococci were present in a much larger propor-
tion of cases than in the longer series. This result is,
however, probably more correct, for in the routine
examination mist«^es were liable to arise in two ways.
Streptococci, on account of their slower and smaller
growth, were probably missed in some oases, and in
others called staphylococci because they were bunched,
it often being impossible to differentiate the two forms
when closely crowded on a cover-slip.

TUBILITT OF KLEB»-l5fFLEB BACILLUS. — PEBIOD
OF CONTA6IOD8NESS.

Investigations were begun aa to the length of time
that the Elebs-Loffler bacilli remained in the throat
after it was apparently clean. Patients are not now
allowed to leave the hospital until the bacilli have dis-
appeared from both throat and nose, as shown by bac-
teriological examination. The results of the examina-
tions in the first twenty-five cases is appended. Con-
•iderable work has recently been done in this direction
bj several investigators. Janson (28) found the bacilli
foarteen days, and Haubner (15) ten days after the
membrane had disappeared from the throat. Tobiesen
(30) examined the throats of forty-six patients, who
left the hospital as well, for diphtheria bacilli. They
were found in twenty-four cases, the length of time
which they persisted bearing no relation to the previ-
ous severity of the case. They were found eight times
four days after the membrane had vanished; three
times, five days after ; three times, seven days after ;
three, nine days after; one, eleven days after; one,
fourteen days after ; one, fifteen days after ; one,
seventeen days after ; and one, thirty-one days after.
These pauents did not present any other pathological
condition. He thinks that the presence of bacilli in
the pharynx is assisted by pathological conditions of
the larynx and nose. This late bacillus had the same
pathogenic influence, on the inoculation of guinea-pigs,
as the others. He regards it as possible that half the

patients who leave a hospital, after having had diph-
theria, have the power to infect their surroundings
with the disease. He found one case who, after leav-
ing the hospital, was certainly the source of infection
for others. Loffler (31) investigated one case daily as
to the presence of diphtheria bacilli. The fever dis-
appeared on the fifth day, and the throat lesions on the
sixteenth day. The Iraicilli, however, remained for
four weeks longer. Verstraeten (32) also found the
bacilli four weeks after the membrane had disappeared
and Boux and Yersin (27) found them in virulent con-
dition fourteen days after the membrane had vanished.
In my cases it was found that the average length of
time that the Elebs-Loffler bacillus remained in the
throat or nose after the membrane had disappeared
was ten days. The average duration was the same for
both throat and nose, although in some cases the ba-
cilli were found in the throat much longer than in the
nose, and vice versa. The bacilli disappeared in one
case the day after the throat was clear ; in three, three
days after, and in one, four days after. In two cases
in which the bacilli were never found in the nose, they
remained in the throat ten and seventeen days respec-
tively. In other cases, they were present in the throat
thirty-seven days, and in the nose thirty-six days ; in
the throat twenty-two days and nose eighteen days ;
in throat ten days and nose seventeen days ; and in
both twenty-seven days. In order to test the virulence
of these late bacilli, a guinea-pig was inoculated with
a pure culture of the bacillus obtained from a throat
which had been perfectly clear for ten days. It died
on the third day, and the Elebs-Ldffler bacillus was
recovered from the seat of inoculation.

PSEDDO-DIPBTHEBITIO BACILLC8.

The so-called pseudo-diphtheritic bacillus was not
considered in this series, as the diagnosis was usually
made entirely on morphology, and the cultural and
pathogenic properties of the bacilli rarely studied. So
much has been written about this organism, however,
that it deserves consideration. The evidence is very
contradictory, however, and the question of its exist-
ence must still be regarded as unsettled. Hoffmann
(16) finds that this bacillus is a frequent and appar-
ently regular inhabitant of the pharynx, and that it
agrees very closely in its morphology and physiology
with the Elebs-Loffler bacillus, but is non-viruleut.
He says that certain definite morphological differences
may be made out on careful comparison with the
Elebs-Loffler bacillus, but fails to state them clearly.
Escherich (17) thinks that the diphtheria bacillus has
in bouillon cultures a greater tendency to arrange itself
in parallel masses, while the pseudo-bacillus lies in
irregular groups. In the pseudo-bacillus there is a
brown color on old agar cultures which never occurs
on diphtheria cultures. He regards as the most dis-
tinctive point the growth in litmus bouillon, which at first
remains violet and then becomes red. Diphtheria cul-
tures produce this more rapidly. By inoculations of
guinea-pigs, no immunity could be produced. According
to his investigations, the pseudo-bacillus has been found
only thirteen times in three hundred and twenty cases.
Fraenkel (33) thinks that it is the true bacillus which
loses its virulence on artificial media, just as the pneu-
mococcus does. Roux and Fraenkel consider the two
bacilli identical, and that the only difference is one of
virulence. Roux and Yersin (27) found that the only
difference between these forms appears to be that the

Digitized by

Google

18H

BOSTON MBDICAL AJfJD SURGICAL JOURS AL. [Fkbscabt 2S, 1894.

false bacillas is foand shorter on sernm, that it devel-
ops more abundantly io bouillon, and continues to
grow at twenty to twenty-two, while the virulent one
grows only slowly. The change in the reaction of the
bouillon takes place less quickly in the pseudo diph-
theritic than in the diphtheritic They sought for this
pseudo-form in forty-five sound children, and found it
in fifteen. They also found it in the throats of tweoty-
six children out of fifty-nine in a village where there
was no diphtheria. It was always present in small
numbers. The inoculation of this bacillas never pro-
duced fatal consequences ; at the most, only a local
oedema. They succeeded in various ways in diminish-
ing the virulence of cultures of the virulent bacilli.
The non-virulent organism thus produced compared
fully with the pseudo-diphtheritic bacillus. These
pseudo and non-virulent forms did not produce any
toxines. In some cases, also, it was possible to
increase the virulence of the organisms. The vim-
lence was increased when the guinea-pig was inoculated
with an active erysipelas culture at the same time.
Neither the weakened bacillus nor the streptococcus
alone could produce the death of the animal, but the
mixed cultures could. Death took place with the
phenomena of diphtheria, and the diphtheritic bacilli
underwent an increase of virulence. The weight of
evidence at present thus seems to show that the or-
ganisms are the same, differing only in virulence.
Further work is necessary, however, before the ques-
tion can be definitely settled.

KEaULTS.

The results obtained from the study of this large
number of cases are not as valuable as they would be
if the clinical side was considered in connection with
the bacteriological. It is probable, for example, that
the mortality apparently due to staphylococci would
be to a certain extent explained by a careful examina-
tion of the cases clinically. The relation of the opera-
tire cases to the bacteria present is also important.
There would be great danger, however, of detracting
from the value of the results as a whole, if too many
factors were considered. It is unfortunate, also, that
the fatal cases could not have been autopsied, as an
accurate knowledge of the pathological and bacterio-
logical conditions would be invaluable. It is extremely
difiicult, however, to obtain autopsies in Boston, and
in no case more so than in that of a contagious disease.
It is to be hoped, nevertheless, that they may be ob-
tained in the future and this vast amount of material
utilized, for here lies the field for conclusively demon-
strating the results of the symbiosis of other forms of
bacteria with the Elebs-Loffler bacillus.

BIBLIOQBAPHY.

1. Klebs. Verbandl. dessweiten Ck>ngTe88 f. Inner. Med., 1883.

2. Liiffler. Hitbz a. d. Kais. Oegundheitaamte, Bd. 2, 1881.

3. Babes. ZeitscbrUt f. Hygiene, Bd. S, p. 177.

1. Welch and Abbott. Jobna Hopkins Hospital Bulletin, 1891.
6. Welch and Flezner. J. H. Bulletin, 1892, No. 20.

6. Babes. Vircb. Arch., Bd. cxlx, Heft 3.

7. Martin. British Mediual Journal, 1892, March and April.

8. Guinocbet. Arch, de Med. experimentale, Tome 4, 1892.

9. Councilman. Medical Communication of the Massachusetts

Mediual Society, zlv, 1, 2(>0.

10. Prndden. American Journal Medical Sciences, May, 1889.

11. Bagineky. Berl. klin. Wochenacbr., February 29, 1892.

12. Martin. Annales de I'lnst. Pavtear, May, 1IJ92.

13. Park. Medical Record, 18U2, zlii, 113.

14. Koplick. New York Medical Journal, August 27, 1892.

15. Heubner. Vortrag gehalten in der Med. Qesellsch zu. Leip-

zig, 1892.

16. Hofmann. Versammluag Deutsches Naturforscher and

Aerzte in Wiesbaden, September, 1887.

Escberich. Berlin kiln. Wocfaenaoht., 1893, Nos. 21 and 23.

Sorenson. Zeitschr. f. klin. Med., Bd. 19.

Booker. Johns Hopkins Bulletin, 1892.

Peer. Korrespondenzblatt f. Schweizer Aerzte 28, 1893.

Osier. System of Medicine, p. 74.

Smith. Kesting's Encyclopiedia of Diseases of Children, 1,

623.
Martin. Annal de I'Institut Pastenr, 1892, No. 5, p. 334.
Ooldscheider. Zeitsch. f. klin. Med., vol. zxii, 1893.
GotUtein. Berl. klin. Wochenschr., 1893, No. 23.
Barbier. Arch, de med. experimentale and d'anatomie path-

ologiqne, Tome 2, 1891.
Bouz and Yersin. Annales de I'Institut Pasteur, 1888, No.

12.
Janaon. Hygiea, April, 1893.
Williams. Medical Communication, Msssachnaetts Medical

Society, 1893.
Tobiesen. Ana dem Laboratoriom f. Med. Bacterlologie in

Kopenbagen.
Liiffler. International Medical Congress in Berlin, Angnst,

1890.
Verstraeten. Annales de la Society de Medeoine de Gand.,

vol. Izz, 1891.
Fraenkel. Berlin klin. Wochenschr., 1893, No. 11.
Sternberg. Bacteriology.

RECltJRRENT APPENDICITIS.^

BV ALBBBT AOODST, M.D., OAMBBIDOB, MASS.

The subject of this paper is a young man, age
twenty-three years, single, student. Born and lives io
Cambridge. Family history negative. Has always been
well until he had typhoid fever three years ago, from
which he entirely recovered, but has been troubled
with chronic constipation since.

His first attack of appendicitis was January 1, 1892,
when he complained of pain across the lower part of
the abdomen, not very acute, but with considerable
soreness ; bowels were constipated. He entered the
Cambridge Hospital at this time, and the record of the
examination showed him to be of fair nutritiou, pale
and nervous, tongue coated with a pasty white coat.
There was general tenderness over the abdomen, bat
it was especially tender in the right and left iliac re-
gions. No dulness on percussion except in hypogas-
trinm, due to a distended bladder, for the relief of
which the catheter was used. The treatment at thu
time consisted of morphia suppositories, sufficient to
keep him comfortable, and flaxseed poultices over the
abdomen.

January 2d, the record shows some resistance in the
right iliac region, with considerable sensitiveness on
superficial pressure. Bowels were flat. I will say
here that our patient was extremely hyperaesthetic.

January 4th, the tenderness over the abdomen had
considerably diminished. Area of dulness had de-
creased in the right iliac region. Bowels were moved
by enema. As our patient continued to improve, the
tenderness became more distinctly confined to the area
of the appendix.

He was discharged well January 14, 1892, having
been in the hospital thirteen days. After he left the
hospital he improved gradually, and at the end of a
few weeks he was able to resume his college work.

His next attack was February 14, 1893, a little over
a year since the first. He had been feeliug poorly for
five days, due to constipation, for which he took com-
pound licorice powder. On the ISth he went to an
evening party, and on his return home began to vomit,
and complained of considerable pain in the abdomen.

He entered the hospital February 16th, where the
recorded examination showed much tenderness in the
right iliac region. The point of extreme pain was just
> Read before the Cambridge Society for Medical Improrement.

Digitized by

Google

Vol. CXXX, No. 8.J BOSTON MEDICAL AND SURGICAL JOURNAL.

187

below a line drawn from the anterior superior spine to
the ambilicDs ; the tender area was about two inches
long, and one and one-half inches wide, with the inter-
nal border about three-quarters of an inch to the right
of the median line. His general and local condition
constantly improved after entering the hospital, so
that he was discharged oo March 2d with only slight
resistance in the right iliac region, bat no dulness on
percussion.

The third attack occurred April 14, 1893, an inter-
val of a little over a month, and again after dancing at
a party. He went to bed feeling perfectly well, but
awoke early in the morning with severe pain in the
bowels, most marked in the right iliac region. He
entered the hospital on that same afternoon. Exami-
nation showed the bowels to be flat; on pressure,
there was slight resistance over same area as described
in previous attack, with the greatest tenderness con-
fined to this region. Examination of urine showed it
to be normal.

A consultation of the hospital stafE was held at this
time with reference to surgical interference, but it was
decided to wait and advise operation during an interval
between the attacks.

He steadily improved with a diminution of the re-
sistance in the right iliac region and disappearance of
the pain, and was discharged well March 22d.

Oar patient gradually improved, but not wholly.
He became very pale and ansBmic, was extremely ner-
vous and irritable, and was obliged to give up his col-
lege work. He was unable to take any immoderate
exercise, on account of soreness and a feeling of stiff-
ness in bis right side; and if any one accidentally
came in contact with him here, it woold cause him
considerable pain. His general condition became ex-
tremely erratic now. One day he felt perfectly well,
and woald indulge either in a day's work or amuse-
ment, for which he would pay the penalty on the next
by being overcome with a sense of weariness and ina-
bility for any unusual exertion ; in other words, he
was reduced to the state of semi-invalidism, so much
BO that in the latter part of July, 1 urged him to take
a journey into the country, to see what a change of air
might do for his general condition. He had grown
extremely nervous about himself, and was in constant
fear of another attack.

On the 24th of July last, he went to New London,
N. H. ; and while there he indulged in considerable
exercise — base-ball and riding (or rather jolting) over
the New Hampshire roads, etc.

On the 26th of July he began to feel ill ; and on the
evening of that day be was seized with extreme pain
in the right iliac region, and vomited considerably.
They had no morphia to give him, and he suffered
extreme agonies ; the only relief he obtained was by
freqaent applicalions of hot poultices. In this way
they brought him through the night, and until they
were able to procure some morphia for him on the next
mommg.

I saw him in New London, July 28th, with a tem-
perature of 102.5", and pulse 120 ; he had not passed
water for eighteen hours, and on his countenance was
s very anxious expression. The abdomen was flat ;
in the right iliac region there was considerable dul-
ness, with the tenderness well marked at McBuruey's
poiat; and the general condition was like that of his
three previous attacks. By means of rest, poultices,
and morphia sufficient to control his pain, we were

able to bring him home, August 3d, when he began to
improve again to a certain extent.

About a week later, August 11th, after running for
a train, he was seized with another attack, very slight,
which confined him to his bed for four days only.

He was now tired of Damocles' sword, and readily
acquiesced when relief waii offered to him by surgical
means.

He entered the Massachusetts General Hospital
August 23, 1893. The operation was performed by
Dr. A. T. Cabot, August 26th, ihe patient having been
previously carefully prepared. On the day previous
to the operation, he was allowed no solid food; his
bowels were well moved with castor-oil ; and an enema,
with turpentine, was administered. On the morning
of the operation he was thoroughly bathed, and an an-
tiseptic poultice placed over the abdomen.

Operation. — Patient was anaesthetized, ether being
used. An incision was made over McBurney's point,
about four and one-half inches long, the general direc-
tion corresponding to the outer border of the rectus
muscle. Passing the fingers into the peritoneal cavity,
the appendix was found in a bed of very firm adhesions,
attached to the anterior abdominal wall. Adhesions
were separated with the fingers, and the appendix was
liberated and brought up into view at the opening.
The appendix was surrounded with adhesive inflam-
matory products, from which it was freed. Heemor-
rhage from a small artery on the external surface of
the appendix persisted, and the artery was tied. A
silk ligature was now passed around the base of the
appendix ; a cuff of the peritoneal coat of the appendix
was dissected back ; the appendix was cut off ; and the
peritoneal cuff was stitched over the stump with silk.
The stump was turned toward the right side of the
abdominal cavity. The abdominal wound was brought
together by means of six silkworm-gut ligatures, which
were passed through all the layers of the abdominal
wall ; the wound was sewed up tight, no drainage
being used.

Macroscopic examination of the appendix showed it
to be two and one-half inches long, with the walls
somewhat thickened ; at the end and on one side it
was perforated, but the surrounding parts were pro-
tected by the inflammatory products. The lumen was
pervious, and no concretion found. I have not re-
ceived the report of the microscopic examination.

He made a good recovery from the ether, and made
a progressive convalescence. His temperature was
practically normal throughout ; his bowels were moved
August 28th with calomel and one seidlitz powder, and
thereafter moved voluntarily. On account of the un-
usual length of the incision, the stitches were not re-
moved until the twelfth day, when everything was
found firmly united. He walked out from the hospital
well, September 1 Ith, sixteen days after the operation.
Since leaving the hospital, he has steadily improved,
both in weight and general condition. He has lost
that nervous irritability to a great extent, and has re-
gained his former ambition. He is now able to go iu
town every day, and do a day's work without any of
the former fatigue. I saw him recently, and examina-
tion of the right iliac fossa revealed no tenderness or
resistance whatever.

The particular etiology of appendicitis is still some-
what obscure, that is, we have no definite set of pre-
disposing causes which we can be sure are the origin
of the trouble. Some writers speak of constipation aa

Digitized by

Google

188

BOSTON MSDIOAL AND SVBGIOAL JOURNAL. [Febrdart 22, 1894.

a tint qua non ; others suppose that diarrhoea plays an
important part ; still others think that it is caused by
the impaction of a foreign body ; and Treves consid-
ers a short mesentery as an important etiological factor,
and a consequent twisting of the appendix as a result
of this.

Constipation seems rather coincident than etiological.
In 209 cases analyzed by R H. Fitz, only 88 had
an antecedent history of constipation ; while Talamon
points out that the most obstinate cases of constipation
are in women, and still appendicitis is four times as
common in males as in females. Again, we have con-
stipation the rule in people of advanced age ; and we
all know that the greatest number of casa^ of appendi-
citis occurs between the ages of fifteen and thirty
years.

Treves says that faecal concretions are not commonly
found ; Matterstack found only nine cases in a series
of 146. Talamon suggests that a considerable propor-
tion of cases are caused by faecal concretions, those not
being found at operation having possibly been forced
back by the muscular contractions of the appendix, or
if an abscess has formed with perforation, that the
faecal concretion has become softened and disintegrated
by the action of the pus.

I have been much interested in Dr. Talamon's the-
ory as regards the predisposing cause. He suggests
the existence of a membranous colitis, or intestinal
atony, where the patient has uncomfortable, distressing
pains in the bowels, irregular stools, sometimes mucoid
and sometimes constipated, and that the faecal and
mucoid matters are deposited in the cul-de-sacs of the
mucosa and are dried, and under favorable conditions
(for example, increased peristalsis) are forced into the
lumen of the appendix. He considers this to be the
primary cause in recurrent attacks, which causes a peri-
appendicitis and consequent adhesive inflammation
about the appendix which binds it at an acute angle
to the caecum, as in the subject of this paper, where
the appendix was bound down firmly to the anterior
abdominal wall in such a manner that all fluids or
solids were forced into the caecum against the action
of gravity. It is very easy to see how the appendix
may become distended with fluids under these condi-
tions, and how congestion and ulceration may follow.

Dr. Cabot has noticed in almost all of his operations
for recurrent appendicitis that the appendix was bound
down by adhesions in such a manner as to twist the
lumen of the appendix out of its proper relations.

Dr. W. T. Bull, in the New York Medical Record
of March 18, 1898, describes twelve cases in which he
also noticed the appendix sharply bent and fastened in
that position by adhesions.

In some cases, the tip of the appendix had been
imbedded in a small abscess-cavity, which remained
latent only to light up and cause a recurrence at the
slightest occasion.

Fitz states that attacks of indigestion and acts of
violence, especially from lifting, jumping and pulling,
are exciting causes in one-fifth of the cases. A local
cause is found in more than three-fifths of all cases, for
example, inspissated faecal matters, or the presence of
a foreign body.

The question of the propriety of operating in the
interval between the attacks is an open one, and must
be considered in each individual case. Dr. Fitz, in his
statistics, places the perceutage of recurrence at 11
per cent. Dr. S. F. Dennis thinks that conservatism

should be used in operating, since only 11 per cent, of
the cases are recurrent, and of these some end in reso-
Intion, or else the lumen of the appendix is ablated by
chronic inflammation, and is reduced to a thickeoed
fibrous cord. In some cases, he says, the perforation
will cause an extra-peritoneal abscess; and in still
others there will be a localized, circumscribed, intra-
peritoneal abscess, which may empty itself by raptur-
ing into the rectum, vagina, caecum or bladder; and
that only a small percentage of dangerous cases would
be left, and he thinks these might be operated on early
in the next attack.

Treves first advised the operation in 1877, and con-
siders that the following indications justify it : (1) If
the attacks have been very numerous ; (2) if the at-
tacks are increasing in frequency and in severity ; (3)
if last attack has been so severe as to place the pa-
tient's life in considerable danger ; (4) if the constant
recurrences have reduced the patient to a condition of
chronic invalidism, and has rendered him unfit for oc-
cupation ; (5) if owing to persistence of certain local
symptoms during the quiescent state, there is a proba-
bility of a collection of pus.

As regards the mortality of the operation. In a
collection of 81 cases by Cabot, there has been only
one death, which was due to sepsis, a mortality of
about 1^ per cent. Treves reports 14 cases operated
upon, all of which made a sound recovery.

It seems to me that if an operation is inevitable, the
sooner it is done the better, that is, before the patient
has had too many recurrences; for then there is a
liability that the adhesions are dense and firm, and
very difficult of separation.

Some writers say that there is no necessity of alarm
in recurrent attacks, for nature protects herself against
general infection of the peritoneum by these very ad-
hesions which are formed, and that general peritonitis
is avoided. Still, Price-has collected 30 cases of re-
current appendicitis, and 20 of these exploded into an
abscess or general peritonitis before the third attack.

The operation during an interval seems a safer one
than that during an acute attack, even if that is done
early ; for in the latter case you have no time to pre-
pare your patient for an aseptic operation. The pa-
tient is in an extremely nervous condition, is fatigued
from pain, his bowels are more or less distended, the
site of the operation has been reddened or blistered by
stimulating embrocations ; so, as Cabot says, it is al-
most impossible to do an aseptic operation. And here
I would reiterate Dr. Cabot's plea, that the general
practitioner who has a case of appendicitis under his
charge, should use antiseptic poultices, which will ren-
der an operation much safer if one has to be done in
an emergency.

It is very much different in an interval between the
attacks. You approach the patient under entirely dif-
ferent conditions ; he has been prepared for the opera-
tion, both in body and in mind ; his diet has been reg-
ulated ; his bowels have been moved, and all flatus
possible has been removed ; and the field of operation
has been made thoroughly aseptic.

The technique of the operation varies according to
the individual taste of each operator. Dr. McBurney
uses the cautery and ligature in all of his cases. Dr.
Treves sews up all of his cases without drainage.

Dr. S. C. Gordon, in the Boston Medical md Sur-
ffical Journal, reports six cases with recovery. He
believes that all cases can be carried through the acute

Digitized by

Google

Vol. CXXX, No. 8.] BOSTON MBDIOAL AND SURGICAL JOURNAL.

189

stage by means of salioes and depletioD, and that it is
much safer to operate in an interval ; be also sews up
without drainage, even those in which he finds an
abscess.

In conclusion, I would say that it does not seem to
me possible to lay down any definite rules as to when
the operation should be done, but that each case must
be considered separately. It seems to me that if it
were possible to carry a patient through the acute
stage without operation it should be done, since the
operation in the interval by a skilful surgeon carries
with it snch a small mortality, and the abdominal
wound can be sewed up tight, therefore minimizing the
danger of a subsequent hernia.

Clinical aDepartment.

A CASE OF MALIGNANT ENDOCARDITIS.**

BT WILLIAM E. rjiT, X.D.

The early recognition of malignant endocarditis is
so often difficult to the clinician that I desire to read
this case. It is with the hope that it may be sugges-
tive of discussion which will elucidate the way of
diagnosis.

The patient was an Irish waiting-maid of twenty-
two. Of her family there is little knowledge. Measles
Id early childhood ; joints swollen and painful, with
rheumatic fever lasting one month at the age of twelve ;
cstamenia beginning three years later, always regular ;
occasional headaches ; and a futile operation to find a
needle she thought lost in her foot, comprises the
known previous history.

On June 22d last, she is reported as standing in a
china-closet, during a thunder storm of unusual sever-
ity, attending to her duties. Suddenly she was unable
to speak. She understood what was said to her.
She knew the words she ought to say, but could not
ntter them. From her own statement she thought she
was all right in every other way, because she could
move her hands and feet, and see and hear and eat.
She experienced a chill some time during the next two
days, when she was placed in the Newport Hospital.
In a few days more she began to be able to say a word
or two. Sometimes she was unable to repeat a word
JDst spoken. She gradually acquired increasing power
of speech during the six weeks of her treatment there.

On August 5th she was transferred to the Carney
Hospital, and admitted to the service of Dr. James J.
Mioot. She had partial aphasia and huskiness of voice.
Pain in left side, under costal border. Temperature
102.5" F. in the evening, subnormal in morning. A
trace of albumen with a few blood and vaginal epithe-
lial cells found at this time soon disappeared. Urine
otherwise unimportant. No error detected in reaction
of pupils to light or accommodation, nor in the protru-
sion of tongue. No paralysis. Throat and lungs nor-
mal. Apex beat of heart seen in fifth interspace, in-
side the mammary line. Pulse full, regular, compressi-
ble. Systolic murmur quite loud at apex, propagated
into axilla, beard posteriorly at border of left scapula,
anteriorly lightly over precordia to base. Pulmonic
lecond sound increased. Splenic area considerably in-
creased, but limits indefinite on account of extreme

> Bead iMfore the Bwton Soolelj for Madioal OtMerratlon, Deoem-
toT4,18a3.

tenderness at this time. No tenderness elsewhere. No
extreme tympany. Skin sensations normal.

During the following two weeks her speech became
pretty natural, except for a certain hesitancy. She
had a daily rise of temperature in the afternoon with
morning remissions between the extreme limits of
96.4° and 104.8°

Ten grains of quinine given at height of fever, caused
gradual dimiuutiou of temperature, .tinnitus and head-
ache. Eight grains daily in divided doses was not well
borne. However, during administration of quinine the
variance in limits of pyrexia was somewhat lessened.
Examination for plasmodium malariaa was negative in
results.

The patient came under my observation, during the
absence of Dr. Minot, in the second half of August.
She presented an aspect of anxiety, pale, eyes becom-
ing slightly sunken. Tongue clean. No cough. No
dyspnosa. No hsemorrhages. No abdominal tender-
ness except over area of splenic dulness. This area
extended from the sixth interspace to the costal limit,
where during inspiration the edge could be dimly felt.
Dull pain here was more or less constant. No rose
spots or petechise. Urine and dejections normal.
Heart's murmur unchanged. Baffled in diagnosis, I
asked Dr. J. J. Thomas to see the case with me and
examine the blood. He found the red to the white as
100 to 1. Bed normal. White in excess. Hsema-
globin 50 per cent A condition more often pertaining
to chronic, and after some acute diseases, as malaria
and pneumonia, not typhoid fever.

About September Ist a small red spot appeared just
below the trochanter of right femur, extending two or
three centimetres. A small abscess developed at the
centre, with infiltrated, uneven edge. Somewhat pain-
ful. Yielded a drop of pus. Healed in three weeks,
under antiseptic dressings. ' Through this month pa-
tient gained a little strength. Splenic pain diminished.
She sat up. A week more, and she was again in bed.
Morning remissions of temperature are a degree or
two less, and the evening rise higher. Pain recurs in
the region of spleen. Urine becomes smoky ; amount
diminished; specific gravity 1,023; sugar absent;
large trace of albumen ; hyalin, fine, granular, fibri-
nous blood and epithelial casts ; free blood and epithe-
lial cells. It is five weeks since the urine was normal.
In another fortnight there is one-eighth per cent,
albumen ; casts more numerous, of both large and small
diameter. The spleen continues to be felt CEdema
of face appears. Semi-comatose condition supervenes.

On November 20th patient dies.

This illness extended over 122 days. In review*ing
the time, it seems to divide itself somwhat into different
periods. First aphasia is prominent, whether due
to functional or organic cause ? The kidneys showed
no evidence to signify a causal relation to embolus.
The mitral valve seemed responsible for a heart mur-
mur, but this was thought to be an old chronic injury
from an attack of rheumatism in childhood, and inci-
dental to this illness. There had been no trauma. It
was difficult to distinguish whether the trouble was
motor aphasia or hysterical aphonia. There was no
mind-blindness nor mind-deaf uess ; and if Broca's re-
gion was impaired, lesion must have been extremely
limited to be without some loss of function in the face,
arm, or leg. In favor of the functional causation
seemed to be the onset of the trouble coincident with
her alarm from thunder and lightning, which frightened

Digitized by

Google

190

BOSTON MEDICAL ASD SVJtGlCAL JOVBNAL. [Febbdabt 22, 1894.

others aboat her ; her age and sex. Also from the
sargeon who sought (he needle in her foot a year be-
fore,ws learned her disposition then, which led him to
suppose it might have been hysterically lost.

As this symptom passed, the question of malaria
offers. There had been one chill reported. A sugges-
tion of malaria accompanied her from the Newport
Hospital. She had almost daily rises of temperature
of four or five degrees, and an enlarged splenic area.
But the lack of distinct periodicity, the tenderness dis-
proportionate and extreme over a moderately enlarged
spleen, the absence of plasmodium malarias io exami-
nations made by the interne (Mr. Dewis), and the in-
tolerance of moderate doses of quinine made this diag-
nosis improbable.

Typhoid fever was disregarded after observing that
the peculiar temperature chart maintained its character
constantly without any typboidal curve, the tongue
clean, no rose spots, and nothing abnormal with the
bowels. In regard to tuberculosis, she had some hec-
tic at times, progressive emaciation ; and but for its
rarity the skin lesion upon the thigh might have pointed
to it, as it somewhat resembled the description in the
books of such affections. Microscopic examination of
scraping from same by Dr. Coggesball discovered no
tubercle bacillus. Examination of the choroids was
not made. Tuberculosis of the spleen is always second-
ary, so far as I know. The lungs were repeatedly
found quite normal, and no other origin of tubercular
affection could be proved.

There was no condition of anemia shown by exami-
nation of the blood to account for the patient's condition.

Some splenic or peri-splenic abscess could not be
excluded by the symptoms ; but the infectious source
to which it might be secondary, and the source of the
sudden severe nephritis did not appear. Cultures
from the blood were not attempted during life. Had
they been successfully made, inoculations in small
animals might have given certainty, where clinical signs
left us in doubt until facts were obtained by autopsy.

Autopsy eighteen hours after death, by Dr. F.
Coggesball : Small stature, emaciation. Rigor mortis
marked. Scar, size of silver quarter, under right
trochanter. Whole brain very soft. Left temporal
lobe and adjacent portions especially softened and
yellowish in color.

Organs were taken to Dr. W. F. Whitney, at the
Harvard Medical School, who found the following:
Heart of normal size. Bight side normal. Left
auricle slightly dilated. In it and on surface covered
with small papillary fibrous projections which were
alsd found on the edge of the mitral valve. With these
were also associated soft, grayish, opaque small masses,
especially abundant on the chords tendinae. Left
ventricle presented nothing abnormal, nor was any-
thing abnormal noticed in the wall of the heart. Lungs,
liver and stomach presented no marked deviations
from normal. Beneath the mucous membrane in the
lower part of the ilium were numerous small hemor-
rhagic spots. At the root of the mesentery was a
swelling, the size of an egg, composed of clotted blood,
which seemed to be more or less extravasated into the
tissues. The spleen was twice its normal size. Sur-
face marked by several depressed cicatricial places, the
base of which had a yellowish aspect. On section
showed the pulp markedly increased ; the cicatrized
portions above mentioned corresponded to more or less
wedge-shaped, yellow, opaque extensions into the sub-

stance of the spleen, and which were sharply differenti-
ated from it. The kidneys were large, capsules slightly
adherent. On section, found to be swollen, very moiit
surface, Malpighian bodies appearing as minute whitish
bodies in the midst of grayish cortical substance, and
with numerous small bsemorrhagic spots. There were
several cicatricial places in the kidney similar in char-
acter to those in the spleen, and which in like manner
were continued into yellowish, sharply differentiated,
somewhat wedge-shaped nodules. Anatomical diag-
nosis : Softening of the brain ; chronic verrucous endo-
carditis, associated with acute vegetative endocarditis ;
anaemic necrosis of spleen and kidneys, results of in-
farction ; acute diffuse and glomerulo nephritis.

I am especially indebted to Drs. Minot and Temple
for permitting me to report a case from their services
at the Carney Hospital, and to Dr. Whitney for his
examination of the organs.

lEUpocti^ of j^octetiejf*

BOSTON SOCIETY

FOR MEDICAL

MENT.

IMPROVE-

J. T. BOWSK. X.D., SECBBTABT.

Reodlab Meeting, Monday, December 11,1893,
the President, Db. C. F. Folbok, in the chair.

Db. J. J. Pdtnau made an oral communication
concerning

A CASK OF MrXOEDEHA.

The patient, who was present, was a woman of
forty-four, and of Irish parentage, though she had
lived a great many years in America. It is interest-
ing to note that her sister, who still lives in Ireland,
also presents symptoms which strongly suggest myx-
oedema.

The patient's symptoms were of gradual onset, and
date back perhaps a year. Previously to this she had
been iu good health, except that for four years past
the menstruation had been irregular, and for two years
she had had " hot flushes." A pufflness of the hands
was noticed a year ago, but not much was thought of
it until six months ago, when a swelling of the face
and a slowness and huskiness of speech attracted her
attention more forcibly. At this time, also, her eye-
lids began to droop, so that she had to drag them up
by wrinkling the forehead. Soon afterwards the feet
became swollen, and the hands were noticed to be dry
and scaly.

These changes are said to have been gradually in-
creasing, but even now there is nothing to attract the
notice of a casual observer.

On close examination there is observed, besides the
above-mentioned conditions, a slowness of the motions
of the tongue, a marked trace of the characteristic
alabaster appearance of the eyelids, a slightly sub-
normal temperature (98° F.), slow pulse (69), and
typical "supraclavicular fulness." The hair has been
falling of late. The urine is normal. The diagaosis
was confirmed by the fact that under treatment by
feeding with dessicated sheep's thyroids (five to ten
grains daily), which had been going on for two weeks,
there had been a steady gain in all respects, except
that the hair had continued to fall out.

[At the present time of writing this improvement

Digitized by

Google

OXIXX, No. 8.] BOSTON MEDICAL AND SURGICAL JOURNAL.

191

fogressed still further, to the patient's great con-
^he temperature and pulse are now normal;
v^eight, which was 187, has fallen a number of
oLs ; the appearance and manner suggest greater
ness. An examination of dried and stained speci-
^ o£ blood, made bj Dr. Richard Cabot, shows the
lal proportion of whites and reds, and no unusual
lia.ritiea.J
B- F. C. SHA.TTDCK presented

CPORT OF POUR CASKS OF MTXCKDBUA. TBEATKD
BY THTROID EXTRACT.^

>R. J. J. FnxNAU : I have been much interested in
i subject for the last year or more, and have been
y glad to hear Dr. Shattuck's paper. To speak of
points to which he has alluded, I should like to
a word about the matter of dosage. I have re-
itly read of a case where, from taking a single
ber large dose of sheep-gland, the anginoid symp-
ns to which he has referred came on, and were
ite serious. It is a curious thing that not only
ins of this character, but also pains of other kinds,
.ve shown themselves from time to time — I think
pecially intercostal neuralgia. Also, in one of
aache's cases, great prostration occurred, with some
3wel complicatioQ, requiring the patient to keep the
ad for some time.

With regard to the frequency with which -this
roable occurs, it seems to me beyond question that
Jine of these cases are often diagnosticated as Bright's
isease. The second case that I saw, and in the treat-
lent of which I took part, had a cousin and an aunt,
oth of whom had died long before anything was
:DOwn of myxoedema, but who had certainly had the
ieease in a pronounced form. I knew them well,
.nd one of them was believed to be a typical case of
Wright's disease. The face was swelled, the lips were
hick, and the voice was husky and hoarse. The face
presented the same appearance, though in more marked
iegree, with that shown in the colored illustrations
that Dr. Shattuck passed around. The sister of the
patient whom I showed this evening also, from her
account, would seem to be a victim of the same disease,
although not recognized. I have not seen her; but
she is said to have shown a similar loss of hair and
marked weakness (without pain and without the signs
of any particular disease), and puffiness of the face
and hands. My second patient, who is still under the
care of my brother, was at one time also supposed to
have Bright's disease, because she had had albumen
and casts in the urine for some time. Those have now
disappeared with the treatment. I think it probably
true, as Dr. Shattuck says, that the dose of thyroid
extract to overcome symptoms will have to be in-
creased in cold weather, because my first patient, who
improved to a considerable degree between July and
October, with the advent of cold weather fell off con-
siderably, aud the oedema of the eyelids returned to a
marked degree. With regard to the first case that
Dr. Shattuck described, and which I am extremely
glad to have had the chance of seeing through his
kindness, although I am not inclined to insist that his
diagnoiia was not correct, and although 1 have no
doubt that it belongs in general to a large class of
trophic disorders of peculiar kind, still it did not seem
to me to be a typical case of myxcedema. The
speech, instead of being slow, was quick ; the mental
* Sm pi(e 177 of (be Jonrnal,

condition was active, instead of being very dull and
apathetic ; and the temperature was not subnormal, as
has been the case in almost all the cases reported.
Dr. Dercum described two years ago two cases which
it seems to me should be mentioned in this connection.
They were cases characterized by a peculiar form of
obesity, with neuralgic pains aud a few symptoms sug-
gesting myxoedema, although many symptoqas were
wanting which would be necessary to make a complete
picture of the disease. It is an interesting question,
which has come up in connection with recent researches
of Vermehren, of Copenhagen, whether some of the
affections from which old people suffer, such as weak
action of the heart and nutritive disorders of various
kinds, may not be due to a slight failure of the
thyroid. At any rate, he found that giving thyroid
improved their condition. Thyroid has been used suc-
cessfully against certain forms of obesity ; and I have
had several cases where patients not having myx-
cedema have lost weight for a time very rapidly, two
or three of them losing in the neighborhood of forty
pounds. The loss did not, however, continue indefi-
nitely ; and there are also other troubles in which it
would appear we may possibly be able to use it with
advantage.

Dr. £. D. Spear : I want to add one suggestion in
regard to the function of the thyroid gland, and that
is the probable regulation of the cerebral circulation
by means of the thyroid through the sympathetic
system. I find that in certain aural cases where there
is a certain noise in the ear which may be called a
bruit, the thyroid gland is always enlarged; that is,
the lobes of the thyroid are always enlarged, and that
in those cases the pulse is always raised usually to 1220
or 130 beats a minute. I only want to speak now of
what has been referred to as pain about the heart in
those cases where the thyroid extract has been given.
I do not know as there is any connection, but I do
know that the thyroid in some obscure way controls
the cerebral circulation through the sympathetic ; how
it does it I cannot say. These clinical observations
which I make in these cases are of interest, and, I
think, should be studied in connection with all those
obscure affections in which the thyroid is spoken of.
It is a fact that, if in these cases I press upon the thy-
roid gland with my thumb to make massage to a light
extent, the pulse drops immediately after from 120 to
60. If 1 continue the pressure the patient faints. If
I stimulate the thyroid gland where it is enlarged by
external irritants, I shall, instead of depressing the
circulation, stimulate the pneumogastric apparently,
and tone up the heart so that the pulse is made nor-
mal. These noises in the head are described by the
patient as roaring noises, and are always accompanied
with changes in the power of hearing, but with no
obvious changes in the ear. I always found, however,
that the turbinate body was enlarged, and that treat-
ment in early cases — that is, in cases lasting from six
weeks to six mouths, we will say — the simple appli-
cation of heat to the thyroid gland by means of hot
water upon a towel or flannel is sufficient to stop the
noise and improve the hearing. Of course, in all, or
most all my cases, I make local treatment. In the
few cases which are slight I rely upon heat ; but were
I to map out a full treatment for a case of this kind
where there is noise in the ear, deafness, I should, iu
addition to the heat to the thyroid, give a nerve stimu-
lant ; that is, strychnia in full doses, aud apply moa-

Digitized by

Google

192

BOSTOS MEDICAL AND SVBGICAL JOVSBAL. [Fkbruabt 22, 1894.

tard or some counter-irritant to the heart, and make
local applications to the ear through the nose.

One other thiug that I would like some of the
nenrologists to take op is to prove if my obBervation
is correct. Of course, I know I am correct in regard
to the function of the thjroid as regalating the cere-
bral circulation, bat whether I am correct in this I am
uncertain. In a large namber of cases it is possible
to induce sleep by means of application to the thyroid.
I can relate one experience which will prove it was
possible in one case to induce sleep by hot applica-
tions. One of my patients used to awake at all honrs
of the night. She was the wife of a fireman who was
deaf, and she listened for his tapper. At any time of
night or day she roused him and got him ready for the
engine. After she came under treatment for nasal
obstruction, I put her upon applications of heat to the
thyroid. One afternoon at three she felt uncomfort^
able, had some disturbance in the head, made an appli-
cation to her thyroid, and went to sleep ! There were
two alarms of fire, and at the end of an hour a police-
man went in and asked what was the matter that she
did not wake him up. I should like to have nenrologists
try this experiment, which is simple, but a very power-
ful remedy in cases of insomnia. The danger to be
avoided is the depression of the heart if the applica-
tions are continued longer than ten or fifteen minutes
at the outside.

Dr. F. C. Shattdck : I quite agree with Dr. Put-
nam that my first case was not a typical one of myx-
cedema. Had it been typical I should not have sent it
to him for an opinion. The absence of mental slug-
gishness and of subnormal temperature does not weigh
mnch in my mind. Increasing experience is constantly
showing ua deviation from the symptoms as now laid
down in the books. The Chairman saw this case ; and
I should be glad to have him give his opinion of it.

Dr. Fulbou : I have not consulted my notes ; but
I am quite sure that this is the fourth or fifth case
which I have seen. The others were before anything
was known about the thyroid-extract treatment. It
seemed to me an unquestioned case of myxoedema. It
is quite true that there was no mental torpor, in the
strict sense of the word, to be observeil ; but I am in-
clined to think there was, in fact, because there was a
certain amount of mental momentum, so to speak, got
up by the exhilaration of the patient sufficient to mask
a considerable degree of mental impairment. As it
seemed to me, the essential points were such that I
felt quite confident of the diagnosis of myxoedema.

Dr. M. H. Richardson showed a specimen of

AN APPENDIX OBLITERATED IN THE GREATER PART
OF ITS LENGTH.

This specimen I removed this morning from a man
thirty-eight years of age. The history of the case is
very interesting in connection with the condition found
at the operation. He had been subject for four years
to occasional attacks of violent pain in the epigastrium.
From the epigastrium the pain would go into the right
iliac fossa. On Tuesday, February 7, 1893, be bad
an attack of " terrible pain " m the epigastrium, with
vomiting. The fever lasted for several days. He
supposed he had the colic, and treated himself for it.
At the end of five days he sent for Dr. Marshall, of
Lynn. He went on from bad to worse until Sunday,
the 19th, when i saw him. The whole of the lower
part of the abdomen from right to left was filled by a

large, fluctuating tumor. It pressed also upon the
rectum. I opened, by an incision parallel to Poa-
part's ligament, without infecting the general abdom-
inal cavity. The mass was made up of several abscess-
cavities. The appendix conld be felt, very large and
thick, intimately adherent to the surrounding parts, so
that it seemed to me inadvisable to make any pro-
longed efforts to separate it. One large tube was pat
down into the pelvis, and another toward the bladder.
About the tubes sterile gauze was packed. The tem-
perature went down after the operation, but about two
weeks later there was a discharge of a pint of pus.
After this he made a good convalescence.

On November 21, 1893, I examined him again.
Since the operation he had been perfectly well till
three weeks ago, when he had another spell that came
on in the same way as the others had — with pain in
the stomach. There was a little fever with this attack.
Examination of the scar showed a well-marked ventral
hernia, slight in extent, but unmistakable. . There was
no tenderness or pain. In view of the second attack,
in its onset precisely like the first, and considering the
hernia in the scar, I advised him to have an operation
performed, first, for the radical cure of the hernia, and
secondly, for the removal of the appendix, should it
seem desirable after exploration. I cut out the scar
tissue this morning, and came down upon the csecum.
There was no trace of the formerly extensive abscess,
except a little induration behind the csecum. The
appendix was attached to the posterior and outer ctecal
wall by strong adhesions. These had to be cut before
the appendix could be separated. There was nothing
left of this organ except a small stump and a rounded
extremity. Between the two, as the specimen shows,
there was nothing but a fibrous cord, which may have
been nothing but the remains of the inflammatory pro-
cess. The condition of the appendix, in my opinion,
would not have justified an operation for its removal,
had we known it beforehand. The one attack of which
he complained did not seem to me alone sufficient to
justify this operation. The presence of the hernia
was a real menace to his health, and alone justified
the interference. Having opened the abdominal cav-
ity, the removal of the fragments of the appendix
seemed to me a raUonal procedure, especially as enough
of the stump was left to account for the symptoms of
the second attack.

BOSTON SOCIETY FOR MEDICAL OBSERVA-
TION.

J. C. HDHBO, I1.D., SICBBTABT.

Regular Meeting, Monday, December 4, 1893,
Dr. J. B. Ater in the chair.
Dr. W. £. Fat described

A CASE OF MALIGNANT ENDOCARDITIS.^

Dr. Ater : I should like to ask whether at any
time the temperature rose more than once in the
twenty-four hours and also whether it is not a very
frequent symptom to have an irregular rise twice in
the twenty-four hours ?

Dr. Fat : There was an absolutely constant after^
noon rise, except when modified by quinine ; one rise
during the day, never two. I do not know bow fre-
quent it is to have the temperature rise twice in the
twenty-four hours. In the BrUith Medical Jbunud a
> See page 188 of tbe Jomaal.

Digitized by

Google

Vol. CXXX, No. 8.]

BOSTON MBDIOAL AND SURGICAL JOURNAL.

193

year ago last March, in a paper by Dr. Frederick
Taylor, is pointed out the long daration of the pyrexia
which wag seen in some cases, during which the fever
was almost absolutely regnlar.

I should like to mention one case of endocarditis I
came across among a number of cases from various
sources of infection. The duration of the case was,
within two days, the same as this one, and it passed
through all the stages and was recognized in life.'

Two months after the illness began a rabbit was
inoculated with a culture of a staphylococcus made
from a drop of blood taken from the finger of the pa-
tienL In another month the rabbit died. There was
an endocarditis of remarkable intensity, vegetations
arising from the valves, and bloody effusion into the
peritoneum. In nearly another month the patient
died. Autopsy showed precisely similar conditions.

Dk. M. H. Ricbabdson showed a specimen of

riBROMA or BBEAST, WITH LARGE GTST 8IHULAT-
INO CABCIN03CA.

This specimen was removed two days ago from a
woman of fifty-three. It was my intention to show
thu tumor in connection with a similar one removed
from a woman of thirtyK>ne. Both involved totally
the left breast and both contained a hard mass distinct
from the main swelling. The axillary glands were
enlarged enough to be felt distinctly in each case. 1
advised operation in each. This specimen from the
woman of fifty-three proves to be benign — diffused,
intracanalicniar fibroma — withoat a suspicion of malig-
nancy ; while the breast from the young woman con-
tained a nodule of cancer three centimetres in diameter
and was itself a mass of fibrous tissue formation.

Dr. W. F. Whitney's report is as follows :

"Mrs. B., age fifty-three. On section it was in
general, firm and fibrous looking, and the surface was
interspersed with numerous cysts of size varying from
a pin's head to one of the size of a small egg ; the
lining of this was smooth and the contents thin and
watery. Microscopic examination showed dilated ducts
and acini of the gland lying in a matrix of dense
fibrous tissue. Some of the dilated spaces were more
or less sinuous, and suggested a growth into the lumen
of a canal of fibrous tissue. The diagnosis is a chronic,
diffuse, fibrous-tissue formation in the breast, with re-
tention cysts. The whole of the gland was affected."

" Miss P., age thirty-one. The tumor of the breast
and axilla from Miss P. showed a large, densely-
fibrous growth occupying the greater part of the breast.
At one part it was opaque, more homogeneous and
grayish. Microscopic examination showed remnants
of gland acini, surrounded by dense layers of fibrous
tiesae, with quite hyaline-looking walls. Involving
these were irregularly-braucbing lines of solid epithe-
lial cells. The axillary glands were enlarged, and
contained large epithelial cells separated by a little
fibrous-tissue stroma. The case is one of a cancer
(rather of the medullary type) which has invaded a
breast where had previously existed a chronic diffuse
fibrous-tissue formation."

The interesting clinical question was that of diag-
nosis. In the younger patient there seemed a strong
doubt as to the presence of cancer, though the enlarged
axillary glands — much more pronounced than in the
older woman — pointed more to a malignant tumor
than the slightly enlarged ones in the older patient.

< Baferred to in Sajoni'* Annnal for 1881.

I advised operation in the latter case because I be-
lieve that all mammary growths in women over forty
should be explored most thoroughly ; and in the former
because, though in a young woman, the appearances
were very suspicions. Cancer developing in a diffuse
fibroma is very unusual in my experience ; its occur-
rence in so young a woman emphasized the importance
of removing snch tumors early. Not that the danger
of malignant degeneration is pressing; but unless we
are able positively to exclude malignancy, we ought to
remove, or at least, to explore, all suspicious tumors,
even if they cause only discomfort and anxiety.

I have frequently found the axillary glands enlarged
in benign tumors, where there is no reason for their
presence beyond a possible irritation. This enlarge-
ment, if not one of irritation, is usually coincident
with a swelling of the glands of the opposite axilla.

The slowness of growth was another point iu favor
of the benignancy of the cystic tumor. The cysts
themselves are often so tense that it is impossible to
tell whether they are the solid irregularities of cancer
or not. Even after the removal of this specimen, it
was impossible to exclude malignant growths until the
tumor bad been all cut to pieces and several question-
able points had been examined microscopically. The
mistakes likely to occur if the diagnosis rests upon
sections made with a punch before operation are ob-
vious. In the young woman's case the specimen re-
moved by the punch very likely would have contained
none of the malignant structures, and depending upon
an apparently scientific demonstration of security, I
should have allowed the patient to lose the favorable
moment for operation. Not that the exploring punch
is of no use. On the contrary, if it does catch the
malignant neoplasm it is a demonstration that may be
looked upon as final ; if it does not, we must at times
still make the radical incision.

In these operations now I close the wound withoat
drainage. My experience in this procedure shows
the rapidity with which a man's ideas may change. I
do not feel ashamed to say that my views on many
subjects are very different from what they were a year
ago. I dare say that in a short time hence I may do
these operations in a very different way from what I
do them now, but it seems at the present time as if
there were not much improvement to be made in the
technique of operations of this sort. The mortality in
breast-operations in my experience has gone down
from four or five per cent., in the carbolic-acid times
to practically no mortality in the last four years. We
have also got rid of the disagreeable features of drain-
age by means of careful asepsis and absolute hsemos-
tasis. If we are careful not to operate in hopeless
local disease or when there is hopeless disease of the
internal viscera, the mortality mnst always remain very
low indeed.

One thing I forget to say about the desirability of
operating in cases of fibromata in young women in
whom the question of disfigurement is important.
Were it not for the cases iu which Dr. Whitney has
found malignant disease complicating these benign
growths, I should not insist upon their removal except
in the rarest instances. When the tumor is small and
movable, I should not interfere. When the tumor
does not demand the removal of the whole breast, the
disfiguring scar can be avoided by Gaillard's method
of post-mammary dissection.

Db. Viokebt : There is a kind of hard, painful

Digitized by

Google

194

BOSTON MEDICAL AND SURGICAL JOURNAL. [Fkbhuaht22, 1894.

lump that quite young women have in their breasts.
It is a source of great anxiety. When I was a student
such lumps used to be left in ; now a good many sur-
geons take tliem oat. I should like to ask Dr. Rich-
ardsoD if he will tell us his view about the matter.

Dr. Richardson : My advice to a young woman
with a fibroma of the breast is this : if it troubles her
very much, she can easily and safely have it removed.
In leaving it alone the dangers to health are very
slight. The pain and tenderness are frequently the
result of her constantly examining it ; if she lets it
alone, and if it is not very large, the tumor often dis-
appears. They are sometimes very large. I have
seen them occupying the whole breast, weighing per-
haps a pound, though the ordinary fibroma is seldom
beyond the size of a hen's egg. A tumor that causes
discomfort ought to be removed because it can be done
with great ease and safety. In none of these cases is
excision necessary on account of the danger to life if
yon can be sure that no malignant complication exists.

Vitttat literatuce.

Introduction to the Cattdogut of the OoUeetion of Cal-
culi of the Bladder. By Sir Henrt Thompson,
F.R.C.S., etc London : J. & A. Chnrchill. 1893.
This little volume is nothing less than a summary
of the entire experience of its eminent author with
reference to operations for stone and foreign bodies in
the bladder. It accompanies the more extensive cata-
logue which, prepared and revised with great care,
was presented by Sir Henry, together with the cabinet
containing his collection of calculi and foreign bodies
removed from the bladder by him, to the Hunterian
Mnsenm of the Royal College of Surgeons in 1892.
This collection represents the whole of Sir Henry's
work in this department of surgery, from his first case
in 1857, up to the date of presentation, which, with
the additions made between that time and April, 1893,
comprises 1,013 operations.

The "Introduction" furnishes statistical tables of
the results of these operations and of the more impor-
tant points connected with them, as well as comments
by the author concerning the matters of especial impor-
tance in regard to the subject. We are glad to note,
under the heading " Lithotrity," that Sir Henry gives
as his latest expression in the matter the full credit
which is its due to the notable achievement of Dr.
Henry .1. Bigelow (" Litholapaxy ").

Sir Henry's " IntrodnctioD," etc., is a multum in
parvo which will well repay careful study, since it
gives, even in this condensed form, a valuable record
of part of the work of one of the most remarkable and
talented of surgeons and men of our day.

A Practical Treatise on Materia Mediea and Hura-
peuliee. By Roherts Bartrolow, M.A., M.D.,
LL.D., Professor of Materia Mediea, General Thera-
peutics and Hygiene iu Jefferson Medical CoUeeo,
Philadelphia, etc. Eighth edition, revised and en-
larged. New York : D. Appleton & Co. 1893.
The recent revision of the United States Pharma-
copoeia has led Professor Bartholow to bring out a
new edition of this well-known and deservedly popular
work : and we need only say that in it, he has adopted
the metric system and included such of the newer
remedies as be deems worthy of recognition.

THE BOSTON

fSteDfcal and ^utgical ioumal.

THURSDAY, FEBRUARY 22, 1894.

A Journal ttfittdieine, Swrgery, and Allied SoitHeu.ptAUtkei at
BoiUm, weeklf, 6|r the u»der$igned.

SVBaoBlPTlon TSBMS : 98.00 ptr pear, i* advamee. pottage paid,
for tkt Unittd Slatet, Camada amd tiexieo ; HM per year for all tar-
ings ommtrict btUmi^MQ to the Poetal Unioit,

All eomwmnieatvMt far the Kdtlor, amd all book* for refieto, tkouU
te addnued to the Kdiiorof the Bottom tttdieal amd SmrgieeU Joitnud,
ns Wathiiiglon Street, Botkm.

All lettert eontaimmg butinett eommumieatiomt, or referrimii to tk*
fuUieaUom, tubtaription, or adverlitinf department of (Mt JtrnnaH,
thonld be addretied to the tmdertigned,

SemUtameet thould be made ty money-order, draft or regittatd
letter.paiiabU to

DAMBELL * CPHAM,
183 WASHnoToii Stbbbt, Bostor, Mass.

DISEASES DDE TO "HARD TIMES."

It would doubtless be an interesting study to inves-
tigate from the inductive tide the morbidity in commu-
nities directly traceable to business depression; this,
however, would require wide observation and careful
collection and collation of data, and the subject would
be at the best a very complex one.

The most that we can attempt to do on the present
occasion is to approach the subject from the deductive
side ; given the want and distress into which large
portions of communities are plunged from lack of work
and lack of money, to deduce the necessary pathologi-
cal consequences in accordance with well-known laws.

Seasons like that through which this country has
been passing are times of great psychical depression.
There is (or has been) profound discouragement among
employers and employed ; among men of business
making no money (or losing), and workingmen idle,
with distress and poverty before them. With multi-
tudes there is paralysis of the higher incentives and
emotional forces, and psychical failure and degrada-
tion.

Among the many startling things uttered by Sena-
tor Stewart, in his lengthy speeches before the Senate of
the United States recently, was the statement that the
mental stagnation, degeneration and darkness of the
Middle Ages was principally due to diminished pro-
duction of the precious metals and consequent depres-
sion of business and lack of remunerative employment
for the masses.

Times of financial depression like the present are
fraught with anxiety and worry among all classes of
society ; and anxiety and worry, along with want of
nourishment and hereditary predisposition, are power-
ful factors in the production of insanity. " Low wages,"
says Maudsley, " mean poverty and bad nourishment,
and lunacy shows a distinct tendency to go hand-in-
hand with pauperism."

The statistics of our insane hospitals bear out this
statement ; nor can we be surprised at the large acces-

Digitized by

Google

Tot. CXXX, No. 8.] BOSTON MEDICAL AND SURGICAL JOURNAL.

196

sions to the ranks of the insane from the lower classes
daring the past year. When chronic worry coincides
with chronic want of work, some form of mental deg-
radation is almost sure to sopervene, for " mental ex-
ercise is the trae foandation of mental health."

If we may trnst Hachard,* mental emotions (and he
specifies chagrin, anxiety, disappointment, worry) may
have a real and positive influence in the origin and
development of eardiopalhi«t, and, in particalar, of
arttrio-ielerotU. The order of morbid events, accord-
ing to this writer, is as follows : Spasm of the arteri-
oles (dae to the emotion), hypertension of the arteri-
oles and capillaries, sclerosis of the arteries, scleroses
of the viscera. The existence of arterial spasm nnder
the influence of even trifling emotion has been demon-
strated by the experiments of Mosso by the aid of his
plethysmograpbs. " If now," says Hnchard, " yon
have a state of prolonged or chronic emotion, as
where the person is in a protracted worry, or is pro-
foundly, permanently disheartened by losses and ad-
versity, yoa have a condition of almost permanent
vascular spasm and of arterial hypertension."

We have not space here to give Huchard's explana-
tion as to how this affects the vasa-vasorum and the
nutrition of the arteries. He finds reason for the be-
lief that strong and repeated emotion may determine
cardiac affections by its incessant action on the peri-
pheral circulatory system ; " and this," he adds, " is
one of the reasons why arterio-sclerosis is (according
to my observations) so frequent in the medical profes-
sion, pre-eminently the kind of life entailing overwork
and worry."

Doubtless, if this writer's views are correct, the
psst year, by its chagrins, anxieties and cares, most
have been a very eventful year in the pathogenesis of
arterio-sclerosis.

It hardly needs to be said that inebriety is a disease
DO less prevalent in hard times than in times of pros-
perity. Idle men naturally flock to the saloons, and
svil and misery drive the poor and the desperate to
seek solace and forgetfuluess in strong drink.

Among the diseases to which times of great business
depreiaiou have a causal relation are all those derange-
ments of the alimentary canal and of nutrition which
are the result of insufficiency or improper quality of
the ingesta. That human beings this present winter
in all our cities are without sufficient food is painfully
known to physicians and all others who are brought
into daily contact with the poor. In very many in-
stances the physician feels that food and not medicine
is needed. Many families, too proud to receive char-
ity, are living on a starvation diet. They cannot af-
ford meat, and they buy only the poorest, cheapest
foods. Hence the evils attendant on anaemia and ina-
nition are soon apparent. The poorly fed soon fall a
prey to grave diseases (tuberculosis, pneumonia, ty-
phoid fever, even influenza, etc.) because their vital
resutance is weakened. Children brought up on a
meagre diet become frail, sickly and neurotic. Are

> Haehard : Maladlw dn Ccenr at del Vmlnmraz, Psrii, 1890.

we destined to witness, as the outcome of this long
period of business depression, a generation of misera-
ble candidates for tuberculosis, for hysteria — physi-
cally stunted, intellectually undeveloped, unfit to bear
the burdens of life, a burden on society.

To the ills which we have mentioned, we might add
all the pathological results of insufficient fuel and in-
sufficient clothing.

Doubtless with the starting up of idle machinery all
over the country, there is the promise of future prosper-
ity ; and the greatest boon which we can ask for the
idle and unemployed is the hygiene of regular work,
for this means plenty of food, enough clothing, strength
of body and mental health.

THE SUPERVISION OF THE INSANE IN NEW
YORK.

The leading medical journals in New York continue
to express thorough dissatisfaction with the State Com-
mission in Lunacy, for the reasons which we have
suggested in a previous number of the Journal.^ In
a recent editorial in the New York Mtdieal Journal^
the statement is made that on all sides in the State the
tendency of the Commission in Lunacy to evolve itself
into an enormous political machine has been subjucted
to severe criticism from honorable men of every pro-
fession, and that the voice of reproof grows louder
every day as the lowering ambitions of the commis-
sioners become clearer and clearer.

A bill has been proposed in the Assembly to abolish
the Commission in Lunacy, and to confer upon a com-
mittee of the State Board of Charities — really upon
the secretary of such a committee — the work of su-
pervising the care of the insane in the State institu-
tions. This plan is essentially the same as those which
have proved so satisfactory in Massachusetts and Penn-
sylvania ; and the reputation of the New York State
Board of Charities for excellent work is such that it
will be quite safe to place additional responsibility in
its bands.

Moreover, the Board has already distinguished itself
for investigations and recommendations with regard to
providing for the insane, and has a familiarity with the
subject that must prove of great practical use, if it can
be made available. In continuation of the studies of
the Board, Dr. Stephen Smith, formerly State Com-
missioner in Lunacy, has formulated a number of sug-
gestions ' for improving the administration of insane
asylums and for increasing the comfort and chances
of recovery of the insane, in which he has especially
recommended the principles embodied in the proposed
law.

We have in this State been so fortunate in keeping
politics out of our public institutions and in having the
management of our State Charities in the hands of
public-spirited persons devoted to their work, that it is
difficult to appreciate how important is the issue at

> Tol. ozxiz, p. SOS.

> Amerloan joiumal a Imanlty, Jaoiui7, ISM, pp. 825-344.

Digitized by

Google

106

BOSTON MEDICAL AND SURGICAL JOVBSAL. [FEBBrAET 22, 1894.

stake in New York. The proposed change in the law
is in the right direction ; and we hope th«t it may be
soon brought about

MEDICAL NOTES.

A National Bureau of Health. — We learn that
the bill presented to Congress by a committee of the
New York Academy of Medicine, for the establishment
of a Bureau of Health, has been so essentially modified
that the new draft is much more likely to represent the
views of the Tarions health bodies of the country, and,
in consequence, to have favorable action at the hands
of the authorities at Washington.

Yellow Feveb at Rio Janeiro. — The yellow
fever epidemic at Rio Janeiro has started up again,
and is increasing to a considerable degree, there being
an average of about forty new cases each day. One
case has occurred on the United States cruiser Newark,
'and the vessel has been ordered to Montevideo to be
disinfected.

SUCGKBBOB to PbOFSSSOR MoLSSCHOTT. —

Professor Luigi Luciani, of Florence, has been ap-
pointed to the Chair of Physiology in the University
of Rome, to succeed Professor Moleschott.

The Study or Leprost in Iceland. — The
Danish Parliament has voted the sum of $840 for the
expenses of a medical mission to Iceland for the purpose
of studying the extent to which leprosy still prevails
on that island. The mission, which is to consist of
Drs. Ehlers and J. Ulrioh, of Copenhagen, with an
Icelandic physician as interpreter, will make its in-
vestigation in July and August of the present year.

Award of the Rueri Prize. — The Riberi
Prize, founded by Prof. Alessandro Riberi, has jost
been awarded to Dr. Camillo Golgi, Rector of the Uni-
versity of Favia, and Professor of General Pathology,
for his essay upon Malarial Fever. The prize amounts
to $4,000, and is open to international competition
every five years. The subject must be one of purely
medical interest, and the essay be the result of original
research. There were three essays this year deemed
worthy of final consideration, that by Dr. Grolgi being
finally awarded the prize. The others were by a
Frenchman and a German.

Medical Practitioners in Scotland. — The
last volume of the census of Scotland, for the year
1891, gives a list of 7,709 medical practitioners, or
one to every 522 inhabitants. This proportion seems
rather large until it is noted that the list of medical
practitioners includes physicians, surgeons, dentists,
veterinary surgeons, sick-nurses, midwives and invalid
attendants. An analysis shows that there are but
2,595 physicians and surgeons, or -one to every 1,550
inhabitants. There were only twelve women physi-
cians.

Coroners or Medical Examiners ? — The clumsi-
ness and inefficiency of the old coroner system is be-

coming each year more widely appreciated. The
committee appointed by the Medico-Chirurgical So-
ciety of Montreal to suggest modifications in the pres-
ent law relating to coroners' inquests has recommended
that the office of coroner be made a purely judicial
one; and (1) that salaried medical examiners heap-
pointed to investigate all deaths occurring under cir-
cumstances calling for medico-legal investigation under
any act, and that these officers be given authority to
make such medical examination of the body as may be
necessary to determine whether death was due to vio-
lence or not ; (2) that in every case the medical ex-
aminers report the result of their examination to the
coroner or other judicial officer charged with investi-
gating the legal side of such cases, who, in case of
violent death, shall make such investigations and take
such measures as are necessary for the proper admiih
istration of the law.

Henoch's Successor. — Prof. Johann Otto Leon-
hard Heubner, of Leipsic, has finally accepted the chau*
of Children's Diseases at Berlin made vacant by
Henoch's retirement. At first he declined the position,
owing to its being only an Extraordinary Professor-
ship, while his own position at Leipsic was that of
Ordinary Professor. Heubner, who is fifty-one years
old, has done practically all his work in Leipsic He
was assistant to Wunderlich in 1868 and private
decent in 1869.

BOSTON AND NEW ENGLAND.

Acute Infectious Diseases in Boston. — Dar-
ing the six days ending at noon, February 20, 1894,
there were reported to the Board of Health, of Boston,
the following numbers of cases of acute infectious dis-
ease : diphtheria 26, scarlet fever 28, typhoid fever 2,
small-pox 7. There was one death from small-pox.
The small-pox cases were reported at about the same
time from three different parts of the city. There
was some difficulty in accounting for one of the cases,
that from the South End, until the arrival at the hospi-
tal of another patient from the West End who had ac-
quired the disease from visiting the family in South
Boston who were supposed to be ill with chicken-pox.
The South End patient was delighted to see in the
West End patient a friend whom he had vuited some
days before, and the chain of evidence was complete.

Small-Pox in Massachusetts. — During the
past six days there have been reported to the State
Board of Health six cases of small pox from places
outside of Boston. One case in Worcester and five
cases in Holyoke.

A Bequest to the Hartard Medical School.
— The will of Rev. William C. Moseley, of Newbury-
port, bequeaths $50,000 to Harvard College, to endow
a professorship in the Medical School. Other bequests
in the will were $20,000 to the Massachusetu General
Hospital, for beds in memory of his son ; $10,000 to
the Boston Lying-in HospiUl ; $10,000 as a trust to
the Perkins Institute for the Blind ; and $10,000 to
the Anna Jacques Hospital, of Newbnryport.

Digitized by

Google

Vol. CXXX, No. 8.] BOSTOIf MEDICAL AUD SURGICAL JOUBNAL.

197

No Medicai, Stddbitts to bi allowed in the
Charitt Cldb Hospital. — The Women's Charity
Clab, of Boston, has voted, 43 to 88, forbidding all
medical students the privileges of clinical instruction
at operations performed in the hospital of the club.
This is the final decision of the club on the question,
which has been before it for some time, whether small
nnmbers of last-year or graduate students might not be
allowed to witness gyneecological operations. The
privilege was asked especially for students of Tufts
Medical School, but no distinction has been made, and
all are to be excluded.

The Feet of Cambbidgs School-Cbildbbk. —
An order was passed last week in the Cambridge
School Committee authorizing Dr. 6. W. Fitz to make
examination in the Feabody School of that city, of the
rapidity and touch of pupils, and to take measurements
of their feet. The latter statistics are to be taken in
reference to the development of the arch of the foot.

VlTISKCTION IN THE POBLIO SCBOOLS. — The

Committee on Education, of the Massachusetts Legis-
lature, gave a hearing last week on the proposed bill
to prohibit dissection or vivisection in the public schools.
The bill was favored by representatives of the Society
for the Prevention of Cruelty to Animals on the
grounds,that vivisection is cruel and unnecessary, and
because it teaches children to practise cruel acts, and
18 calculated to cause suffering to animals, and does no
good.

Committee on Pcblio Health Heabinos. —
The Committee on Public Health, of the Massachusetts
Legislature, gave a hearing on Monday, February 19th,
npon a proposed bill for the establishment of hospitals
or wards in the various cities of the Commonwealth
for the treatment of venereal disease. The hearing
of the same committee upon a proposed bill for the
eoDttmctioD and maintaining of hospitals for conta-
gioDs diseases in the various cities and towns, said hospi-
tals to be under the control of the local boards of
health, which was ordered for the same day, was post-
poned to March 9th. The hearing on public vaccina-
tion was postponed to March ath.

la^ceHanp*

PBESIDENT ELIOT ON THE REGULATION OF
ATHLETIC SPORTS.

In the annual report of Harvard College for 1892-
93, just issued, President Eliot devotes considerable
space to a consideration of College Athletics. Accord-
ing to our custom, we shall notice this report at
length. This week we can only give the conclusions
reached by the President in regard to the regulations
of College Athletics. Under the head of "Possible
Checks on Excess in Sports," he says :

" If the evils of athletic sports are mainly those of
exaggeration and excess, it ought not to be impossible
to point out and apply appropriate checks. The fol-

lowing changes would certainly diminish the existing
evils: (1) There should be no Freshman intercolle-
giate matches or races ; (2) no games, intercollegiate
or other, should be played on any but .college fields,
belonging to one of the competitors, in college towns ;
(3) no professional student should take part in any in-
tercollegiate contests ; (4) no student should be a mem-
ber of a university team or crew in more than one
sport within the same year ; (5) no foot-ball should be
played until the rules are so amended as to diminish
the number and the violence of the collisions between
the players, and to provide for the enforcement of the
rules; (6) intercollegiate contests in any one sport
shonld not take place oftener than every other year.
Finally, if trial shall prove the insufiicieDcy of all these
limitations, intercollegiate contests ought to be abol-
ished altogether.

" These suggestions are by no means of equal im-
portance ; some of them concern many persons, and
some but few ; but all or any of them could be put into
force by a single college without diminishing that col-
lege's chances of success in such intercollegiate contests
as it undertook.

" Different persons will undoubtedly strike the bal-
ance differently between the advantages and disadvan-
tages of athletic sports ; but one important fact will
for many people incline the balance in favor of the
sports — '' the fact, namely, that there has been a decided
improvement in the average health and strength of
Harvard students during the past twenty-five years.
The gain is visible in all sorts of students — among
those who devote themselves to study, as well as among
those who give much time to sports. In 1888 the
Faculty passed a useful vote to the effect that all holders
of scholarships were expected to present themselves
twice every year to the Director of the Gymnasium
for a physical examination. The Faculty passed this
vote under the impression that the bodily condition of
these hard students would be fqand to be unsatisfac-
tory ; but it has turned out that, though some were
weak, others were strong, and that the development
and condition of the larger number were fairly good."

THE PATHOLOGY OF BICYCLING.

The list of diseases of occupation has received an
addition, this time a whole pathology ; and the bicycle
is to blame. The fear of kyphosis has terrified the
young man into an erect position npon his wheel ; but
now a French physician brings forth an array of le-
sions caused by riding the velocipede which is sugges-
tive of the extent of Uie present passion of Parisians
for the wheel.

Dr. Pezzer^ reports a considerable series of cases
where more or less injury has been caused by the
pressure of the saddle upon the soft or bony parts of
the rider. Superficial lesions he has seen almost en-
tirely on female riders ; they consist of inflammatory
affections of the labia majora, the urethra and adjacent
parts. Twice he observed acute lesions of the hsemor-
rhoidal veins, with tumor and haemorrhage in men ;
twice, also, acute retention of urine from prostatic irri-
tation. Many patients were troubled by prolonged
erections while riding, due to impeded venous return.
There were several cases of annoying ansesthesia of

> Anuales dea Muladlei del Organes Qenlto-Urlnairei, January,
1894.

Digitized by

Google

198

BOSTON MBDIOAL AND SURGICAL JOORNAL. r^sBBUABT 22, 1894.

the regioDB supplied by the pudic nerves. The more
serions lesions, however, occnrred in the urethra ; caused
in women by friction, and in men by prolonged press-
are on the bulbous portion. One patient suffered from
ystitis after riding ; and there were several cases of
ruptured urethra (periurethral abscess), and one case
of acute dislocation of the kidney.

It will be seen that after all bicycling is but little
less dangerous than foot-ball.

THE PKESENT GENERATION.

An overtaxed nervous organization is not the pecu-
liar possession of the American people of to-day, as has
been claimed. In his opening lecture on Therapeutics
Landouzy gave the following picture of *' the present
generation of neurotics, which numbers so many
youths of enfeebled ardor, of waning desires, of
sterile intellects, and of saddened, restless and suspect-
ing character ; so many young women who are always
anxious, dissatisfied and of constant functional insta-
bility, never ill but always disordered ; so many impa-
tient, capricious women, at once charming and unen-
durable, of strange itati cTdme, ruled by casuistry, full
of sparkling laughter and of ready tears, with high-
pitched voice (exhausting but inexhaustible) whose
talk is inconsequential, discursive and hyperbolic: so
many women who are despondent, never satisfied, in
love wjth realism not with the ideal, who will soon
have eyes only for the impressionists, taste only for
symbols, and passion only for literature and music of
a certain kind ; so many beings needlessly discouraged,
faltering and baffled in the struggle for life."

ANTI-CHOLERAIC INOCULATION.

Thb LaneM publislies the following communication
from Haffkine, reporting upon his work of anti-chol-
eraic inoculaUon :

"Anti-choleraic inoculations continue to occupy all
my time, and the process has now been applied to
about 16,000 persons. I try to work on as large a
scale as possible, because it is impossible to know be-
forehand in what part of the country cholera will make
its next appearance. I append the names of the places
where inoculations have been freely made up till now :
Agra, Alligarb, Lucknow, Delhi, Sanawar, Karsauli,
Dagshal, Fatiala, Rajpoorab,. Chirat, Jhansi, Simla,
Jatagh, Rawal-Findi, Murree, Abbottabad, Peshawur,
Sangrur, Nowshera, Na'iQi-Tal, Almora, Ranikhet,
Dworahat, Ka'iuur, Pauri, Sakniana, Mussa Gali, Srina-
gar (Garhwal), Tehri, Mussoorie, Dehra Dun, Hard-
war, Lahore and Meean Meer. In all these localities
it has been attempted to make the inoculations upon
persons who are living in precisely the same environ-
ments as their uninoculated fellows ; that is to say, I
have selected half of a regiment, of a school, of a prison,
or of a village for treatment. A record of the names,
social position and surroundings, symptoms which ap-
peared, etc., has been carefully kept of each case, with
most minute details, and copies of these records have
been given to the medical officers in these localities ;
and it is from these gentlemen that I hope to receive
clinical observations upon the subjects of operation
when next an epidemic appears. The constitutional

differences displayed by man with regard to cholers
are so large that no experience gathered from oue,
two, or ten individual cases would give even the moat
general result; the probability being that all the ten
selected persons might be constitutionally incapable of
being affected by the disease in the recognized manner.
On the other hand, operations on animals on account
of the particularity of the symptoms which result, are
always open to discussions. The results of experience
now placed before the eyes of the medical service in
India, will bring about, I hope, in the near future a
direct revolution in our ideas of the nature of cholers
and the means of combating the disease."

A MEMORIAL SKETCH.
WILLIAM F. HUTCHINSON, M.A., M.D.

Db. William F. Hutchinson died suddenly on Septem-
ber 80, 1893, at Providence, R. I. He had spent the whols
day in the usual routine, practising and writing letters, and
after dinner made a social call.

He had organic disease of the heart, and several times
has had attacks in consequence, in which he was attended
by his friend. Dr. Remick. Dr. Hutchinson was sick only
fifteen minutes, being conscious to the last. He greeted
his medical adviser pleasantly, saying, " Too lal« this
time, I feel I am going, it is filling up gradually, I cannot
breathe."

These were his last words, after which he expired, with-
out a struggle, genial and social till the last, just as bia
life had been. Our departed friend was so talented thst it
is Impossible to say wnere he excelled most. He was a
jovial companion, a true friend, a linguist, a journalist, a
tourist, a patriot, a scientist, a true physician and as a spe-
cialist an authority in electricity.

He was the friend of his patients, and prominent In all
public benevolent enterprises of the day ; as a citizen, he
was scrupulously honest, generous, and public-spirited,
warm-hearted, cordial and genial. As a Freemason he had
received the tiiirty-third degree.

Dr. Hutchinson was bom in Oswego, N. Y., October 28,
1838. His collegiate education was obtained at the Uni-
versity of PennsylTania ; and after receiving the Bachelor's
and Master's degrees at that institution, he pursued the
study of medicine at the Buffalo Medical College and also
abroad in the most celebrated of the French and Glermsn
universities.

Since 4^ close of his student career his life has been a
most active one in the service of his conntry, in both army
and navy, in the work of hischosen profession, in literature,
art and travel.

He was a linguist, and had travelled much, in fact, had
been almost everywhere, particularly in Germany and the
West Indies. His memory was wonderful ; he could advise
about all routes in travelling with more exactness than an
excursion agent, tell the time-tables, best ways to take, the
names of hotels and their charges. In the West India
Islands he was acquainted with every place and every-
body, and even could tell of individuals, their habits and
their state of health.

As a patriot he was a veteran of the army and navy, and
thereby became a member of the Loyal Legion. When the
Civil War broke out he went to the front with the Twenty-
second Regiment of New York Volunteers, as Assistant
Surgeon, in May, 1861. At the battle of Antietam, while
Kivine a drink of water to a wounded Confederate soldier.
Dr. Hotuhinson was struck by a bullet just over the heart.

At the first battle of Bull Hun he was taken prisoner of
war; and from July 21, 1861, spent nine weeks in Libby
Prison, when he used an opportunity to escape. He partic-
ipated in the battles of Cedar Mountain, Rappahannock,
Catlett's Stadon, Yorktown and South Mountain, Antietam
and second Bull Run. At the latter place he was captured

Digitized by

Google

Vol. CXXX, No. 8.] BOSTON MEDICAL AND SURGICAL JOURNAL.

199

again, but escaped three days after. He was promoted
Angast 18, 1862, to Sureeon and later to Brigade-Surgeon.
He was in charge of FaUs Church U. S. A. General Hospi-
tal from March to August, 1862, also Provost-Marshal of
Fairfax County and commanding Post at Falls Church ; on
duty at the office of the Surgeon-General and at U. S. A.
General Hospital, Portsmouth Grove, R. I. He was
wounded several times, and as a consequence suffered every
winter afterwards during his life, which necessitated a
wjoom in a warmer clime. For Uiis reason he generally
ipent two months from January in some parts of the West
Indies.

On April IS, 1863, by act of the War Department, he
was discharged from tlie army with the rank of Colonel,
and transferred to the navy as Acting Past-Assistant Sur-
geon on the sloop-of-war Vincennes. He remained with
this branch of the service throughout the remainder of the
war. Next he was on the U. S. frigate Potomac at the
N^ of Fort Hudson, La., at siege of Vicksburg, and at
the battle of Mobile Bay, where he was wounded and taken
prisoner again. From the navy he was honorably dis-
charged in December, 1869.

The next four years of his life were passed at Minneapo-
lis, where he acquired an extensive practice.

In 1873 Dr. Hutchinson came to Providence, where he
has since resided, except for his frequent European and
South American trips. He made electricity a specialty.

He was Assistant Secretary-General of the Pan- American
Medical Congress, the organization of which society owed
much to his efforts, as he was the representative who
brought about the co-operation of the medical men in the
Spanish American countries. He was also Vice-President
of the American Electro-Therapeutic Association and a
Fellow of the Soci^t^ Fran9aise Electro-Th^rapeutiqne.

As a journalist he was considered particularly clever,
and for a considerable time was attached to the regular
staff of the Star and Press. He was formerly an editor of
the old American Magazine; and up to the time of his
death he was the associate editor of the following periodi-
cals: NetB England Medical Monthly and The Prescrip-
tion, The Times and Register (Philadelphia), and Journal
of Balneology (New York).

He has written many valuable editorials and other medi-
cal articles, one of his last was " Electrical Anaesthesia by
means of the Singing Rheotome," and also a text-book,
" Practical Electro-Therapeutics," which has had a large
eircalation. Among his other works are many interesting
novels and volumes of travel in South America. His prin-
cipal work was " Under the Southern Cross." His style
of writing is vividly descriptive, and very interesting to
read.

Or. Hntchinson was a prince of good fellows, and moved
is the best society. He had been one of the best known
nen in Grand Army circles. Immediately after his arrival
in Providence, he joined Slocum Post, and afterwards be-
came its commander. Later he organized Arnold Post, of
vhlch he was also commander for several years. He was
a member of the Rhode Island Historical Society, of the
fihode Island Medical Society ; and at the organization of
tlie medical department at Tufts College he was chosen a
professor.

The funeral of Dr. Hutchinson took place at Providence
OD Tuesday, October 8d, with military honors. After prayer
by the Rev. Mr. Bassett at the house, 78 Mawney street,
at i o'clock his remains were taken to the Church of the
Epiphany, where the funeral service was held. After all
the aeats in the church had been filled, Rev. Mr. Bassett
and Chaplain Webb escorted the remains to the altar,
and the two ministers proceeded with the Episcopal burial
service. The solemn rite was very impressive by additions
of very tasteful organ preludes and singing of a male quar-
tet. Beautiful flowers covered the coffin. After the ser-
vice the military cortege followed the remains to Pocbsset
Cemetery, where the burial service of the Grand Army
Veterans was held and the body placed in the earth with
the customary military honors.

KoBKRT Nkwmam, M.D., New Yobk.

Cocceie()>onDettce.

THREE UTERINE PREGNANCIES DURING AN
EXTRA-UTERINE PREGNANCY.

WoRCKSTEK, Mass., February 15, 1894.

Mr. Editor: — The enclosed cutting from an old news-
paper * is certainly curious, and may be interesting to some
of your readers.

DIED.

In Uxbrldee, Feb. 1, Mrs. Ruth Ellis, wife o( Mr. Charles
Ellis, 32. It hkd been ber singular lot, for nearly eteht years,
to have borne an eztra-uterlne foetus of full size, dunne which
period she had become the mother of three healthy children.
Her health evidently' declining during the last fall, from its
presence, no alternative seemed to be left but Its removal,
which was effected on the 31st of December, by the Doct's.
Miller, of Providence, R. I., and Franklin, Ms. The snbsecment
discovery, however, of a free communication, which had oeen
previously formed by ulceration, between the small intestine
and the sac, and by which all nutriment, received into the
stomach, passed through the artificial opening, destroyed all
hopes which her physicians, at the successful termination of
the operation, may have been disposed to entertain of ber
eventual recovery. Her sufferings were less than before the
operation, but emaciation' progressed rapidly; and became ex-
treme, and she at length sank. Her life having been doubtless
prolonged by the serenity of mind and calm resignation with
which she awaited her fate. (Com.)

I have not found any record of the case in text-books
and monographs. Very truly yours,

Grorob E. Francis, M.D.

< The Masmabosetta Spy, 'Woroester, Second Month (Feb.) 10, IMI.
Its motto was, " The liberty of the press Is esaential to the security
of freedom."

RECORD OF MORTALITY
Fob TBI Wbxx bmsixo Satcboat, Fbbbuabt 10, 1894.

Deaths reported 2,718: under five years of age 768; principal
Infections diseases (small-poz, meaalea, diphtheria and croup,

Digitized by

Google

200

BOSTON MEDICAL AND SVSGIOAL JO USUAL. [Fbbbuaet22, 1894

diarrhoeal diseases, whoopiDg-coaeh, erysipelas and fever) 342,
acoie lung diseases 670, consumption 313, diphtheria and cronp
160, scariet fever 42, diarrhoeal diseases 38, measles 33, tjpboid
fever 23, whooping-congh 16, cerebro-spinal meniDgitis 11,
small-poz 9, erysipelas 8.

From measles New York 19, Hilwankee 8, Philadelphia 6,
Brooklyn 1. From typhoid fever Philadelphia B, Washington 4,
Boston, Cincinnati and Cleveland 3 each, Charleston, Worces-
ter, Fall River, Lynn and Quincy 1 each. From whooping-
cough Boston 4, New York, Philadelphia and Brooklyn 3 each,
Cincinnati 2, Cleveland 1. From cerebro-spinal meningitis New
York 6, Worcester 2, Cleveland 1. From small-pox New York
9. From erysipelas Brooklyn 4, New York 2, Philadelphia and
Boston 1 each.

In the thirty- three greater towns of England and Wales with
an estimated population of 10,458,442, for the week ending
February 3d, the death-rate was 20.0. Deaths reported 4,012;
acute diseases of the respiratory organs (lx>ndon) 385, whooping-
cough 158, diphtheria 109, measles 64, scarlet fever 46, fever 41,
diarrhoea 34, small-pox (Birmingham 6, West Ham 2, London,
Bradford and Gateshead 1 each) 10.

The death-rates ranged from 13.3 in Blackburn to 29.2 in
Liverpool; Birmingham 20.9, Bradford 16.6, Croydon 14.4, Hnll
23.8, Leeds 18.6, London 19.4, Ilanchester 19.1, Newcastle-on-
Tyne 17.6, Nottingham 17.7, PorUmoath 18.9, Sheffield 18.6,
Sunderland 16.6.

HETEOBOLOOICAL RECORD,

For the week ending February 10, in Boston, according to ob-
) by Sergeant J. W. Smith, of the United

Beryations tnmisbed
States Signal Corp*:—

Baro-

Thermom-' Belative

Direction

Telocity We'th'r.

1

meter

eter.

hamiditT.

of wind.

of wind.

•

Date.

1

f

i

a
S

a

■a

ai
-J

61

n
>.'
S

00

94

78

a

i

ft

S

a'

s.

a

a'

■i

a'
S

aS

N.

a

s

8.. 4

29.80

«i\r,

27

N.W.

N.W.

8

9

o.

0.11

M.. 6

30.28

18122,11

B'J

56

64

N.

W.

17

10

p.

0.

0.07

T.. 0

80.36

21 S3 9

4K

60

64

W.

S.-W.

3

12

n.

0.

W. 7

30.10

36 46|2fi

741 69

72

a.w.

SW.

13

17

0.

O.

T.. 8

29.96

43 SO

36

76

82

69

s.w.

w.

10

12

R.

c.

P.. 9

3a07

36 '39

32

74

99

K6

N.

N.R.

3

23

O.

R.

0.28

S..)0

29.81

36

38

32

100

96

98

B.

N.W.

18

7

B.

O.

0.26

tr

0.71

•O-.elaiidyi Celori F., fain U.,fO(i B.,bu7i 8.,imok7i lUimlBi T.,Um*t-
nlDKi N..niaw. « IndleatM tract of niatall. a^MMnterwMk.

OFFICIAL U8T OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. 8. ARMY, FROM FEBRUARY 10, 1804,
TO FEBRUARY 18, 1894.

Leave of absence for one month and ten days, to take effect
upon the adjournment of the Eleventh International Medical
Congress, to be hel,d at Rome, Italy, March 29 to April 6, 1894,
is granted Colonkl Josbph R. Shith, assistant surgeon-gen-
eral.

Leave of absence for one month is granted Captaik Rbubbk
L. Robertson, assistant surgeon, U. 8. A., with permission to
apply for an extension of one month.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. 8. NAVY FOR THE WEEK ENDING FEB-
RUARY 17, 1894.

A. F. Pkics, surgeon, ordered to the Torpedo Station, New-
port, R. I.

H. E. Ambs, surgeon, detached from Torpedo Station and to
the " Richmond."

M. W. Barnuu, assistiint surgeon, ordered to temporary duty
on the " Ranger." Upon the reporting of relief detached from
the " Ranger," ordered home and wait orders.

Q. T. Shitb, passed assistant surgeon, detached from Naval
Hospital, Chelsea, and ordered to the " Banger."

M. R. PiooTT, assistant snrgeoD, detached from " Richmond"
and to Naval Hospital, Chelsea.

T. B. Batlbt, passed assistant surgeon, detached from the
" Machlas " and to the " Richmond."

Jab. F. Krenbt, passed assistant surgeon, died on board the
U. S. S. " Banger," February 10, 1894.

SOCIETY NOTICE.

Boston Socibtt tob Mbdical Impbovbhbnt.- A regnlar
meeting of the Society will be held at the Medical Library, No.
19 Boylston Place, on Monday, February 26, 1894, at 8 o'clock,
p. u.

Dr. E. N. Whittier: " Digestive Paresis." Discussion opened
by Dra. E. O. Cutler and W. W. Gannett.

Dr. J. G. Humford : " Compound Fractures." Discussion
opened by Drs. A. T. Cabot and B. W. Lovett. Dr. Gotdthwait
will show a new method for the direct fimtion of the fragments
in severe fractures of the long bones.

Dr. J. H. Wright will show cultures from " Gonorrhoea."

Members are requested to show interesting cases and patho-
logical specimens.

JoKN T. BowBN, M.D., Sterttary.

HARVARD MEDICAL SCHOOL.
Etbn»o Lbctubbs.

The next iectore will be given on Wednesday evening, Febm-
ary 28th, at 8 o'clock, by Prof. E. S. Wood. Subject, " Urinary
Diagnosis." Physicians are cordially Invited.

RECENT DEATHS.

Sam ubl Maombb Dokatom, BLD., M.H.S.8., died in Qnincy,
Mass., February Ittth, aged forty-two years. He was town

Shysician of Quincy for a number of years and was appointed
ity physician the first year of municipal government, and
held the position to the time of his death. He was one of the
visiting physicians to the Qnincy City Hospital.

AuovsT HiBSCH, M.D., professor of special pathology and
therapenties and of the history of medicine in the University of
Berlin, died January 28th, aged seventy-seven years. His great
renown was gained by the publication in 1859 of his invaluable
band-book of " Geographical and Historical Pathology." Sub-
sequent to this he was a member of several German Scientific
Commissions, notably the German Imperial Cholera Commis-
sion in 1873. He represented the German Government at the
International Sanitary Conference at Vienna.

Fbancisco Alonzo Rdbio, M.D., professor of obstetric
medicine in the University of Madrid, died recently. He was
President of the Royal Council of Pablic Health, President of
the Royal Academy of Medicine and perpetual President of the
Spanish Gynecological Society.

BOOKS AND PAJKFHLETS RECEIVED.

Tariff Reform : A Hannfactarer's Point of View. By Arthur
T. Lyman. 1894.

Hernia and Its Mechanical Treatment. By John B. Walker,
M.D. Reprint. 1891.

Non-Malignant Tumors of the Larynx. By W. Scheppegrell,
A.M., M.D., New Orleans, La. Reprint. 1893.

A Case of Ringworm of the Scalp Simulating Alopecia Areata.
By Henry H. Whitehonse, H.D. Reprint. 1893.

Where to Send Patients for Water Cures and Climatic Treat-
ment. By Dr. Thomas Linn. London : Henry KImpton. 1894.

Establishing a New Method of Artificial Bespiiation in
Asphyxia Neonatoram. By J. Harvie Dew, M.D., New York.
Reprint. 1893.

On Methods Used and Results Obtained in Making Germicidal-
Efficiency Tests of a Disinfectant for Use in Railway Sanitation.
By William T. Sedgwick, Ph.D. Reprint. 1893.

Operative Surgery. By Th. Kocher, M.D., Professor at the
Universityand Director of the Surgical Clinic at the Berne Uni-
versity. With one hundred and sixty-three illustrations. New
York : William Wood & Co. 1894.

Philadelphia Hospital Reports, Vol. II, 1893. Edited by
Charles K. Mills, M.D., Member of the Neurological Staff, and
James W. Walk, A.M., M.D., one of the Directors of Charities
and Correction. Philadelphia : Printed by J. B. Lippincott Co.
1893.

The National Dispensatory, Containing the Natural Histoiy,
Chemistry, Pharmacy, Actions and Usee of Medicines, Including
those recognized in the Pharmacopceias of the United States,
Great Britain and Germany, with numerous references to the
French Codex. By Alfred Stills, M.D., LL.D., Professor Emeritus
of the Theory and Practice of Medicine in the University of
Pennsylvania; John M. Maisch, Phar.D , Late Professor of
Materia Hedica and Botany in the Philadelphia College of
Pharmacy, and Henry C. C. Maisch, Ph.G., Ph.D. Fifth edi-
tion. Enlarged and revised in accordance with the Seventh
Decennial Revision of the United States Pharmacopoeia. With
three hundred and twenty illnstrationi. Philadelphia: Lea
Brothers & Co. 1894.

Digitized by

Google

Vol. CXXX, No. 9.] BOSTON MEDIOAL AND SUBGIOAL JOURNAL.

201

<9cigtnal ^cttclejer.

CASK OF FATAL HEMORRHAGE FROM THE
LEFT LATERAL SINUS, CAUSED BY A BLOW
ON THE JAW.

A. H. L., a tall, athletic studeDt, aged nioeteen, was
atnick in a frieDdly eparring bout upon the left jaw by
the right hand of his opponent. The blow was de-
livered very nearly Btraigbt from the shoulder, and
over the uplifted hands of the recipient, whose
head was bent forcibly backward by the impact. The
fist in striking was pronated. Large gloves were
used. The patient on receiving the blow commented
in a natural manner upon its excellence, and asked
with which hand it had been struck ; immediately after
this he said that he felt queer, then put both hands to
his head, jumped ap and down several times, reached
ont his hand for the wall, staggered and fell uncousciousi

The accident occurred about five in the afternoon,
Tuesday, February 13, 1894.

EflForts at resuscitation on the part of the students
proving ineffectnal. Dr. Lamarche was summoned, who
advised removal to the patient's room. From this
time on consciousness was not recovered. The breath-
ing became stertorous ; the pupils were first dilated,
then contracted. Within about four hours rigidity had
appeared in all four extremities, preceded by restless-
ness. Drs. J. L. Hildreth and J. Homaus were called
io consultation. The rigidity became more marked,
the toes at midnight being drawn down violently. At
one o'clock in the morning Dr. Walton was called to
advise regarding localization and operation. Dr. Pease
was also summoned to assist in case of operation. The
condition at this time was as follows : all four ex-
tremities were in a condition of tonic rigidity, the legs
atifflj extended, the feet in a condition of plantar re-
flexion, the left great toe being in addition drawn up
tpaimodically. Clonic movements of the right hand
were also superimposed upon the tonic rigidity of this
extremity. The elbows were flexed, the hand clenched
with the thumbs inward. There was no trace of spasm
or paralysis of the face. The eyes were turned some-
what to the left, without strabismus. The pupils
were alike, reacting only slightly to light. The neck
was flexible, and there was no apparent irregularity of
the cervical vertebras. The unconsciousness was com-
plete; the breathing heavily stertorous, abdominal,
with moaning on expiration. There was a tendency
to Cheyne- Stokes respiration. Both pupils were
large, the left perhaps a trifle the larger. There was
a tendency to lateral nystagmus. The knee-jerk could
not be obtained on account of the position of the limbs,
but continoal ankle-clonus was present. There was
so priapism. The pulse was 96, full and strong. The
temperature was 101°. There had been no bleeding
from the nose or ears, no subconjunctival hemorrhage.

It was concluded that a large haemorrhage had
taken place, involving the base of the skull and extend-
ing into the vertebral canal. The most probable
starting-point of the htemorrhage was deemed a fract-
ure of the left glenoid fossa from the impact of the
condyle of the jaw, an adjacent vessel being ruptured.
Operation was seriously considered, but was decided to
be inadvisable, as there seemed no chance that the
essential part of the clot could be removed, namely,
that pressing upon the pyramidal tract in the medulla
oblongata, an opinion borne oat by the autopsy.

The condition remained practically unchanged until
the next morning. The ice-bag had been applied to
the head, counter-irritants and heat to the lower ex-
tremities.

Wednesday (second day) spasms recurred at 4.45
and 5.30 a. u. At 7.30 the patient was breathing
quietly, the eyes slightly open. There was profuse
perspiration. Temperature 102.2°, pulse 100, respi-
ration 28. At 8 A. If. all extremities were still rigid,
the rigidity in the right arm and leg being most marked,
with spasmodic tendency in these parts. The pulse
varied from 76 to 90. At noon the breathing was still
quiet, with slight snore on inspiration and low moan
on expiration. The pupils were now somewhat dilated,
alike. During the afternoon the pupils were widely
dilated. The rigidity remained the same, with slight
twitching of the right hand. The head was drawn
somewhat to the left. The temperature fell to 101.2°.
During the night of this day the rigidity lessened ; the
pupils were widely dilated, and responded slightly to
light. The urine had been passed involuntarily before
the catheter was used. The jaws were less rigid, but
the patient could not swallow. The head was turned
somewhat to the left, the eyes markedly so. Attacks
of choking occurred daring the night.

Thursday (third day) the temperature rose to 102°,
the respiration to SO. Breathing stertorous. Head
straight, About four ounces of urine drawn. The
rigidity had entirely disappeared, leaving all four ex-
tremities almost completely relaxed, and paralyzed.
The knee-jerk absent. Nutrient enemata not retained.

Operation was carefully considered on this day. Dr.
M. H. Richardson being called in consultation regard-
ing this point. It was again decided inadvisable, for
the reasons already stated.

Friday (fourth day) the condition had remained un-
changed, excepting that twitching of the right eyelid
and right angle of the mouth had appeared, with slight
spasm of the left upper lip. Very slight spasm of the
right leg and hand appeared at the same time. The
knee-jerk was absent. The pupils were alike, rather
small, the eyes turned somewhat to the right, the left
not following perfectly. At 11 A. U. the respiration
was very shallow ; the pulse varied from 58 to 84.
Enemata were retained. The catheter showed the
bladder empty. Daring the preceding night the respi-
ration had been very irregular, at times sighing in •
character. The eyes had turned sometimes to the
right, sometimes to the left. Every half-hour there
were short cessations of breathing, followed by spas-
modic cough, with intermittent pulse, rising to 90, then
falling to 48. Bespiration 50.

Saturday (fifth day) the condition remained much the
same ; the patient gradually failing ; the temperature
rising in the afternoon to 105°, dropping back to 104° ;
the pulse rising to 130 and becoming very feeble.

Sunday (sixth day). Patient steadily sinking ; tem-
perature rising in the afternoon to 106.4° ; hands
purple. Patient died quietly at 3.50 p. h.

The autopsy was made the following morning by
Medical Examiner Swan, Drs. Councilman, Romans,
Hildreth, Durrell, Walton, F. W. Webber (of New-
ton), Pease, and G. W. Fitz (of Cambridge), being
present. The result of the autopsy was as follows :

Body of a spare, muscular, well-built young man.
Rigor mortis present Lividity of dependent parts.
No external marks of violence. Head opened. Sub-
cataneoas tissue of scalp shows no evidence of injury.

Digitized by

Google

202

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Mabob 1, 1894,

Calvarium removed. Sarface of brain covered with
extravasated blood beneath dara, (most marked over
occipitailobes,) of blackish color and tarry consistency ;
greatest quantity on the left side. On removing brain,
middle fossa on left aide foand to contain several
oances of the same black, tarry blood, and base of
brain covered with the same (filling the posterior fossa
and extending into the vertebral canal). There was a
small rent in the lateral sinas near onter margin of
temporal bone. About this rent, for a short distance,
the dara mater was dissected up. No fracture of upper
part of skull or upper cervical vertebra. Brain, on
section, showed marked injection of blood-vessels and
flattened convolutions ; otherwise normal. No extra-
vasated blood or fluid in ventricles.

Pleura everywhere smooth and glistening. Lungs
large, soft. On section, upper part of longs dry and
crepitant. Much dark and frothy fluid flowed from
middle and lower portion of lungs (oedema). Peri-
cardium smooth and glistening. Beart normal size.
Walls of right ventricle slightly thicker than normal.
Valves smooth and soft. Aorta smooth, soft and elas-
tic, and measares only six and one-half centimetres,
just above the aortic valve. Peritoneum everywhere
smooth and glistening. Stomach conUins a little dark,
slimy mucns. Small intestine contains small amount of
yellowish, gruel-like material. Large intettine contains
gas and lumps of small, yellow faeces. Mucous mem-
brane throughout normal. Liver, tpken and kidneys
engorged with blood, otherwise normal. Panereat
normal. J^adder contains a little turbid urine. Great
vessels of trunk contain dark liquid and clotted blood.

Diagnosis, rupture of lateral sinus and resultant
heemorrhage, caused by blow on head.

BEHABKS (dE. G. L. WALTON).

On account of the widespread interest io this
nnfortunate case, «nd in consideration of the gen-
eral desire on the part of practitioners to know the
exact facts, it was thought best to publish the ac-
count at once, without attempting a review of sparring
accidents in general, the collection of the necessary
data for which would require considerable time. A
ritumf of the important pointo at issue will not, how-
ever, be out of place.

On holding to the light the base of a skull, from
which the calvarium has been removed, it will be seen
that the roof of the glenoid fossa, which receives, on
either side, the condyle of the jaw, is extremely thin.
Cases are on record, and specimens preserved, in which
blows upon the jaw have produced fracture at this
point. The condyle has been found in one such case
driven directly through the skull. Study of the parU
would lead one to expect this accident with compara-
tive frequency if the condyle were not so placed that
the violence of such a blow is quite as apt to be dis-
tributed to the sides (more particularly to the poste-
rior and inner walls) as to the roof of the glenoid fossa.
In fact, the violence of most blows upon the jaw, upon
the chin, for example, would naturally be so far distrib-
uted in other directions (upon the teeth, or through
the superior maxillary bone) to say nothing of the mo-
bility of the jaw iuelf, and its liability to fracture,
that it must be only in a very exceptional case that
the full force of impact is transmitted to the roof of
the glenoid fossa.

Rarely as fracture occurs in this locality from this
cause, it is probably even more unusual for a blow of

this nature to produce haemorrhage without fracture.
Assuming the vessel wall to be healthy (and the au-
topsy revealed nothing to the contrary) the most plausi-
ble explanation in this case seems to be that if the
force of the blow was expended on the jaw it was
directly trausmitted to the posterior upper wall of the
glenoid fossa (firm bone), thence through the zygoma
and petrous portion of the temporal, expending itself,
by a species of contre coup, upon the point of least
resistance on the other side of the bone, namely, the
thin wall of the adjacent sinus. This course would
follow an uninterrupted path of solid bone; which
broadens into the petrous portion of the temporal, and
furnishes a buttress well fitted ordinarily to withstand
blows from this direction. The term contre coup should
not be here confounded with its ordinary surgical usage,
for there was no indication that any haemorrhage,
contusion, laceration, or other lesion, was produced
ftpon the opposite side of the cranium.

Possibly the compression of the jugular vein may
have caused sudden tension in the sinuses, contrib-
uting to the result.

It will not be out of place briefly to discuss the
localizing symptoms and the question of operation,
vital considerations in this class of cases.

In the first place, regarding the nature of the lesion,
all the geqeral symptoms pointed to haemorrhage. The
fact that the patient was not momentarily stunned (as
shown by his remarks on receiving the blow) ruled out
concussion in the ordinary surgical acceptation of the
term. The onset of reeling, falling, loss of eonscions-
ness, deepening stupor, stertorous respiration and full
pulse, with alteration of pupils, pointed conclusively to
the pouring out of blood ; the severity and fulminating
character of the symptoms indicating a haemorrhage of
rapid onset and considerable extent.

With regard to the seat of the clot, convulsive rigid-
ity of arms and legs pointed to implication of the motor
tracts of these members somewhere in their course, or
to their cortical centres, the absence of facial involve-
ment showing the escape of the facial centres and
tracts. Haemorrhage into the internal capsule could
at once be ruled out by the bilateral nature of the
symptoms from the first The only accessible regions
left to consider were the motor centres for the arms
and legs on the cortex, the crura cerebri, and the pyra
midal tracts at the base, especially in the medulla
oblongata, where they come to the surface.

In the case of bilateral symptoms resulting from
unilateral pressure on the cortex (for example, in
cases of middle meningeal haemorrhage, with trans-
mitted pressure to the opposite side) the onset of
symptoms is always unilateral. Supposing, again, so
improbable a lesion as double middle meningeal haam-
orrhage from a blow of this nature, the iaxatX centres
could hardly escape.

At the base, however, we find the fibres for both
upper and lower extremities for the two sides ranniog
so closely together that involvement of all four limbs
would be the natural consequence of haemorrhage
pressing upon this region. The facial nerves having
left the motor tract above the pyramidal crossing,
would explain the absence of facial spasm and paraly-
sis, in case the bulk of pressure was brought to bear
at this point. We have only to suppose that the
facial nerve in its course, escaped sufficient pressure
to cause paralysis, a not unreasonable theory, con-
sidering the comparative immunity of basal peripheral

Digitized by

Google

Vol. CXXX, No. 9.] BOSTON MEDICAL AND SURGICAL JOURNAL,

203

Derres sometimes observed in cases of even extensive
basal exadatioD. The ocular nerves were certainly
almost free from implication in their coarse along the
base. It is especially noteworthy that there should
have been no paralysis of the abducens, for the long
coarse of this nerve over bony irregularities renders it
especially liable to pressure, so much so that internal
strabismus sometimes resolts from pressure downwards
of the brain itself, caused, for example, by a large
tumor in its substance.

While it might be conceivable that convulsive symp-
toms from irritation of the cortex should result from
pressure at the base, this seems a hardly probable
supposition, and in any event the symptom-complex
should have included facial spasm.

The most reasonable explanation of the rapid onset
of convulsive rigidity of all extremities, with ankle-
clonus, seemed, therefore, that irritation of the pyram-
idal tract in the medulla was quickly produced by
the haemorrhage, the succeeding paralysis with relaxa-
tion resulting from loss of conduction through these
tracts on account of the extreme pressure of the clot.

Let OS now consider the other symptoms in the
order of their localizing value. The occasional slight
difference between the pupils, in favor of the left, was
due to paresis of the third nerve on that side, from
pressure of the clot in the middle fossa extending to
the sphenoidal fissure, as pointed oat by Hutchinson,'
in cases of middle meningeal hemorrhage. The tem-
porary weakness of the internal rectus, shown by the
left eye not perfectly following when the eyes were
deviated to the right, points to the same pressure on
the left third nerve.

Conjugate deviation of the eyes, as well as bilateral
dilatation and contraction of pupils, are common in
various lesions, and furnished very little assistance as
localizing factors in this case.

With regard to the conjugate deviation, the direction
was generally to the left while convulsive symptoms
were present, this condition alternating with deviation
toward the right when paralytic symptoms ensued.
This &u:t would tend to negative the view that the
symptom was due to extension of the clot to the centre
for coujagate deviation in the angular gyrus. In this
event the extension would naturally be more marked
on the left than on the right, and would seem rather
to torn the eyes to the right than to the left, since
deviation away from the lesion is the rule in case of
cortical irritation, towards the lesion in that of cortical
paralysis.

Irritation and paralysis of the sixth nucleus in the
medulla oblongata cause, respectively, conjugate de-
viation toward and away from the lesion through
fibres connecting the sixth nucleus of one side with
the third of the other ; this nucleus is, however, so
iu removed from the surface, that is, in the floor of
the fourth ventricle (where no evidence of lesion
existed) that the pressure of a clot at the base could
hardly be expected to cause such irritation and press-
ure, at least, affecting the nucleus on either side alone.
A centre for conjugate deviation also exists in the
second frontal convolution, which may or may not have
been directly or indirectly afiected by the extension of
the dot. In point of fact conjugate deviation is a
symptom so readily provoked by lesions in various
localities, as well as iu cases without recognizable local
lesion (as in simple epilepsy) that it is of compara-

I On Compnnton of the Brala, London Hoipltal Beporta, 1867.

tively little value as an absolute guide to localization,
though sometimes valuable as a corroborative element
in diagnosis.*

The comparative rapidity of the pulse in spite of
the extreme degree of compression, while possibly
merely an accompaniment of elevated temperature,
may have denoted paresis of the pneumogastric.

Analogous cases can hardly be adduced to throw
light on this one, for, as far as we know, we have to
do with the first instance on record of this exact in-
jury.

An unfortunate coincidence of hemorrhage at the
base and a blow received in sparring, occurred in 1884,
at New Haven. The physicians differed as to the
probability of fracture. It was said, however, by ob-
servers of the bout, that the young man commenced
to fall before the blow (upon the forehead) was struck.
Dr. Foster writes Dr. Hildreth regarding this case,
that stupor and paralysis of all the extremities followed,
and that death ensued six days later. No fracture
was found, and Dr. Fosterj who had disbelieved in
fracture from the first, regarded the blow merely co-
incident, not causal, the apoplectic attack being pre-
cipitated, iu his opinion, by excitement. This case
comes, therefore, under a different category.

No report of autopsy after death from a blow upon
the jaw has come as yet to our notice, though we are
informed that this is not the first instance of such un-
fortunate result *

Cases of haemorrhage following blows directly upon
the head, without fracture or predisposing arterial dis-
ease, are already sufficiently rare to be worthy of pub-
lication, but that such a blow as here received should
produce this result, would seem almost impossible were
the fact not demonstrated by such a case as the one
under consideration. The occurrence must be regarded,
therefore, as a rare result of a chance blow, which
could not have been foreseen and which may never
occur again.

With regard to the question of operative interfer-
ence : Had the symptoms pointed to middle meningeal
haemorrhage of the usual seat, whether upon the side
upon which the blow was struck or upon the opposite
side, the advisability of operation would have been at
once established. The symptoms of this lesion are
sufficiently well marked, and the successful issue of
operation sufficiently well established, to place this
contingency among the well-recognized indications for
surgical interference. The same is true of haemor-
rhage from the middle cerebral artery, the symptoms
in this event being identical, the seat of the clot being
practically the same, except that it is subdural instead
of extradural. The chief localizing symptoms in both
these lesions are spasmodic movements of the opposite
side of the face, and of the opposite arm and leg, fol-
lowed by hemiplegia, the symptoms later becoming bi-
lateral. Such symptoms may be delayed, a period of
perfect consciousness intervening after the stunning
effects of the blow have passed away and before the
deepening stupor of haemorrhage ensues. In one such
case under Dr. Homans's care, reported in the Boston
Medical and Surgical Journal (February 12, 1891)
spasm of the right angle of the mouth preceded by
aphasia and followed by convulsions involving the
right arm and leg, becoming rapidly general, appeared
seven days after a fall upon the right side of the head.

' See yteTordt(IMagno<tUL der Inneren ErsnUielteD, s. Ml) on the
LooallxiBg Yaloe of Conjugate Deriation.

Digitized by

Google

204

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Mabch 1, 1894.

Heemorrhage by contre coup was diagnosticated, and
the clot Baccessfullj removed at mj saggestion by Dr.
Homana, perfect recovery following. The bsemorrhage
was subdural and involved the motor tract and tempo-
ral region, most copious over the facial area.

In the present case we had to do with a haemorrhage
in such location, and so qaickly poured out, that by
the time the symptoms were sufficiently marked to
point with any definiteness to the seat of the lesion,
the base of the skall had been flooded, and the verte-
bral canal so far invaded as to cause severe pressure
upon the medulla oblongata. The only excuse for
operation here would seem to be the otherwise hope-
less condition of the patient. Upon this point the
personal equation varies greatly, but the prevailing
feeling among the consnUants in this case was that
while any hope of relief, however faint, would justify
the attempt in so desperate a situation, there was realty
absolutely no prospect of relief by surgical interference.
The patient was on the verge of death, which the
shock of operation might only precipitate, and remove
the remote (certainly extremely remote) possibility of
absorption. Ligature of the carotid artery was hardly
advisable. This procedure, aimed to control, for ex-
ample, middle meningeal hiemorrhage, though pro-
posed by Forneaux, Roser, Simons and others,* prom-
ises very little in these cases, as shown by Gallez * in
his recent contribution \p the study of trephining, who
points out that the haemorrhage is not always controlled
in this way, and that even if it be controlled, the con-
sequences of the clot are not averted.

The question of trephining for haemorrhage at the
base, with or without fracture in this location, is one
upon which study is not exhausted. Possibly future
experience may lead to less conservatism in this class
of cases, but we do not gain sufficient encouragement
from the present status of cerebral surgery to afford
hope that drainage of the base of the skull, difficult at
the best (particularly on account of pressure down-
wards of the cranial contents) can be satisfactorily es-
tablished in so desperate a case as this, in which the
vertebral canal has been already invaded.

Gallez,* in commenting upon this point, after speak-
ing of the comparative hopelessness of operations for
very extensive haemorrhage, uses the following lan-
guage : ** It is even less justifiable to undertake opera-
tion when symptoms exist of compression of the bulb,
and of the nerves at the base of the brain ; dilatation
and paresis of the pupils, or rapid pulse (caused by
paralysis of the pneumogastric). The extravasation is
too diffuse."

Jacobson and Agneau are quoted by this writer in
substantiating this view, ihe former authority adding
that the condition points to extensive fracture. This
would certainly in a majority of cases be true, and
was to have been expected in our case, but whether
fracture were present or not, the contra-indications to
operation for haemorrhage of this extent and seat,
would seem absolute.

The autopsy, in the opinion of all present, certainly
justified the conclusions drawn, both regarding the
localization and the question of operation, the vital
points in the case. The existence or non-existence of
fracture had comparatively little practical bearing,
either on the diagnosis, prognosis or treatment.

• Lancet. 18XS ; Medical Times, October IT, 1883, page 648.

• La Trepanation da Cr&ne, Parit, 1893.
> Loc. alt , page 272,

MALIGNANT DISEASE OF THE RECTDM.»

BY OBOBOB W. OAT, H.D.,
SvrgeoK to the Btnton OUy Ho$pU<U.

The brief paper which I venture to present to you
to-night is a sort of running commentary upon some of
the salient points of this disease and upon some of the
cases met with in my practice. As there is no known
permanent, radical cure for these affections, our efforts
are necessarily directed to the management of the cases
with a view to prolonging life, and to making it as en-
durable as possible while it lasts.

The first point to receive consideration in all dis-
eases of the rectum is the diagnosis. I should not feel
called upon to advise and to urge upon the younger
members of this Society the very great importance of
a digital and visual examination, had I not seen and
made some very embarrassing mistakes by neglecting
this important essential. Every hospital or consulting
surgeon has met with cases of malignant disease of the
anus and rectum which have been treated as piles,
simply because no proper examination had ever been
made.

A noted musician, whom the older portion of this
community remembers with pleasure, came into my
office some years ago, saying that he had thepiiea, and
had been treated for them off and on for two or three
years. He wanted to know what was the matter with
him. I was shocked at his appearance; emaciated,
sallow, weak, a wreck of his former robust self. A
digital examination revealed a large mass of malignant
disease situated just above the internal sphincter, which
any one could easily have found, and the character of
which could not have been mistaken for anything else.
It need not be said that I received much undeserved
credit in the case by simply telling him bis real condi-
tion.

As further showing the importance of making a
careful examination in cases of suspected disease of
the rectum, I may allude to the case of a woman who
was brought to me by a reputable physician for an
opinion as to the character of a rectal tumor which he
had detected by a vaginal examination alone. Epsom
salts and warm-water injections removed the lump in
a few days.

Both of these mistakes could have been easily avoided
by simply making a digital examination of the rectum.
The diagnosis should never be made upon subjective
symptoms alone. The external parts should be care-
fully inspected, and the finger should be carried as far
up the rectum as possible. A lady was put under my
care several years ago by Dr. Brainard, for the re-
moval of a small patch of malignant disease situated
nearly or quite five inches from the anus. It was
reached with difficulty by the finger, and a careful,
thorough search was necessary for its detection. Haem-
orrhage was the principal symptom.

A woman about fifty-two years of age is under my
care at the present time, who for several weeks had
pelvic pain and colic, which were greatly aggravated
by laxatives or cathartics. Constipation was obstinate.
Repeated vaginal and rectal examinations revealed only
a uterine fibroid on the posterior surface of the womb,
which, it was thought, might be the cause of the pain
and constipation through pressure. Etherization re-
laxed the parts, so that this explanation was at once

1 Read before the Boston Society for Hedloal Obserratlon, Jsb-
osry 1, 18M.

Digitized by

Google

Vol. CXXX, No. 9.] BOSTON MEDICAL AND SUJtOIGAZ JOUBNAL.

205

abandoned, and a fibrous strictare was detected, as far
np the rectum as the fiDgers could be carried. It was
aDDolar, movable, firm, not bard nor nodular. Its
character may be inferred from the fact, that the symp-
toms were promptly ameliorated by inunctions of oleate
of mercury, and the administration of iodide of potash.
These cases are sufScient to show the importance of a
thoroagh digital examination.

The last case leads me to speak of the great value
of an anaesthetic io all rectal affections located above
the sphincters. Except in very thin people with lax
tissues, it is not possible to make a thorough and satis-
factory examination of the pelvic organs without an
anesthetic. This rule is emphatically true, as regards
affections of the rectum. With the patient under ether
in the lithotomy position, the sphincters are to be thor-
oughly stretched, and the rectum cleared by an enema
if necessary. A digital examination can now be made
to the best advantage to detect strictures, growths or
ulcers. With a Sims's speculum and a horizontal light,
a good view can be obtained of from four to six inches
of the lower part of the rectum, which is the location
of nine-tenths of its lesions.

Boogies, sounds and catheters are of little use in
making a diagnosis of stricture of the rectum. They
impinge npon the promontory of the sacrum, or get
caught in a fold of the mucous membrane, thereby
giving untrustworthy evidence as to the true condition
of the part. The linger is the only reliable sound, and
the diagnosis of those rather rare strictures located
above its reach is to be made from the symptoms, such
as colic, abdominal distention, etc.

The majority of abnormal growths found in the rec-
tum of adults are either specific or malignant in char-
acter. Aside from these causes, strictures may be due
to tuberculous or other inflammatory changes, or they
may be traumatic in character. Neoplasms or strict-
ares due to other causes than cancer or venereal dis-
ease, are not very common in our metropolitan hospi-
tals. Dr. Kelsey, in the late edition of his admirable
work npon diseases of the rectum, makes the statement
that almost as many strictures of the rectum, not ma-
lignant, are non-venereal as are venereal. Considering
the facts, that little dependence can generally be placed
upon the therapeutic test of the nature of the affection ;
that the clinical appearances are not always sufficiently
characteristic ; and that histories of cases through ig-
norance, carelessness, or wilful deception, are proverbi-
ally unreliable, I am unable to understand this state-
ment. Specific and venereal diseases permeate society
to such an extent, and are met with in such unexpected
places, that the older practitioners, who have seen a
good deal of these affections, will hesitate to subscribe
to the above statement.

I ventare the assertion that strictures of the rectum
' in adnlts, non-malignant and non-venereal are not often
met with in our large hospitals. It is by no means
easy in every instance to decide at once as to which of
the two most common classes the patient belongs, but
the cases are rare which cannot fairly be ascribed to
malignant or venereal causes.

A differential diagnosis is of much importance, as
affecting the prognosis and treatment. Specific and
other DOD-malignant strictures may, and not infre-
quently do, send their owners to the poorhoose ; but it
is only after many years of suffering that they find
rest in the grave. On the other hand, malignant dis-
ease of the rectum asoally runs its course in two to

three years, and terminates fatally in the vast majority
of cases. The exceptions to this rule are so rare, that
I have ascribed the recovery in two instances to a mis-
take in the diagnosis.

When a digital examination reveals a hard, nodular
mass in the rectum, more or less immovable, involving
the mucous, submucous and adjacent structures, and
encroaching upon the lumen of the bowel, there can
be little doubt as to the malignant character of the dis-
ease. It is safe to entertain the same opinion in cases
of hard, ragged ulcerations with indurated edges, and
deep attachments. Not infrequently a rather soft, fri-
able upgrowth is met with, which bleeds easily, grows
rapidly, and is liable to recurrence.

Malignant disease at the anus resembles epithelial
growths in other regions of the body, presenting an
ulcerated surface with or without an upgrowth, and
having a hard indurated base. The surrounding skin
usually presents a healthy appearance, rather than a
sodden, fissured, or nodular surface, as is so frequently
seen in cases of specific disease in this region.

A broad, general distinction between malignant and
specific disease of the lower bowel is, that the latter
involves the anus, while the former is located higher
up, so that oftentimes an area of healthy mucous mem-
brane separates the disease from the sphincters.

While the therapentic test is usually disappointing
and unreliable, yet occasionally it is very satis&ctory.
Four years ago I saw, with Dr. Joseph Stedman, a
woman under forty years of age who had extensive
disease of the rectum above the sphincters, which was
hard, indurated, involving adjacent tissns, thereby lead-
ing me to express the opinion, that it was malignant
in character. She was put upon the compound tinct-
ure of iodine, and given an unfavorable prognosis.
She took the medicine faithfully for many months,
and still continues its use at intervals. She is very
well, and has evidently derived great benefit from the
drug. In this case the diagnosis was wrong, but the
treatment was right.

It goes without saying that the prognosis in malig-
nant disease of the rectum, as in other parts of thie
body, is unfavorable. While there is no known cure
for these affections, yet much can be done to prolong
life in many cases, and nearly always to make it more
endurable.

The treatment is palliative or radical. I think that
the opinion is gaining ground in this country that the
former is preferable in very many patients. The
operation, or mode of treatment, which cures cancer,
has not been discovered. Hence the object of our
efforts in the management of the affections under con-
sideration is to give the sufferers all the comfort possi-
ble. It does not always seem desirable to prolong
life, and yet that is very properly one of the objects of
the physician's work.

The treatment of this disease may be considered
under three heads, namely : the alterative, the opium,
and the operative methods. Whether one or all of
these modes of treatment shall be pursued in any given
case, depends upon circumstances.

A good illustration of the alterative method was seen
in the case of a policeman about forty years of age,
who bad a maliguant ulcerating mass three inches in
diameter upon the anterior wall of the rectum above
the sphincters. Its location precluded any radical
operation, and the symptoms did not call for colotomy.
He took from nine to twenty-seven drops of the corn-

Digitized by

Google

206

BOSTON MEDICAL AND SUSOIOAL JOURNAL.

[Mascu 1, 1894.

poand tincture of iodine daily for apwards of two years ;
once or twice a day Le took an enema containing from
one to two grains of cocaine. He was thus enabled to do
his work as patrolman for the above period. The time
finally came when bis strength began to fail ; and on the
day that he was discharged from the force, he went into
an adjoining room, "and shot himself dead. He fully
understood the hopeless nature of his disease ; and the
moment that he was disabled he took the management
of the case into his own hands.

In view of the fact that this man was always better
on resuming the treatment, his physicians could not
but think, that it had a decided beneficial effect.

It is nearly three years since I removed a growth
two inches in diameter from the rectum of a man forty-
seven years of age, by Cripps's operation. It was
pronounced malignant by competent authority. The
symptoms were pain and haemorrhage. He has taken
the iodine daily since the operation, and there has been
DO return of either symptoms or growth. I dread,
however, to see this man enter my office, as I do any
other person, upon whom I have operated for cancer;
for it is probably only a question of time when a re-
currence will take place.

Six years ago I removed a similar growth from the
rectum of a middle-aged lady, by Cripps's operation.
For tour years she took Chian turpentine, and drank
Ypsilanti water constantly. There has been no recur-
rence of the hiemorrhage, or of the disease. I am in-
clined to ascribe the cure in this case to a mistake in
the diagnosis, rather than to the treatment.

Many years ago Dr. Henry M. Field, of Newton,
suggested to me the iodine method of treating malig-
nant disease of the rectum. He thought that he had
seen beneficial effects from its use ; and so far as re-
gards two cases, which I saw with him, I can confirm
his opinion. For a long time I have given the drug
to nearly all of my patients with malignant disease,
wherever located, provided they could take it without
disturbing the stomach. In many cases I could not
see that any benefit was derived from its use. The
rapid growing and markedly malignant ones, as might
be supposed, derive less aid from it thau others.

The natural course of malignant disease varies so
much in different individuals, that it is extremely
difficult to arrive at reliable conclusions as to the true
value of any drug in checking or modifying the new
growths. Chian turpentine, cnndurango and many
other articles have had their day, and have been dis-
carded because they did not stand the test of experi-
ence. I do not claim anything for iodine. I use it,
because I think it is our duty to give these unfortunate
people the benefit of every possible aid ; and for this
particular purpose, I know of nothing better at pres-
ent than the compound tincture of iodine.

Sooner or later most patients afflicted with malig-
nant disease of the rectum are compelled to resort to
opium to relieve their sufferings. The pain is usually
due to obstructed peristalsis, colic as we call it, or to
the pressure or other influence of the growth itself upon
the nerves. The first is paroxysmal, and is coincident
with the vermicular action of the bowels. The latter
is a steady, grinding, boring, or aching pain, very wear-
ing to the nervous system, and very distressing to bear.
Both can be controlled to a certain extent with opium.
Both are relieved temporarily by excision of the
growth. Colotomy usually relieves the colic perma-
nently, but may do the pressure-pain little, if any good.

A fair example of the opium treatment was recently
under my care through the courtesy of Dr. Whittier.
A man, sixty-eight years old, had suffered about two
years with a cancer of the rectum. It was located well
above the sphincters, hard, nodular, and involving the
neighboring parts to a wide extent. Colic and pressure-
pains were severe. The liver was greatly enlarged by
a secondary growth extending nearly to the umbilicus.
Several surgeons were consulted at different times, and
all very properly advised colotomy. The patient
finally became so weak and exhausted from the progress
of the disease, aggravated by the great difficulty ex-
perienced every week in his efforts to empty the bowels,
that he realized the fact that something mast be done.
The opium and operative treatments were fully ex-
plained to him and he decided to try the former. At
first a quarter of a grain of morphine given twice daily
under the skin was sufficient to relieve most of the
pain. This quantity was gradually increased until he
took between three and four grains daily, with the
effect of keeping him fairly comfortable. The bowels
did not move for nine weeks after he began the mor-
phine. His diet consisted of gruels, soups, and beef
extracts. No clear or unmodified milk was given dur-
ing this period. After some weeks of this complete
olMtruction, the faeces could be easily felt in the left
iliac region. The abdomen never became distended to
any extent, although very little flatus escaped for
several weeks. The paresis of the intestines produced
by the morphia was surprising. There was no vomit-
ing, hiccoughs, delirium, nor headache. Thirst was
urgent, and the mouth and throat were very dry and
parched, in spite of all our efforts to prevent it. The
emaciation became extreme. The bowels finally began
to move of themselves, without aid of any sort; and
during the last weeks of his life he had from two to six
stools daily, thereby completely removing the collec-
tion above the stricture. There was no haemorrhage.
He died from exhaustion. A seasonable colotomy
would doubtless have enabled this man to keep about
longer, and to have postponed the opium stage for a
time. Whether his life would have been prolonged
thereby, is a question not so easily decided.

Under the head of operative treatment there are
three measures, which require consideration, namely,
Cripps's and Kraake's operations and their modifica-
tions, and colotomy. The first is particularly adapted
for cases in which the disease is limited to the first five
inches of the bowel. It consists briefly in dividing
both sphincters and rectum as high as the tip of the
coccyx, and then dissecting out the growth or diseased
tissues.

Judging from a limited experience, this is a very
satisfactory operation. The dangers are shock and
hemorrhage. 1 have never seen incontinence of gas
or faeces to a troublesome degree follow this operation.
It is especially indicated for the removal of grovths
which are limited in extent, movable, and not located
over the urethra and prostate.

Kraske's operation is designed for the removal of
growths located higher up than five inches, or above
the reach of the finger. The sphincters are not divided.
The bowel is reached through an incision over the
sacrum and coccyx. The latter bone and a portion of
the former is removed. The gut is divided above and
below the diseased portion ; the latter is removed ; and
the ends of the healthy bowel are joined with sutures
or fastened in the wound, as the oondition require*.

Digitized by

Google

Vol. CXXX, No. 9.] BOSTON MSDJOAL AJSfD StUtGlOAL JOURNAL.

207

Tbe peritoneal cavity is nsoally opened in this oper-
ation, thereby adding another element of danger from
Bxtravasation of fieces.

Finally, we come to the most satisfactory operation
for the relief of the majority of cases, colotomy. This
is now mbst frequently done in the left inguinal region,
for the reason that the operation is more quickly and
easily performed, the wound can be attended to far
better by the patient, and the danger is no greater
than in the loin. The relief to the obstructive pain or
colic is usoally complete and permanent. The press-
are-pain may still require opiates or other treatment.
Many lives are prolonged ; and, more than that, they
are made comparatively comfortable by this operation.
Jn most cases the patient can keep himself clean and
free from odor. A woman upon whom Dr. Bradford
performed right lumbar colotomy worked for many
months alongside another woman, without the latter
ever suspecting that anything was the matter with her
companion.

Kelsey's description of tbe operation is the best one
I have seen. The incision parallel with Poupart's
ligament is made about an inch from the left anterior
■nperior spine. The peritoneal cavity is opened, and
the colon bronght out of tbe wound. The " bar " is
made by joining the edges of the incision with a silver
wire passed underneath the bowel. The intestine is
then joined to the edges of the wound with sutures,
and two or three days allowed to elapse before the
bowel is opened. The operation is neither difficult
nor dangerous, and in very many cases it is a most
satisfactory one to both patient and surgeon.

By way of recapitulation it may be said, that the
treatment of malignant disease of the rectum is essenti-
ally palliative. Colotomy is indicated to relieve ob-
■tractive colic, and it should be done early in order to
save the patient's strength. The radical operations
are indicated in the early stage, when the growth is
limited in extent, free from deep adhesions and infil-
tration, and not infringing upon the urethra or pros-
tate. Opium, the king of drugs, is to be avoided as
long as possible, and given judiciously, in order that
its beneficial effects may not be lost by over-doses
before the time comes when it is needed the most.
While the disease is incurable, very much can be done
by judicious management to make the patient's life
endarable and his death peaceful and easy.

A CASE OF PULMONARY STENOSIS IN AN
ADULT.

BT OLIYBB B. ETBBKTT, M.D., W0BCB8TER, MASS.

Thk following case is interesting in that the diag-
DOsis was made incidentally, and not because the pa-
tient complained of any symptoms pointing to her
heart. Furthermore, the rarity of tbe lesion in an
adult makes it worthy of record, as well as the fact
that the patient has attained her present age with so
Few symptoms. Professor Loomis, in reporting a
iimilar case,^ speaks of it as one of the " curiosities of
medicine."

Mrs. X., twenty-seven years old, a native of the
State of New York, of French-Canadian parentage,
applied for admission to the Memorial Hospital, No-
rember 10, 1893, thinking she had typhoid fever, as

1 Jntematioiukl Clinlos, 1893, Moond series, ToL It, p. 13.

she had been taking care of a patient with that dis-
ease. She had a slightly elevated temperature, and
was admitted for observation. She says she has al-
ways been fairly well, though never strong and cannot
do bard work without getting tired and out of breath.
Even as a girl she could not join in active plays.
There is no history of rheumatism, chorea or other
disease except scarlet fever and la grippe. When she
was ten or twelve years old her dyspnoea became more
marked ; and in the course of the next few years she
was examined by several physicians, who said she had
heart disease. There has been nothing abnormal about
menstruation since that function was established at the
age of fourteen. Since that time she has never but
once consulted a physician for her heart. She was
married ten years ago, and has had four children.
She has always suffered from cold hands and feet, and
occasionally has had slight swelling of the ankles.
She does her own house-work, with some help about
washing and ironing.

She is a fairly strong-looking woman, of medium
height, face slightly flushed, but not cyanotic or livid.
Finger- and toe nails somewhat rounded, and blue
(instead of the normal color) under them. On exami-
nation of tbe chest the most striking point is a long
inspiration, like a sigh, occurring from three to six
times a minute. She says she always breathes in this
way, feeling as if she should smother otherwise. The
night-nurse reports that there is no irregularity in her
breathing when asleep. The apex beat of the heart is
faint and diffused, and can be only definitely localized
when she is sitting up. It is then found in the mam-
mary line below the seventh rib. No thrill is percep-
tible over the heart, nor any impulse to be felt below
the ensiform cartilage. The heart's dulness begins at
the upper border of the fourth rib, thence to the apex
beat, and thence to the middle of the sternum. Over
most of the cardiac area the heart-sounds are normal,
though rather faint, and there is no murmur over tbe
aortic valves. To the left of the sternum, however,
in the first, second and third intercostal spaces, is a
soft, blowing, systolic murmur. Its point of greatest
intensity is in the second intercostal space, close to the
sternum, whence it may be traced upwards, and to the
left, in a line pointing directly to the middle of the
clavicle. Downwards it cannot be heard further than
the third intercostal space. The murmur does not dis-
appear on full inspiration. The pulmonic second
sound is fainter than normal, and there is no thrill or
impulse to be felt over this artery. Percussion and
auscultation reveal nothing abnormal in the lungs.
Dulness is normal over the liver and spleen. There
is no ascites, and no oedema of any part of the body.
Superficial veins of legs and upper part of the chest
are well marked. There is no pulsation in the jugular
veins, nor are they particularly prominent. The
radial pulse is small and weak, has ranged between 70
and 90, and is alike on both sides. Examination of
the urine shows it to be acid, specific gravity 1,015,
and containing neither albumen nor sugar. Since be-
ing in the hospital she has once spit up a little blood,
or bloody mucus, which I did not see, and have no
reason to suppose came from tbe lungs ; but the fact
is interesting in view of the frequent termination of
such cases in phthisis, with haemoptysis often an early
symptom. Her temperature became normal the next
day after her entrance, and she has shown no symp-
toms of typhoid fever.

Digitized by

Google

208

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Habch 1, 1894.

Having now a case of murmur over the seat of the
pulmonic valves, the first question is as to its origin.
Balfour' says, "The pulmonary area has been not
inaptly termed ' the region of romance,' " referring to
various interpretations which have been given to
murmurs in this location. This is one of the less
common situations of cardiac murmurs, which, when
present are usually inorganic. Flint* says an inor-
ganic pulmonic direct murmur is not infrequent,
though it seems to be far less commoa than an aortic
inorganic murmur. That the murmur in this case is
pulmonic and of organic origin I feel very sure. It is
not heard at all to the right of the median line of the
chest, nor is it transmitted into the carotids as Flint*
says is always the case with an aortic murmur. Neither
cftn it be heard at all towards the heart's apex, nor in
the back, as a mitral murmur would be; out can be
traced from its point of greatest intensity, upwards
and outwards, towards the middle of the left clavicle.
All these points show its pulmonic origin. Murmnrs
in this situation have been ascribed by some authors to
mitral regurgitant lesions, heard here instead of at the
apex as usual. lu accordance with this theory, which
has been advocated by Balfour, the murmur comes
from the dilated appendix of the left auricle coming
close to. the chest wall. Such a murmur is differenti-
ated from one arising in the pulmonary artery by its
point of greatest intensity being a little further to the
left, in such a position that when the stethoscope is
placed over it there is at least the width of the tip of
the middle finger between the instrument and the left
border of the sternum. With a pulmonic murmur the
stethoscope, when over the point of greatest intensity,
touches, or even- overlaps, the sternal border. Author-
ities differ as to such a murmur being ascribed to mitral
insufficiency. Flint dismisses it very summarily, say-
ing the question is hardly worth the discussion which
has been given to it. However that may be, there is
in the case reported an entire absence of any symptoms
pointing to mitral disease, and the murmur is best
heard when the stethoscope is close to the sternum.

Now, most pulmonic murmurs are inorganic Is
that the case in our patient ? I think not. The color
of her skin and mucous membranes is good, and shows
no sign of anaemia ; there is no venous hum in the
vessels of the neck ; and the pulmonic second sound is
fainter than normal, instead of being accentuated.
The heart's dulness on percussion is somewhat in-
creased; and there are positive signs of engorgement
of the systemic veins, in the blue finger- and toe-nails,
and the venous enlargement in the legs and chest. In
addition to these points in the differential diagnosis,
Bramwell ' mentions the difference in the character of
the pulse. In early anemia it is of good tension, but
irritable and variable in rate, while in pulmonic steno-
sis the pulse is small and weak, and may be intermit-
tent. Furthermore, this patient has had rest, tonics
and good food ; yet while she feels better than on en-
trance to the hospital three weeks ago, her murmur is
just as clearly marked as at first.

Dr. Nelson, at the Memorial Hospital, has very
kindly examined this patient's blood, according to
Ehrlich's method, as described by Dr. W. S. Thayer
in the Boston Medical and Surgical Journal for Feb-

> Clinleal LectnrM on Diseases of the Heart and Aorta, London,
1876, p. 184.

> Manual at AoMoltatlon, etc, Philadelphia, 1890, p. 2U.
• Loc. oit., p. 234.

> Dlseaiet of the Heart and Thoraolo Aorta, Nev Torlc, 1884, p. BBS.

rnary 16 and 28, 1893, and finds no indication of
ansemia. Dr. Nelson's report is as follows :

" Red corpuscles normal in size, form and color.
Red and white corpuscles in normal proportion. Dif-
ferent varieties of leucocytes are in about normal
proportion ; neutrophiles 75 per cent., eosinop'hiles four
per cent., small mononuclears 18 per cent., large
mononuclears and transitional forms three per cent."

For these reasons an inorganic, ansemic origin of
the murmur may be excluded.

Before considering stenosis of the pulmonary artery
as the cause of the murmur, there are some other
conditions, which may give rise to it, to be taken into
account. When the left lung is retracted, as by ad-
hesions from an old pleurisy or by long standing dis-
ease, the pulmonary artery may be in contact with the
inner surface of the anterior chest wall, making its
pulsation visible and palpable, and producing a systolic
murmur. There is no history of any such disease of
the lung in this case, nor any physical sign of such a
condition now existing. Balfour says that under these
circumstances the murmur is produced by compression
of the artery between the parietes and the heart in
systole; and he describes such a case.* A murmur
depending on retraction of the lung disappears on a
full inspiration, which is not the case with this patient.
Bramwell * speaks of cases where a pulmonic murmur
was produced, which he ascribes to a deposit of lymph
outside the pericardium, the result of an antecedent
pleurisy. Pressure upon the artery by a tumor in the
mediastinum, or by enlarged bronchial glands, may
cause enough narrowing of its calibre to give rise to a
murmur. In an article by R. Douglas Powell, in
Reynolds's " System of Medicine," * a case is given
where an aneurism of the aorta pressed upon the pul-
monary artery, causing signs of pulmonary stenosis,
as well as those of a thoracic aneurism. Displacement
of the heart by fluid may also cause a pulmonic murmur.
Hayden * refers to cases reported by Da Costa, of pul-
monic systolic murmur believed to be caused by the
pressure of solidified lung on the left branch of the
pulmonary artery. He also speaks of a case where
such a murmur developed shortly before death, proba-
bly caused by thrombosis. None of the above condi-
tions seem to exist in the case of Mrs. X. Her em-
barrassment of respiration dates back too many years,
and has no history of any antecedent lung disease.
One other cause of such a murmur needs only to be
mentioned. In children, and in adults with thin,
yielding chest walls, it may be produced by pressure
with the stethoscope.

If then, this murmur is not inorganic, nor caused
by pressure, or other causes outside of the artery
itself, it must be caused by some obstruction within
the vessel. This may be either a narrowing at the
pulmonic orific, some valvular lesion, or a diminution
in calibre of the artery. Occasionally the stenosis
takes place in the conns arteriosus, or infuudibulum,
of the right ventricle. Exactly what the condition is
in a given case cannot be positively known. The
general name of pulmonary stenosis embraces them all.

Such a lesion may be either congenital or acquired,
with the probabilities very greatly in favor of the
former. Roseustein '"' says that there are only a very

• Medical Tlmea and Gazette, lx>ndon, Deoember 12, 1874, p. S8B.
■ ' loc. oit., p. 661.

• Ainerloikn Edition, Philadelphia, 1880, TOl. II, p. 899.

• Diseasea of the Heart and Aorta, Dublin and London, 18T6,p.lOI».
u Zlenuaen'i C^oloptedla, Tol. Tl. p. Itfi.

Digitized by

Google

Vol. CXXX. No. 9.] B08T0W MSDIOAL AND SUROIOAL JOURIfAL.

209

few acattered cases (he meotions foar) of the acquired
form, and on this point all aathorities agree. In the
BriHA Medical Journal of a later date " is reported a
cue supposed to be acquired, and not congenital, and
the apecimen is described. It is asnally the result of
intra-oterine disease (endocarditis) or of arrested foetal
development. A diagnosis between the acquired and
congenital varieties in an adult cannot often be made
with certainty. Keating and Edwards '* say there is
" no sign or sequence of signs by which a congenital
marmnr can be definitely differentiated from an ao-
qaired lesion." Bramwell ^ says the history of the
case is the only means of differential diagnosis, and
we may be helped by the fact that several members of
a family oiay have congenital heart disease. He also
tsys it is " only when symptoms and signs of cardiac
disease have been entirely absent in early life that the
diagnosis of the acquired form can be made." On the
other hand, even the history of cyanosis and dyspnoea
from early childhood is not conclusive proof of con-
genital disease, as such a history may be found in other
cases.

So that unless the case has been seen, both be-
fore and after the establishment of the murmur, the
differential diagnosis seems to be purely a matter of
probabilities. Assuming then, as there is no evidence
to the contrary, that we have a case of congenital pul-
monary stenosis, let us see what is the usual course of
rach a lesion, and then compare this with the history
of the present case.

Of all forms of congenital heart disease, pulmonary
itenosis is the most common. This stenosis may be
tt the infandibnlom of the ventricle, at the pulmonary
orifice, or a general narrowing of the artery and ac-
companied by different conditions of the various foetal
openings, io the heart and great vessels. The most
common form is stenosis of the artery itself as far as
its bifurcation. With this condition is usually found
either an open foramen ovale, or a deficiency in the
ventricular septum. The ductus arteriosus may be
either open or closed, more often the latter. The
intervoDtricalar septum is normally closed at the third
month of foetal life. If the pulmonic obstruction occurs
before this time the blood finds its way through this
opening, preventing its closure. Obstruction occur-
ring after the third month finds some relief by the
flow of blood directly from anricle to auricle through
the foramen ovale. After birth, in either case, some
blood goes to the lungs through the ductus arteriosus,
if this remains open. If this is closed there is a cer-
tain amount of collateral circulation established by
means of the bronchial, oesophageal, or other branches
of the aorta. (Compensation for the stenosis is not
perfect by any of these means, so that there is usually
hypertrophy of the right side of the heart, with more
more or leas dilatation, and also cyanosis and enlarge-
ment of snperficial veins, in greater or less degree.
The more complete the compensation, the less marked
are the aymptoms, or as Keating says, compensation is
the " key-note in prognosis " in these oases.

Bramwell divides cases of stenosis into three groups,
according to the severity of the symptoms.

(1) Where the lesions are severe, and the patients
die at once or soon after birth. If they live for any
length of time there is great cyanosis, a subnormal

^ DsocnlMr 17 1881 d 963

> DfMuai at the Heart uid Clreulatton In Infuioy and Adolee-
enea, FtaUadalphla, 1888, p. SB.
<>IiDe.olt.,p.6S8.

temperature, somnolence, dyspnoea, dropsy, and often
fatal convulsions.

(2) The lesions are less severe, and they may live
several years, but with heart symptoms from the first.
Cyanosis may be only noticeable on coughing or exer-
tion, and is more marked on the periphery of the body.
Fingers are dubbed, and superficial veins prominent.
When compensation becomes imperfect, or is interfered
with by intercurrent bronchitis or other trouble in the
lungs, to which these patients are very liable, dyspnoea
and palpitation increase. CEdema is usually a late
symptom, at which period there may be convulsions.
At the same time albuminuria and enlargement of the
liver and spleen may be found. If the patients sur-
vive puberty, they generally die young from phthisis.
Haemoptysis is frequent, being often the earliest symp-
tom of lung invasion.

(3) The lesions are slight, and symptoms may not
arise till years after birth. They are caused by fail-
ure of compensation, which is either gradual, or brought
about more rapidly by intercurrent disease. At about
the time of puberty, compensation is very apt to be
disturbed. The cases then ran the same course as if
the symptoms had been present from early life.

Children with this defect usually develop slowly,
both mentally and physically. Menstruation is apt to
be late in its establishment. The hypertrophied heart
presses upon the yielding ribs and cartilages, causing
a bulging of that part of the chest wall. A majority
of the cases die before adult life is reached. The ele-
ments which favor survival are a slight- or moderate
degree of stenosis, a sufficient opening through some
of the foetal passages, and a good collateral circulation.
Lebert " quotes a table from Knssmaul showing that
out of 64 cases, 41 died under ten years of age, 14 be-
tween ten and twenty years, and only 9 lived beyond
twenty years. One case of undoubtedly congenital
stenosis lived to the age of sixty-five, and two cases of
complete closure of the artery died respectively at
twenty-one and thirty-seven years (Lebert). Another,
with stenosis and open foramen ovale, died at fifty-
seven, from cerebral apoplexy (Keating and Edwards,
p. 38). These cases are, of course, exceptional. As
a rule, even for favorable cases, middle age will not
be passed, and there is a remarkable tendency for
them to terminate in pulmonary tuberculosis, a combi-
nation which is rare in any other form of heart disease.
This is a curious fact to which Lebert (in " Ziemssen's
Cyclopaedia " ) devotes oousiderable space. He finds
that the cases so terminating show no hereditary ten-
dency, and he can only ascribe this frequency of tuber-
culosis to a deficient blood-supply in the lungs, and the
pressure upon them of an hypertrophied heart. The
left lung is usually first attacked.

As no dyspnoea was noticed in the patient till she
was ten or twelve years old, while it usually ap-
pears early, the following table (Keating and Edwards,
p. 41) may be interesting, in 4L cases of congenital
defect, cyanosis first appeared at the age of

2 weeks In S oases

3 week! In I ease .

I month In S eases

1 to 2 months in 7 oases

2 to 6 months In S eases

6 to 12 months >n 5 oaaee

1 to 2 rears In 3 oases

2 to 8 rears in Bosses

6 to 10 rears In I case

10 to 2U rears In 6 cases

SO to 40 rears In 1 oase

Over 40 rears . Inloase

>< Ziemssen's 07fllopiBdla,iTol. t1, p. 321.

Digitized by VjOOQ IC

210

BOSTON MEDICAL AND SURGICAL JOVBNAL.

[Mabch 1, 1894.

In only nine did cyanosis first appear after the age
of five years.

The case reported seems to be one of a mild degree
of Btenosis, and she has been able to live in great com-
parative comfort. She has been singularly free from
any diseases tending to disturb the compensation ef-
fected by her moderately hypertrophied heart. There
is evidence of some disturbance of compensation at
about the time of puberty. She says she has had la
grippe twice ; but, if so, her account shows that neither
attack could have been very severe. Cyanosis only
shows itself in the extremities, and there has been no
oedema except occasionally at the ankles. She has the
cold hands and feet mentioned by the authorities. The
physical signs about the heart and lungs support the
diagnosis, tbongh the cyanosis and dyspnoea, even oo
exertion, are of a milder degree than usual. Sansom,'*
however, reports the autopsy of a child where pulmo-
nary stenosis was found, though there had been abso-
lutely no cyanosis, but rather pallor. The indications
of hypertrophy of the right heart are less marked than
nsnal, and there is not the epigastric impulse usually
felt ; yet this symptom was entirely absent in a case
of congenital stenosis" where great hypertrophy of
the right ventricle was found, and where the symptoms
came on suddenly at the age of eighteen. Her lesion
is not severe enough to have interfered with her
growth and development As long as no extra strain
IS brought on her heart she is likely to go on as she is
for some time. She has lived unusually long without
the appearance of tuberculosis, which may be expected
to develop later. It would not be surprising to see it
show itself by haemoptysis at any time, though at pres-
ent her lungs seem to be in a normal condition.

The cause of cyanosis is an interesting question in
this connection, which has been argued by several
writers. Two theories have been advanced. Accord-
ing to one the coloration is due simply to venous
stasis, the blood backing up in the right side of the
heart, and then in the systemic veins. The other
theory ascribes cyanosis to the fact that there is a
mixture of nnoxygenated blood circulating with the
arterial blood, the two being allowed to mingle by the
persistence of one or more of the fcetal openings which
should have closed under normal conditions. Some
think the color of the surface is due to the operation
of both of these causes combined. In an article on
cyanosis in the Practitioner for 1888, the writer takes
the ground that less than a normal amount of blood
goes to the lungs in these cases. The lungs then be-
come partially csollapsed, respiration is impeded, and
what blood does go to the lungs is not properly aerated.
This he regards as one of the most important elements
in producing cyanosis.

THE RADICAL CURE OF HYDROCELE.'

BT K. P. OATDT, ]t.D.

The different methods osed for the radical care
,of hydrocele are antiseptic incision, excision of a part
or the whole of the sac, and injection : all other meth-
ods are now obsolete. It is with the last-mentioned
method my paper will mainly deal. The open inci-

> Baad bsfora tbs Boston Soolsty for Hsdioal Obserrstlon, Jan-
nary 1, 1S94.

" Laotarei on the Phnloal DlagnoaU of Dlieases of the Heart,
Philadelphia, 1876, p. 180.
u Lanoet, Augoat 2, 1884, p. 183.

sion, with or without excision of the sac, means the
administration of an anaesthetic, detention in bed for a
varying period from one week to four, while to un-
dergo an operation has considerable effect on the minds
of most of our patients.

There are cases where the open incision is the only
operation to be considered : where there is a questioQ
of diagnosis ; where a hernia exists ; where injection
has failed — congenital hydrocele ; where the sac is
much thickened. In all of these some form of open
operation is called for.

There is a large class that can be successfully treated
by injection. Perhaps it is well to inquire why injec-
tion has so often failed to cure the disease.

Let us hear the explanation as given by Jacobson,
for the many failures : (1) The use of too weak a solu-
tion ; (2) not bringing the solution in contact with the
whole of the sac ; (3) not withdrawing all the hydro-
cele fluid ; (4) injecting large hydroceles immediately
after they are emptied ; (5) making use of injections
in unsuitable cases.

No simple, uncomplicated case of hydrocele ought
to be treated other than by injection. The use of
tincture of iodine, the simple as well as the compound,
is too often followed by failure to urge its use, which
is often attended by a scene — patients often fainting,
and suffering from griping pains, retraction of the tes-
ticle, nausea and even vomiting; nnpleaaant things to
have happen in one's office. Since about six years
I have treated all suitable cases of hydrocele by in-
jecting half an ounce of a solution composed of equal
parts of carbolic acid, alcohol and glycerine — a small
bulb syringe answers very well. A little care is neces-
sary in the use of the solation. Protect the skin sur-
rounding the canula with a little gauze or absorbent
cotton, so as to avoid the burning sensation so easily
produced on the tender skin covering the scrotum;
allow the fluid to remain. The injection is practically
painless, and no unpleasant effects follow its use.
Patients are allowed to attend to their ordinary busi-
ness ; and in from two to four weeks the acute hydro-
cele disappears.

I have no record of the number of the cases so
treated ; but since I have used it, I have seen only one
relapse. The method has proved so effective, and with
none of the drawbacks of other methods, Uiat I feel
warranted in bringing it before the Society. I have
never dared to use carbolic acid as recommended by
Dr. Levis. I am unable to give the name of the
originator.

fl^elncal ^j^txtfi^.

RECENT PROGRESS IN OBSTETRICS.

BT SDWABD BBTVOLDS, It.D.
SINQLB LIGATCBB OF THE COBD.

NoUTBN Khao Can ' bases his opinion of the supe-
riority of a single ligature upon his observation that
out of 68 cases of labor with double ligature of the
cord, there were four cases of retention of the placenta ;
and out of 146 cases with single ligature, only two
cases of retention. The duration of the third stage
with the doable ligature averaged 64 minutes, while
with the single it was bat 27 minutes.
, > Algeria. Aroh. da Toe. et de Qjn.

Digitized by

Google

Vol. CXXX, No. 9.] BOSTON MEDICAL AND SUBGWAL JOURNAL.

211

The author believes that a rapid dimination in (be
rize of the placenta, due to the free escape of the intra-
placental blood, favors retro-placental hasmorrhage,
and consequent complete separation of the placenta,
and that it fnrther lessens the obstacle to its escape
from the nteras and vagina by the resulting decrease
in size. He recommends that double ligatare of the
cord shonld be reserved for cases of twin pregnancy.
While we think that there is a question as to the cor-
rectness of the anthor's reasoning on the first point,
there can be no doubt as tu the advantage of diminish-
ing the size of any body which is to pass the os uteri,
and we think that we have ourselves noticed a greater
ease of delivery of the placenta in cases in which but
one ligatare had been applied.

The su^estion of Nguyen Ehac Can is certainly of
valne. It should be easy to prevent untidiness by
catching all the intra-placental blood in a suitable basin,
but the determination not to check intra-placental
hemorrhage, of course, implies a careful palpation of
the uterus before the cord is cut, and an absolutely
positive elimination of the possibility of a twin preg-
nancy.

CHOLSBA IN PBKONANOT AND LACTATION.

L. Gaillard * reports seven cases of cholera during
pregnancy. Five terminated fatally, two were lightly
attacked and recovered. The synopsis of the fatal
cases is as follows :

(1) Seven months pregnant; premature labor on
second day ; intravenous transfusion. Patient died
on the sixth day.

(2) Eight months pregnant. Labor did not appear.
DeaUi of the foetus on the sixth day, and of the mother
on the eighth day.

(3) Six months pregnant Intravenous transfusion
on the fourth day. No labor. Death of fcBtns on the
seventh day ; of the mother on the tenth day.

(4) Patient tuberculoas, and six months pregnant.
Death of the foetus on the ninth day ; of the mother on
the fourteenth. No labor.

(5) Eight months pregnant Foetus dead when first
seen. Spontaneous labor on the eleventh day. Intra-
venous transfusion just before death.

Gaillard thinks that foar of these cases would have
recovered, if they had not been pregnant His experi-
ence supports the classic belief that pregnant women
lapport cholera badly ; that the disease is almost in-
variably fatal to the foetus ; that it is almost always
accompanied by abortion, miscarriage, or premature
labor; that such an occurrence increases the danger
to the mother ; and that this risk increases in propor-
tion to the previous duration of labor. Gaillard has
seen nearly 400 cases of cholera, and considers preg-
nancy by for the most serions complication of the dis-
ease, worse even than senility and phthisis.

When nursing women are attacked by cholera the
mammary glands frequently become congested and
painful. In spite of the depleting effect of choleraic
diarrhoea opon all the other fluids of the body, the
secretion of milk persists in normal quantity. Lacta-
tion does not seem to be a serious complication, so far
as can be judged from the author's experience, six out
of ten patients having recovered.

STMPHTSKOTOHT.

The proper limitation of the field for this operation,
* Anh. d« taa. at da ajn.

the determination of its value and of its risks, have
occupied a prominent place in the obstetrical work of
the past six months ; as is evidenced by the publica-
tion of 64 papers upon the subject during this time
and of about half that number of cases.

Byron Stanton ' gives a good abstract of the latest
opinions of the best authorities upon the amount by
which the pelvic space is increased.

Experiments upon puerperal cadavera have shown
that the gain in the pelvic diameters is in direct pro-
portion to the amount of separation; that, in high
degrees of contraction, the proportional gain is greater
than in normal pelves and in the lower degrees of de-
formity ; that this gain is not limited to the conjugata
vera, but is also present, and to a greater degree, in
the transverse and oblique diameters, at both the inlet
and outlet ; that the increase of these latter diameters
varies between three-fourths and one-third of the length
of the inter-pnbic separation, while the increase in the
conjugate is about one-fourth of this space. Morisani
quotes experiments showing that for each centimetre
of pubic separation, the lines between the promontory
and the extremities of the separated pubic bones are
increased two and one-half millimetres, that is, that
two inches of separation of the symphysis would yield
a gain of half an inch in the conjugate ; while with
three inches of separation, the gain is three-fourths of
an inch ; and to this amount is added a possible still
further gain by the projection of one parietal protuber-
ance into the distensible space between the separated
pubic bones. Gases have been reported in which more
than three inches of separation has been possible with-
out injury (Novi, of Naples, S^ inches; Caruso, 3-^
inches) ; but, as a rule, three inches is the extreme
degree of separation which is safe. We must not,
therefore, count upon a gain of more than three-quarters
of an inch in the conjugate, an inch in the oblique, and
an inch and a half in the transverse diameters.

Limitatiomi of th» Operation. — The size of pelvis
in which symphyseotomy is appropriate has been placed
as low as 2^ inches, and as high as a normal pelvis
with an unusually large head, but these limits are prob-
ably far too wide. At the lower limit given the oper-
ation would probably result in the loss of the child
unless the latter was extremely small. The application
of this operation to normal pelves can hardly be too
severely criticised. It is probable that there is not
one case in 10,000 in which, in competent hands, the
loss of the chUd during its extraction through a normal
pelvis can fairly be laid to pure disproportion between
the head and pelvis, and the success of symphysiotomy
has been so marked that there is grave danger that it
may be used in cases that could be treated equally well
by the ordinary obstetric operations.

Technique. — The most scrupulous asepsis is neces-
sary. The first step in the operation is freeing the
surface of the mons veneri and labia majora of hair,
rendering the skin thoroughly aseptic by the usual
methods of preparing the abdominal walls for coeli-
otomy, and disinfecting the vulva and vagina. The
patient may be placed at the side of the bed with knees
drawn up and separated, or the operator may take his
place between the extremities of the patient

The technique of the operation has been improved
by the more complete separation of the operation
wound from the vulva by making the division of the
symphisis sabcutaaeous. The incision should lie in

* Am. Jonr. Obit., Baptamber 1888.

Digitized by

Google

212

BOSTON MEDICAL AS1> 8UBOIOAL JOURNAL. [Mieoh 1, 1894.

the median line, should be long enough to admit two
fingers, and should terminate at its lower extremity just
above the symphysis. This incision not only renders
asepsis more easy of attainment, but places the wound
in a situation where the bandage which fixes the pelvis
during the after-treatmeut does not press upon the
wound. The incision should be carried through the
skin and subcutaneous fascia, and should lay bare
the insertions of the recti on the pnbes. These should
be separated from the pubic bones by a transverse sub-
cutaneous incision to an extent sufiBcient to admit two
fingers, and care should be taken thai the prevesical
space is not opened in separating these insertions from
the bone ; as the posterior layers of the fascia of the
abdominal wall may with care be separated from the
symphisis by blunt dissection with the finger without
this accident. A catheter should be passed into the
urethra, and the soft tissues behind the symphisis widely
separated from the bone by the finger, it should then
be placed behind the symphisis with its tip upon the
subpubic ligament; Gralbiati's knife, Harris's modifi-
cation of the same instrument, or in case of emergency
any strong blunt-pointed bistoury, should be passed
behind the symphysis with the finger as a guide, and
should divide the joint and subpubic ligament from
behind forwards, and from below upwards. The oper-
ator should then open the symphysis by abduction of
the patient's knees, and should continue the separation
till he judges that a sufiScient amount of space has been
gained, or till he feels the check due to the sacro-iliac
ligament. The wound should then be covered with a
protective dressing and a firm bandage placed around
the pelvis below the orests of the ilia in such a manner
as to prevent any further separation during the extrac-
tion of the child. After the delivery of the child the
bladder should be injected with warm milk or some bland,
colored fluid in order to determine the existence of
any injury which may have been inflicted upon this
organ during the extraction. Should such be found,
it should be repaired at once. If no injury is detected,
a strip of gauze should be placed in the wound, the
remainder of the skin wound should be sutured ; a dress-
ing should be applied; and the divided snr&uie of the
symphysis should be held in place by a firm bandage
round the pelvis below the orests of the ilia.

Mortali^. — The latest general statistics noted gave
a death-rate of about six percent, from all causes ; but
it must be added that in many of the cases the patients
were already in bad condition, and that the fatal result
could be attributed to the operation itself in only one
case (to be referred to later). These statistics are in-
complete, contain the early cases, and are probably
less favorable than could be now reported, unless an
allowance must now be made for the fact that fatal
cases are often unreported. Dr. B. P. Harris, in a
recent personal letter, says that there have been 85
American cases, with four deaths. ' Of these, one was
due to post-partum hsemorrhage, uneonnecUd vith the
operation ; one was due to shock' in a much exhausted
patient, more the result of lugUeted labor than of the
operation ; one was due to uterine sepsis, the operative
wound remaining clean, probabfy unconnected with the
operation; and one was due to sepsis in the sym-
physeotomy wound, directly a retult of the operation.
Among the successful cases there had been no perma-
nent unfavorable after-results. The operation must
then be still considered a major procedure with a con-
siderable mortality; but it is only fair to add thatj

among the cases which were operated upon early, there
has so far been no death-rate peculiar to the operation,
other than that from sepsis, which should, of course,
be preventable.

EOLAKPSIA.

Alphonse Hergott * has conducted a further series
of experiments with the blood and urine of women
suffering from eclampsia. His investigations lead him
to believe that the convulsions of parturient women
may be produced by either of two different causes.
The first class he considers due to lesions of the kid-
neys ; and the renal lesion may, he thinks, be produced
by pregnancy. The second variety of eclampsia he
considers due to the activity of a special pathogenic
microbe which finds a suitable field for its development
only when the organism haa been modified by preg-
nancy. The first is an auto-intoxication, the second a
baotero4ntoxication. He thinks it likely, though not
yet proved, that eclampsia of the second variety is not
caused directly by this microbe, but by the action of
the toxic products of its activity upon the nervous
system, when modified by pregnancy.

A. Charpentier * writes upon the treatment of eclamp-
sia from the basis of a clinical experience, which he
has divided into three classes : The first treated by
blood letting; the second with sedatives, that is,
chloroform or chloral ; and the third by the prompt
termination of labor. He is an advocate of active in-
terference when labor is already underway, but refuses
to induce labor unless in very exceptional oases. He
bases this refusal upon the following theoretical con-
siderations: He believes emptying the uterus may
ameliorate the condition of albuminuria and eclampsia,
but cannot cure it, as it depends on a renal lesion,
which may not disappear with the delivery of the child ;
the induction of labor requires a longer time than is
consumed in an eclamptic attack; any excitation of
the uterus is sufficient to cause a convulsion ; the
manoeuvres necessary to the induction of labor neces-
sarily furnish such excitation. He mentions forced
labor only to condemn it. He recommends the ad-
ministration of chloral by enema in doses of one drachm
of the drug every five or six hours, and uses chloroform
at the time of each seizure, advising conservative treat-
ment till labor appears. If labor is fairly rapid, he
deprecates interference, but, in case of delay, permits
the use of forceps.

Charpentier believes that venesection may be of
value in cases where congestive symptoms are perma-
nent, and especially where there is reason to believe in
the existence of congestion of the lungs or brain. He
thinks that, though not in itself a cure, it can be
counted upon to diminish the frequency and force df
the eclamptic seizures. His conclusions are as follows :

(1) Whenever a trace of albumen is found in the
urine of a pregnant woman, she should be pat at once
on a rigid milk diet.

(2) When the convulsion occurs in a strong woman
of fuU habit and is accompanied by marked cyanosis,
bleed and administer chloral as described.

(3) If the patient is delicate and the cyanosis is not
extreme, the treatment should be limited to the use of
chloral.

(4) Let labor appear spontaneously, and be con-
cluded by the efforts of nature whenever this is possible.

4 Annals* de Oniaaologl*,

* Monralla Aiab. d'Otnt. at (to Ojii.

Digitized by

Google

Vol. CXXX, No. 9.] BOSTON MSDWAL ASB SURGICAL JOURS AL.

213

(5) Should interference be necessary, delirer as
rapidly and with as little manipolation of the ateras as
pouible.

(6) Interference shoald never be resorted to Ull the
M is folly dilated.

(7) Liabor should be induced only in the very ex-
ceptional cases, in which all other methods fail to
cheek the attacks.

(8) Never resort to forced labor.

Ooe is struck by bis entire neglect of the active
treatment of the skin and kidneys, upon which Ameri-
can obatetrtcians have been accustomed to place the
first reliance ; and we cannot but believe that his objec-
tion to forced labor, that is, gentle but rapid dilatation
of the OS and subsequent immediate extraction of the
child, under full surgical anaesthesia, is due to the fact
that he has reserved it for desperate cases, and for
them only, instead of resorting to it, as is the practice
here, whenever the convulsions are so frequent and
severe as to make the prognosis for the mother really
grave, or whenever in milder cases the patient's condi-
tion fails to improve under conservadve methods.

Heyoct]^ of j&ocieti(]E(*

BOSTON SOCIETY FOR MEDICAL OBSERVA-
TION.

JOBS O. XUHBO, X.O., SBCBBTABT.

BseuLAB meeting, Monday, January 1, 1894, Db.
J. Stbdhan in the chair,
Db. M. F. Gavin read a paper on

THB RADICAL CUBE Or HTDBOOKtB.'

Dr. Gat : I have used the pure carbolic acid treat-
ment in three cases, and it is a pretty severe treatment
and not a very certain one ; so I long ago gave that
Dp. At one time the red oxide of mercury was talked
about. It consisted in tapping the hydrocele, and then
with a small director or grooved probe carrying a little
of the oxide into the sac. It seemed to me a bungling
way. Then I learned the method I think a good deal
of, and that is tapping, emptying thoroughly and in-
jecting two ounces of the compound tincture of iodine.
The compound tincture is especially indicated, because
that mixes thoroughly with water or with this fluid of
the hydrocele. It is sqneeEed about inside of the sac,
so that all parts shall be bathed with it, and then all
that will is allowed to run out of the canula. I have
nsed this treatment a few times in my ofBce, and so far
I like it. I never have had but one uncomfortable re-
sult from it, and that was a spasmodic retraction of the
testicle. This in one case was rather uncomfortable
for two or three weeks, but it finally passed away, and
the man got a complete cure of his hydrocele. The
only points about it are, that the sac is to be thoroughly
emptied, the compound tincture to be used, and enough
used to thoroughly moisten the inside of the sac, and
then the soperfluous part to be allowed to run out.
The pain for two or three minutes is intense, and then
it gradnally quiets down, so that by the time the pa-
tient leaves the office he has a feeling of warmth in
the scrotnm. I do not claim this as a universal cure ;
but, aside from the pain, it is a very good way of treat-
' 8m pHta no of th* Joonal.

ing the hydrocele that are not too old. I think Dr.
Gavin's classification is an excellent one. The old
ones want something more than injection.

Db. Bcbbbll : 1 was not fortunate enough to hear
Dr. Gavin's paper. There is one point about the
question of radical cure for hydrocele of which I should
like to speak. Of late I have been making open inci-
sions and packing the sac of a hydrocele. I have been
strengthened in my opinion that this was the wisest
procedure by what I have found inside the sacs. Mot
infrequently I have found bits of fibrinous material
which acted as foreign bodies, which were a constant
source of irritation, and which kept up the effusion of
fluid into the tunica vaginalis. This has led me to
lean strongly towards the more radical operation of
opening and seeing the condition inside the sac than to
the more indefinite method of injection.

Db. RiCHABDSON: I am sorry I was not able to
hear Dr. Gavin's paper. I have preferred when possi-
ble to dissect out the sac entirely. My experience
with milder methods, like injections of iodine and car-
bolic acid, is very limited. I have seen all methods
fail except the dissection and removal of the sac. This
is lAirely the end of the hydrocele, but in many instances
the method is severe. With a patient unwilling to
submit to so radical a measure I hiave always intended
to use the method of injection. Such methods are
very desirable in those oases in which for any reason
it it unsafe to etherize or to subject the patient even
to the slight dangers of radical excision of the tunica
vaginalis.

Db. Gatin : I should like to ask Dr. Richardson if
he had a simple case of hydrocele come to his office,
who had not been tapped, if he would recommend ex-
cision without any treatment to begin with ?

Db. Biohabdson : If the patient wishes to be ab-
solutely certain of cure, and if there is no reason
against the operation, the best plan is to dissect out
the whole tunica vaginalis except the portion that
covers the testicle. I prefer this method because I
am used to it, and it it always successful. The opera-
tion shoald be limited to simple drainage when the sac
is very thick and adherent. In children I make a
simple puncture of the sac with a glover's needle, —
a method which sometimes succeeds and sometimes
does not.

I do not wish to be understood as opposing the
method recommended by Dr. Gavin, for I have had
no experience with it. I have no doubt that his
method will be found admirable in a great variety of
cases. Now and then, however, one will be found in
which the fluid will return. This recurrence it teen
in all operations upon hydrocele except' that of com-
plete extirpation of the tunic. In one instance I found
a hydrocele of the cord which pressed upon a hydrocele
of the tunica vaginalis, the two being blended into one
tumor ; this accounted for the return of the hydrocele.
The second attack was a hydrocele of the cord.

Perhaps I am too much inclined to give the patient
the more radical operation first, for there is certainly
no objection to trying the methods which may be called
palliative. The last radical operation that Dr. Mum-
ford and I performed was about two weeks ago upon a
man of seventy. I had tapped him for a long time,
and advised him to continue that treatment. He de-
cided, however, to have a radical cure. We removed
the tunica vaginrfUt entirely, and he hat made a most
tatitfaotory recoveiy.

Digitized by

Google

214

BOSTON MBDIOAL AND SVB6IOAL JOURNAL.

[March 1, 1894.

Db. 6. W. Gay read a paper on

MALIONANT DI8KASB OF THE RKOTCH.*

Db. Burbell : I have been very muoh interested
in the paper presented bj Dr. Gray. Becently I have
twice sapposed that I was going to operate upon a
case of hemorrhoids, and a careful rectal examination
under ether showed the presence of malignant disease
high up in the rectum ; and I believe that a high rectal
examination cannot be too strongly insisted upon be-
fore any operation about the sphincters is undertaken.

In reference to Dr. Gay's position in regard to the
radical cure of cancer in the rectum, I am very much
disappointed at his outlook. I have been looking at
the operation for the relief of cancer in the rectum in
a much more favorable light. After listening to the
report of his cases, especially the one in which after
four years the disease returned, I shall be very loath
to speak of any permanent cure of a case under foar
years. Before I heard Dr. Gay's paper 1 had arranged
the operations for cancer in my mind in this way : Ex-
cision of the growth in the lower end of the rectum,
and a Kraske operation for excision of the growth in
the upper part of the rectum. I have come to believe
that an iliac colotomy is the operation of selection as
a palliative measure. It is siudfile ; the relief is very
great ; and it has seemed to me a preferable operation
to lumbar colotomy, which requires a deep dissection ;
and the location of the two openings is in favor of the
iliac operation, as an artificial anus in this position can
be better controlled. In favor of the Eraske operation,
I can say that I have one patient upon vhom I oper-
ated two years ago, and whom I have seen within a
month, where there has been no return of the disease.
I shall evidently have to wait longer before claiming a
permanent cure.

But setting aside for a moment the question of its
being a radical cure, I think there is a word to be said
in reference to the Kraske operation as a palliative
operation. On comparing it with lumbar colotomy
and iliac colotomy, an iliac colotomy simply taps the
stream of fieces above the disease, and leaves the
growth tn titu; and while occasionally it is possible
to make a spur in the bowel which shall prevent faeces
passing beyond the artificial anus, yet this is often an-
successful. This has always seemed to me an objec-
tion to colotomy, in that it does not deal with the dis-
ease tn titu. On the other hand, the Kraske operation,
as I have recently performed it, does not seem to me
as severe as it sounds in description. To speak of the
removal of the coccyx and the removal of a portion of
the sacrum, seems a great deal, as we listen to it ; but
if carefully and rapidly performed, and especially if,
after removal of the coccyx and a portion of the sacrum,
one cuts into the right cellular interspace and practi-
cally shells out the rectum by a " dry dissection," there
is but very little bleeding. On clamping the rectum
above the growth and below, a quick excision of it can
be made ; and even if the peritoneal cavity is opened,
it can be sutured, and bat little danger exists of infec-
tion, especially if the patient is kept in a semi-upright
position.

By the Kraske operation we have all the benefit of
a colotomy, plus the great relief of the complete re-
moval of a mass of malignant disease, which, of course,
may return in the future. Patients after a Kraske
operation are very comfortable, have but little pain,
' S«*iMig*tM of the JonmaU

and when a pad is properly adjusted can go aroand
with but little inconvenience to themselves and no
offensiveness to others.

Da. J. C. Stedkan : During my service on the
house-staff of the Post-Gradnate Hospital, New York
City, I find, on looking over my records, in the service
of Prof. Charles B. Kelsey, 14 cases of maUgnant
disease of the rectum treated by him $ and of these, 10
were treated by inguinal colotomy, two by extirpation
(Cripps's method and Kraske's method), one by ingninsl
colotomy first and sulMequently amputation of rectum,
and one was discharged without an operation. Twelve
of these cases were discharged very much relieved and
improved; and two died in the hospital. As most
cases of malignant disease of the rectum consult the
surgeon three or four months after they complain of the
first symptoms, it only remains for the surgeon to give
them some form of temporary relief, for in these cases
they will generally suffer a great deal before they will
make up their minds to accept the treatment proposed
by the surgeon. Therefore it is according to the ex-
tent of the disease and the severity of the symptoms
that will determine the line of treatment to be carried
out, whether simply palliative or more radical. As
most of the cases of cancer of the rectam treated by
Professor Kelsey in the Post-Graduate Hospital were
those where the disease was advanced three months or
more, and not only the rectal walls, but the surround-
ing tissues were involved, he therefore performed
inguinal colotomy on most of them, as the best plan of
treatment for the immediate relief of distressing symp-
toms and also prolongation of life. If the bowel is
diseased within three inches of the anus, and from ex-
ambation it is thought to involve only the gut, then
Professor Kelsey may perform Cripps's operation, or
proctotomy ; and if the disease is above that and below
the promontory of the sacrum, and the gnt only in-
volved, then he may perform Kraske's operation, or
else amputation of the rectum ; but generally he prefers
inguinal colotomy, and presently I will give his reasons
for the same.

I will not take the time to review the 14 cases in
detail, but only to state, in general, that most of them
were suffering with burning sensation in the rectum ;
great pain on going to stool, with frequent desire and
great tenesmus, and passing large quantities of blood
and mucus; losing flesh and strength; having in some
cases fulness over the abdomen ; not able to sleep well
at night, but constantly getting up to use the commode,
and suffering great pain. Of course, these cases were
in various stages of development, generally three
months to a year from the time they noticed the first
symptom, and located in different parts of the rectum,
and in one case in the segmoid flexure.

Professor Kelsey prefers inguinal to lumbar colotomy
for several reasons : It is an easier and quicker oper-
ation, and as safe if not safer in these days of antiseptic
surgery. Another great point in its favor is the con-
venience to the patient in keeping the parts clean, as
compared with the difficulty and inconvenience of doing
the same in the lumbar region ; and the terminal por-
tion of the gut can be more easily cleaned out of any
fsBcal or irritating matter which may collect in it.

The techniqtie of the operation, as performed by
Professor Kelsey, has been admirably described by Dr.
Gkty. I will simply lay more emphasis on the silver
wire which forms the spur, as Dr. Kelaqy is very
particular in regard to forming a good apur in the

Digitized by

Google

Vol. CXXX, No. 9.] BOSTON MBDWAL AND SUSOIOAL JOUBNAL.

216

bowel. The silver wire is passed an inch from the
right of the line of incision, and half-way between
the middle and lower thirds of the incision, through
the mnscnlar walls, peritoneum, under the gut, through
the mesentery, and up the opposite side an inch to the
left of the incision, and then drawn tight and fastened
with the lead button and slot. It thus forms an ex-
cellent spur, and when opened serves as a barrier to the
feces from passing down the terminal end of the bowel.
The colon is left intact for two days, unless for some
connter-indication, in order to allow the peritoneum
time to adhere firmly to the colon, and thus prevent
extravasation of faeces into the abdominal cavity. It
is then opened with a curved bistoury and scissors,
cntting well down to the line of incision, no ether being
necessary. From that time on, the patient, as a rule,
will have one to three normal movements a day. The
wire is taken out at the end of the fourth day, and the
patient is generally sitting up at the end of the tenth
dsy.

The vround, immediately after the operation, is
dressed; first, with Lister's protective next to the
bowel and incision, to prevent the parts and dressings
from becoming matted together by the effusion of
lymph ; next to that, bichloride pad and gauze, cotton
sod bandage. After the gut is opened, a simple dress-
ing of sheet-lint, vaseline, cotton pad and bandage is
all that is used. At the end of the third or fourth day
the distal end of the bowel is generally irrigated with
a weak solution of carbolic or bichloride, or even hot
water — either from anal opening or the inguinal.
When the patients leave the hospital they either use
ooe of Dr. Kelsey's trusses, made for the purpose, or
the pad and bandage mentioned above.

Professor Kelsey's reasons for preferring inguinal
eolotomy are these, as he has stated to the class over
and over agam ; they will be found in the fourth edi-
tbn of his works on rectal diseases :

" It prolongs life by the relief of pain. It substitutes
io many cases a painless death for one of great agony ;
. . . does away with the constant tenesmus and dis-
charge from the rectum, which by their exhausting
effecu are the immediate cause of death ; delays the
development of the disease by preventing the straining
and congestion of defecation ; prevents absolutely the
complication of intestinal obstruction, which is another
cause of death ; enables the patient to sleep, eat and
^n flesh ; and often makes him think himself cured
in spite of the plainest prognosis to the contrary. In-
atead of passing his days and nights upon the commode,
wearing oat his life in the effort to free the bowel from
its irritation, he has one or perhaps two solid faecal
evacuations from the groin in twenty-four hours. Is
it pleasant to have the gut end in the left groin ? No.
But after a very few days the patient with cancer of
the rectam, whose anus has been placed in the groin
by the surgeon, will tell you that life, from having
been a constant torment, has again become worth
living."

Another reason is, the mortality is less in inguinal
eolotomy than in any other operation for malignant
disease of the rectum. During my service with Pro-
fessor Kelsey, he performed 16 inguinal colotomies :

10 -mtm tor malignant dlseaw of the raotum.
t vna for non-malignant itriotnre.
1, nlaention, with itrlatnre.
1, azteiulT* dysantarlo nloeratlon,
I, djsenterla atriotnre.
1, itrietare of Mgmotd flunre from peMe Mllalitls, with

Of these 16 cases, two died; the others were dis-
charged much relieved and improved.

I speak of these for this reason ; it is thought by
many physicians, and very naturally so, of coarse, that
it is very disgusting to hare an anal opening in the
groin and that patients object to it very much. Now
my experience in the hospital has been the reverse of
what would be supposed. Over and over again, the
patients have said, in person or by letter, that " they
would not return to the old order of things — pain,
tenesmus, blood, etc. — on any account"; that they
were perfectly satisfied and very much pleased with
the relief obtained. And of the lesser evil, inguinal
eolotomy is to be preferred ; and in most cases they
have gained strength and fiesh.

Therefore, the good results obtained, as regards
quickness of operation, relief of distressing symptoms
to patient, and prolongation of life, makes inguinal
eolotomy the line of treatment preferred by Prof.
Charles B. Kelsey in the great majority of cases of
malignant diseases of the rectum.

Db. M. H. R1CHA.RD8ON : I am very much interested
in the practical aspects of this paper. We owe a great
deal to the older men who call our attention to the re-
sults of their experience in diseases of this kind. As
our experience gets larger, and after we have seen so
many recurrences following operations for cancer, we
cannot but become more and more conservative in
advising surgical interference. Some years ago I
looked up the oltimate results of all the operations
performed upon cancer at the Massachusetts Greneral
Hospiul for ten years. The resnlu in breast cases
were encouraging, especially after the radical opera-
tions performed in the later years. Cancer of the
tongue was invariably fatal sooner or later. I did not
investigate cancer of the rectum; I took it for granted
that the patients were all dead. At the present time,
nevertheless, I do not feel as hopeless in regard to
malignant disease of the rectum as Dr. Gay does. In
the first place, we must be very careful that our ex-
amination is thorough in cases of suspected cancer of
the rectam. If we examine thoroughly every case of
suspected cancer, and take nothing for granted, we
discover frequently facts of the greatest importance,
and at times avoid errors in diagnosis that would be
laughable if they were not tragic. I remember a case
that came to me with a diagnosis of cancer of the rec-
tum— a hopeless case. On careful examination I
found a carious coccyx surrounded by inflamed and
thickened tissues quite like cancer on careless exami-
nation. I removed the dead bone and the man recov-
ered. In connection with the difficulties of diagnosis
at times, I would like to speak of a man operated on
in one of the New York hospitals, for malignant tumor
of the bladder. He recovered perfectly from a very
brilliant operation. Later I examined him, and told
his friends that he could not live. There was a long
scar in the linea alba, in the mass of an evidently re-
current malignant tumor. He had a hopeless recur-
rence, as I thought ; but 1 heard the other day that he
got perfectly well, and is now at work in perfect health.
This was a mistake in diagnosis, even after the great-
est care in examination, in operation, and in gross in-
spection of the tumor : followed by the most expert
microscopical examination. We ought, nevertheless,
to have a microscopic examination in every case.

The only favorable instance of removal of malig-
nant disease of the rectam in my practice was that of

Digitized by

Google

216

BOSTON MEDICAL AND SUBOIOAL JOURNAL.

[Marcs 1, 1894

a jeweller who had to sit all day on a high Btool, and
who noticed very early some trooble in hi» rectam,
which I snpposed to be cancer. I operated on him
three or four years ago ; a year later I repeated the
operation for a recarrence, thoogh I had no idea that
the man would permanently recover. Yet he has
been well ever since. Presenting at first the gen
eral and local characteristics of malignant disease, he
now has become robust, and there is no local recur-
rence. Bat the disease was not cancer ; it was a ma-
lignant adenoma, with infiltration and indaration. The
pathologists have told me that in the cases of malig-
nant adenoma, if we can get the disease all out, the
prognosis is very good. While operating, we shonld
have always at our elbow the microscopist, as we
shonld have in abdominal work the bacteriologist

In regard to the Kraske operation and its modifica-
tions, I have seen this operation performed, but I have
never foond a case of my own in which it seemed best
to perform it. The mortality is 28 per cent., as re-
cently reported by Kraske, and by Schide 85 per cent.
— somewhat higher than Kelsey's.

I have performed many times the operation of in-
gninal colotomy, but I have never felt obliged to make
a spur. Almost always the operation has been per-
formed for cancer of the sigmoid flexure. I have op-
erated in the left groin, right groin, and median line
for the disease. For cancer of the rectum colotomy
has been done very infrequently in my practice. I
have never seen any subsequent distress or discomfort
from the absence of a spur, though I dare say that this
is completely at variance with the experience of others.
In one instance I opened in the left and found a dis-
tended coil of intestine, fastened it to the groin, and
opened immediately. The opening proved to be in the
head of the cecum. The patient lived about a year in
a state of comparative comfort, resumed his duties in
college, gave his lectures, and told me the year had
been a year of satisfaction and happiness. I do not
say that it is not a good plan to make a spur such as
Dr. Kelsey has described, or one like that which Dr.
Keene has just reported, but I have not seen any good
reason for following the method in my own cases. I
dare say that it is better in some instances to provide
for the total escape of the contents through that open-
ing, bat not infrequently strictnred bowel becomes per-
vious. In several cases the artificial anus has closed
entirely, the discharges have resumed their normal
course, and the patient Las been relieved from the
discomforts of the artificial opening. Under these oir-
. cnmstances the local discomfort from obstruction and
from tenesmus has also disappeared.

It is said in cancer of the rectum, as in cancer of
the breast, that three years of immunity after opera-
tion means cure. I do not believe in this time limit —
at least not enough to feel safe as to recurrence even
after five or six years. Absence of recurrence after
operation on the breast at the end of three years is no
certain assurance that the patient is safe. Those who
have watched the progress of enlarged axillary glands
when only the breast has been removed, must have
observed how slowly at times they grow. In certain
instances it has taken two or three years before they
could be very perceptibly felt ; yet, of course, the cells
of the disease have been there and have been prolifer-
ating. I do not believe, therefore, that we caa adopt
any such limit as three years, and say that if the dis-
ease returns before three years it is not a care, while

if it returns after three years it is a second and wholly
distinct attack. In looking ap a very large number of
cases of breast-cancers there were many instance! io
which after four, five, or six years the disease had not
returned ; on the other hand, there were one or two
cases in which after four or five years there was a re-
currence. In cancer generally, therefore, I do not
feel sure that the patient is permanently cured until
many years have elapsed without a sign of reap-
pearance.

Da. Gatin : My experience for relief in malig-
nant disease of the rectam has been wholly confined
to colotomy. 1 have always done the lumbar colotomy.
I have done that operation eight or ten times. I have
never had any diflicalty about the absence of the spur.
I had one case at the City Hospital two and one-half
years ago. A man had complete obstruction of the
bowel. I did the lumbar colotomy. He went out
well and engaged in his ordinary occupation, and a
year and a half later he came to my ofiBce to know if
he could not have that thing sewed up. A few months
later he died. Lumbar colotomy has always given
relief to the patient, and I have no doubt prolonged
the life of the patient.

Db. Paul Thobndikb : I want to say a few words
about the Kraske operation, as compared with the
anal operation of Mr. Cripps. While it is true that
we are not justified to-day in promising our patient a
care from either of these operations, it is also true that
both have distinct and well-defined places in surgery.
In cases when the disease is low down near the anus
we do the Cripps operation, hoping for a radical cure,
and sure that if our patient survives we shall have
prolonged his life and lessened his pain. For these
same reasons should we make use of the Kraske oper-
ation in oases when the disease is higher np in the
rectum. The former operation has a mortality of 10
to 15 per cent., is bloody and inaccurate. The latter
operation has a slightly higher mortality — 15 to 20
per cent. — is less bloody, and offers an easy, direct
road to the diseased bowel, thus making possible a very
careful and thorough removal of the diseased area. It
is an operation which seems more severe than it really
is, and which is not receiving the attention it deserves
in this country. Whatever may be our belief as to the
possibility of radical cures of rectal cancer, there is a
certain percentage of cases when the disease is appar-
ently well defined and limited to the anal region,
where it is plainly our duty to try for a radical removal
of the duease. Just so there are other cases when the
disease is higher up in the bowel, where the Kraske
operation is demanded.

Db. Biohabdson : I hope that my renaarks will not
be understood by Dr. Thorndike as opposing this oper-
ation. I did not intend to oppose it, because I have
seen it most successfully used in the hands of Dr.
Cabot ; moreover, it seems to me at times a naost desir-
able procedure. I spoke of the dangers from having
seen Schede's and Kraske's mortality recently reported
— one of 28 per cent, and the other 35 per cent.

I have demonstrated the anatomy of this operation
time and again at the school ; it is a beautiful way of
getting at the rectum. I have not performed the oper-
ation because I have not seen a case in which it seemed
wise to apply it. In the hands even of an experienced
operator it is one of the bloodiest operations I have
ever seen. I remember one of the first cases at the
hospital ; the haemorrhage was so great that we had no

Digitized by

Google

roi.. CXXX, No. 9.] BOSTON MEDICAL AND SURGICAL JOURNAL.

217

idea that the patient would live ; bat she did live, and
k very satisfactory result followed. I was surprised
:o hear Dr. Thorudike say this is a palliative method.
[ had supposed it was iDteoded to be the most radical
[>f radical measures.

I have seen recently described a method of bringing
the apper part of the bowel down into the lower, so as
to prevent formation of fistula and to restore the func-
tion of the bowel. If this could be performed success-
fully, we should have a most desirable condition of
tbinge, — the absence of opening in the groin and res-
toration of the alimentary canal ; yet it seems to me
that the dangers are great, and that they must be great
until we have had considerable experience in perform-
ing the operation.

In regard to the difference betweeu the lumbar and
inguinal colotomy, I should like to see Dr. Gavin a
convert to the inguinal method. I abandoned entirely
the lumbar route, after having performed the Littr^
operation a few times. The advantages of the latter
method are so great, both as to teehniqiu, and as regards
the subsequent ease of the opening, that it seems to me
very certain that lumbar colotomy will be performed
only in those cases of obstructive cancer which are
aitaated too high up for the inguinal incision.

MASSACHUSETTS MEDICAL SOCIETY.

COUKCILLORS' MeETIMO.

A STATED meeting was held at the Medical Library,
Boston, on Wednesday, February 7, 1894.

The meeting was called to order at eleven A. m. by
the President, Db. Jaues G. White. One hundred
and nine Councillors were present.

APPOIMTMSNT OF DBLBGATE8 AND OOHKITTBB8.

On nomination by the Chair, the following dele-
gates to other State medical societies were appointed :
Maine: Drs. J. E. Garland, of Gloucester; M. H.
BichardsoD, of Boston.

Nev Hampthire : Drs. J. G. Blake, of Boston ; C.
C. Odlin, of Melrose.

Rhode Hand: Drs. F. W. Goss, of Roxbury; R.
H. Faunce, of Sandwich.

(jOtmeclieut : Drs. G. £. Francis, of Worcester ; C.
H. Cook, of Natick.

New Jersey: Drs. C. A. Carlton, of Salem; H.
Colt, of Fittsfield.

Committees were appointed :

'lo Audit the Treaturer't Accounts: Drs. 6. G.
Tarbell, A. D. Sinclair.

To Examine the By- Laws of District Societies:
Drs. S. D. Presbrey, F. W. Chapin, H. J.' Barnes.

Id accordance with the recommendation of the Com-
mittee on Medical Diplomas, it was voted that the
degree of Tufts College Medical School be recognized
by the Society.

The principal interest in the meeting centred about
the report of the Committee on Securing Uniformity
Id Censors' Examinations. The President, as Chair-
man of the Committee, offered the report, and made
remarks in support of the statements in the preamble.
The report was as follows :

At a meeting of the Councillors, held October 2, 1893,
the report of Uie Committee on securing Uniformity in

Censors' Examinations was presented. To it objection
was raised that it might exceed the limitations of the char-
ter. The subject was thereupon referred to a new Com-
mittee, to be appointed by the Chair, and to include the
President himself. The Cotnmittee thus appointed, con-
sists of one member from each District Society.

Your Committee has carefully considered many plans for
the establishment of a uniform examination of candidates
for admission to this Society. The present status for ad-
mission is somewhat as follows : Different standards are
established by eighteen different Boards of Censors, nut
acting in concert, and having only in common the welfare
of the Society. The objections to this plan are the fol-
lowing :

(1) That in certain Districts a comparatively severe
examination is held for admission to the Society ; that in
other Districts a comparatively easy examination is held.

(2) Tliat the Boards of Censors, as a rule, are com-
posed of young men but a few years out from the Medical
School, who are naturally sharper critics than the older
Fellows of the Society.

(8) That at present the Boards of Censors know very
little of the requirements for admission into other State
Societies.

(4) That there are many excellent regular practitioners
scattered throughout the State, and that their number of
late has been increasing, who are not members of the Soci-
ety. This is owing to failure on their part to present them-
selves for admission to the Society, and this failure is due
to their wishing to avoid the rigor of an examination con-
ducted by young men ; in many instances by rival practi-
tioners.

We believe that it will be for the interest of the Society
to establish a uniform standard of examinations throughout
the Commonwealth, and further that such examinations
shall be elastic at the discretion of the Censors, in order
that practitioners of established reputation shall not be

your Committee re-

hindered from entering the Society.

In order to accomplish this object
spectfuUy suggests that the Councillors and the Society
authorize the following changes in the By-Laws.

(1) By-Law I to be changed by striking out part of line
21 on pi^ 9, and lines 22 to 26 mclusive, and substituting
the following words, so that the By-Law shall read, " and,
by such further examination as the Censors shall deem
expedient."

(2) By-Law XIII to be changed by omitting the words
■' five Censors," in line 22, and adding in line 2S the
words " five Censors, all of whom shall have been Fellows
of the State Society for at least ten years, one of whom
shall be also a Councillor, and be designated a Supervisor,
and Ex-Ufficio Chairman of the Board o( Censors."

(3) By-Law XIX to be changed by adding after the
word "held," in line 19, the words "they shall appoint the
time and place of the annnal meeting of the Supervisors";

(4) After the title " Censors," commence By-Law XX
with the following additional provisions relating to super-
visors :

The Censors, elected Supervisors, shall form a Board.

They shall elect their own Chairman.

The Recording Secretary of the State Society shall be
their Secretary.

For the transaction of business ten Supervisors shall
constitute a quorum.

They shall hold an annual meeting at such time and
place as the Council shall direct; and may hold other
meetings at such places and times as they may agree to
appoint.

At their annual meeting, or adjournments thereof, the
Supervisors shall formulate and adopt a uniform plan, con-
sistent with the requirements of the By-Laws, to be pur-
sued the ensuing year, by each District Board of Censors,
in the examination of candidates.

They may authorize the Secretary to have printed, at
the expense of the Society, all blanks and examination
papers necessary to caryr out their plans.

The Secretary shall furnish examination papers, to Su-

Digitized by

Google

218

BOSTON MEDICAL AND SUSGICAL JOUBNAL.

[Maech 1, 1894.

pervisors only, and in such number as each ma/, in writ-
ing, request.

It ihall be the duty of each SupenriMr to convey to the
Board of Censors of the District Society to which he be-
longs, together with the necei'sary examination papers, a
report of the method and spirit in which the Board of
Supervisors have directed that their plan should be used,
and to see that in all examinations the designated details
are properly executed.

Should a candidate otherwise qualified, but without a
diploma from one of the schools accredited by this Society,
satisfy the Censors of the District Society where he re-
sides, by examination, that he has received an education
equivalent to that prescribed by the By-Laws of this Soci-
ety, the Supervisor of said District Society shall present
the name, standing and qualifications of said candidate, to
the full Board of Supervisors at their next meeting, where-
upon the assenting votes of two-thirds of the Supervisor*
present and voting, shall elect such a candidate to be a
Fellow of this Society.

(5) By-Law XX to be changed by adding after the word
" By-Laws," in line 2, the following, so that the By-Law
shall read : " The Censors shall examine, according to the
rules and By-Laws, and in conformity with the directions of
th^ Supervisors," such candidates, etc. ; also after the word
"day," in line 21, by adding the following, "but not at the
same hour or hours."

(6) By-Law XXI to be changed by substituting the word
" supervising," for the word " senior," so that thu By-Law
shall read, " and the supervising Censor shall preside."

Dr. J. C. White, President.
Dr. 6. W. DoANB, Db. J. F. A. Adams,

Dr. F. a. Hubbard, Dr. B. J. Handt,
Dr. R. B. Root, Dr. A. H. JoHNgovr,

Dr. a. C. Dkane, Dr. W. H. Fombrot,

Dr. D. W. MiNRR, Dr. S. W. Kellkt,

Dr. H. B. Howard, Dr. E. R. Ctttlbr,
Dr. M. V. PiKRCE, Dr. J. F. Welch,

Dr. H. F. Bordbn, Dr. J. H. McCollok,

Dr. E. B. Harvet, Dr. F. H. Thompson,

Committee.

After discasgion by Drs. Hartbt, Williahs,
Wheeler, Francis, F. C. Shattuck and Cutler,
it was voted :

That the report be accepted, and that the changes
in the By-Laws, as far as the Council is concerned, be
adopted.

The Librarian reported that, id accordance with
the vote at the last meeting, the publishers were
notified that no orders for future numbers of " Braith-
waite's Retrospect" would be given, and that an
aclinowledgment of the receipt of the notice had been
returned.

The Treasurer offered the following votes, which
were adopted :

Voted, That the Librarian shall be the cnstodian of
sach papers, manuscripts and books of record belong-
ing to the Society as are not in use by its officers.
He shall properly catalogue them, and see that they
are stored against the risk of fire. He shall arrange
and file them in such a manner as to promote the con-
venience of Fellows of the Society who may desire to
consult them. He shall include in his annual state-
ment a report upon their condition.

Voted, That as the Censors are officers acting for
the State Society, the different Boards of Censors are
hereby directed to forward to the Librarian of the
State Society snch books of record as are not in
present use.

On motion, the question of the reduction of the
annual assessment was taken from the table.

Voted, That the subject be indefinitely postponed.

In accordance with notice given at the last meeting,
Dr. Forster moved, and it was voted, that Role 2
of the Rules and Orders of the Councillors be anDnlled.
The following was the rule in question :

" There may also be annually prepared, under the
direcUon of the Councillors and at the expense of the
Society, a retrospect of the medical literature and
science of the preceding year, having reference espe-
cially to discoveries and improvements of practical
value."

THE NEW YORK ACADEMY OF MEDICINE.
SECTION ON ORTHOP.ff:DIC SDRGERY.

Stated Meeting, December 15, 1894, W. B. TowH-
bend, M.D., Chairman.

conoemital torticollis.

Dr. Rotal Whitman presented two cases of con-
genital torticollis complicated by induration of the
sterno-mastoid muscles. The induration of these mus-
cles was not the cause of the torticollis, but was sec-
ondary to it.

The first infant, now five months of age, was first
seen at the age of three months. There was at this
time well-marked left torticollis, hemiatrophy of the
face, and congenital club-foot on the same side. In
the middle of the contracted muscle there was an in-
duration the size of a pigeon's egg. The labor was
normal. The distortion of the head and the induration
were noticed by the mother on the fourteenth day after
birth. This induration in the muscle could still be felt,
and the torticollis and hemiatrophy of the face were
very evident.

The second infant, now seven months old, was first
seen at the age of six weeks. Then, as now, there
was marked torticollis, and an induration in the mus-
cle, similar to that in the preceding case. In this case
the child was delivered by forceps after a difficult
labor. Immediately after birth the mother noticed the
distortion of the head.

That the torticollis in the first case was of intra-
uterine origin was shown by the hemiatrophy of the
face and by the club-foot. That scar contraction had
nothing to do with the deformity in the second case
was proved by the fact that the deformity was noticed
immediately after birth. Injury at birth might have
caused the deformity, but not scar contraction follow-
ing rupture of muscle. Simple rupture of a normal
muscle, shown by induration, was not, as a rule, ao-
companied or followed by torticollis.

pott's PARAPLB6IA.

Dr. Whitman also presented a case of Pott's para-
plegia in which a rather unusual form of paralysis was
the very first symptom. About the first of last Octo-
ber the child, two years of age, was noticed to be
stumbling; when first seen by the speaker, about two
weeks later, there was not the slightest pain, and no
angular deformity. The paralysis was of the flaccid
type like that of anterior poliomyelitis. At the pres-
ent time, two months after the appearance of the pa-
ralysis, there was still no angular deformity of the
spine, although a change in outline due to muscular
spasm was apparent. Within a week there bad been
complaint of pain, and the paralysis was now of the
spastic type.

Digitized by

Google

Vot. CXXX, No. 9.] BOSTON MEDICAL AND SUSGIOAL JOURNAL.

219

PKBSI8TENT PSOAS COMTRA.CTIOK.

Dr. Whitman preseoted still another patient, a boy
nine years of age, who illustrated an extreme and per-
sistent psoas contraction. When first seen, about two
years ago, there was deformity of the mid-dorsal region,
with slight psoas contraction ; subsequently while un-
der the care of an instrument-maker, an abscess formed,
which opened spontaneously. The deformity of the
ipioe was not well-marked, and the leg was firmly
held at a right angle with the body. It was probable
that an extensive tenotomy and fasciotomy would be
required to bring it down to the normal line. He was
iaclined to think, that, if psoas contraction were al-
lowed to persist, it exerted a very unfavorable influ-
ence on the deformity, because it was impossible to
maintain by apparatus a proper attitude.

Db. y. P. GiBNRT said the occurrence of paralysis
before the deformity was exceedingly rare, and in a
aeries of fifty cases of Pott's paraplegia which he col-
lected at one time, it was the rule for them to develop
at first a little stumbling, but examination failed to
show exaggerated reflexes until some time later. It
was well to emphasize the fact, so apt to be overlooked
by the general practitioner, that Pott's disease may
occur without the pain or other usual signs described
in the books. These are the slow cases of "caries
sicca."

He did not agree with Dr. Whitman that it was
necessary to treat the psoas contraction itself under
ordinary circumstances. If one could exclude hip-joint
^sease, there need be no hurry about much treatment
directed to the contraction.

Db. WaiTXANsaid that psoas contraction caused by
true psoas abscess, that is, abscess within the sheath or
snbstance of the muscle, was very likely to become
permanent distortion, as illustrated by the case that he
had presented — a distortion which made it impossible
for the child to stand erect. Psoas contraction was
best treated by temporary rest on the back, and by the
direct treatnaent of the abscess which caused the con-
tracUon.

THE LOBENZ TBEATUKNT OF HIP-DISEASE.

Dr. y. P. GiBNBT presented a patient with hip-
disease, who was being treated by the Lorenz method.
This consists in applying a plaster-of-Paris spica band-
age to a point midway between the knee and the foot,
and then on the following day adding an iron stirrup
which projects beyond the foot, and is secured by a
starch bandage. It is claimed that with a high shoe
on the sound foot the patient is able to go around
easily. It would probably prove very useful where a
good perineal crutch was not easily obtainable.

EZOISIOH OF THE HIP.

Dr. Gibney presented several cases of excision of
the hip. The first one was that of John K., who was
•dmitted to the hospital on October 8, 1892, at the
age of eight years. The limb could then be flexed to
110°, and extended to 145°. After about one month
of treatment in bed with the weight and pulley, a hip-
splint was applied. On December 2d, an abscess was
aspirated, but as it soon refilled and began to burrow,
a partial artbrectomy was performed, and by the fol-
lowing February extension and flexion were nearly
aonnal. On liLty Slst, he was discharged, still wear-
ing the spHot. There is now about one inch of shorten-

ing; flexion to nearly 90**, and extension to 170° ; the
other motions are very fair, and the hip seems to be
quite firm.

The second case was a boy admitted on October 1 2,
1891, at which time there was but a small range of
motion. The disease began the year previous, and
during that year he had an abscess. As there was
marked abduction, it was treated with the Taylor ab-
duction brace. On November 21, 1891, the limb could
be extended to 170°, but the limb was everted. On
January 6th it was noted that he was wearing a
Thomas brace, and that there was much spasm and
tenderness. An abscess on the anterior aspect of the
limb was aspirated, and a few drops of pus removed.
On May 17th, the trochanter major, with the head and
neck of the femur, were removed. He remained in
the country all the summer, and in the following No-
vember it was found that extension could be made to
180° and flexion to 110°. The next March an abscess
formed in° consequence of a fall, so it was incised and
several ounces of pus evacuated. He was discharged
the following September without a brace, but wearing
a one-inch-bigh shoe. At present, the limb comes
down straight, and can be flexed to 90° ; there is little
resistance to abduction ; there is slight adduction and
rotation, and one inch shortening.

The third case was a boy who was four years old
when his duease began in February of the present
year. He was admitted in June ; and in spite of re-
peated aspirations, a large abscess with marked deform-
ity persisted, so that on November 10th, excision was
performed. The wound healed very rapidly. On
December 15th, a jointed Dowe's splint was applied.

The fourth case was a boy, five and a half years
old, with a double hip-joint disease which began in
May, 1891. His right hip was excised in Christ's
Hospital, Jersey City, three months after the begin-
ning of the disease. When first seen by the speaker
the left hip was painful, and there was an abscess in
this locality. The joint was excised on November
24th by posterior incision, and the head and neck re-
moved. The case has done well.

These cases were presented to show that in hospital
practice, there is a certain number which seem to re-
quire excision and which do well after it. None of
the oases had a weak joint.

Db. a. M. Phelps said he had seen this Lorenz
brace applied many times. It was better than the
Thomas splint, for it protected the limb, and it was
superior to the long-traction splint, for the cases treated
with it did not recover with the angular deformity so
commonly seen after the use of the long-traction splint.
The objections to the Lorenz splint were that it was
cumbersome, that the patient walked upon it, and it
did not apply extension in the line of the adductor
muscles to prevent intra-articular pressure. With it
abscesses were just as frequent as with the Thomas
splint, and there was almost always shortening.

He heartily agreed with all that Dr. Gibney had said
about the cases of excision. He had abandoned aspi-
ration of abscesses, for eventually they must be in-
cised. If by aspiration the presence of pus in a joint
were detected, the sooner the abscess was incised, the
better. By this means one was also enabled to explore
the joint with the aseptic finger, and so determine
whether or not an excision was required. No one
could tell this from external examination alone. He
favored the posterior incision and the removal of the

Digitized by

Google

220

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Mabch 1, 1894.

great trochauter in order to secure free drainage ; in
short, Dr. Sayre's method of leaving the periosteam
and packing the wound with antiseptic gauze was still
tb<) best mode of treatment.

The Chairman dissented very emphatically from
the opinion that the aspirator was useless, and that all
these ab&cesses should be incised. In a series of cases
of abscess which he bad collected, nearly fifty per
cent, were permanently relieved by aspiration. There
were many abscesses situated near joints which were
not intra-articular, and also many abscesses supposed
to communicate with a joint until examined at the
time of operation, when it was found that they did
not.

Dr. N. M. Shaffer said no abscess was opened in
the Orthopedic Hospital during the year ; yet be would
be perfectly willing to compare bis results with those
of Dr. Phelps.

Dr. Rbqinald H. Satbk objected to the Lorenz
treatment, as shown in this patient, on the ground that
a good deal of pressure was borne by the hip, because
part of the weight fell on the condyles of the femur
instead of on the ischium. He had been much pleased
with the cases of excision ; and he would contrast the
motion in these joints with the ankylosed joints which
Dr. Whitinan said at the last meeting the Germans
considered to be superior. The European operators
were not careful to save the periosteum.

Dr. Ualsted Myers said that in connection with
this discussion he wished to report a case. A girl,
when six years of age developed hip-disease ; and two
mouths later an abscess formed. After wearing a
traction splint for six mouths, the joint was excised.
She was kept in the hospital without a brace for a
year, and was then discharged "cured." Soon after
this she slipped, and another abscess developed. She
was again - admitted, and five months later was dis-
charged cured. Three years after this she had an-
other fall, and another abscess appeared, which was
cured in three weeks. One and a half years afterward
still another abscess formed, and was cured in four
mouths. In September, 1893, or when she was four-
teen years old, there was found to be three and one-
quarter inches shortening, an increase of three-eighths
of an inch in the last two years ; there was also slight
telescoping. The motions allowed in the joint were :
flexion 180° to 140°, adduction 30°, abduction 10°,
and considerable rotation. She bad no abscess, no
pain, and no longer wore a brace. She limped badly,
but did not tire easily. The case seemed to show that
after such excisions, the shortening might be steadily
progressive, and also that all the disease was not re-
moved at the time of excision, else there would not
have been these frequent abscesses.

Dr. Whitman said he had been misunderstood at
the last meeting, for at that time be was speaking of
excision done as a last resort, and not of the class of
cases represented by the patients just presented. Re-
production of bone after excision, with a firm and
movable joint, was a result to be hoped for, but not
confidently expected.

Dr. Satre regretted if he had misquoted Dr. Whit-
man ; but he had himself recently noticed a number of
German articles in which it was stated that a stiff joint
represented the result which should be sought for after
excision for tubercular disease of the hip.

Dr. Gibnet, in closing the discussion, said he re-
gretted that Dr. Phelps still persisted in the belief

that every abscess in a tubercular joint should be ui-
cised. Regardiug Dr. Myer's case, he said he did not
see how the limb could grow when the apper epiphjais
had been destroyed, whether by cicatricial tissue or by
the removal of the epiphysis.

EXCISION OF THE TARSC8 FOR CARIES.

Dr. a. M. Phelps presented a girl who had been
brought to him at the Posi-Graduate Hospital, two
months before, with disease of the tarsus and the end
of the tibia. At the operation it was found that the
disease involved the astragalus, os calcis, cuboid and
scaphoid boues, as well as the ends of the metatarsal
bones and the end of the tibia, so these parts were all
removed, leaving a shell of bone with the periosteum.
At the end of six weeks the case was dressed, and it
was then found that there bad been perfect reprodac-
tion of the entire tarsus, and of nearly all of the meta-
tarsal bones, together with the end of the tibia. Find-
ing a metatastasis in the scapula, the spine of this
bone was removed.

Dr. Gibney said he had treated very successfully a
number of cases of extensive disease of the entire
tarsus without operation. The results were perfect in
the great majority of such cases.

Dr. S. Ketch said that very badly diseased tarsa:
were often cured by simple protection and avoidaooe
of traumatism and pressure. It had been his experi-
ence that disease of the ankle-joint was usually followed
by better functional results than disease of the other
articulations.

Dr. Phelps said that when, on catting into the
tarsus the bones were found separated and necrotic, he
thought no protection would be of much importance.

LAMINECTOMY FOR TLBERCDLAR DISEASE OF THE
SPINE.

Dr. Carl Beck presented a patient on whom he
had performed laminectomy. He was first seen two
years ago, aod was then three years old. Resection of
the shoulder was first performed for the removal of
tubercular foci in the humerus. One year later it was
found that there was some rigidity and pain in the
spine. He was treated for some time in one of our
hospitals, and when he came again to the speaker, it
was found, on removing the plaster dressing that there
was a kyphosis. He was greatly emaciated, and there
was a large fluctuating tumor in the left gluteal region.
An incision was made into this abscess ; and after in-
serting a drainage-tube and gauze, he was placed in a
RauchfuBS apparatus. After three weeks, a plaster
jacket was applied, and he was treated as an out-patient.
Soon after, a prominent kypbos appeared at about the
ninth dorsal vertebra, and the child bad paraplegia.
An incision was made from the seventh to the last
dorsal vertebra ; and on exposing the spinal cord, it
was found that the meninges were hyperaemic and
thickened. Free drainage was established for the
abscess, and the fistulae curetted and packed with
gauze. He was again placed in the Rauehfuss appa-
ratus. His condition had greatly improved since the
operation, and he hoped that eventually the child
would be able to discard the plaster jacket. The open
treatment, the speaker considered the treatment par
excellence.

Dr. Beck then exhibited a new instrament for use
in connection with these abscesses ; be called it " the
irrigation trocar."

Digitized by

Google

ToL. CXXX, No. 9.]

BOSTON MEDICAL AND SURGICAL JOURNAL.

221

A mw OPERATION rOB THX RKLIKF OB ODRB OF
SOTABT l,A.TEBAL OCBTATCBB OF THE SPINE. PBO-
FOSRD FOB DISCUSSION OF THE SECTION.

Db. Sbaffeb read a short paper describing a new
operation which he proposed for the relief and cure of
rotar; lateral corrature of the spine. After having
performed it several times on the cadaver, he had pro-
posed it in a certain case of a young girl, when the
rototioD had progressed steadily and persistently in
apite of all that could be done with mechanical treat-
oieDt, exercises, etc. The surgeons to whom he had
proposed the operation, in formal consultation, did
not approve of the procedure, not that the surgical
riak would be so great, but rather on account of our
present imperfect knowledge of the pathology of these
persistent and inveterate curves. Under these circum-
Btaoces be brought the subject before the Section for
discnasion.
The operation proposed is as follows :
A large curved incision is made, which extends from
one inch above the upper end of the pathological curve
to one inch below it. An incision is now made
through the trapezius muscle, which with the super-
fidal tissues is dissected off until the erector spinse is
fully exposed. This is now divided transversely, as
numj transverse incisions being made as there are in-
tervertebral articalations to loosen. The fibrous ds-
aaes between the transverse processes are divided so
far as possible. A curved director is then passed
noder the costo-transverse ligament, which is divided
with a blunt-pointed, curved bistoury. All the acces-
lible soft parts having now been divided, a forceps
lever is placed Ifetween the transverse processes, and
they are gently forced apart In the cadaver, after
the costo-transverse ligament was divided, it was found
that the articular processes could be easily forced
apart, and the vertebrae separated on the concave side
of the curve.

Id the cadaver it seemed easy to avoid the spinal
artery and nerve, and with care there seemed to be no
danger of wounding the pleura.

In view of the recent operations upon the spinal
column, it seemed to the reader of the paper that the
proposed operation was both feasible and justifiable,
eapecially as applied to rotary curves of an inveterate
type, if recognized in the early stage.

Db. Whitman said the case of Dr. Beck was evi-
dently suffering from double psoas contraction, and
that as the attitude exaggerated the deformity, the
treatment should be rest on the back.

Db. Phelps said he had done seven laminectomies
— two for Pott's disease, and five for fracture. The
latter had yielded more favorable results. He believed
laminectomy should be performed in cases of Pott's
disease where paralysis was present, where there was
incontinence of urine or faeces, and where there were
abscesses and every indication of extensive disease of
the bone.

Db. Samuel Llotd had been much interested in
diis case. The latest statistics showed that 103
laminectomies had been performed for Pott's parai-
pl^ia simply. Dr. Phelps has summed up the indica-
tioDs for operating well, but had applied Lauenstein's
rale too rigidly, as this rule had never been intended
to apply to Other tham traumatic cases. The number
of cases requiring laminectomy was very few, and the
operating surgeon should not attempt to operate until

he had satisfied himself that efficient mechanical treat-
ment had been employed previously without success.

Dr. Shaffer would find a good precedent for hu op-
eration in those operations which had been done for
rotary and lateral dislocations of the spine. As the
pleura was thickened, it was likely to be pushed aside
out of harm's way, and the haemorrhage should be the
same as in laminectomy, that is, it should be readily
controlled by packing.

Db. Ketch said he did not consider laminectomy
for Pott's disease a justifiable operation except where
it was done as a life-saving measure. He agreed with
the last speaker that the continuance of paraplegia or
the presence of incontinence of urine and faeces were
no guides to the operation. He thought most of the
cases of Pott's disease operated upon would have done
just 88 well without operation.

Db. I. S. Hatnes said that it should be remembered
that a thick layer of tendinous fibres was present, and
should be thoroughly divided in a number of places.
Again, nothing could be gained until the anterior
costo-transverse ligament had been completely divided.
No arteries of importance were encountered. Primary
union was very desirable, for if healing occurred by
granulation, the cicatricial contraction would only
serve to aggravate the original condition.

[Discussion to be continued at next meeting.]

Vitttnt Xtterature*

Aneuthetiet : 2%«V Uses and Administration. By
Dddlet Wilkot Buxton, M.D., B.S., Member of
the Royal College of Physicians ; Member of the
Royal College of Surgeons of England; Admin-
istrator of Anaesthetics and Lecturer in University
College Hospital, the National Hospital for Paraly
sis and Epilepsy, Queen's Square, and the Dental
Hospital of London. Second edition. Philadelphia :
P. Blakiston, Son & Co. 1892.
This is the second edition of this work, which has
done much towards systematizing our knowledge of
ansesthetics. It is written from a historical as well as
a practical standpoint ; but while many different forms
of inhalers are shown, the author has not given the
advantages or disadvantages of each apparatus. The
author's conclusions regarding the value of different
anaesthetics are judicious. The effect of chloroform is
well described.

The book will well repay perusal by those adminis-
tering anaesthetics.

A Practical Treatise on Nervous Exhaustion {Neur-
asthenid) : Its Symptoms, Nature, Sequences, Treat-
ment. By Geoeoe M. Beaed, A.M., M.D. Edited,
with notes and additions, by A. D. Rockweli,,
A.M., M.D. Third edition, enlarged; 8vo, pp.
262. New York 5 E. B. Treat. 1894.
To the third edition of this well-known work the
editor has added a brief chapter on the etiology and
pathology of nervous exhaustion. In this chapter he
speaks of the changes in the nerve cells caused by
fatigue, and points out the relations such changes may
bear to neurasthenia. He also touches upon the in-
fluence which the conditions of American life have in
producing the disease.

Digitized by

Google

222

BOSTOS MBDIOAL AND SUSOICAL JOURNAL.

[Mabch 1, 1894.

THE BOSTON

Thursday. March l, 1894.

A Jomnutl <tf Medieiite, Sftrgtry, and Allied SeUHe*M,ptMi$hed at
BotUm, treekty, by the tutdenig*ed.

SlTBaCRiPTiOH Tkemb: f 8.00 per year, in adva»ee, po$tag*peM,
Am- (*« UiMtd atatei, Qmada emd Mexico ; 98M perymrfor all for-
eign ootmtriet bekmginf to the Postal Unitm.

All eommmieatxmi for the Editor, and all booki for review, tkomU
be addreieedtothe Bditorofthe Bottom Medieal amd SurgiealJomnuU,
283 fTatkingUm Street, BotUm.

AH Utteri containing buiineie comnumieoMoiu, or referring to the
fnbUeation, tubeeription, or advei tiling department of (JUf Jimmal,
ehould be addretied to the ymdenigned.

Semittamoe* ehould be made by mimey<rdtr, draft or regittertd
letter, payable to

JiAXBXLL ft TTPHAH,
m WASHoroTon Stbut, Bo«toh, Knai.

FEEBLE-MINDED CHILDBEN.

Sib Douglas Galton has written an intereeting
article in the N%n«t««ntA OSmtery, in which he calls
attention to the importance of making special provi-
sion in the elementary schools for training those chil-
dren who are more or less defective, or who are suf-
fering from mal-developments which are associated
with defects in the brain.

To Dr. Francis Warner belongs the credit of bar-
ing soggested metbods for carrying into effect an inquiry
into deviations from the normal in children in various
London elementary schools. He has now reported on
over 80,000 children seen individually by him in 148
schools, having taken notes of all cases presenting any
visible defect, that is, 14,297 children. The method
of procedure was as follows : " As the children stand
in rank, each is viewed separately, without being
toached, or questions asked. The child is then directed
to imitate a few simple movements. Any deviation
from the normal in bodily development or in conforma-
tion of the head or a feature is recorded ; also any ab-
normality in expression, balance, movement of the
eyes, or acUon in the haitd or fingers is noted as an
'abnormal nerve-sign,' indicative of the state of the
nerve-system, and these particulars are recorded in
schedule forms." A fall description may be found in
the "Beport on School-Children," by Dr. Warner,
to the Charity Organization Society, 1892.

StatisdcB of the first 50,000 children seen (1890-
1891) have been arranged and presented to the Local
Government Board ; this report is now published by
the Bureau of Education, Washington, D. C.

Four primary groups of cases were easily arranged :
"development cases," including all children present-
ing one or more defects ; " nerve cases," each child
presenUng one or more "abnormal nerve^igns";
" nutrition cases," children pale, thin, delicate ; " dull
children," as reported by the teachers in school.

The same children often appear in more than one
group ; thus, of the " development cases," 52 per cent.

also presented abnormal nerve^igns ; and of the " nerve
cases," 60 per cent were also " development oases."
Of the children " pale, thin and delicate," 71 percent,
of the boys, and 74.6 per cent, of the girls were also
"development cases." In these figures, we see the
physical co-relation of congenital defective develop-
ment producing a tendency to nerve.dutarbance and
low nutrition of body.

In all schools, a larger proportion of boys than girls
deviate from the normal. There is, however, a rather
larger proportion of girls who are " pale, thin and
delicate"; and congenital weakness in constitution,
however slight, renders a girl more likely to ill-health
than a boy ; and any nerve disturbance oocorriDg in
her is more liable to be rendered permanent than in
the boy. When, however, we take boys and girls
presenting no defect in development, we find the pro-
portion who are delicate equal in both sexes. Let the
teacher then, arrange the curriculum for the normal
girls, and modify it when necessary for the weaker
members. Neglect of the latter precaution may lead
to deplorable results ; but the whole level of the school
need not be lowered to the capacity of the weaker
pupils.

One defect stands prominent among the girls : cranial
abnormalities have the highest co-relation with defec-
tiveness of health and brain power. The sub-class
"small heads" forms S.4 per cent, among English
girls, as compared with 1.3 per cent, for boys, and is
largely attended with mental dulness,' low nutrition,
and abnormal nerve-signs. Of girls in industrial
schools, 6 per cent, were " small headed " ; this condi-
tion is more common among the children of large
blocks and warehouses.

Many points,44>dii^ct educational importance have
been elucidated. It has been shown that of the group
of children presenting abnormal nerve-signs, 41 per
cent, are dull mentally ; and in a varying degree the
same may be said of children presenting each separate
nerve-sign. As examples ; many children do not move
their eyes properly in looking at objects, but turn the
head toward the point looked at in place of moving
the eyes ; 43 per cent, of these children were reported
as dull by the teachers, they are bad readers and bad
observers. If this condition is known to the teacher,
the fault may be corrected ; eye-movements shoald be
trained in the kindergarten.

A listless attitude in the pupil is not condacive to
mental aptitude, but it is not generally understood that
a good balance of the body in every detail, even to
the hand and fingers, promotes in the braia an aptitude
of mental brightness, and that cultivation of symmetry
and accuracy in movement and attitude promotes a
healthy brain state ; yet snch appears to be the troth.
In removing abnormal balances and action in move-
ment, the teacher helps to improve the activity and
balance of brain.

It is most commonly among boys that we see frown-
ing, or the formation of horieontal creases on the fore-
head by muscular action ; this is very oomnaon among

Digitized by

Google

Vou CXXX, No. 9.] BO STOUT MEDICAL AND SUBOIOAL JOUBNAL.

223

imbeciles — and it may be added, in monkeya also.
Now sDch a boy will often cease to frown when he is
ioterested ; that lesson improTos his brain daring which
frowning ceases. This condition is mnch more fre-
quent among boys in the monotonous life of the Poor-
Schools than in the elementary day-schools. It is the
"development oases" that tend the most to defective-
ness of bnun-power and to low nutrition ; such cases
do the best in the day-schools. Their educational
DBglect tends to fill the ranks of pauperism, criminal-
ity, and the unemployed.

In one school, fourteen children were promptly
taken to the Ophthalmic Hospital for correction of
squint and other defects ; their needs had not been
noticed before.

The number of children presenting defective condi-
tion of the eyes is large ; uncorrected squint is very
common, and though this defect is often preventable
by the use of spectacles, comparatively few pupils use
them among those who ought to. Eye-diseases in all
stages, often contagious cases, were seen in many day-
icfaools, and other examples of preventable conditions.
Here is a large field for good work. The want of
correction of faults by the teachers, and neglect of
esses needing medical treatment probably arise mainly
from ignorance of existing conditions ; but it may be
hoped that a more widely spread attention to the study
sod observation of children among all classes will
inspire a more intelligent interest in their care and
training.

Defectiveness of body, brain-weakness and low nutri-
tion are evils confined to no social class ; it appears,
on comparing the conditions of 10,000 children in
schools of the middle and upper social classes with
26,000 children in poorer day-schools, that in each of
the four primary groups of defects the proportion goes
against the children of the upper class. This is very
sarprising and needs further inquiry.

The greater the number of visible defects in a child,
the greater is the probability of its being dull ; so that
of children appearing in three of the primary groups
of defects, 44 per cent, were said to be mentally dull.
The children presenting certain of the "abnormal
oerve-signs," are those commonly called nervous chil-
dren ; they are usually intelligent and quick at lessons ;
they are inaiutive and gregarious. Whether it is
advisable to allow such children to sit together at
school is questionable ; on the other hand, dispersed
among the more average pupils, they tend to impart
their quickness.

It has been shown by observation that spontaneity
is the foundation of intelligence, yet the attempt is
often made to keep young children quiet and almost
motionless — often destroying spontaneity in place of
oo^idinating it. The endeavor should be to encourage
spontaneity, and to co-ordinate it to intelligent action
adapted to the age of the child.

Spontaneity of movement to the extent termed
fidgeline** is often the result of fatigue and exhaus-
tion ; if teachers were acquainted with tlie signs of

fatigue, they could better control the child's condition.
Fatigue in children is common ; it may be the result
of bad sleep, late hours, excitement of home life or
school work. The signs of fatigue may be marked in
the morning and lessen during the hours of school ; or
they may be most apparent in a certain class-room, if
it be ill-ventilated and overcrowded. There is a small
class of pupils presenting well-made bodies and well-
acting brains who are said by teachers to be very dull,
and doubtless this is true. Such children should not
be discouraged ; they may become useful members of
society, and need not be treated exceptionally ; though
they have often been spoken of as idiotic, which is not
true ; and it u discouraging to give them a bad name.
Gallon's article is full of valuable suggestions, show-
ing that a more exact knowledge of the physical and
mental conditions existing among children is needed.
The scientific principles which have enabled the ob-
server to detect the various degrees and items of mental
weakness already point the way to their removal ;
and were instruction in such studies given to teachers
and others, the methods of classification and training
might be reduced to better order and adapted to the
needs of groups of children.

THE INDEX CATALOGUE OF THE LIBRARY
OF THE SURGEON-GENERAL'S OFFICE,
UNITED STATES ARMY, VOL. XIV.

T^B latest contribution to the Index Catalogue
cannot be passed without notice, though this present
volume was issued several weeks ago. It completes
the Index through the word " universally."

The Index Catalogue has been published now for
so many years that one grows retrospective in the con-
templation of another volume. Perhaps no publica-
tion of recent years has done more for the general
good of the profession than this. It^ influence has
been felt in many directions and it is by no means easy
to define exactly its effects. Perhaps they show them-
selves chiefly, but by no means exclusively, in our
literature. The knowledge of previous writings on
any subject is more easily gained as the Index ap-
proaches completion, and in consequence the writings
of our forbears is less often overlooked ; and medical
men have gained the habit of looking at their unusual
cases as but the experience of a single man which
needs to be compared with similar experiences on the
part of others, in order that it may have its proper
value. In this way the classification and knowledge
of unusual cases has increased.

One thing is very noticeable. The " Curious Cases "
have vanished from our periodical literature, certainly
from the more important journals. Authors and edi-
tors have learned that the title of a medical paper must
give some clue to its contents if the case is to have any
value beyond a mere curiosity and the facts narrated
are to be of any service. Many a case which might
be considered as absolutely unique is found to be but
a repetition of previous experience by reference to

Digitized by

Google

224

BOSTON MEDIO AL AND SVB61CAL JOVBNAL.

[Uabcb 1, 1894.

records which are made acceuible by this Index. It
mast also be said that the value of genuine observa-
tions is made manifest, and thus the record of cases is
encouraged.

Medical libraries have grown in a way hitherto un-
equalled since the Index Catalogue has given an added
value to their contents; yet it is rumored that Uie
principal promoter of this valuable work has said, we
presume in a careless moment, or at a time of such
self-depreciation as occasionally comes to all busy
workers, that he would rather have done a single piece
of original work, however small, than have compiled
this Index.

In one of the best regimental histories of the late
war, the editor speaks as follows of some of his old
comrades:

"We know men in the Thirteenth .... with a
record that every man who respects courage and forti-
tude under trying circumstances would be glad to take
off his hat to when meeting them on the street, but
only their comrades know what soldiers they were.
You never hear them mention the fact, for they see
nothing heroic in anything they did themselves, while
they imagine that every man did something better."

This quotadon does not seem out of place here, for
it illustrates the way in which modest men often re-
gard their own accomplished deeds.

One of the interesting things one finds in this vol-
ume is the catalogue of testimonials to the qualifica-
tions of eminent aspirants for medical appointments —
a collection which must be of equal value with the
portraits of medical men ; though it is doubtful if any
hint of the humau frailties inevitable to ub all could
be found in these testimonials.

MEDICAL NOTES.

Ahbbioan ^ibitobs at tbb Imtbbnational
Medioal Conobbsb. — Prof. N. J. Johnston-Levis,
of Chiatamone, Naples, desires to inform American
visitors that he will be pleased to aid and advise those
medioal gentlemen who will visit Naples at and about
the time of the International Congress.

Small-Pox in a Pittbbuboh Hospital. — A
case of small-pox occurred this week in a general ward
at the West Pennsylvania Hospital in Pittsburgh, and
the board of health has ordered a quarantine of the
hospital, which contains some 950 patients and over
100 nurses.

Intbbnational Sanitabt Confbbbnob. — The
International Sanitary Conference at Paris has already
formulated a series of measures to prevent the Mecca
pilgrims from spreading the cholera. The subject of
immigration to this country, which was suggested by
(he United States delegates, was laid aside for later
consideration as not falling within the primary purpose
of the conference.

The Russian Jambdl Commission. — The Russian
Gcovernment has sent a commission composed of physi-

cians to Asia Minor to inquire into the properties of
the jambul plant, which has been reported to have
marked eflScacy in cases of cholera.

Rbsionatiom of Db. Latham. — Dr. Latham has
resigned the Downing Professorship of Medicine in
the University of Cambridge, England, after having
held the post for twenty years.

The Wondbbful Jioama Boot. — The discoverer
of the Mexican Jicama root, which has been found
useful in cases of typhus fever, claims now that it will
cure small-pox and yellow fever. The list is not yet
extended further.

SBPTIOiEMIA in the EdINBUBOH MATBBNITT HOS-
PITAL.— The Edinburgh Maternity Hospital has been
temporarily closed in consequence of an epidemic of
septicsemia. Several consecutive cases occurred re-
cently ; and no new patients have been admitted for
the present.

FiBEs IN AsTLUMS. — Two fatal fires have occurred
the last week iu asylums where great care should be
exercised. One in the laundry building connected
with St. Vincent's Male Orphan Asylum at Albany,
N. Y. There were 130 boys in the main building
who were at no time in immediate danger. The other
fire was more serious and occurred at the New Jersey
Training School for the Feeble-Minded in Vineland,
N. J. The Robinson Memorial Cottage was totally
destroyed and the inmates were rescued with some
difficulty. The engineer and his wife were burned to
death.

BOSTON AND MEW ENGLAND.

AcuTB Infbotiods Disbabbb IN Boston. — Dur-
ing the eight days ending at noon, February 28th, 1894,
there were reported to the Board of Health, of Boston,
the following numbers of cases of acute infectious dis-
ease: diphtheria 35, scarlet fever 54, measles 19,
typhoid fever 18, small-pox 12. There were four
deaths from small-pox.

Small-Pox in Masbaohosettb. — During the
week ending at noon February 28th, but two cases of
small-pox have been reported to the State Board of
Health from places outside of Boston, one each in
Lawrence and Holyoke.

The Annual Bepobt of Habtabd College:
The Medical School. — The report of the Dean of
the Medical School in the annual report of Harvard
College states the falling off in the number of matric-
ulants this year 4 — due probably to the change to a
four years' course which went into effect at the begin-
ning of last year — at twenty-five. Owing, however,
to the large size of the higher classes the total number
of students in the school will not be diminished. The
diminution of the percentage of college graduates in
the entering classes, previously noted and discussed,
still continues. The causes of this, whatever they
may be, are still operative. The percentage, having,
between 1884 and 1892, fallen from 53.9 to 28.2, has
in the present year dropped to 23. The President of
the University directs the serious attention of the two

Digitized by

Google

TOL. CXXX, No. 9.] BOSTON MEDICAL ASD SURGICAL JOVBHAL.

226

GoTerning Boards and of the University CoQnoil to
thii teDdency, which, in his estimation, threatens the
be)t interests both of the school and of the commnnity.
The school is in a soond financial position, and the
total ezpenditare for salaries, which in 1891-92 was
$47,212, has been raised in the year 1892-93 to
1(17,112. Daring the year a laboratory of experi-
mental therapentics has been established for carrying
00 original investigations and for training advanced
stndents in pharmacological research.

The Dental School. — The nnmber of students
io the Dental School is steadilj increasing ; there were
fifty-three matriculants the past year. The instmo-
ton continue their diligent and self-sacrificing devotion
U> the interests of the school. A new building with
increased accommodations and greater facilities is more
sod more needed with the increase in the number of
stadents. The attempt made a year ago by the Fac-
ulty and friends of the school to raise a building fund,
itarted under favorable auspices, but has been much
mterfered with by the prevailing financial depression.
The fond now amounts to $18,000, and $20,000 more
are urgently needed for the purchase of a desirable lot
which the Faculty has in view.

Thk Vetbrihart Sohool. — The encouraging
growth in the number of students previously noted,
has been fully maintained. But the school is in great
need of endowments for prosecuting its educational
work to advantage. The annual deficit in the finances
of the school is made up from the receipts of the hos-
pital, the work of which is thereby restricted. The
Dean gives expression to this need in the following
closing sentences of his report : " I feel that I must
lose no opportunity of urging the endowment of this
totally aneodowed school. As has been shown, we
can use even a few hundred dollars a year to great
advantage ; for we have here a well-founded institu-
tion, at which a science of the widest usefulness to
mankind, and the greatest humanity to dumb animals,
is being well and thoroughly taught to good classes of
bright and earnest young men ; but this established
institution ia sorely in need of more room in which to
carry on the work which its own prosperous career has
brought it. It certainly seems remarkable to one who
knows what has been accomplished by this depart-
ment of the university during its short life, and how
much need there was that the subject should be taken
np by a strong American university, that among all
the generous givers to the higher education, among the
many who are interested in questions of public health,
and among all those who love horses and dogs, none
have yet been found willing to give us material financial
support. The sohool is not an experiment ; it is an
assured fact. Where else has a scientific sohool, in
any subject, ever been established that has fought the
battle of the higher against the lower education suc-
cessfully without endowment of any sort ? "

Fire in a New Hahpshirb Insane Abtlck. —
A fire occurred in the Bockingham County (N. H.)
Insane Aeylnm last Sunday, but was fortunately ex-

tinguished with small loss. No cause has been dis-
covered for the fire.

Shall-Fox in Waterburt, Conn. — A case of
small-pox was discovered on Monday in Waterbury,
Conn., in a house occupied by six families aggregating
twenty-nine persons.

new tore.

Tubkrodlosis in Cattle. — It is said that there
are at present about twenty thousand head of cattle in
the State which are affected with tuberculosis and
have been condemned by the health authorities, but
which cannot be destroyed for lack of funds to accom-
plish this object and compensate the owners. A bill
has recently been introduced into the Legislature pro-
viding for an appropriation for the purpose of award-
ing proper compensation to those whose cattle it is
found necessary to kill on account of this disease.

A Case of Trauuatic Fulmonart Tcbkbculo-
Sis. — An interesting case of pulmonary tuberculosis,
the exciting cause of which was traumatic in character,
has just terminated fatally in the person of Dr. Robert
N. Manney, a veterinary surgeon residing at Morris-
ania, in the annexed district of this city. Two years
ago Dr. Manney got into an altercation with a black-
smith, and was stabbed in the side by the latter. The
knife penetrated one of his lungs, and as a result of
this injury tubercular disease eventually developed.

St. Mask's Hospital. — The new building of St.
Mark's Hospital, on Second Avenue, near Eighth
Street, was formally opened on February 17th. The
building can accommodate about sixty patients, and
the operating facilities of the hospital are of an admi.
rable character.

The Gbrhan Hospital Trainino School for
NoBSES. — The large new building erected for the
Training School for Nurses of the German Hospital,
at Seventy-fourth Street and Park Avenue, was
opened with appropriate ceremonies and a reception
on February 22d. It is five stories in height and is
ninety-five feet long and twenty-five feet wide. There
are two entrances upon the hospital grounds and from
the basement a tunnel extends to the main hospital
building. On the first floor are the apartments of the
superintendent and his family, as well as a large lec-
ture room, and the rest of the building has been fitted
np for the accommodation of the pupils, forty in num-
ber. The cost of the structure was $72,000.

Mehbekship of the New York Countt Medi-
cal Association. — At the last meeting of the New
York County Medical Association, held February 19th,
Dr. S. B. W. McLeod, who has been re-elected Presi-
dent for another year, delivered bis annual address.
In the course of it he gave an interesting review of the
growth and history of the Association during the first
decade of its existence. At the time of its first meet-
ing for scientific purposes there were 109 members,
and there are now over 950 on its roll. The first
paper read before the Association' was by the late
Prof. Austin Flint, on "Pathological and Practical

Digitized by

Google

226

BOSTON MEDIOAL AND SURGWAL JOURNAL.

rMABOH 1, 1894.

Belations of the Doctrine of the Bacillos Tobercnlosb."
The meeting occurred January 14, 1884. During the
ten years 75 membera have been remored by death.

A BILL RELATIVE TO VACCINATION.

Thb following bill, relative to vaccination, was in-
troduced in the Massachasetts Senate by Senator Har-
vey, of Worcester, and has been referred to the Com-
mittee on Public Health :

Section 1. Parents and guardians shall canie their chil-
dren and wards to be duly vaccuiated before they attain
the age of two years. For eve^ year's neglect, the party
offending shall forfeit the sum of ten dollars.

Sect. 2. The board of health in any city or town shall
require and enforce the vaccination and re-vacoination of
all the inhabitants thereof whenever in the opinion of said
board the public health or safety requires such action.
Every person over twenty-one years of age, not under
guardianship, who neglects to comply with such require-
ment, shall forfeit the sum of ten dollars.

Sect. 8. The lioard of health in any city or town shall
furnish the means of free vaccination or re-vaccination to
all the inhabitants thereof whenever in the opinion of said
board the public safety requires it.

Sect. 4. Incorporated manufacturing companies, super-
intendents of almshouses. State reform schools, industrial
schools, lunatic hospitals and other places where the poor
or sick are received, masters of houses of correction, jailers,
keepers of prisons, the warden of the State prison and
superintendents or officers of all other institutions supported
or aided by the State, shall, at the expense of their respec-
tive establishments or institutions, cause all the inmates
thereof to be vaccinated or re-vaccinated whenever in the
opinion of the board of health, in the city or town in which
such establishments or institutions are situated, the health
of the inmates thereof or the public safety requires such
action.

Sect. 5. Sections fifty-one, fifty-two, fifty-three, fifty-
four and fifty-five of Chapter eighty of the Public Statutes
are hereby repealed ; provided, that nothing herein con-
tained shall be construed as affecting any action that may
be pending under said sections at the time of the passage
of this act

Our readers will find the snbstance of the existing
law stated on page 22 of this volume of the JoDRHiiL.

ACTING ASSISTANT SUBGEONS.

Thb Association of Acting Assistant Surgeons has
been endeavoring for some time to have Congress re-
move a technical disability of rank which prevented
the members from obtaining admission to certain or-
ganizations. A bill has been introduced in both the
Senate and the House of Representatives which is
intended to provide for snch cases. The following
extract from the preamble and the bill will show its
purpose.

" Whereat, Because these acting assistant surgeons were
not commissioned as officers, but were employed by contract
as such, they are denied admission to military organizations
like the Loyal Legion and the Grand Army of the Repub-
lic ; and to relieve this unjust discrimination, and to give
a proper recognition to their patriotism, duties, responsi-
biuties, services, hardships and exposures, they ought to l>e
entitled to receive the rank for which they are allowed

pensions and which will relieve them from these disadvan-
tages. The appended bill is offered for this purpoae. It
involves no expense to the United States Government and
no change in the relative rank of officers of the medical
corps of^the United States Army who have been or are
now In the service of the United States; Therefore,

" Resolved, That private physicians who were employed
as medical officers in the armies of the United States for a
period of not less than three months, and who were known
officially as acting assistant sureeons of the United States
Army, and whose services were nonorably terminated, shall
be commissioned by the President of the United States as
acting assistant surgeons of the United States Army ; and
the date of employment as acting assistant surgeons to be
the date of commission and muster into service, and the
date of the honorable termination of service as acting as-
sistant surgeon to be the date of discharge or mnster out of
service;

" Provided, That no pay or. allowance shall be made to
any such acting assistant surgeon by virtue of this act; and
this act shall not affect the rank, pay, or emoluments of
commissioned medical officers of the United States Army."

SUICIDE IN NEW YORK.

Thb Committee of the New York Medico-Legal
Society appointed to consider the repeal of the exist.
ing law in New York relating to suicide have sub-
mitted the following report :

We recommend the repeal of the existing law punishing
unsuccessful attempts at suicide, for the folRtwing reasons :

(1) It is wholly indefensible from the standpoint of ttua
great principle, Uiat all penal laws should have for their
object the deterring rather than the punishment of crime.

(2) It in effect repeals the former laws making suicide a
crime, and makes its unsuccessful attempt punidnable only ;
so that its effect is to stimulate the would-be suicide to
higher efforts towards self-destruction to avert the pimish-
ment it visits only upon failure.

(3) The act, therefore, instead of serving as a deterrent
to the commission of crime, which should be the aim of penal
legislation, is one which, in its whole scope and effect, in-
cites to and probably actually increases the volume of titis
crime.

(4) Civilization, in the recent centuries, has regarded
and treated suicide as a crime, and has attempted to so
frame its penalties as to act as a deterrent upon the minds
of those who sought or have contemplated it.

The majority of mankind would be influenced by any
post-mortem punishment that would bring disgrace or re-
proach upon the names, family, or friends of the suicide.

The existing statute ignores the universal recent judg-
ment of the race in relieving the successful suicide from ul
such restraints, with their conceded deterrent effects.

(5) A large proportion of suicides are confessedly those
laboring under insane delusions. Unsuccessful attempts by
such, under the existing statute, are pitiful examples of
the incongruity and unwisdom of the law in its practical
operation.

(6) It is claimed, and with great propriety, that the
present statute is practically inoperative.

We respectfully submit that this enactment should no
longer remain among our criminal statutes.

IN MEMORIAM. — SAMUEL M. DONOVAN, M.D.

QuiMCT, Mass., February 20, 1894.
A breath of spring is in this winter morning ; but its
sweetness is tinged with profound sadness that I^. Samuel
M. Donovan whom so many have known so long as physi-
cian and friend, lies in the silence of deatb. His sunny

Digitized by

Google

Vol. CXXX, No. 9.] S08T0S MSDJCAL AND SURGICAL JOURJ/AL.

227

snule ind cheery welcome are smone the Tslued recollec-
tions of the put. With an accomplisned mind that led him
to a conscientioas absorption of what his profession tanght
bim, was a rare, refined taste that embraced whatever was
fine in art, music and science. His acquaintance with roses
wag a particular eleipent ; and while we, duller, knew and
loTed tnem as roses ; he had the species and variety of each
especial flower at tongue's end.

Tenderness in him was of a delicate qoality, especially
towards children. " His quiver was full, but he did not
pass by any child slightly. Meeting him one morning with
his baggy crammed full of little ones, we pointed to one,
asking, "Are they all yours?" " No," said ne," that one is
not." " Whv," said we, laughingly, " have you not enough
of your own ? " " Well " was the answer, " that little chap
law us, and wanted a ride, so I took him in." Lately,
speaking of illness and weakness, he said, " I ask one thing,
to see all my children grow up to be fine." Now, the
little light-haired, blue-eyed brood are fatherless.

His ready assimilation of medical knowledge made him
a valued physician. He was a fond husband and a good
friend. Ue was prominent in our charitable work and
among oar poor. We were not ready to spare him ; but
resting in the hope that if his brief life had incompleteness
here, and trusting that it will find full completeness in the
beyond to which he precedes us, we lovingly, respectfully,
lay this memento of a friend of many years, upon his bier.

A. £. F.

HETBOROLOOICAL RECOBD,

For the week ending Febmary 17, in Boston, according to ob-
servations furnished oy Sergeant 4. W. Smith, of the United
States Signal Corps:—

CorreitfpotiDetice*

THE MEDICAL SOCIETY OF THE STATE OF

PENNSYLVANIA.

COMMITTEE ON SCIENTIFIC BUSINESS.

PHII.ADKLPHIA, February 15, 1894.

Mb. Editos : — At its last meeting the Medical Society
of the State of Pennsylvania appointeid — under the provi-
sions of a by-law proposed at Uarrisburg and adopted at
Williamsport — a Committee on Scientific Business, "to
secure scientific papers and to provide scientific discussions
for each annual meeting, and to co-operate with the Com-
mittee of Arrangements and Credentials in arranging the
programme." The members of this Committee are Drs.
DnUes, of Philadelphia ; Goreas, of Harrisburg ; LeMoyne,
of Pittsburgh f Tyson, of Philadelphia ; and Towler of
Marienville. The object of this change in the law is to
have a permanent committee which, becoming familiar with
the subject, shall find it easier to secure good scientific work
than is possible for a committee that is appointed new
every year.

The Committee on Scientific Business is working in con-

E' nction with the Committee of Arrangements, of which
r. £. £. Montgomery is Chairman, and will co-operate
with it in arranging the programme.

The Committee nopes that each member of the State
Society will aid it in attempting to make the meetings of
the Society of greater scientific importance than they have
been in the past. To this end the Committee will welcome
SDggestiODS from any member of the Society and especially,
at this time, offers of contributions to the work of the next
meeting at Gettysburg, May 15th to 18th. It is desired
that there should be as many brief, concise, practical papers
sa possible ; and it is proposed to have a discussion on
" Tut>erciiloei8," devoting tbe morning to "Medical Tn-
berculoais," and tbe afternoon to " Surgical Tuberculosis."

Any communication from members of the Society in
regard to the work of the Committee, will be welcomed by
it.

Members of the Society desiring to read papers, or to
take part in the discussion on Tuberculosis will please notify
the Chairman of tbe Committee,

Db. Charles W. Dullkb,
4101 Walnut Street, PhOadelpkia.

Baro-

Tlierniom-

Belative

Direction

Velocity
of wind.

We'th'r.

meter

eter.

hamidity.

of wind.

•

Date.

i

a

t

f

i

i

»

i

li

li

M

M

>«

a

*>

►.

,g

-i

g.

K

M

tt

■H

t,

■4

h

'i

S

1

1

!

5

1

S

OD

s

00

8

CO

8

s

00

0.

a. .11

29.88

84

38

30

•7

67

87

w.

w.

23

16

o.

M..I2

30.22

21

27

IR

e;

100

84

N.W.

N.E.

11

24

0.

N.

T..13

30.10

18

28

8

100

60

80

ST.

N.W.

20

17

N.

O.

W.14

80.37

17

26

9

n

M

82

N.W.

N.X.

B

4

O.

N.

T..1B

2S.4S

i)1

38

14

lOO

»9

94

U.E.

W.

23

12

N.

().

F..16

28.08

18

25

It

87

«6

62

N.W.

N.W.

20

17

V.

0.

8.. IT

30.42

18

39

1

69

7S

71

8.W.

S.W.

t

12

F.

F.

a-

80.17

81

14

77

0.16
0.71

0.86
1.74

•0.,clsii<l7i Colewi F.,f>lri 0.,fas4 H., hu7i S.,unokTi B.,niliii T.,tlinM-
utlngi N..inow. t IndleatM trace of nOnfmll. s^ Mean for weak.

BECOBD OF MOBTAUTT
Fob tbb Wbkx BHoxira Saivbbat, Fxbkvabt 17, 1894.

1

^1

Percentage of deaths from

Oitlea.

¥

i..

I'a

n

P

NewTork . .

1,891,806

866

361

16.92

22.68

7.20

S.24

2.38

Chioago . . .
Pbiiadelpbia .

1,438,000

Sf(«

149

19.98

11.61

6.94

.81

2.13

1.116,662

—

—

—

—

—

^

Brooklyn . .
St. Loida . . .

978,394

371

116

12.96

2t.Il

7J6

J(7

3.16

660.000

—

—

'—

•^

—

.—

...

Boston . . .

487,387

lU

66

12.69

36.38

tM

—

1.4iS

Baltimore . .

600,000

—

^

—

—

—

—

1..

Washington .

806,431

^

—

—

—

—

..

Clnelnnatl . .

306,U)0

102

33

6.b8

17.61

1.96

—

—

CleYeland . .

290,000

76

29

18.48

21.12

0.28

S.96

Plttabarg . .

263,709

94

St

14.84

19.00

8M

»

4.24

Mllwankae . .

260,000

80

88

23.60

12.60

8.76

1.25

1.20

NaahTille . .

87,764

7

—

UM

67.12

28.66

—

Charleston . .

6S,lt>&

29

B

—

13.00

—

—

Portland . . .

40,000

—

—

—

—

—

—

^

Worcester . .

96,217

29

18.80

13.80

6.90

—

...

Fall River . .

87.411

41

7.32

IIM

—

_

Lowell . . .

87,191

—

—

—

—

—

—

Cambridge . .

77,100

38

21.04

21.04

^

—

18.41

Lynn ....

62,666

19

16.7»

10.62

5.26

—

^

Springfield . .

48,684

16

—

2U.U0

—

—

^

Lawrence . .

48,366

31

23^

14.28

^

^

^

New Bedford .

46,886

19

2lM

16.78

—

—

16.78

Holyoke . . .
Salem ....

4U78
31,233

10

10.00

20.00

""

^

10.00

Brockton . .

82,140

8

12.00

iixo

12.00

—

Haverhill . .

31,896

12

—

8.33

—

_

_

Chelsea . . .

30,264

14

—

42J>4

—

—

Maiden . . .

29,394

7

^

28J6

^

—

_

Newton . . .

27,686

6

—

^

—

—

_

ntchburg . .

3T,I4«

^

—

—

^

—

^

Taunton . . ,

26,972

■I

—

14.28

—

«_

_

Gloaoester . .

26,688

11

9.00

18.18

—

^

^

22,068

7

14.28

14.18

14.38

^

^

Qnlnoy . . .
Pittslield . .

19,643

6

16.66

—

—

....

«_

18,802

2

50,00

—

—

^

.^

Everett . . .

16,686

V

—

14.26

—

Northampton .

16,331

3

^

—

^

—

^

Newbnryport .

14,073

6

^

20.00

^

^

^

Amesbury . ,

10,920

3

~

~

~

~"

Deaths reported 2,621 : under five years of age 919 ; principal
infectious diseases (small-poz, measles, diphtheria and croup,
diarrhoeal diseases, whooping-cough, erysipelas and fever) 441,
acute lung diseases SOI, consumption 3(M, diphtheria and croup
153, scarlet fever 67, measles 3S, typhoid fever 32, diarrhceal
diseases 30, cerebro-splnal meningitis 22, whooping-cough 19,
small-pox 18, erysipelas 16.

From typhoid fever Chioago 9, Milwaukee 6, New York 4,
Cincinnati, Lawrence and Cleveland 3 each, Pittsburgh 2,
Brooklyn, Boston and Cambridge 1 each. From diarrhoeal dis-
eases New York 11, Chicago 4, Brooklyn and Milwaukee 3 each,
Cleveland and Fall River 2 eaich, Boston, Worcester, New Bed-
ford, Fittsfleld and Marlborough 1 each. From cerebro-splnal
meningids New York and Chicago 5 each, Brooklyn, Cleveland,
Lynn and Somervllle 2 each, Worcester, Gloacester, Quinoyand

Digitized by

Google

228

BOSTOH MEDICAL AND SURGICAL JOURNAL.

[Mabch 1, 1894

Marlborough 1 each. From whoopiDg-cooeh New York B.
BrooklTii and Boaton 4 each, CindnDan, Milwaakee and Fall
Biver 1 each. From imall-pox Chicago 13, New York 5. From
erysipelas Chicago 6, New York 6, Boston 2, Brooklyn and Maah-
▼iUe 1 each.

In the thirty-three greater town* of England and Wales with
an estimated popaliKion of 10,468,142, (or the week ending
February 10th, the death-rate was 19.1. Deaths reported 8,830;
acute diseases of the respiratory ormns (London) 372, whooping-
oongh 138, diphtheria 89, measles 76, scarlet ferer 46, ferer &,
diarrhoea 33, small-pox (Birmingham 4, West Ham, Halifax
and Bradford 1 each) 7.

The death-rates ranged from 12.1 in Croydon to Si.S in
Bristol; Birmingham 22.6, Bradford 16.8, Brighton 1B.8, Hnd-
deisfleld 18.0, Hall 21.8, Leeds 18.6, Leicester \%X>, Uverpool
24.2, London 18.4. Manchester 21.7, Newcastle-on-Tyne 18.6,
Nottingham 20J>, PorUmoath 17.1, Salford 19.0, ShefBeld 18.6,
Swansea 19.7.

OKFICLAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SEBTINQ IN THE MEDICAL
DEPARTMENT. U. S. ARMT, FROM FBBBU ART IT, 1894,
TO FEBRUARY 23. 1894.

FiBST-LuuT. Bkmjakiv L. Teh Etck, assistant surgeon, U.
S. A., will report in person to CoLOMai. Josxph C. Bailt,
assistant surgeon-general, president of the examining board
appointed to meet at Fort Sam Houston, Texaa, at such time as
he may be required by the board for examination as to his fit-
ness for promotion.

Aboard of medical officers to consist of Coi^x >l Chablbs
H. Aldbm, assistant surgeon-general; Libut.-Col. Wuliam
H. FoBwooD, deputy surgeon-general ; Ma job Chaki.m Smabt,
sargeon ; Hajob Wai.txb Rbbd, surgeon ; Caftaix Jambb C.
Mbbbill, assistant surgeon Js constituted to meet at the Army
Medical Museum Bollding, Washington, on the 12th of March,
1894, at tan o'clock a. m., for the examination of candidate* for
admla*l<m to the Medical Corps of the Army.

OFFICIAL LIST OF CHANGES OF STATIONS AND DUTIES
OF MEDICAL OFFICERS OF THE UNITED STATES
MARINE-HOSPITAL SERVICE FOR THE FOUR WEEKS
ENDING FEBRUARY IT. 1894.

MuBBAT, R. D., surgeon. To proceed to Key West, Fla., tor
special duty. January 26, 1894.

Bailhachb, P. H., surgeon. Granted leaTe of absence for
twenty days. February 6, 1894.

Pubyiaiccb, Gxobob, surgeon. Detailed as chairman, Board
of Examiners. February 12, 1894.

Stombb,' G. W., surgeon. Detailed a* member. Board of
Examiners. February 12, 1894.

Cabtbb, H. R., surgeon. To report at Bureau for temporary
duty. February 2, 18M. To proceed to Brunswick, Ga., Quar-
antine as inspector. February 6, 1894. Detailed a* recorder,
Board of Elxamlners. February 12, 1891.

Whttb, J. H., passed assistant surgeon. Granted leave of
absence for seven days. February 17, 1891.

Cabbinoton, P.m., passed assistant surgeon. Granted leave
of absence for thirty days. February 19, 1894.

Bbattok, W. D., passed assistant surgeon. Granted leave
of absence for thirty days. January 20, 1894.

surgeoi
absence for thirty days. January 30, 1894.

VAnoBAM, G. T., passed assistant surgeon. To report to the
Secretary of the Treasury for special duty. January 26, 1894.

YocNO, G. B. , assistant surgeon. Ordered to examination for
promotion. February 14, 1H91.

STDmoM, W. G., assistant surgeon. Ordered to examination
for promotion. Febmary 14, 1894.

Bbown, B. W., assistant surgeon. Ordered to examination
for promotion, rebrnary 14, lw4.

RosBNAV, M. J., assistant surgeon. Granted leave of absence
for thirty days. February 26, 1894.

CorsB, L. E., assistant surgeon. To proceed to Mobile, Ala.,
for duty. January 30, 1891.

Eaoxb, J. M., assistant surgeon. Granted leave of absence
for four days. January 30, 1891.

Blvb, Rcpbbt, assistant surgeon. Granted leave of absence
for eight days. January 26, 1894.

NoBMAH, Sbatom, assistant surgeon. Ordered to examina-
tion for promotion. February 14, 1894.

Pbochazba, Emil, assistant surgeon. To proceed to New
York, N.Y., for duty. January 24, 1891. To proceed to Buffalo,
N. Y., for temporary duty. Febmary 2, 1894.

SOCIETY NOTICES.

Boston Sooibtt fob Mbdical Obsbbvatioh. — A r^fular
meeting will be held at 19 Boylston Place, on Monday, March
Bth, at 8 o'clock.

Readers: Dr. J. S. Greene: "The Obscure Origin and Inde-
terminate Course of Acute Infection, as Illustrated by a Case,
Possibly of Multiple Neuritis, and by a Case of Malignant Endo-
carditis."

Dr. E. H. Greene: " CiysUlline Deposits in the Urine; Their
Occurrence and Significance."

Report of Treasurer.

Report of Committee on Admissions.

Appointment of committee to nominate officers for ensoing
year. Jobh C. Mvhbo, M.D., 8txriUtr)i.

Tbb Suffolk Dibtbict Mxdical Socibtt, Suboicaj. Sbc-
TiOM . - The Surgical Section of the Suffolk District Medical
Society will hold its regular monthly meeting at 19 Boylston
Place on Wednesday evening, March 7. 1894, at 8 o'clock.

The subject for discussion will be introduced by Dr. J. W.
Elliot: "A Oall-Stone Removed by Opening the Common
Bile Duet, the Wound in the Duct being Closed by Sutures."

Drs. Q. W. Gay, B. H. Fitz, C. B. Porter, H. L. Burrell, J. C.
Warren, A. T. Cabot, M. H. Bicfaardson and W. M. Conant will
briefly discuss the " Surgery of the Oall-Bladder."

Chablb* L. Sousdbb, MJD., Sscrstory, 1 Marlborough St

HABVABD MEDICAL SCHOOL.
Evxinira Lbctitbbb.

The next lecture will be given on Wednesday evening, March
Tth, at 8 o'clock, by Dr. John Homans. Subject, " Ovariotomy."
Physicians are cordially invited.

ERRATUM.

In the note on the hearings of the Public Health Committee
in last week's issue of the Joubhai., the date for the hearing on
public vaccination should be March Tth instead of March 6th as
given.

BBCENT DEATHS.

BBHjAifix Stobbb CoDKAir, H.D., M.M.S.8., died in Boston,
February 22d, aged seventy-eight years. He gradnated from
the Harvard Medical School in 1846. In 1866 he retired from
practice and established the firm of Codman & Shurtleff, deal-
ing in surgical instruments. He was a trustee of the Home for
Intemperate Women.

Db. QnsTAv Sckbntbacbb, Professor of pathological anat-
omy in the University of Pesth, died January 28th.

BOOKS AND PAMPHLETS RECEIVED.

The Absorption of Immature Cataract, with Restoration of
Vision. By J. Hobart Egbert, A.M., M.D., Ph.D. Reprint
1893.

The Surgery of the Hand. Sarcoma of the Kidney: Its
Operative Treatment. By Robert Abbe, M.D., of New York.
Reprints. 1894.

A Human Embryo of the Second Week. Early Human Em-
bryos and the Mode of their Preservation. By Franklin F.
Mall. Reprinu. 1893.

Proceedings of the Philadelphia County Medical Socie^.
Volume XIV, Session of 1893. Lewis H. Adler, Jr., M.D., Edi-
tor. Philadelphia: Printed for the Society. 1893.

The Present Status of the Treatment of Uterine Fibroids.
Etiology of Pelvic Diseases in Women and their Prophylaxis.
By X. O. Werder, M.D., Pittsburgh, Pa. Reprints. 1893.

Antiseptic Therapeutics. By Dr. E. Z. Trouessart, Paris,
France. Translated bv E. P. Hard, M.D. Two volumes. The
Physicians' Leisure Library. Detroit: George S. Davis. 1893.

A Text-book el the Theory and Practice of Medicine. By
American Teachers. Edited by William Pepper, M.D., LL.D.,
Provost and Professor of the Theory and Practice of Medicine
and of Clinical Medicine in the University of Pennsylvania. In
two volumes. Illustrated. Volume II. Philadel^ia: W. B.
Saunders. 1894.

Holden's Manual of the IHssectlon of the Human Body.
Edited by John Langton, Surgeon to, and Lecturer on Anatomy
at St. Bartholomew's Hospital ; Member of the Board of Exam-
iners, Royal College of Surgeons of England, etc. Sixth edinpn.
Revised by A. Hewson, M.D., Demonstrator of Anatomy, Jetter
son Medical College, etc. Three hundred and eleven lllnstrsr
tions. FhiladelphU: P. Blakiston, Son&Co. 1894.

Digitized by

Google

Vol. CXXX No. 10.] BOSfOHf MSDIOAL AND S&ROIOaL JOVRNAL

22d

(Anginal %ttit\t^.

OBSERVATIONS ON PNEUMONIA.*

BT WIIiLIAK H. FBKSOOTT, II.D.

ACUTB FIBBISOUS FNBDHONIA WITH CMDSDAL EX-
TENSION OF THE FIBRINOUS EXUDATION.

These u nothing of especial importance in the
clinical history of this case. The patient, a man about
thirty-five years old, was brought into the hospital
with well-marked evidences of pneumonia. There
was complete consolidation of the lower half of the
left lung and slight br'eathbg, with less well-marked
consolidation in the lower posterior portion of right
long. The temperatare was high, and the breathing
very much accelerated. The condition of the patient
steadily grew worse, and he died forty-eight hours
sfter entry into the hospital.

The autopsy was made November 25th, twenty-four
boars after death. The body is that of a slightly
bailt man. The mucous membrane pale, rigor mortis
well developed. The superficial veins over chest
prominent. The face cyanotic.

Scalp slightly adherent. Dura mater of ordinary
thickness. Pacchionian granulations well developed.
The pia slightly cloudy. The convolutions of brain
well marked. Brain slightly oedematous.

Subcutaneous fat slight in amount. Muscles red.
Peritoneal cavity moist. The appendix bound down
bjr old adhesions extending across from the ileum.
These adhesions involved the proximal two-thirds of
the length of the appendix, leaving the tip free. The
peritoneum over appendix thickened. Diaphragm on
right side at lower border of fifth rib ; on left side, in
fifth intercostal space.

In the left pleural cavity about 500 cc. of cloudy
serum containing fiakes of fibrin. Both cavities free
from old adhesions. Lungs do not retract on removal
of sternum. The precordial space small. On the
anterior surface, especially over the upper two-thirds,
there is a thick fibrinous deposit on the epi-pericardial
tissues. The pericardial cavity is obliterated over the
anterior upper portion by fresh, thick fibrinous adhe-
sions. In the lower portion of the cavity there is a
•mail amount of clear fluid. The visceral pericardium
in its upper portion, extending especially over the
root of the aorta, is covered with a thick fibrinous ex-
udation, containing here and there small haemorrhages.
The myocardium is generally pale. Immediately be-
iiut^Ju "t.ae ]^ricardium where the exudation is thickest
the tissue is somewhat opaque and contains small
hsmorrhages.

The heart of ordinary size. On the right segment
of the mitral valve near its attachment, there is a
minute superficial erosion not more than one millimetre
in extent, covered with a thin, granular, hsemorrhagic
fibrinous deposit.

Over the entire pleural surface of the left lung
there is a thin fibrinous exudation, and in the pleura
beneath it there are numerous small haemorrhages.
Over other portions of the pleura the exudation is
thick and yellowish, and is easily removed as an adhe-
rent membrane, leaving the underlying pleura cloudy.
"Rte upper lobe of this lung is hypereemic, cedematous,
and more solid than normal. On pressure much

> A matrlbatton to tbe fortboomlng Hedloal and Snrgleal Baport
wtte Boston City Hoapltal, from tlia Pathologleal Deputmant of
B* Hoqittal. onder dliMtion of Dr. W. T. Goimollmui.

blood-stained serum can be squeezed from the cut
surface, and thick purulent exudation from the bronchi.
The upper and lower lobes united by fresh adhesions.
Fully two-thirds of the lower lobe is completely solid.
The cut surface of this is gray, granular, and on press-
ure pus can be squeezed from the bronchi. The re-
mainder of the lobe is intensely congested and partially
solidified. Portions of the lobe will fioat in water.
The costal pleura on the left side is covered with a
thick fibrinous exudation. On being stripped off the
vessels in it are enormously dilated, and haemorrhages
have occurred everywhere in the tissues. The inter-
costal muscle, especially in the upper half of the
pleural cavity, appears swollen and softened. On
section the intercostal muscle and subpleural tissues
are thickened by an exudation which is intimately as-
sociated with the tissues. This exudation in places
appears to extend through the entire thickness of the
intercostal muscle, and there is apparently a sharp
line separating it from the healthy tissues. At the
apex of the pleural cavity a similar condition exists,
and extends from here into the posterior mediastinum,
and into the cervical regions. Some of the deep-lying
cervical lymph-glands are reddened and swollen, and
around them this fibrinous exudation is seen. In one
place in the epi-pericardial fat there is a small collec-
tion of thick, creamy, gelatinous pus. The right lung
is voluminous. The pleura smooth and free from
fibrinous deposit. On section the lung is in general
hypersmic and cedematous. In the lower lobe there
are scattered foci of consolidation varying in size from
one to five centimetres. Pus can be squeezed from
the bronchi in these places.

Liver is large. The surface pale. On section
cloudy and opaque with indistinct lobules. The bile-
duct free. Tbe gall-bladder contains clear, yellowish
bile.

The kidneys somewhat enlarged. Capsule easily
stripped off. Surface smooth. On section, markings
somewhat obscure. Cortex swollen and opaque.
Glomeruli anemic.

The spleen slightly enlarged. The capsule wrinkled.
On section rather soft and dark. Neither traberculse
nor Malpighian bodies are visible. The adrenal glands
and pancreas normal. The mucous membrane of
stomach and intestines is hypersemic, otherwise normal.

The mucous membrane of larynx and trachea is
congested. Beginning in the lower part of the larynx
and continuing uniformly through the trachea as far as
the bifurcation, the mucous membrane has a granular
appearance due to the presence of small vesicular-look-
ing granules, of regular size, on the surface. This does
not disappear on washing, but on gently rubbing tbe
granules disappear and a tJiick fluid takes their place.
This condition is due to small masses of the mucus
distending the glands. The aorta and other arteriee
are normal.

ANATOMICAL DIAONOSIS.

Acute fibrinous pneumonia with consolidation of
lower lobe of left lung. Slight consolidation in upper
lobe of left lung. Fibrinous lobular pneumonia of
right lung. Acute fibrinous pleurisy of left pleura
with extension of the process into the chest walls and
into the posterior mediastinum. Acute fibrinous peri-
carditis with extension into myocardium. Acute endo-
carditis of mitral valve. Acute parenchymatous degen-
eration of liver, heart, and kidneys with slight fatty
degeneration.

Digitized by

Google

230

BOSTON MSDJOAL AND SUBOWAL JOURNAL. [IIasoh 8, 1894

Cover-elipg made from the lung, from the fibrinous
exudation on the surface of the pleura and from the
pericardium, showed large numbers of the diplococcas
lanceolatus with well-marked capsule staining. In the
fresh sections of the intercostal muscles the same con-
dition was found. Fresh sections of the kidney showed
swollen and granular epithelium in the oonvolnted
tubules, with here and there minute drops of fat on
the addition of acetic acid. The glomeruli were un-
changed. Sections of the liver showed swelling and
granular degeneration of the hepatic cells. Sections
of heart showed a very slight fatty degeneration of the
muscle. Portions of the various tissues were hardened
in alcohol for further examination.

Microscopic examination of the consolidated portion
of left lung. The alveoli are everywhere distended
with fibrin and pus cells. Numbers of diplooooci were
found in the pus cells. Sections made from the less
consolidated portions of this lung and from the areas
in the right lung show a less advanced process. The
vessels in the alveolar walls are dilated, and the walls
themselves infiltrated with leucocytes. Within the
alveoli there are small amounts of fibrin with numerous
red and white corpuscles.

The most interesting conditions were found in the
pericardium and in the pleura. The fibrinous exuda-
tion of the pericardium is very dense, and the fibrin is
in places in the form of large, broad fibres which are
frequently united together to form hyaline masses and
a reticulum, somewhat similar to that in the diphtheritic
membrane. In places it extends into the tissue of the
myocardium. In these places there are numerous
leucocytes, round and epithelioid cells between the
muscular fibres. The muscular fibres appear swollen,
and the nuclei are indistinct. In the least affected part
of the myocardium there are no leucocytes in the tissue,
but there are numbers of large epithelioid cells and
round granulation cells between the muscular fibres.
In these places there is no fibrin, and the muscular
fibres themselves appear to be but little altered. Fur-
ther back in the more affected portions the leucocytes
are found, and with these masses of fibrin. Diplococci
were found in g^eat numbers in the exudation, both
inclosed in the pus cells and scattered through the
fibrin. None were found where the tissue contained
only the epithelioid and round cells.

The process appears to invade the fat in the same
way. In places, as observed with the low power, the
fibrinous exudation and the leucocytes extend directly
into the fat, passing along the connective-tissue septa.

On examination with a higher power, in the areas
of fat, which under the low power appeared to be un-
changed, there is a similar condition to that found in
the myocardium. There are numerous large epithe-
lioid cells between the fat cells, of the same character
as those found in the myocardium. The fat ves-
icles themselves appear to be somewhat compressed
and distorted by the formation of cells between them,
but are otherwise unchanged. In some places only
one or two of these larger cells were found, and in
others they are more numerous. The inflammatory
process appears to extend into the tissue along the
lymphatics and blood-vessels. In one place a longi-
tudinal section of a capillary is seen, the nuclei of
which are swollen and granular, and the lymph sheaths
of the larger blood-vessels are completely filled up with
these large granular cells.

lizamination of the intercostal muscle shows a

similar condition. The fibrinous exudation with leuco-
cytes extends into this, generally in the form of large
b«nd8 in the intermuscular septa. There is also an
extension in the muscle nearest the pleura between the
individual muscular fibres. In the mostaffected places
the muscular fibres are swollen, granular and necrotic ;
the nuclei do not stain, and they have lost the cross
striation. In advance of the fibrinous exudation with
leucocytes, there is simply a cellular infiltration with-
out either fibrin or leucocytes. The cells in this are
almost all of them large epithelioid cells with a clear,
brightly staining nucleus. In one or two places nuclear
figures were found in these large cells. Diplococci
were only found associated with the presence of the
leucocytes and fibrin.

A rabbit was inoculated from the fibrinous exudation
in the intercostal muscles, a small portion of the mus-
cle being placed beneath the skin of the back of the
animal. An acute swelling developed at this place,
but there was no distinct abscess formation. The
animal in the course of the next few days lost some
flesh, but it continued to eat comparatively well until
it was killed, ten days after the inoculation. There
was a large subcutaneous swelling at the point of in-
oculation, which had extended from this in all direc-
tions, especially downwards on the side where the in-
oculation was made. The entire subcutaneous tissue
of the abdomen was swollen and infiltrated with a dense
fibrinous exudation. Here and there in this exudation
were softer places from which a thick tenacious pus
could be squeezed. The tissue in places was one cubic
millimetre in thickness. The inguinal and axillary
lymph-glands on the side of the inoculation were red-
dened and swollen. No bactaria were found, either in
the purulent portions or in the fibrinous masses, neither
on the direct examination of cover-slips nor in the
cultures which were made, both from the seat of the
inoculation and from all the internal organs.

This case is interesting on account of its unusual
extension. Practically in all cas68 of acute fibrinous
pneumonia there is a similar fibrinous exudation on
the pleura covering the affected portion of the lung, to
that in the lung itself. In most cases the fibrinous
exudation is not confined to the pleura immediately
over the affected portion of the lung, but extends from
this over the entire surface. There will usually be
found a similar condition on the costal pleura, but not
so marked as on the visceral. An extension of the
process into the chest walls and into the mediastinal
tissues from the pleura is exceedingly rare.

In this case there is no question but that thef. ,:,...r
in the chest walls is one of direct extension from the
pleura. The histological examination of the tissues
here was of great interest. Apparently the first change
which took place in the intercostal muscle, in the myo-
cardium, and in the fat of the pericardium was a cellu-
lar proliferation of the interstitial tissue. The new
formation of cells appeared to have taken place from
the interstitial tissue, most probably from the cells of
the capillary walls or from the lymph spaces. The
newly-formed ceHs were of two sorts. There were
large cells with an abundant protoplasm and a large
brightly staining nucleus, and small cells similar to the
lymphoid corpuscles of the blood, with a nucleus al-
most filling up the body of the cell. In this tissue
there were no leucocytes nor fibrin. They appear to
come later, and with the leucocytes and the fibrin the
organisms were always found.

Digitized by

Google

ox..

CXXX, No. 10.] BOSTON MEDICAL AND SURGICAL JOURNAL.

231

OXTTB INFECTION "WITH THE DIPLO0OCOD8 LANOE-
OX.A.TCB IN A CHILD riFTT-SIX HOURS OLD, THE
XITPBGTION PEOBABLT TAKINO PLACE AT TIME OP
X>B!HVBBT.

X am indebted to Mr. J. B. Poor, of the Harvard
l^edic&l School, for the autopsy and for the history of
^is caae.

fbe mother of the child was a primipara, belonging
a t;lie crimiDal class. Two months before delivery an
.bscess of the breast had developed, following on a
^ick. At the time of delivery this was completely
lefded, leaving a stellate cicatrix. The mother was a
lealthy young Irish woman. Since delivery the mother
aas done well, with the exception of a very slight rise
af temperature on the third day, apparently due to a
family row. There was no respiratory trouble what-
ever. The birth took place at noon, May 12th. The
delivery was a somewhat slow one, necessitating the
application of forceps. The child was slightly asphyx-
iated at time of birth. The respiration was rather
alow, necessitating hot and cold applications. No trou-
ble noticed in the child until the 14th, forty-eight
hours after delivery : then it appeared to be rather
dnll and slightly cyanosed. It died suddenly at seven
p. M., fifty-six hours after delivery. Before death
vomited slightly.

Autopsy made twelve hours after death. Male child,
large and well formed. Posterior to the right ear
there is a large ecchymosis made by forceps. A very
alight haemorrhage in the dura, on the right side, cor-
responding to the external ecchymosis. The brain is
normal. In the peritoneal cavity there is a small
blood-clot. No adhesions. In the anterior mediasti-
num there is a slight amount of haemorrhage, the thy-
mus glands being especially infiltrated with blood. In
each pleural cavity there is a slight amount of hsemor-
rhagic exudation. The pleural surface of the right
lang over the lower lobe shows in places a fine fibri-
nous exudation. The entire lower lobe of the right
lung completely consolidated. The lower portion of
the upper lobe also consolidated. The pleural surface
of the long sprinkled with fine ecchymoses. The con-
solidated lung is of a dark-red color, looking somewhat
like a hgemorrhagic infarction. On section it is dark
red. The cut surface is dry and smooth. The granu-
lar appearance of an ordinary croupous pneumonia is
absent, but the lung is not so smooth as it would be in
a purulent or hsemorrhagic consolidation. The bronchi
contained bloody mucus. The left lung shows almost
the same condition as the right. Consolidation com-
plete io the lower lobe and in a considerable portion
of the npper. In the pericardial cavity there is a con-
riderable quantity of slightly opaque serum. The
visceral pericardium sprinkled with small haemorrhages,
which are also seen in the myocardium.

The valves of the heart normal. The ecchymoses
are not only found in the pericardium, but extend from
this into the muscular tissue of the heart, and espe-
cially into the intraventricular septum. In the trachea
there is a quantity of blood-stained mucus. The phar-
ynx sod oesophagus are normal. In the stomach there
is a considerable amount of dark blood. The liver
large, rather pale, and on section there are numbers
of opaqae, slightly reddish foci of an average size of
half a millimetre, which contrast sharply with the sur-
roondiog parenchyma. The spleen is large. On seo-
tioD homogeneous, rather soft. Neither Malpighian

bodies nor trabeculae are visible. No abnormal condi-
tion found in the other organs.

Cover-slips examined, made from the lungs, show
enormous numbers of typical diplococci with well-
defined capsules. Similar organisms were found in
the blood from the heart, and in the scrapings from the
other organs. Cultures made from the organs gave
pure cultures of diplococci from the lungs, heart, blood,
liver, spleen and kidneys.

A rabbit inoculated with scrapings from the consoli-
dated lung died in three days of typical diplococcns
septicaemia.

Examination of the consolidated portions of the lung
showed an absence of typical appearance of fibrinous
pneumonia. The consolidation was almost entirely
due to htemorrhage into the lung. In places there
were small amounts of fibrin. Usually this was mingled
with the red corpuscles, bat in some places it was
found in the alveoli almost alone. Here and there a
few leucocytes were found along with the red corpus-
cles, but the numbers of these were exceedingly scanty.
There was everywhere hypersemia of the vessels, and
as far as could be ascertained by the examination of
the cross-sections of the larger vessels, there was no
leucooytosis. In many portions of the lung the ap-
pearance resembled that of the foetal lung. The
mucous membrane of the bronchi in these places was
convoluted and the alveoli imperfectly expanded.
Diplococci were everywhere present in enormous num-
bers. They were found not only in the haemorrhagic
exudation within the alveoli, but were also present in
the alveolar walls and in the cross-sections of the larger
blood-vessels. Fresh sections made of the various
organs at the time of the autopsy showed no abnormal
condition.

This case is of especial interest from the early age
of the child, and the character of the infection produced
by the diplococcus lanceolatns. In this case there was
a general infection of the entire organism, similar to
that which is usually produced in rabbits by inoculation
with virulent cultures of the diplococcns. In spite of
the early age of the child, it is not at all probable that
the infection took place in utero. The mother was
absolutely free from pneumonia or from any other
pathological condition at the time of birth.

Welch has gone over carefully, in his paper on the
diplococcus lanceolatus, all of the cases which have
been reported of intra-uterine infection of the foetus.
In most of these cases death of the infant has taken
place two to five days after birth ; and although the
infection was probably intra-uterine, the possibility of
this having taken place during or after birth cannot
be absolutely excluded. The most satisfactory of
these cases is that reported by Birch-Hirschfeld. On
the fourth day of a fibrinous pneumonia, the mother
gave birth to a seven-mouths' still-born foetus with in-
tact membrane. There were haemorrhages in the
maternal and middle parts of the placenta. The only
lesion noticed in the foetus was ecchymosis in the pelvis
of the kidney. Typical diplococci were found by
culture in the liver, iieart's blood, and umbilical vein.

It is well known that acute fibrinous pneumonia
developing during pregnancy is likely to bring about
miscarriage. This is the case not only in haman
beings, but in mice and rabbits which have been inocu-
lated.

The character of the exudation in the lungs was
also of interest. The exudation in the lungs was to a

Digitized by

Google

3S2

BOSTON MBDIOAL ASD SUBOIOAL JOVRSAL.

[Makch 8, 1894.

large extent hnmorrhagio in character, and the condi-
tion most resembling that produced by the organisms
in the adalt was the fibrinous exudation on the pleura.
There can be little doubt from the extent of the lesions
in the lung that the organisms had entered the lungs
first, and probably at the time of birth. The artificial
respiration carried on may have been responsible for
the entry of the organisms into the lungs.

The two cases also show a marked contrast, not only
in the character of the lesions in the human cases, but
also in the character of the lesions produced in the
animals. In the first case there was a marked tendency
to a local extension of the organism, with the produc-
tion of a typical fibriuous exudation wherever it was
found. The same thing was seen in the rabbit which
was inoculated with the exudation.

These varying effects which are produced by inocu-
lation with the diplococcus lanceolatus are probably to
be referred to especial differences in the action of the
organisms, and not to a mere difference in the degree
of virulence. Cultures of the pnenmococcus are some-
times met with which will always produce in every
generation the same definite lesions.

CASES OF APPENDICITIS PRESENTING UN-
USUAL FEATURES.*

BT KAVBIOX H. BIOHABOSOX, IU».
AOCTE 0A8B8.

Thb following unusual cases of appendicitis have
been selected from those under my care in the past
four weeks. They are reported in detail because each
presents some variation from the ordinary case, and
because in the existing uncertainties as to etiology,
pathology and treatment, every observer owes to work-
ers elsewhere a faithful report of his cases, whether
successful or unsuccessful. There are many points of
interest in regard to which these cases are too recent
for deductions of value ; in certain other respects, how-
ever, they justify definite conclusions.

I. Fulminating peritonitis : removal of gangrenous
but nnperforated appendix on second day ; death.
(Specimen.)

In a recent paper on appendicitis ' I stated that in all
severe acute cases with marked general and local symp-
toms, every appendix which I had removed was found
to be perforated ; and that in my belief the first symp-
toms depended upon such perforation. This opinion,
though based upon a careful observation of many cases,
is open to the criticism of being too strongly expressed.
I hasten to report, therefore, an exception to this
statement — a fatal fulminating case in which no per-
foration could be found on the most careful examina-
tion. The following are extracts from short-hand
notes:

" Benjamin J. S., aged thirty-eight, single. East
Boston. Dr. O'Keefe. Thursday, December 21, 1893.
The previous health has been good. He was ruptured
ten years ago. He has already had five attacks sim-
ilar to the present. The last one occurred a year ago,
keeping him from his business four or five days. Night
before last he first began to feel a little pain in the
bowels. Nevertheless, yesterday he was up and about

> Bead b; title iMfon the Boeton Society for Ifedtoal Improve-
ment, January 8, litM.
* Ameriaan Journal of Medleal Soi«D«M, JaBoarj, 18M.

till towards night. The symptoms had by that time
increased so much that he had to go to bed, where he
passed a restless and sleepless night. There was no
vomiting. This morning he had a chill. All this
afternoon the pain has been persistently located in the
right flank, and has been growing worse. He fixed
the seat of pain at first in the centre of the abdomen
(indicating the median line just above the pabes).
This morning it was half-way between the umbilicus
and the anterior superior spine of the ileum. The
pulse this morning was 80 ; the skin cool. He has
vomited two or three time* to-day. He has passed
some gas, but not mudi.

*' Pkytietd Examination. — He is in a state of mod-
erate shock. The general appearance is bad ; he lies
in bed restless and groaning. The pulse is 112, weak;
the temperature 100°. The extremities are cool. The
very rigid abdomen is dull over the bladder ; elsewhere
resonant. There is general tenderness, with constant
eructations of gas. By the stethoscope no intestinal
sounds can be heard. Though assured that the case is
practically hopeless, his friends wish him to go to the
hospital"

I sent an ambulance immediately, and an opera-
tion was performed by Dr. Newell in about two honn
from this time. A thick and short appendix was re-
moved, the tip of which was gangrenous. There was
free fluid in the abdominal cavity. The intestines
were congested and paralyzed. The appendix was
tied and removed; the abdomen irrigated. No cult-
ures were made. The patient gradually sank, and
died at one o'clock Saturday morning.

The general condition of collapse, the rigid and dis-
tended abdomen, made the prognosis in this case nearly
hopeless. I had predicted confidently a gangrenoaa
and perforated appendix, with general infection. The
general infection and gangrenous appendix were found,
but no microscopic or macroscopic perforation could
be detected. Though no cultures were taken, there is
little doubt that an escape of micro-organisms from
the appendix had taken place through the patch of
gangrenous tissue. The absence of perforation in this
instance is the feature which 1 wish to emphasise. I
had never met with just this condition of the appendix
before. It would seem that in general infection per-
foration does not necessarily exist. Not that this ob-
servation detracts in any way from the importance of
the early interference in cases of this kind. What-
ever the pathological condition of the appendix may
be, the escape of its micro-organisms into the peri-
toneal cavity, whether through a large opening or
through a small one, or by grtdual march through the
lymph spaces, places the patient in the utmost jeop-
ardy. Excision of the organ, with drainage and irri-
gation, should be performed at the earliest possible
moment in every such case.

II. Appendicitis of three weeks' duration; large
abscess in pelvis ; complete intestinal obstruction ;
fsBcal vomiting ; operation ; relief of obstruction ; death
in six hours.

This patient presented the unusual complication of
acute obstruction. There was no doubt upon this
point, for the intestinal contractions, seen throogh the
thin abdominal walls, were accompanied by load bor-
borygmi and intense pain. The patient was very much
reduced in strength, and was already regurgitating the
contents of the upper bowel.

" George T. B., aged twenty-one, South Baoover,

Digitized by

Google

Vol. CXXX, No. 10.] BOSTON MBDIOAL AND SUBGIOAL JOURNAL.

2S3

Mass. Friday, December 22, 1893. Drs. Charles
and McMillan.

" About four weeks ago he had a slight attack of
appendicitis, with localised pain and tenderness. He
described his pain as 'across his bowels.' Later, it
was in the right iliac region. The pain subsided, and
he began to improve, so that he got np and went
aboot the house. Then the pain came on again.
After two or three days he got better, and was not
seen by Dr. Charles till last Monday. On that day
he said that he had the pain only onoe in a while. In
the beginning there was a temperature of 101°. Last
Friday he had an attack like gastralgia, with pain in
the epigastric region. This soon subsided, and has not
been a prominent symptom since. There have been
DO chills. He gave a history of two previous attacks.
The first one lasted but one day. The pain at that
time was in the same place, ' across the bowels,' ' across
the pit of the stomach.* Bepeated questioning as to
the locality of the pain elicited the same answer ;
'right across the bowels.' The vomiting began last
Saturday afternoon, and has continued ever since.

^ Ptytical Examination. — Fnlse 116, temperature
normal. At times during the examination be oom-
plaioed of violent colic. Accompanying the pain,
spasmodic intestinal contractions could be seen through
the thin abdominal wall. Rectal examination showed
a large tamor pressing on the bladder and apparently
filling the whole pelvis. In this tumor irregularities
in consistency could be felt, so that the question of
draining by rectum was considered. The existence
of acute obstruction decided me to select the incision
through the median line.

" Operation. — A median cut was made between the
ombilicos and the pnbes. An acute obstruction of the
bowels was found, caused by an omental band. The
•mall intestine above the obstruction was dark-red in
color and excessively distended. Deep in the pelvis
filled with foul pus, was a large abscess cavity, the
adhesions of which were separated with great difficulty.
After catting the band the cavity of the pelvis was
washed out with peroxide of hydrogen, packed with
ganze, and drained by means of a rubber tube. The
operation was very rapid, not lasting more than twenty
minutes. The patient died on the following morning."

This case is very similar to that of Mrs. C. F. A.,
reported last year,* in which recovery was due un-
doubtedly to a spontaneous opening in the coecum
through the stump of the appendix. In the present
instance the coils of small intestine were bound down
in the pelvis, and were relieved with great difficulty.
There was no apparent hypertrophy of the intestinal
wall, though its lumen was dilated and its peritonenm
darkly congested.

The question of relieving the obstruction by open-
ing the gut is interesting in these conditions. There
is reason for supposing that such relief would have
been attended by less risk than the methods used ; yet
the chief trouble would have remained untouched
by a simple enterotomy. Moreover, the opening must
have been made in the small intestine, possibly so high
np as to interfere with nutrition. It seemed better,
therefore, after thorough exploration, to remove at
onoe the cause of obstruction. The immediate cause
of death was the shock caused by manipulations upon
the abscess, though they were extremely brief. The
contents of the abscess cavity soiled the adjacent coils

' Tm Daji of AppeodloltU, Boston Hedioal uid Sorgloal Joarnal.

of intestine. They were immediately disinfected as
thoroughly as possible by means of peroxide of hy-
drogen. Even if the bowel had been opened after
separating the adhesions about the appendix, it is not
likely that recovery would have followed. A rapid
enterotomy alone might possibly have tided the patient
over the crisis until strength enough could be stored to
enable him to undergo even the slight manipulations
of drainage.

III. Appendicitis ; apparent general peritoneal in-
fection ; mechanical obstruction ; removal of perforated
and gangrenous appendix ; drainage ; recovery. Peri-
toneal exudate sterile; colon bacillus in appendix.
Recurrence of obstruction in four weeks. (Specimen.)

This case is the only one in my experience in which
I have demonstrated satisfactorily an acute mechanical
obstruction in the first days of an appendicitis. That
the obstruction would have continued cannot be as-
serted ; yet it was sufficient to cause unmistakable
faecal vomiting, and was immediately relieved by sepa-
rating the adhesions by which the small intestine was
glued into the vesico-rectal fold by inflammatory adhe-
sions.

"Binney, L. H., twenty-four years old, cabinet-
maker. Thursday, December 28, 1893. Dr. Stevens
of Cambridge.

"Last Sunday afternoon he first had pain in the
belly, which he tried to relieve by walking. He walked
around for a long time without relief. The pain con-
tinued two days. Wednesday morning it became in-
tense and Dr. Stevens was called.

" Dr. Slevem. — ' When I came he had a great deal
of pain in the abdomen, a pulse of 72, and a tempera-
ture of StS". His hands and feet were cold. His abdo-
men was flat, retracted, rigid, and tender ; more tender
on the right than on the left, from the pubes round to
the right side. It acted like a perforation of the ap-
pendix. He was in a state of collapse, and it did not
seem wise to interfere until he should rally. At five
o'clock that afternoon be had rallied. Temperature
108°, pulse 110. He was pretty free from pain. At
eleven o'clock, Wednesday night the temperature was
101°, pulse under 100. No vomiting. On Sunday night
be had a chill. There was a little nausea, but no
vomiting. On Monday he took a cathartic. This
(Thursday) morning the temperature was 100° and the
pulse 76. There was no vomiting. He could not pass
his urine. The abdomen was slightly tympanitic.
The muscles were extremely rigid, especially on the
right side ; and he had a pretty sick look. He has
gone on through the day in about the same condition.
At the present time (8.45 p. h.) he is in great pain.
He has never had anything like this before.'

" Palimft Statement. — ' I was taken Sunday abont
four o'clock. It was a good deal like a stomach-ache,
and yet it was not. The pain was right across my
stomach and my bowels, here (indicating the region of
the bladder). The pain now is in the same place as
at first. The attack was preceded by a diarrhoea fol-
lowing the use of rhubarb.'

" Phytical Examination. — Pulse 72 to 80, temper-
ature 99.8°. Complains much and groans constantly.
Very tender on both sides in the lower part of the ab-
domen. There is some general tenderness without
rigidity. No tumor ; no dulness. Rectal examination
negative.

'* Friday, December 29, 1893, 10.20 A. h. Pulse
70, temperature normaL The abdomen is distended,

Digitized by

Google

284

BOSTON MSDWAL AND SVBOIOAL JOURNAL.

[Mabch 8, 1894

and tender in the lover portion, where he complains
also of pain. No sounds can be heard bj stethoscope.
The vomiting is distinctly fsecal in odor and color."

Dr. Taylor, of Cambridge, was present at this ex-
amination ; also Dr. C. A. Porter, of Boston. It was
a question, first, of appendicitis ; secondly, of a general
peritoneal infection ; and, finally, of an acute obstruc-
tion. It seemed to me most lilce an acute intestinal
obstruction. A grave prognosis was given.

An incision several inches in length was made in
the right liaea semilunaris. On nicking the peritoneum
slightly cloudy serum escaped, from which a culture
was immediately taken. The coBcum was found col-
lapsed : the last three inches of the ileum were empty
and flattened. The small intestines presenting were
very much distended. The peritoneum was nearly
normal, but slightly injected. The free fluid in the
peritoneal cavity was removed as well as possible by
means of dry sterile gauze. Adhesions could be felt
about the appendix, which was situated in the pelvis
between the rectum and the bladder. Grause barriers
were suitably placed to protect the general cavity of
the abdomen before separating the adhesions, about
which a small amount of faecal pus was found. The
parts abont the abscess were irrigated freely with per-
oxide of hydrogen. The lowest segment of the ileum
was caught at a sharp angle deep in the pelvis among
the adhesions abont the appendix. Above this angle
there was great distention ; below, collapse. After
the adhesions had been separated and this portion of
the bowel delivered, gas at once filled and distended
the coecum.

The recovery of the patient seemed very doubtful ;
yet he rallied, and is now well. Vomiting continued
two or three days, and was treated by absolute rest to
the stomach and intestines, neither food nor cathartics
being given. At the end of three days the bowels
began to move, the vomiting ceased, and the patient
became convalescent.

It has been said in reference to this case, that the
obstructions described frequently exist in acute general
peritonitis. A general infection was thought to be
present at the time, though the appearances did not
indicate a general peritonitis. Moreover, it must have
been an inflammation independent of micro-organisms,
or, at least, of those which grow upon the medium of
blood-serum, for to this day the tube inoculated from
the fluids free in the abdominal cavity remains sterile,
though from the appendix itself abundant growths of
a large, thick bacillus have developed. Furthermore,
that the obstruction was not due to a paralysis of the
intestine was shown by the existing borborygmi.

In this case the sterility of the free fluid is a fact of
the greatest interest, and it explains the rapid recovery.
In many instances a fluid apparently precisely similar
has shown a rapidly growing microbe. lu such cases
death has invariably followed.

IV. Probable appendicitis at the age of seventy-
eight ; no operation ; recovery.

The following case seems worth recording in detail,
becanse it presents the typical history of appendicitis
at a very advanced age.

" Andrew H., aged seventy-eight. North Hanover,
Mass. Thursday, December 21, 1892. With Dr.
McMillan.

"Night before last his trouble began with severe
pain in the right side. He was cold and pallid. For
many years he had been ruptured on both sides. There

was no indication of any strangulation or incarceration ;
there was no protrusion at the rings. The first symp-
tom day before yesterday was vomiting, which lasted
about ten minutes, and was followed by pain which
ceased yesterday. He had two movements of the
bowels from oil and enema. He never had anything
like this before. The temperature last night was 103° ;
this morning it is 101°. The pulse was 101; now 90.
His general appearance was good. There is tender-
ness in the right side of the abdomen, near the crest of
the ileum, where there is also resistance and dnlnesi.
The temperature night before last was 103°. The
right side was hard and tender." The condition of
pyrexia in this case continued a few days. The symp-
toms gradually subsided, and the man is now well.

The history of this case is precisely like that of ap-
pendicitis with localized peritonitis. It is very unusual
to see an appendicitis at this age. In one instaooe I
have found, at the autopsy, in a woman of about seventy,
a gangrenous and perforated appendix containing a
gall-stone. If this man had been younger, or if there
had been evidence of an abscess in the right iliac fossa,
I should have advised interference. The patient was
very much opposed to operation, preferring to die.

V. Appendicitis complicated by bronchitis ; removal
of appendix slightly affected ; pneumonia; empyema;
thoracotomy and excision of rib ; recovery.

On Wednesday, June 7, 1893, I saw in East Bos-
ton, with Dr. Morrison, Fred A. R., aged six, who was
taken sick the previous Saturday morning, complain-
ing of pain in the side. (The father indicates the
right lumbar region.) He had a good deal of pain,
with some vomiting. He could keep nothing on his
stomach. Sunday he was the same, complaining also
of headache. On that day he was seen by a physi-
cian. Vomiting continued during Monday. Last
night he was first seen by Dr. Morrison, who found
him with a temperature of 104.5°. There was no
symptom except this pain in the right iliac region, just
between the umbilicus and the anterior spine. The
left side of the abdomen was also tender. This morn-
ing he had rather more pain than last night, but there
has been no vomiting since day before yesterday.

Pk^tical HxaminatioH Pulse 120, respiration 40,

temperature 102°. Though the abdomen was gener-
ally distended and tender, the tenderness was especially
marked in the region of the appendix. There was no
tumor ; the tongue was clean. The thighs were flexed.
The respiration was noisy and rattling ; the cheeks
were flushed ; the eyes sunken. The general appear-
ance was bad. There seemed very little doubt that
this boy was suffering from an acute inflammation of
the appendix, with perforation and a more or less gen-
eral infection. The respiration of the left chest in-
dicated trouble there, probably pneumonia. (This
proved to be the case.) The surroundings of this
child were so bad that we decided to send him to
the hospital. The history and physical examination
of this boy pointed clearly to appendicitis. On arri-
val at the hospital he was seen by Dr. Beach, who
confirmed the diagnosis and opened the abdomen. The
appendix was removed and found apparently normal.
The child rapidly developed a pneumonia, from which
he recovered. The abdominal wound healed firmly,
and he soon became convalescent. This patient, in
July, while under my care, developed an empyema on
the right side, for which a rib was resected and drain-
age applied. The boy recovered rapidly from this op-

Digitized by

Google

toi. CXXX No. 10.] SOStOir MibtOAt A^iy SOitGIOAL JOXJkSAL.

2d5

entioD, gained very mach in weight and strength, and
was discharged from the hospital a picture of health,
in spite of the fact that tubercle bacilli were found in
the spatum.

I am informed by Dr. Beach that after removal of
the appendix, on careful examination a condition of
thickening and of catarrhal inflammation was found.
That this condition of the appendix was not the cause
of the acuteness of the symptoms, seems to me very
certain, for the general pain and tenderness, with the
rigidity of the abdomen and the flexion of the thighs,
mean gangrene and perforation, or at least a septic
extravasation, if any value at all can be placed upon
this combination of signs.

Very similar to the last case is the following which
I saw in consultation with Dr. Berlin on January 1,
1894. Had it not been for the experience gained in
the above instance I should have said that this, too,
was an acute inflammation of the appendix, compli-
csting a pDeumonia, and possibly I should have ad-
vised exploration. I certainly should have done so,
had I adopted the rule to operate npon every case of
appendicitis ae soon as the diagnosis was made.

VI. Foeumonia apparently complicated by appen-
didUs ; no operation ; recovery.

Malcolm E., aged four, January 1, 1894.

" Always delicate. Two years ago had whooping-
cough, after which he went South for the winter.
Last Thnrsday, the 20th, he said he had a stomach-
ache. The abdomen was flat. The only symptom was
pun. At one time he would complain of the right
side, and at another of the left. The symptoms were
not alarming. The temperature was 101°, the bowels
free. On Friday, there was evidence of trouble in one
of the lungs, thought to be pneumonia. There was
DO local abdominal tenderness. On Saturday the tem-
perature reached 105°, and he said his stomach hurt
him. He complains of a good deal of pain in the ab-
domen (indicating the epigastrium). This morning he
locates the pain in the right side all the time."

The cheeks were red and the respiration was rapid,
though not labored. The abdomen was somewhat
prominent, but not rigid. Intestinal sounds could be
heard with the stethoscope. There was no dulness.
Pulse 120, temperature 102.2°. Tenderness more or
less general.

The complaints of this child, with the physical signs,
obscure though they were, would have been strongly
(oggestive of an acute appendicitis, had it not been for
the experience gained in the preceding case. The evi-
dence in this case, however, is much less indicative of
>D appendicular trouble than that in the former. In
children and young males persistent pain in the abdo-
men, of whatever nature, even if far removed from the
nsaal seat of the appendix, is usually dependent npon
an inflammation of that organ. The errors to which
we are liable are not in the direction of early inter-
ference or mistaken diagnosis; they depend rather
npon our overlooking the lesion and delaying its ap-
propriate treatment. For one instance in which the
iuterference has been useless or too hasty, I could
point out a large number in which failure to appreciate
early the gravity of the case has been followed by a
fatal termination.

Abdominal symptoms occurring in the course of
acute thoracic diseases are not unknown. Dr. Russell
Sturgis writes me in regard to this as follows: "I
have several times been able to confirm the observa-

tions of Dr. Eustace Smith, made in 1876, that the
pain of pleurisy in children is frequently referred to
the belly, and I have noticed abdominal pains as not
of infrequent occurrence in the pneumonias of chil-
dren. Dr. Smith thinks that the reference of pain to
the belly is due to implication of the lower intercostal
nerves, the ends of which ramify in the abdominal
walls."

In addition to the above cases, I have seen several
others which do not differ from the usual type enough
to justify their insertion under the title of this paper.
In one, the fatal extravasation of faecal matter was the
direct result of salines. In another, the onset of the
disease was ominous, but rapid recovery followed. The
third was saved from a general peritonitis by early
drainage. A fourth called the physician on the seventh
day for the first time. Nothing could be done for the
child, who survived only twelve hours. A fifth was
doing very well under medical treatment, when he be-
came collapsed, and died twenty-four hours after an
emergency operation by another surgeon. A sixth
presented the features of the severest type of intra-
abdominal disease not pointing especially to the ap-
pendix. Nothing tangible could be made out Op-
eration was not advised, because no definite indications
could be found to guide incision. A day later all un-
favorable signs had disappeared. A seventh case is
recovering iSter drainage. In an eighth an appendix
was found in violent paroxysmal contractions upon
several feecal concretions. The appendix was removed,
its stump covered with peritoneum, and the wound in
the abdominal wall tightly closed. The results are on
the whole encouraging. Surgical interference, how-
ever, must be insisted on in the initial stages of this dis-
ease rather than when the patient is hopelessly infected.

BBCDKBINO CA8B8.

The following cases of appendicitis, in which the
appendix was removed during the period of abeyance,
present one or two conditions hard to explain, and give
rise to doubts, first, as to the probable dependence of
the symptoms upon the lesion found, and, secondly, as
to the advisability of surgical interference.

J. Removal of thickened and adherent appendix in
period of abeyance; rapid recovery; subsequent at-
tack like those previous to operation. (Specimen.)

William T. G., aged twenty-four. I saw this young
man on January 30, 1893, at Dr. Hildreth's house in
Cambridge. I give in detail the history of this attack,
in order to make a comparison with that occurring in
December following removal of the appendix.

" Monday, January 30th. Yesterday he felt faint
in chnrch. In the afternoon he stayed at home on the
lounge, and iu the evening came to Cambridge. Was
pretty sick in his room that night, suffering from pain
through his stomach and bowels. This morning he
has vomited. He had a pulse of 90, and a tempera-
ture of 99.3°. During the night he vomited two or
three times, but did not seem to get much relief from
it. The abdomen was flat. The pain was exactly in
the region of the appendix, where there was a good
deal of tenderness, but no tumor. He has had pain in
the region of the appendix before, while playing ten-
nis, but never so severe.

" Pkytieal Examination. — Temperature 99.2",
pulse 80. Tenderness over the appendix, without dul-
ness. Rectal examination negative. No operation
advised.

Digitized by

Google

236

BOSTON MStolOAl AND StJttOtOAl JOtJttlfAl.

[Mabcb 8, 1894.

*' February 7th, Dr. Hildreth wrote that soon after
mj visit a small bunch appeared in the region of the
appendix, which gradually subsided. He has been on
the whole in very good coudition ever since.

"October 18, 1893, Mr. 6. said : ' I have had con-
siderable pain since. In June I bad an attack which
laid me up two weeks. There was not much fever.'
October 20tb, he said : ' I am very well now, though
at times I have a little pain. Since the attack in Janu-
ary I have had in all about five weeks' disability.' "

Operation at the Massachusetts General Hospital,
October, 1893. A small incision was made parallel
with the fibres of the external oblique muscle, begin-
ning in the right linea semilunaris over the usual seat
of the appendix. The coecum and the parts about the
appendix were much congested. The enlarged and
thickened appendix was cut off close to the caecum.
The stump was covered in by peritoneum with inter-
rupted silk stitches. A rapid convalescence followed.
He was kept on his back four weeks, to allow the scar
tissue to get perfectly firm.

On Tuesday, December 18th, I made an examination.
He said that on the preceding Thursday morning he
had had the same dull pain in the stomach as before,
which grew worse and worse. At first he thought he
could bear the pain ; but it became so severe that he
finally went to the doctor, who sent him to bed. The
pain lasted till Friday morning, when it left him quite
weak. He did not eat anything until Saturday, for
he had no appetite. At first the tenderness was gen-
eral, but afterwards it seemed to be in the same spot
as before. It pained him to lie on that side, or to
make any motion from one side to the other. The
soar was firm, and there was no tendency to hernia.
There was no local tenderness.

When the appendix was removed at the hospital, in
October, it was very much thickened. Its peritoneal
covering was brilliantly injected, and everywhere at-
tached by old adhesions filled with blood-vessels. The
mucous surface was dark, rough and reduplicated.
The cavity was filled with thin, muddy fluid of dark
oolor. There was no concretion found.

The attack following the operation differed in no
respect from those which preceded it. Had the ap-
pendix presented normal, or even substantially normal,
features, it might be said that there had been an error
in diagnosis, and that the attacks were dependent upon
other conditions.

Had enough of the organ been left, we might ascribe
the late attack to an appendicular colic or a very limited
inflammation ; but the silk was applied close to the
coecum. The symptoms, therefore, demand some other
explanation. The most reasonable one is that the
ooBcum shared in the appendicular inflammation, and
had not recovered its normal condition. On the other
hand, the trouble may have been an acute indigestion
similar to the previous attack, but of entirely different
origin. The pathological coudition found exceeds, in
the apparent variation from the normal, all lesions I
have been able to observe in this class of cases. As
far as one can judge, this appendix invited disaster
both by the character of its contents, and by its evident
condition of chronic inflammation.

The two following cases are reported not only for
their intrinsic interest, but because the condition of
the appendices found does not seem sufiScient to account
for the symptoms for which they were removed.

IL Appendicitis; abscess; drainage; recovery;

ten months later an attack like the former, without
abscess ; removal of appendix which had become almost
entirely obliterated ; recovery. (Specimen.)

Andrew M. B., aged thirty-eight, shoe-fitter, of
Lynn. Drs. Marshall and Lovejoy. Sunday, Febru-
ary 19, 1893.

" I am subject to constipation. When first taken I
felt as if some one had hit me in the stomach. After
that I had terrible pain. This was a week ago last
Tuesday. I vomited several times and have vomited
since." There was a rise of temperature for two or
three days after the first symptom, the highest being
102°. He had no physician at first and treated him-
self for coli& He seemed to be doing well. About a
year ago he had had a similar attack, which was a very
slight one, comparatively. On examination I found a
very large tumor in the lower part of the abdomen.
The general condition was good. There were no urgent
symptoms. Drs. Marshall, Lovejoy, Colman, Little
and Harmon were present at the operation. A large
incision was made over that part of the tumor present-
ing in the right iliac fossa. About four ounces of pus
of fsBcal odor were evacuated through the first incision.
The adhesions toward the left were separated with
difficulty, and much pus was evacuated from that side.
The appendix could be seen in the depths of the wound,
large, thick and gangrenous, but so intimately adherent
to the surrounding parts that it seemed inadvisable to
make any very prolonged efforts for its release. The
wound was drained by means of rubber tubes, one
deep in the pelvis and another towards the bladder.
The whole was packed loosely with sterile gauze.

About two weeks after this there was a discharge of
a pint of pus from the wound. The temperature
dropped at once to normal. Later it went up to 103°,
where it stayed for a week. Nothing could be felt in
the abdomen except impacted fssces.

He recovered entirely, and remained well until
November, 1893. On November 2Ut, he came tome
and said that " three weeks before he had had a sick
spell, coming on like the previous attacks." He had
pain in the pit of the stomach ; " not a real sharp pain,
but a dull sort of pain." With this attack he had a
very little fever. In other respects he was well. The
pain seemed to go down from the epigastrium to the
right iliac fossa, as it did in the attack in February.
In answer to the question " How did the last attack
begin?" he said: "Well, it is hard to explain. It
began with this dull, soft pain in my stomach [indicat-
ing the epigastrium.] It kept going down, so that it
was a real sharp pain — a stoppage-like pain. Then
the trouble would go down to where I was cut. With
the last attack there was no vomiting. When I was
taken I felt sort of squeamish. It seemed as though
I ought to vomit. I have had no other attack since
the operation, except that I felt a pain or soreness in
my side."

I found a hernia in the scar. There were no other
symptoms. I advised first an operation on the hernia,
and then, should there be reason for it, an excision of
the appendix.

On cutting into the abdomen I found the parts about
the coBcum glued together by adhesions, which were
easily dissected. The remains of the appendix were
found adherent to the outer and lower border of the
ccBCum. The tip was separated from the base of the
appendix by an interval of an inch and a half made up
of connective-tiMue. I dissected off the tip of the ap-

Digitized by

Google

Vot. CXXX, No. 10.] BOSTON MEDWAL ASD SURGICAL JOURNAL.

237

peodiz, and cat the stamp close to the ccecam. The
tbdominal woond was closed immediately by inter-
rapted sutures. A very gratifying convalesceDce fol-
lowed. He was sent home at the end of three weeks.

III. Recurring appendicitis; removal of remains
of extra-peritoneal and adherent appendix. (Speci-
men.

Joseph H. M., aged twenty-nine, Washington, D. C,
January 1, 1894. This patient has always been in
good health up to the time of the present illness.
About four years ago he had an attack of indigestion,
as the physician in New York thonght. There was
severe pain through the lower part of the abdomen
(indicating a spot a little to the right of the median
line, between the umbilicus and the pubes.) This pain
lasted aboat a week, accompanied by slight fever. The
pain was intense, folluwed by vomiting. He recovered
from this very well. He was not conscious of a bunch
in the side at any time. The next attack was about a
year after that, and resembled closely the first. The
pain was in the same place, was very acute, and lasted
about the same length of time. The next one was six
months after the second, and was very similar. About
six months ago he was taken, after getting tired, with
what was again supposed to be indigestion. This was
accompanied by pain in the same place. The mnscles
over this part of the abdomen were rigid and hard. " I
was all drawn np, and it was about a week before I
eonld stand ap straight. The whole effect of this at-
tack lasted about three weeks." About the middle of
November he had another attack, with which there
was some fever. The physician discovered a swelling
in the right side at that time. "I have lost about
diree weeks in the last year. Between the attacks I
have a great deal of soreness in the same spot"

I found the patient rather pale and spare. In the
right iliac fossa there was a tumor about the sise of
the finger, hard, somewhat irregnlar, and only slightly
movable. This tamor was situated apparently at the
onter border of the coecum, and behind. Its irregular^
ity and hardness suggested malignant disease. The
diagnosis of appendicitis was made, and an operation
was advised. This operation was performed on Janu-
ary 3, 1894. The parts about the c<Bcnm were exten-
sively infiltrated by an inflammatory mass, in the centre
of which the remains of the appendix were found.
This mass lined the right iliac fossa and extended un-
der the caput oosci to the brim of the pelvis. The
adhesions could be separated only with the knife. The
rounded end of the appendix was adherent to the ccecum,
its onter border about at a level with the anterior sape-
rior spine of the ileum ; the base of the appendix was in
its nsnal posiUon at the brim ; between the two there
was nothing but cicatricial tissue ; the whole interven-
iag portion had been obliterated. I removed the tip
and the stamp of the appendix dose to the coecum.
Its lumen was so large that it seemed best not to close
the wound at once. The patient has made, thus far
(January 17th), very satisfactory progress, and will
andoobtedly recover.

The appendices removed in the two last oases show,
u yon will see, very similar gross appearances. The
chief difference is in the sise of the remaining frag-
ments. In both, the central portion has disappeared,
and its place has been taken by connective-tissue. In
each instance the tip b smooth, rounded, and firm.
The peritoneum is injected. Internally the mucous
iorface is velvety ^apd reduplicated. The closed cav-

ity of the tip contained a thin fluid. In Case III no
cultures could be obtained on agar-agar.

In Case II ten months have elapsed since the first
operation. The micro-organisms have been imprisoned
in the cavity of the tip long enough to deprive them
of their virulence and activity, though this is not a
fact resting upon any bacteriological investigations of
the case. The wound was closed immediately in Case
II because the appendix was opened only at the base,
and extravasation was prevented by covering the stump
with peritoneum.

In Case III the opening was so large in the appen-
dix, and the chances of contamination so great, that I
packed the parts with gauze and left the wound partly
open. The harmlessness of the contents, as shown by
sterility of the cultures, proves that this precaution
was unnecessary. Drainage is all the more to be re-
gretted because of the increased liability to hernia.

Case II is interesting also because of the trivial re-
mains found after one of the most extensive abscesses
in my whole experience. Nothing could be found ex-
cept a slight induration behind the ccecum, and the
contiguous cicatricial tissue in which the appendix was
found embedded.

In Case III, on the other hand, in which there was
either absorption of the abscess or rapture into the
bowel, there was an extensive induration which involved
the whole right iliac fossa.

Whether these operations, viewed solely in the light
of the condition found, were justified or not may be a
matter of opinion. The appendices can certainly do
no harm now. From all the evidence to be obtained
beforehand, the operative interference was well justi-
fied. Indeed, if we remove every appendix which is
probably or even possibly diseased, we shall save many
lives and prevent much suffering, even if we occasion-
ally perform an unnecessary, though safe, operation.

TWO CASES OF CHANCRE OF THE EYELID,
WITH AN ACCOUNT OF THE MANNER OF
INFECTION.!

BT KriiBS STAHDISH, K.D..

Ophthalmia amvem, tfanaehiuetU CJtaritable Eye and Bar Infirm-
ary; OphtkMmio Surgeon, Camay BotpUati Jttiitemt in Oph-
thalmoligy. Harvard iltdieal School.

Cases of chancre of the eyelid are not unknown.
There are some thirty cases in medical literature ; bat
there is every probability that the very rarity of the
affection has caused other cases to be overlooked in
the haste of large ophthalmic clinics, as the infection,
in a large proportion of cases, takes place at the mar-
gin of the lower canaliculus, and the amount of swell-
ing which accompanies the lesion is very great, so that
as a result the gross appearances counterfeit an ordinary
lachrymal abscess so exactly as to easily lead to a mis-
taken diagnosis.

The two cases I am about to report are of interest
from the fact that in each the manner of infection of
an innocent person was distinctly traced, and are there-
fore, of importance from a prophylactic point of view.

The first case was brought to the oat-patient depart-
ment of the CATuej Hospital by Dr. F. W. Stuart,
with the following history :

H. K , a man thirty-one years of age, married, had
first noticed a swelling at the inner angle of the lower

1 Bead before the Botton Society for Medloal ImproTement, Juia-
*rj 8, 1891.

Digitized by

Google

238

BOSTON MEDICAL AND SURGICAL JOVEMAL.

[Mabcb 8, 1894.

lid of the right eye ten days before, attributed by him
to a poisoDing of the lid from a splash of greeo paint
which he had received in the right eye a day or two
before the swelling was discovered. The gross appear-
ance much resembled an active lachrymal abscess.
There was a rather large, rounded swelling at the
inner angle of the lower lid, red and slightly painful
when touched. Upon examination there was discov-
ered in the centre of the tumor a round infiltration,
bard and surrounding the opening of the lower canali-
culus ; no abrasion of the skin or conjunctiva was dis-
covered, but such a condition might have been easily
overlooked as the amount of swelling was so great that
the lid could not be everted in order to get a good
view of the opening into the canaliculus. The patient
had always been well and robust, and there was abso-
lutely no venereal history. There was a history of
considerable pain locally the past week. There was
one small pre-auricular gland to be felt.

The patient was admitted to the hospital ; and in
the course of four or five days not only the pre-auricu-
lar glands swelled rapidly but the sub-maxillary glands
on the right side, became very rapidly enlarged so that
in the course of five days there were three glands be-
low the angle of the jaw as large as hen's eggs.

It is but fair to state that during this period he de-
veloped a pharyngitis and tonsillitis with a high tem-
perature, and was so ill that he kept his bed.

As soon as the fever subsided, the patient becoming
dissatisfied, left the hospital and returned to his home,
and came again under the care of Dr. Stuart. Both
in the hospital and immediately upon his return home,
active mercurial treatment was maintained. The
swollen glands diminished in size without suppuration

The patient was next seen by me a little over two
months later, when he came again for treatment. He
then had an active syphilitic iritis in the right eye, the
same eye upon the lid of which the initial lesion was
situated. The pupil was small and its margin attached
to the capsule of the lens throughout almost its entire
circumference. Under the active use of atropine and
hot fomentations, however, the synechisa were all
pulled off, and I again lost sight of the patient ; but
Dr. Stuart informs me that subsequent to the iritis he
had a characteristic secondary eruption appear.

Dr. Stuart was much interested in the case, and
undertook an investigation as to the manner in which
Uie original infection was acquired; and by his kind
permission I am enabled to report his results.

The patient was, as I have said, a married man and
lived with his wife in a small house in South Boston ;
the only other member of the household was a male
boarder. Upon investigation this boarder was found
to be suffering at the time of the original infection
from a secondary syphilitic eruption. The two men
occupied different rooms, and only used one article in
common, namely, a roUer-towel over the sink in the
kitchen. It was their habit upon coming in from
their work at noon and night to go to this sink, turn
on the water at the faucet and wash their hands and
faces in the running water, and then to use the before-
mentioned roller-towel to dry their hands and faces.
There is no doubt but the disease was transferred from
one man to the other by the means of this towel.

The subsequent history of this family is also inter-
esting.

The patient was warned repeatedly, both by Dr.
Stuart and myself, as to the danger of infecting hit

wife ; nevertheleas, during the secondary stage he did
infect his wife. The initial lesion was upon the vulva.
At the time of the infection the wife was four-and-a-
half months pregnant, and subsequently, at full term,
she gave birth to a syphilitic child, which died a few
weeks after birth.

The second case which I have to report came also
to the out-patient department of the Carney Hospital
about four months before Dr. Stuart brought his case
there. He was a man twenty-five years of age, un-
married, and a brakeman upon a freight-train on a
railroad leading out of Boston. He reported that
about two weeks before — he could not fix the exact
date — he had gotten a hot cinder in his eye. since
which time it had given him more or less trouble.
Upon examination, the lower lid was seen to be con-
siderably swollen and reddened ; and when the lid
was everted, an ulcer, a centimetre long and about
half as broad, was found in the conjunctiva of the
lower conjunctival sac. This ulcer had sharp edges, a
grayish, dirty-looking base, covered with a somewhat
viscid, yellowish discharge. The base of the ulcer
could be felt through the lower lid to be a dense, firm
induration. The pre-auricular glands were found to
be hard and about the size of cherry-stones.

A diagnosis of an initial syphilitic lesion was made,
and he was given an ointment of the red iodide to put
into the eye ; and a pill of hydrarg.-protiodid. (gr. \, t
i. d.) was prescribed. The appearance of the ulcer
was such, however, that I did not feel absolutely sure
but what it might be tubercular.

The patient was well and strong, and there was no
tubercular or syphilitic history to be obtained. Dr.
J. J. Thomas was kind enough to make an examina-
tion of the material obtained from the base of the
ulcer, for tubercle bacilli. None were found. A
week later I removed a portion of the tissue itself
from the margin of the ulcer. Dr. Thomas examined
this also, and reported that after a very careful search
he was satisfied that there were no tubercle bacilli in
the specimen.

In the course of a week's time from the first visit,
the pre-auricular glands became much enlarged, and
soft to the touch. Having satisfied myself that the
diagnosis was correct, I questioned the man to see if I
could determine the source of the infection. I found
that our patient was a brakeman upon a local freight-
train, the crew of which consisted of two other men
and himself ; that they occupied more or less a small
car carried on every freight-train for the convenience
of the crew, called a "caboose"; that in this they
changed their clothes and washed up when they were
through their work ; bnt that they did not sleep in the
car. Upon inquiry, I ascertained that the other
brakeman on the train had had of late some kind of
an eruption upon his face, which from the described
appearance, duration and an acknowledged history of a
recent initial lesion was in all probability an eruption
of secondary syphilis. All the men upon the train used
the same towel upon " washing up " when their work
was over.

The patient was a very unreasonable man, hard to
manage ; and when my diagnosis was finally told him,
took offence and ceaseid to attend the clinic.

I saw him, however, quite by accident, several
months after he ceased to come to the hospital ; and
there was no doubt in my mind but what he then bad
an eruption of leoondary typhilis.

Digitized by

Google

Vol. CXXX No. 10.] £OSTOlf MMDlOAL AtfD SDHGIOAL JOXJttHAL

239

The method of infection in these two oaaes is, to my
mind, of great interest. It is evident that in roughly
drybg the face the delicate oonjancliral surface at the
edge of the lids could be easily abraded, as no matter
how carelessly a towel is used, every one is sure to
dry about the eyes when the face is dripping wet, to
prevent water entering the eyes upon opening them.

It seems to me to follow, as corollary, that, if a
chancre of the lid can be acquired in this manner, that
k chancre of the lips or edge of the nostril could be
acquired in the same manner. The moral is evident :
A public towel is an abomination, and should be abol-
ished from all workshops, railroad toilet-rooms, and
other pnblic places.

ON SP£RMATORRH(EA AND INCIPIENT HY-
PERTROPHY OF THE PROSTATE, AND A
PROPOSED METHOD FOR ITS TREATMENT.

BT BKH. HOOMKB, M.D., BOBTOH.

A LONG time is always necessary to collect facts ;
and as it is better, moreover, that they be collected
from widely-spread sources, I have not hesitated to
communicate the few cases noted below (interesting in
themselves, but still more through the great groups of
diseases to which they belong), in the hope that more
attention may be drawn to prostatitis, especially to
that form I have found in spermatorrhoea, and to in-
cipient hypertrophy of the prostate.

During the past summer six or seven youths, be-
tween the ages of nineteen to tweuty-eight years, came
at very nearly the same time under treatment for
apermatorrhoea, — fo$t matturbatiotum. All had been
previously treated by the " usual methods," but with-
out improvement The " usual methods " were per-
Bued also by me with physical and psychical improve-
ment in view, besides exercises in the open air, bathing,
encouragement, sedatives, cold-water spinal douche,
et& ; moreover, tond a demeure ; but all in vain.

The cases were in many respects alike bat also in
some points very unlike.

Concerning the usual symptoms it may be mentioned
that the frequency of the ejaculations varied between
two or three and ten or twelve a week. The condi-
tions of the prostate were the most interesting part in
these cases. Its amount varied considerably, from be-
ing increased so that the apex could not be approached
with the finger, to being rather diminished so that it
was palpable everywhere with a very slight movement
of the finger ; and the consistency was in the former
case more or less fleshy (sometimes giving the impres-
sion of swelling around a firmer part) ; in the latter,
more hard, without any swelling at all. The former
groups (four or five cases) belonged, as to duration
and symptoms, to the milder ones ; the latter to those
of longer continuation and severity, where the ejacula-
tion often occurred without feeling. In all the oases
the prostate was found to have an increased sensitive-
ness or pain to the touch, either over the whole organ
or over a portion of the same, in one case apparently
only in the region where the lateral lobes begin to di-
verge, a pain which I have not yet found in uncompli-
cated cases of masturbation. The symptoms suggested
chronic prostatitis in different stages, occupying most
frequently the whole organ, and — with regard to the
frequent ejaculations — in my opinion, especially the
mnseolar elements. And why would this not be so ?
The prostate, an organ both muscular for ejaculations

and follicular for secretions, becomes during the sper-
matorrhoea more strained than under normal conditions.
In spite of spermatorrhoea, the " patients " often con-
tinue with masturbation ; and the prostate muscles,
moreover, appear to remain (if I may use the expres-
sion) in a kind of " half-primed " state, or one of " con-
stant expectation," and to be in a sickly, irritable con-
dition, with the result that sometimes only the least
influence is necessary to produce ejaculation. A hy-
pertrophic gland is in a hypersemic semi-inflammatory
condition ; and a muscle which is unnaturally strained
often becomes the seat of inflammation. In the sper-
matorrhoeas are found, therefore, the possibility for
both a folliculitis and a myositis of the prostate, ptr
continuitcUem affecting each other. The discharge
from prostatic follicles forms a part of the sperma just
as certainly as the secretion from the vesiculi seminales ;
then why should not a follicular prostatitis be primary
as well as a spermato-cystitis ? ' The prostate giand
has surely a doable function (secretive and ejaculatory),
while, on the contrary, the vesiculi seminales have
chiefly only one (secretive) ; therefore the prostate be-
comes strained proportionately in double measure dur-
ing spermatorrhoea, while the vesiculi seminales are so
only in one function. Therefore, it seems to me, that
the prostate can be primarily diseased as well as the
vesicles.

In his treatise Dr. J. Lloyd says ' : "In the majority
of cases where prostatitis is thought to complicate a
urethritis it is the seminal vesicles which are the seat
of the inflammation, and not the prostate at all."

When Dr. Lloyd thinks that the urethritis spreads
through the ejaculatory ducts, why should it not be
carried through the fifteen to twenty excretive foUica-
larducts which empty below on part proilaticaurethnef
I will not speak further on this subject, but maintain
that with spermatorrhoea (which is here especially
treated of) the prostate gland is just as directly affected
as the other genital organs.

The intention is not to draw general conclusions
from a few cases ; the attempt has been rather to ex-
press my impressions and reasons why the prostate be-
gan to be treated with massage as in other cases of
myositis ; while nerve-pressure ' was given at the same
time, and in some cases, moreover, gymnastic move-
men is so applied as to lead the blood from the pelvic
viscera.

Massage was given once or twice daily per rectum
(while the patient was recumbent with elevated pelvis,
at the same time placing his fists under the buttocks),
partly while the sound (solid No. 10) lay within,
partly after it was withdrawn, and continued as long
as possible, that is, only a few minutes, as long as the
physician can endure it. As a conductor during the
massage the sound is of great value, because it makes
the prostate more approachable and steady ; moreover,
it causes the massage to be so much more effective by
reason of the double pressure, which is given by the
finger per rectum and the instrument per urethram, a

> On Sperniiito-Gyitltls (iDflunmatton of the seminal Teslolei). By
Jordan Lloyd, M.D., F.R.C.8. Laneet, Ootobar 31, 1881, pp. 87, 874,
eto.

> Loo. elt., pp. 876, 876.

> With **neiTe-preaaar8" If meant, a loeal pretsare on a nerve
(trunk, branch or plezua), glTen In such a way that the nerTe li
presaea tor gome leoondi nrmly between the tip of the finger and a
mora or leas deep-lying bone, while at the same time the hand Is
made to tremble ao tliat under the pressure of the finger the Tlbration
1* transferred to the nerre. The moTement is intended to create a
moleeular irritation or change by means of which one seeks to trans-
form the abnormal eondltlon — as far as it oan depend on a oentro-
■pinal ebange — to a normal on*.

Digitized by

Google

240

SOStOlr MSDIOAL ASJ> SVRQtGAL JOVBSAL.

[Maeob 8, 1894.

presanre which becomes more local than that between
the finger and ramus pubis, against which the organ
otherwise is resting when the sound is removed.

The cases treated became so much better after two
to three weeks that the subjects considered themselves
well. The severest was an upholsterer, twenty-eight
years old, who had tried " all kinds of remedies " for
five or six years, but without success. The patient
had a spermatorrhoea appearing each or every second
night, and sometimes as many as three times in eight
hours. The powers of body and mind were depressed ;
but the patient was able, however, to continue his
work. The prostate was not swollen, but rather small
and hard ; but what impressed one most was its ex-
cessive tenderness, equally spread over the whole
organ. Massage and nerve-pressnre were employed
once daily ; also a promenade three-quarters of an hour
long before and after each treatment. After two
weeks the treatment was discontinued, because one
ejaculation a week seemed to the patient to be " noth-
ing." The general health had improved considerably.
The tenderness in prostate had disappeared.

In comparison with these cases was one with incipi-
ent hypertrophy of the prostate, a man thirty-three
years old, who had been married five years, who sought
a consultation ostensibly for the reason that for two
years past " it had dropped so long " after urination.
No stone ; no stricture. The urine was clear, passed
perhaps more frequently than formerly. The bladder
discharged its contents wholly ; and still there was a
desire soon after to urinate again, so that the patient
did not feel comfortable before he had passed some
drops more. The prostate gland, of exceedingly
fleshy consistency, was considerably enlarged as a
whole. The apex of the right lobe was especially
diffic«lt of approach by the finger. The lateral lobes
felt knnrly, especially the right one, in the upper part
of which, moreover, a stringy mass of lobes was felt
proceeding from the lower inner part to the upper
forward part, and gave the impression of enlarged,
perhaps somewhat dislocated vesiculi seminales ; which
mass of lobes as well as the prostate as a whole was
noticeably tender to the touch. It took a long time to
introduce the catheter; also it had to be inserted
deeper than usual, and the posterior part of the urethra
was excessively tender, bleeding easily. Gonorrhoea
had never existed ; neither spermatorrhoea ; but the
man had, nevertheless, masturbated.

Among formerly employed methods was used — but
without success — electrolysis. The treatment now
was with massage alone, with and without the sound,
on the prostate gland twice daily (except Sundays).

After two months' time the patient's " dropping " dis-
appeared, so that it was " nothing to speak of," and
the prostate became diminished so much that it could
almost be considered normal, was rather hard and not
swelled at all. The knurly character of the left lobe
had disappeared, and only a suspicion of unevenness
remained in the right lobe. The stringy mass already
mentioned had disappeared, and instead somewhat en-
larged ordinary vesicles were felt above the right lobe
of the prostate. The tenderness had also disappeared.

That especial importance was attached to making
the sound, orificium urethrse and the fingers aseptic,
scarcely need be mentioned.

Several years ago I had already tried to treat the
diseases mentioned, with the use of the sound (then
without massage), but no particular success was met.

The signal success resulting from last summer's expe-
rience may, therefore, be ascribed alone to the mas-
sage.

As stated, the changes of the prostate, in the cases of
spermatorrhoea examined, have been regarded as a
prostatitis and treated as such ; and also the condition
in the case of incipient hypertrophy of the prostate
referred to, in which the prolonged dropping (a symp-
tom common, moreover, to the senile prostatic hyper-
trophy), seems to me to indicate that the changes in
the prostate even spread to the musculi detrusor and
sphincter vesicw, both of which connect with the pros-
tate muscles.

Therefore the ease can rightly be considered as hy-
pertrophia prostatas ^<e ttnuit or incipiens, which was
arrested by massage.

But if, instead, the prostatitis had continued, it is
probable that the prostate would have become in time
harder, and fibronsly hypertrophied, that the nrinary
troubles would have increased, and that the subject
would finally have had a regular hypertrophia pros-
tatsB senilis.

The spermatorrhoea with its abnormally exaggerated
secretion and ejaculation (probably from the beginning
tropho-neurotic and neurotic, but afterwards just as
much musculo-glandular in its pathogenesis), it seems
to me that a serions circulns vitiosus is established ; a
nervous irritation has increased the secretion, and this,
in turn, the ejaculations, that is, caused the muscular
strata to be unnaturally primed or active, which has an
influence on the innervation of the prostate, this on the
secretion in the follicles and in the remaining genital
organs, etc. To this is now added, moreover, the men-
tal depression and the great loss of the specific " vital
energy " of the sperma, which in turn also contributes
to the diseased condition. Massage was destined in
this case to break a link in such a chain.

If prostatitis has been found in spermatorrhoea, then
one must imagine the stages preceding, developed by
degrees through the masturbation, that is, stages of
irritation which finally (through accidental injuries,
taking cold, a hurt, etc., or most commonly through
continued straining) merge into a regular inflammation.
The condition can be the same after exaggerated, nat-
ural ejaculations and even so in the irritated condition
of the prostate following gonorrhoea. In short, several
causes, especially sexual ones, seem to be found, which
very early call forth a condition of irritation in the
prostate, which from one reason or another is easily
transformed into prostatitis mnscularis, which, more-
over, as in other cases of myitis, etc., untreated, con-
tinue through life and increase by degrees ; and herein,
I consider lie, in great measure, the causes of the fre-
quently occurring '* hypertrophia prostatas senilis," so
much the more, as we can easily imagine here a new
" circulus vitiosus." When the prostate has grown to
a certain degree, it causes a hindrance to the passage
of urine. The walls of the bladder become hypertro-
phied through a process in all respects like a myitis of
exceedingly long duration. The affection of the mus-
cles of the enlarged bladder extends also to the pros-
tate muscles (these muscles being so closely connected),
and so the hypertrophy of the prostate increases, also
the difficnlties of urination. That such a long-continued
muscular prostatitis is transformed into hypertrophy
and not into atrophy certainly depends on the great
quantity of blood, physiologically located in the genital
region.

Digitized by

Google

Vol. CXXX No. lO.] BOS f ON MSDWAL AND SVttGtOAl JOVttNAl.

241

W. White sayg * that one must, from the theories
ooncerniug prostate hypertrophies, provisionally accept
that of Velpeau (Thompson) : " The growth or growths,
which make op the enlargement in prostatic hyper-
trophy are analogous to those fibro-myomata so fre-
qaentiy found in the uterus." It seems to me, rather,
they are analogous to metritis bypertrophicans. Either
may be the case. But just as the fibro-myomata cer-
tainly have been preceded by an irritation, just as the
metritis (partialis or universalis) which are treated
with massage with the greatest success according to
Thnre Brandt's method, just so surely have we even
seen an incipient hypertrophy or a prostatitis removed
by massage. As metritis often depends on something
connected with the sexual life (sach as, for example,
after colds or hurts, especially during, or immediately
preceding or following menstruation, after partus, after
infectious coitus, etc.), we have here also a similarity
between the probable stages of both fibro-myomata or
at least of metritis bypertrophicans and the hypertro-
phis prostatsB senilis ; the latter of which, for reasons
mentioned, seems to stand in relation to the sexual life,
an assumption which is further strengthened by the
fact, that a bilateral castration diminishes the senile
prostatic hypertrophy.

When White asks, " In what cases is a purely ex-
pectant treatment proper ? " he answers, " Only in those
in which enlargement has produced no symptoms, and
catbeterism u easy and shows no residual urine." I
will answer, on the contrary, that every enlargement,
every tenderness of the prostate should be treated, in
the attempt to prevent hypertrophy, which the surgeon
can so beautifnllj operate upon, but with uncertainty
of cure.

It is unfortunately true that one seldom finds a per-
lon willing to be treated — at least for any length of
time — for a sickness which has not appeared ; but I
believe, if my comprehension of the beginning of " old
men's troubles " is the right one, both that it is the
duty of the physician to warn the young or middle-aged
man (who, moreover, has already noticed, perhaps, the
dropping and prolonged urination) of what can follow
if be lives ; and that there will be many who would
gladly undergo preventive treatment. If we find, even
accidentally, during the examination, the prostate in
ttadio irriUUUmit or in itatu myitieo, then the time
has come to attempt a treatment.

At present I know no better treatment than massage ;
bat if science finds a less laborious one, so much the
better.

It is assumed that faypertropbia prostate senilis must
have its curable stages. May attention be called to
this, and testimony from many directions throw light
on all sides of this important subject !

A Fbbnch Cask or Illegal Practice. — A cnri-
ODi case of illegal practice is reported from' the small
town of Sarrao in France. A woman dying in ad-
vanced pregnancy, the priest, who was present during
her last moments, persuaded a person who was at her
deathbed to perform Csesarean section, in order that
he might baptize the child. The authorities, consider-
ing this practice to be illegal, proceeded against the
operator, who was proved guilty of practising medicine
without a qualification, and was fined three dollars.

' llw PtiMDt Podtion of the Sorcerr of tha Hypertraphied Prot-
>«•- B7 J. William VUte, MJ>., Annals of Snrgarr, August, 1888,
P-lM.Mo.

fl^ebtcai ^ro0re$($(.

REPORT ON DERMATOLOGY.

BT JOBS T. BOWB2I, IC.D., BOSTON.

NEW BEHBUIB8 IN DEHHATOLOOT.

Wb quote from a careful ritume of this subject by
Dr. A. Strauss,' some of the more important items.

Europhen- Bayer. — Gottheil, of New York, saw the
best results from the use of this drug in ointment form,
in tertiary syphilitic ulcerations. Three cases were
quickly healed, one was much improved. Brilliant
results were also obtained in tinea versicolor, and in
tinea circinata. No eSect was produced on acne and
folliculitis. Pruritus senilis, alopecia areata, and
keratosis pilaris were improved, but no more than by
other methods. It proved of value in cases of chronic
eczema, of none in acute. Six out of seven cases of
psoriasis showed as good results as after treatment by
chrysarobin. The remedy was chiefiy used in the
form of a ten-per-cent. mntment, which proved unirri-
tating and innocuous. An Italian observer has noted
better results in venereal ulcers from europhen in
powder than from iodoform, while he was less success-
ful in syphilitic gummata. The absence of odor is
emphasized, in comparison with iodoform.

Amylum lodatum. — This has been recommended as
an application in place of iodine, in the following
ointment :

S Amylllodati. 3.0

LanoUn W.O

OL Calami stts. lU M.

Ruoreinci. — An amorphous, brown powder, smell-
ing of iodine, compounded of resorcin and iodoform.
Dr. Bielajew saw good results from this powder in
chancres, ulcers of the legs, scabies, psoriasis, eczema,
lichen, and in badly healing wounds. It has a very
favorable action on pruritus, but must be used in its
purity only in gangrenous, or very torpid ulcers.

K Renroinol S.0

Talolven 20.0 M.

Hydrargyrum Betoreino Acetiewn. — A dark-yellow,
crystalline powder, insoluble in water and mineral oils.
It was used by Ulmann in the form of injections for
syphilis, and was found to correspond in local reaction
with gray oil and thymol-mercury.

K Hydrarg. resonino-aeetloi . . . , S.6

Parafan. llqnid lUt

Lianolln aohydr 2^

(1 00m. oontaina 0,387 of the metal.)

THE TBBATMBNT OP ACNE.

Jamieson,' in an article on the subject of acne, asserts
that in treatment local measures are of the first im-
portance, while constitutional regulations are necessary
as an adjuvant. The increased secretion of the seba-
ceous glands must be combated by forcing out the
hardened sebum by a watch-key or comedo extractor,
taking care, however, to use no force. Afterward
douching, spraying or bathing in very hot water is
effective. The soap selected should be a neutral or
superfatted one, preferably one in which the alkali is
potash rather than soda. A superfatted soap with
sulphur, or Eichhoff's resorcin and salicylic soap may
be cautiously used. The auto-iuoculability of the acne
pustules may be combated by touching the beginning

> U onatdiaft. filr prakt. Dermatol., Bd. svt. No. 10.
* BritUh Jonmal of Dermatology, Jannary, 18M.

Digitized by

Google ,

242

BOSTOlT MUD W At AUt) StJSGICAL JOtJRifAL.

[Marcb 8, 1894.

papules with a solution of ichthyol in water, one part
to four, or wheu pustules have appeared, by paintiog
each with pure carbolic acid, and afterward coating
with flexible collodion. [The latter procedure shoold
be used spariogly and with {great caution. — Rbp. j
When the pustules are large aud inflamed they may
be covered with Unna's mercury and carbolic acid gntta-
percha-plaster-mnslin, as has been recommended by
Malcolm Morris in the case of boils. Lotions are more
efficient than oiiitments. Sulphur is of great value,
both for its action in exfoliating the outer layers of
epidermis, and in antagonizing the growth of the pas
micro-organisms. Precipitated sulphur with spirits of
camphor, glycerine and lime-water may be employed,
or when irritative effects are feared, the sulphur may
be combined simply with calamine lotion. It is usually
best to apply the sulphur lotion at night, washing it
off with tepid water in the morning, and then dusting
the face with a bland powder, as

K Aoid. borM 10.0

Zlno, oxid 10.0

Tsloi 80.0 M.

Boll ArmenliB, q. i.
Pl»t pnlrls coiorota.

For the ordinary case of acne rosacea the sulphur
and calamine lotion is advisable. The dilated vessels
may be destroyed by the scarifier or by electrolysis
with a fine needle. When the pnstules are very deep,
they may be opened with a fine knife ; and when large
aud obstinate, Unna's salicylic and creosote plaster as
used in lupus, is effective. The I>e8t are those of the
proportion of fifteen to thirty, or twenty to forty. The
plaster is cut into strips and accurately applied to the
whole area affected. It should be kept in place by a
muslin bandage or by a cotton mask. The plasters
are removed twice a day, the parts washed with super-
fatted potash soap and warm water, and then fresh
plaster applied. This is kept up until the face is too
tender for further application, or until the pustules
have flattened down. The raw surface is then covered
with Unna's zinc-ichthyol-salve-muslin. Afterward
the treatment with lotion and dusting powder may be
followed with effect.

Another method, which is hardly so satisfactory is
the use of a strong resorcin paste, to exfoliate the
epidermis.

K Bnoroin. alb. 40.0

Zlno. oxld ao.O

KaoliD 2.0

Adipla 2S.0 M.

It is rubbed on lightly twice a day, without the nse
of water, and occasions some inflammation and pain.
When the latter effect has been produced, a simple
powder should be substituted until the desquamation has
ceased, when the sulphur lotions may be employed.

Internal treatment consists in combating all errors
that can be discovered. A wineglassful of Hanyadi
Janos water in a tumbler of hot water taken on rising
is an effective aperient, and iron, alone or in combi-
nation with sulphate of magnesia, is often indicated.
Ichthyol is recommended in capsules containing from
three to five minims twice a day.

Diet is to be carefully regulated. Water is to be
taken freely midway between meals. Hot liquids and
spiced dishes are to be avoided in acne rosacea or when
there is a tendency to flush ; as well as exposure to
heat from the sun, or to the snow or sea. A cold
sponge-bath in the morning, with the addition of salt
to the water, is a stimulant to the cutaneous moscles.

Riding is especially extolled as the best form of outpof-
door exercise.

THE INFLCKNCE OF 80LAB BATS ON THB SKIN.

Bowlei * considers from his observations on sonbam
that the subject is of wider scope than might be sup-
posed, and one that must claim the attention, not only
of dermatologists, but of physicians, surgeons, physi-
ologists and physicists. A previous paper by the same
writer was published in the Alpine Journal in Novem-
ber, 1888.

It is admitted that the son on snow burns more
quickly than on rocks or in valleys, although the heat
may be felt more in the latter situations. Veils, masks
and snow-glasses are only adopted when the snow is
reached. This seems singular, in consideration of the
fact that the heat rays must be occupied in melting the
snow and thus rendered latent. Glass and iron work-
ers do not become burnt, although subjected to an in-
tense heat ; and it is maintained that the radiation from
heated rocks and valleys causes a far greater heat than
can be present on the snow — and yet one is not sun-
burnt. Hence there must be some other factor in
sunburn than heat alone. Tyndall declared that be
was never more burnt on the snows of the Alps than
he was while experimenting with the electric light at
the North Foreland lighthouse.

Instances are enumerated where several people have
been sunburnt on the same day (when the heat was
not excessive) who had never been burnt before; and
these experiences raise the suggestion that the sun's
rays are at times acted upon by atmospheric, electrical
or other causes in such a way as to make their effect
similar to that produced when the rays are reflected
from snow. Sunlight reflected from freshly fallen
snow has a greater burning force than that reflected
from older snow. The writer has made numerous
experiments in the Alps that show that when the face
is painted there is no burning, and that on snow where
one burns most, the temperature is lower than that on
rooks and in heated valleys. The experience of an
English officer in India, who had shown great suscepti-
bility to the effects of the sun's rays is related. He
had noticed that exposure to heat rays emanating from
a source of low chemical activity, was never injurious
in its effects, while men working with powerful arc
electrical lights, as search-lighta, were constantly af-
fected in the same way as from direct solar rays,
although the radiant heat from the search-lights was
comparatively mild. From this he concluded that sun-
stroke and sun-fever were not due so much to the heat
of the sun as to the chemical power of the rays ; and
hence he argued that if he " treated himself as a sensi-
tive plate, and enveloped his body in any color be-
tween yellow and ruby-red, he should protect himself
to the same degree as the photographer protects his
plate." Acting on this theory, he had all his clothes
and hats lined with a cheap material of an orange
color, with the result that he was able to bear iuteijse
heat much better than his comrades ; while if the
orange material were removed, the old susceptibility
returned.

Bays reflected from the snow have an especial in-
fluence in producing pigment changes in the skins
This pigment, which is derived from the vessels, may
be regarded as an effort on the part of nature to pro-
tect the nerves and vessels of the skin from further

> BriUsh Journal of Dermatolonr, Angnit, ISSS.

Digitized by

Google

Vol. CXXX, No. la] BOSTON MEDIO AL AND SUS6I0AL JOURNAL.

243

irritation. It is asserted that snails, slugs, licards and
other aaimals assame darker colors the nearer they
tre to the snow. The people who winter in Davos
become moch darker than do those who summer there,
although the suu is much stronger than in winter.
Another peculiarity is the brown color of the ch&lets
of the higher Alps, while those in less elevated regions,
which are not touched by rays reflected from snow, are
learcely, if at all, so affected. The writer has investi-
gated this subject with care, and has found that those
parts of the ch&lets so situated that no rays reflected
from the snow oonld reach them, were of a dirty-white
color.

His conclusions are : (1) That heat of itself is not
the cause of sunburn ; (2) that there is strong evidence
for believing that it is caused by the violet or ultra-
violet rays of lights reflected from the snow, which
reflected light is not necessarily of the same quality as
that which is incident ; (8) Captain Abney finds that
the violet or ultra-violet rays are very strong at high
altitodes, and believes that altitude has much to do with
sanbum; (4) that altitude alone does not explain sun-
burn, for one may not be sunburnt on rocks, say at
10,000 feet, and yet be immediately affected on de-
scending to a glacier 3,000 or 4,000 feet lower down ;
(5) that sunburn and snow-blindness arise from sim-
ilar causes, and that sunstroke may be associated with
them; (6) that rays from the electric light produce
moch the same effect as sun-rays reflected from snow ;
(7) that the bronzing of the skin and the browning of
the wooden chalets are probably produced by rays re-
flected from snow.

The "summer eruptions" of Hutchinson [Basin's
hydroa vacciniforme — Rbp.] — eczema solare, etc. —
tre briefly mentioned at the close as pathological con-
ditions produced by the sun's rays, upon which the
bearing of the foregoing observations must be deter-
mined by further study.

PJiTHOLOOIGAL ANATOHT OF KBTTHKHA MCLTI-
FORME AND PCBF0KA.

It has been repeatedly pointed out that erythema
moltiforme may occur symptomatically in the course of
various infectious and inflammatory diseases, especially
those of a suppurative character. Among these dis-
eases the most prominent are cholera, typhus, septicee-
mia, nraeoiia, endocarditis, diphtheria, gonorrhcea and
syphilis. Boeck has noted the appearance of erythema
after angina, and abscesses of the tonsils. Finger him-
self has seen two instances: one of erythema ma-
calatam et figuratum in a severe case of ursamia;
the other of erythema annulare of the backs of the
hands and forehead, in a case where an extensive ul-
cerated initial lesion was found in the rectum.

These erythemata may be interpreted in various
ways. In the cases of ursemic erythema, we may sup-
pose it a toxic erythema. If in the ursemic cases there
is a suppurative process in the kidneys, or if, as in the
esse of abscess of the tonsils, there are deep-lying,
local foci of suppuration, the explanation is twofold.
It may be due to the absorption of toxines from the
pas into the circulation ; and in this case the erythema
is a toxic one, belonging in the same class with the
•rjithema ab ingestis, and the drug eruptions. But it
may also be surmised that a part of the organisms that
were the cause of the pus formation, find their way
into (he skiu, and here exercise a local pathological
* Kaget : AreUr. t, D«rm. n. Syph., 18S3, Heft t.

action. In this case the erythema would be classed as
an infectious erythema, caused by a metastasis of bac-
terial nature. These erythemata are frequently de-
scribed, and some writers have inclined to the one
view, some to the other. Streptococci have been found
by Neumann in the urine, in a case of typhoid compli-
cated with erythema maculatum ; and in the abscesses
of the skin by Laufer in a case of typhoid accompa-
nied by severe erythema multiforme.

Two cases were examined anatomically by Finger.
The first case had been diagnosticated as typhus fever,
in that, three days before death a thickly-diffused papu-
lar erythema had appeared over the body, especially
marked upon the backs of the hands and feet. The
autopsy showed a disseminated diphtheritic process,
beginning on the soft palate and pharynx, and extend-
ing down the oesophagus into the stomach. There
was pericarditis, double pleurisy and metastatic foci in
the kidneys and myocardium. From the latter, pure
cultures of the streptococcus pyogenes were obtained.

Histological examination of the papules gave the
usual meagre changes seen in an erythema. Bacteri-
ologically, however, large numbers of cocci were found,
solely in the vessels. The papillary blood-vessels were
so densely packed with them that they gave the im-
pression of injected capillaries. In the reticular layer
they were found mostly in clumps, situated along the
walls of the larger blood-vessels, and were to be seen
also in the vessels about the sweat-glands and in those
of the subcutaneous tissue. These cocci were arranged
in chains and were constant in their appearance ; and
as the streptococcus pyogenes was cultivated from the
metastases in the kidney and myocardium, it is fair to
assume that they were the same species. Finger,
therefore, considers that the papules of the erythema
papulatum were directly produced by the streptococcus
pyogenes, carried to the skin through the circulation.
The affection may be described as a metastatic, bacte-
rial dermatitis.

The second case revealed at the autopsy, fatty de-
generation of the heart, slight atheroma of the aorta,
slight enlargement of the spleen, subacute parenchy-
matous nephritis of both kidneys, together with nu-
merous spots of purpura on the trunk and the extrem-
ities.

Microscopically there were found extravasations of
red blood-globules in the papillary and reticular layers
of the corium, and a remarkable number of polyuu-
clear leucocyteo. The latter were found to be espe-
cially numerous in the periphery of the hemorrhagic
foci. Small, round cocci, arranged singly or in pairs,
were found scattered through the hsemorrhagic foci,
and especially in their periphery. They were also
fonnd in numerous blood-vessels. The microscopic
examination shows, therefore, that there was not sim-
ply a haemorrhage, but also an inflammation, as proved
by the presence of the numerous polyuuclear leuco-
cytes. These pus corpuscles point to a local inflam-
matory irritation, such as extravasated blood cannot
cause, but which is doubtless produced by the cocci
which are brought to the skin by the blood-vessels, and
cause both the haemorrhages and the inflammatory
appearances.

These two cases, therefore, are proved by the micro-
scopic and bacteriological examinations to be neither
angio neurotic nor toxic erythemata, but metastatic
bacterial dermatitides. It i6 not possible to predict
the frequency of these forms, yet it is probable that

Digitized by

Google

244

BOSTON MBDIOAL AND SURGICAL JOURNAL.

[Mabob 8, 18H

many cases of symptomatic erythema, especially those
associated with suppurative processes, as toosillary
abscess, suppurative nephritis, pyelo-nephritis and cys-
titis, have the same etiology. The same may be said
of the erythemata in severe typhoid, endocarditis and
puerperal affections. The idiopathic erythemata prob-
ably have a different etiology. Pieces of skin from
two cases of the latter (which bad been in alcohol for
a long time) were examined, with negative result. A
negative result was also recorded in six cases of pur-
pura, which had appeared iu connection with endocar-
ditis, pneumonia and diphtheria.

(Tobt continned.)

VitpQttit of Jtotietlt0.

BOSTON SOCIETY FOR MEDICAL IMPROVE-
MENT.

J. T. aOWXir. M.D., SaCRBTAKT.

Rkoclar meeting, Monday, January 8, 1894, the
President, Dr. C. F. Folsom in the chair.
Db. 6. W. Gat showed a case of

LIOATIOM OF BOTH GOKUON OABOTID ARTKBIBB

in a healthy-looking man twenty-seven years of age.
When he was seven years old, a small bunch was
noticed npon the left side of his neck just above the
collar-bone. It grew very slowly, till three years ago,
since which time the size had markedly increased, until
at the time of operation, it was as large as a small
orange. The tumor had always pulsated ; this was
controlled by pressure upon the artery below.

On July 31, 1892, the left common carotid artery
was tied an inch above the clavicle with two silk liga-
tures half an inch apart, and the vessel was divided
between them. No shock or other disturbance of any
sort followed the operation. The patient was sitting
np in two weeks, and was discharged well in three
weeks.

On June 13, 1893, the right common carotid artery
of this man was tied in the same manner, as described
above, for a small aneurism situated at the bifurcation
into the external and internal carotids opposite the top
of the thyroid cartilage. This tumor, an inch in diam-
eter, pulsated like the one upon the left side before
operation, and had been in existence ten years.

In exposing the artery, a large vein, probably the
internal jugular, was wounded with the director, giv-
ing rise to a troublesome beemorrhage from its location
at the bottom of a deep wound. Ou coming out from
under the influence of the anaesthetic, it was found that
the patient's voice was very hoarse. A laryngoscopic
examination by Dr. Farlow showed paralysis of the
right vocal cord, due undoubtedly to entanglement of
the recurrent laryngeal nerve in the ligature applied to
the vein.

The wonnd healed by first intention, and the man
left the hospital in three weeks. Both tumors were
free from pulsation. At the present time, the tumor
upon the right side has disappeared entirely. The
original tumor upon the left side is nearly gone, but
about three months ago, that is, three or four months
aftor the last operation, a small pulsating swelling
made its appearance over the upper edge of the tumor
upon the left side. Evidently a small collateral branch

has found its way into the original sac, and will require
further attention. The man is well with this excep-
tion, and is at work in a dental instrument manufsc-
tory. The voice is as good as ever it was, except be-
ing a little weak, when he attempts to shoot. The
hoarseness has entirely disappeared. There were no
cerebral symptoms following either operation.
Dr. Mtles Standibh read a paper on

TWO OASES OF CHANCRE OF THE ETELID.^

Db. Abnbb Post : I have very little to add to Dr.
Standish's interesting account of the two cases. The
chancre of the eyelid occurs occasionally in other than
ophthalmic dinios. I am pretty sure I have seen two
cases. The first was referred to me by Dr. H. W.
Williams. The ulceration occurred rather on the ex-
ternal surface of the lower lid, so that its appearance
differed somewhat from that described by Dr. Standish,
as it would naturally. In Dr. Standish's second case
the ulceration was apon the conjunctival surface, where
it had that grayish base which is described in all these
cases and which resembles more or less closely the
surface sometimes seen under the prepuce. In the first
case of mine the ulceration was very slight and had
that reddish appearance which is common to chancres
whose ulcerated surface is exposed to the air. It was
surrounded by an indurated areola and resembled the
chancre more closely than anything else ; and it may
be worth while to mention that this woman on whom
this supposed chancre occurred was the wife of a ndl-
road brakeman employed somewhere in the vicinity of
this city, though her home was either in Vermont or
in New Hampshire. The brakeman I never saw.
This sore had existed some time, the induration in-
creasing. It had been treated in varions ways ; and I
simply suggest the primary syphilitic source as the
most probable solution of its cure. There were no
pre-anricular glands to be felt, nor were the glands at
the angle of the jaw enlarged at all. It began to di-
minish very slowly, bnt very steadily under the influ-
ence of mercurials internally, and vanished. She was
under my observation for a few weeks ; but as soon as
the supposed primary sore had disappeared, she disap-
peared, and whether the diagnosis was ever confirmed
in any subsequent history I do not know. She was
confined to her bed immediately afterwards by some
supposed disease of the chest which was acato. Some
time or other I shall know the subsequent history of
that case ; and if it proves to be syphilitic I shall be
very glad to report it.

The other case is the case of a child of five, who
was healthy np to the time of her infection. The
father and mother had become syphilitic after her birth.
They had a syphilitic child in the family, and this little
syphilitic child lived with the syphilitic father and
mother and baby in close intercourse. Her syphilis
was evident from glandular enlargement and syphilitic
papules which were particularly prominent about the
region of the vulva and about the mouth and nose.
The mother gave the history of the appearance of a
sore on the eyelid which she supposed was an ordinary
stye. That was the first thing. The eruption appeared
a few weeks after. When I last saw her the other
eruption had disappeared. There still remained on the
spot of the supposed stye a certain amount of thicken-
ing, such a condition as one finds after primary lesions
on other parts of the body. The pre-auricular glaud

' Sm page 287 ot the Joniul.

Digitized by

Google

oi.. GXXX, No. 10.1 BOSTON MBDIOAL AND SURGICAL JOURNAL.

245

BIS not enlarged, though the glands about the neck
ere. I can only say that in her case I believe that
le Bore on the eyelid was the primary sore, the point
• 'which syphilis entered the system.

I am particularly glad to have such cases reported,
ecaase it serves to emphasize the fact that syphilis is
ot simply a disease of venereal origin, but that it is a
ise&se which is communicated from one individual to
nother, oo matter what the contact or whether the
ontacC be immediate or mediate. The primary sores
hat occur about the face are very numerous indeed ;
. have within a month seen four primary sores of the
ip> Towels are by no means the only media by which
inch iaoculation takes place. During the same time I
liave also seen four physicians who have been inocu*
lated upon the hand in some shape or other. It is, I
think, hardly extending the subject too widely to draw
attention to the other numerous cases which exist about
us in which syphilis has been contracted in some other
than the orthodox manner.

Db. E. Wigglesworth : I agree entirely in re-
gard to the necessity for such papers as this, and I am
sorry that I cannot from memory report any cases oc-
curring in my own individual practice. The public at
large are hardly anatomical enough to recognize the
distinctions of specialties, and these cases go to the
ophthalmologist instead of the dermatologist, as a rule.
There is one thing to be said; namely, that these
lesions do not always occur at the entrance of the
lachrymal duct. They may be found even inside of
the lids, as well as outside, or upon the border of the
lids. They may be found upon the caruncle itself;
and these are, perhaps, the worst cases of all. I re-
call with reference to the number of reported cases,
which Dr. Standish tells us is now about thirty, that
when I was in Vienna, in 1866, the cases amounted to
only ten. Since then I have not taken the opportu-
nity to look up the number. At that time there were
only ten, including those on all parts of the lids, both
external and internal. There are now in the Warren
Museum three of the preparations of Baretta, which
represent very well the appearance of this lesion
before, daring and after treatment. The sclerosis was
upon the upper eyelid of a seamstress.

Oar first duty, of course, is to decide whether the
lesion is in its nature specific ; but even then there is
some danger of error as to stage, since papules, or
other manifestations of secondary lesions, may occur
here as well as elsewhere ; and it is not relatively rare
to find even gummata in this situation, which belong,
of course, to the later stages. The method of infec-
tion is by means of the fingers, as the rule. This
seamstress had, I think, been sewing some bauds to be
applied to a person, and perhaps applied them herself,
and then carried the finger to the eye. Another case
is reported of a man engaged in the "orthodox"
practices alluded to by Dr. Post, who felt an itching
in his eye, and carried the hand to the eye and rubbed
it violently for quite a while. This was followed by a
primary lesion. There are other cases where, at
acconcbements, physicians have infected themselves.
Bat the fact of primary lesions occurring upon the
face and other parts, to which Dr. Post alluded, was
very well shown this morning in my clinic at the City
Hoapital. The wife of a laboring man appeared with
two primary lesions, which fact is, of itself, relatively
rare, jast below the angle of the mouth, on the left-
hsnd tide ; these were of two months' or more dura-

tion. She gave a very good history of initial manifes-
tations; that is to say, red spots, and subsequently
papules with dry crusts on top ; and, what is especially
interesting, stated that they passed by degrees from
that condition into the secondary stage of mucous
papules ; and they are now in the condition of mucous
papules, and very well marked. The rest of the body
is covered with papules. The general treatment is, of
course, the same as when the initial lesion is situated
elsewhere.

Ds. F. B. Grrenodoh: I have never seen a
chancre on the eyelid. Of course, there is Ao reason
why it should not occur there, the only factor being to
have the syphilitic virus in contact with the mucous
membrane or skin where it may be absorbed, and
we see the primary lesion appear in nil sorts of places.
Dr. Standish does not mention any examination to prove
that there was no primary lesion anywhere else. I have
no question of the diagnosis or of the primary lesion ;
but at the same time, in all such interesting cases as this,
I think the possibility of primary lesion on the penis
or somewhere else ought to be excluded. In the first
case he reports I am rather astonished at the size of
the glands — as large as a hen's egg. I have seen
several chancres about the lips, and one or two on the
face, but never saw the glands anywhere near as large
as that. I think we owe a great deal to Dr. Standish
for his interesting paper.

Dr. Post : May I refer to one remark of Dr. Wig-
glesworth in regard to the rarity of a double inocula-
tion, or two primary sores at the same time? My
own experience differs somewhat from Dr. Wiggles-
worth's, apparently. It is customary to say that the
primary sore of syphilis is single, while non-syphilitic
venereal sores are multiple. There is certainly some
foundation for this, but 1 should prefer to say that in
the majority of cases the primary sore is single ; but it
may be multiple, exactly as a man may be vaccinated
in one spot or in several. It seems to me that the
stress that is laid upon a single sore as a diagnostic
point of the initial lesiou of syphilis is carried too far,
and leads to error.

Dr. Grbenocgh: I should like to endorse Dr.
Post's remarks. Dr. Chenery, who was my assistant
at the Dispensary, made statistics. I have forgotten
the number, but there are certainly quite a number of
cases in which there were two primary sores. I think
I have seen three.

Dr. Wigglesworth : I merely spoke of the rela-
tive frequency. Of course, what Dr. Post alludes to
is perfectly true. The case was of especial interest,
not only from the comparative rarity of multiple
lesions, but also from the fact that we had.here two
(primary) lesions occurring at the same time, and of
the same size, close together, upon an unusual situa-
tion, and passing by degrees into (secondary) mucous
papules. There was a sore on the mouth of the hus-
band, so that there was an explanation of the source
of inoculation.

Dr. Standish: Concerning the question of the
possibility of these patients having an initial lesion
somewhere else, in the first case we had a physical
examination, and there was no lesion anywhere else ;
in the second case the man was very intractable, and
no such examination was possible. The glands in the
neck were very large in the second case — so much so
as to obliterate the concavity under the angle of the
jaw, so that the line of the face ran straight down to

Digitized by

Google

246

BOSTON MEDICAL AXD SURGICAL JOURNAL.

[M^BOH 8, 1891

the shoulder. We mast remember he was suffering
from pharyngitis and tonsillitis, which may bare ag-
gravated matters very mnch. The sitoation of these
initial lesions, of coarse, may be anywhere oa the out-
side or inside of the lid.

Db. M. H. Riohabdson showed

SPECIMENS OF TKBHIFOBH APFENDIOES PBE8ENTIHO
CNDSCAL FBATCBE8.*

Hecettt gtteramre«

Atleu of Clinical Medicine. By Btboh Bbahwell,
M.D., F.RC.P., F.RS. Edin., Assistant Physician
to the Edinbargh Royal Infirmary, etc Vol. II,
Parts II and 111. Edinburgh : Printed by T. and A.
Constable. 1893.

The second volume of this very handsome " Atlas
of Clinical Medicine" is now completed with thejssue
of the third part. We have already noticed the pre-
vious issues. In the second and third parts of the
second volume, the standard promised at the inception
of the work is maintained, and the original excellence
of letter-press and plates continues to be realized.

The text of Part II is largely devoted to syphilis
and Asiatic cholera, and most of the plates are illus-
trative of the former disease. The active treatment of
the primary sore, and the exhibition of internal reme-
dies before the appearance of secondary manifestations,
as advocated in the text, has the authority of Hutchin-
son, but is not generally regarded in this country as
having the sanction of our best authorities.

Part III is devoted to exophthalmic goitre, acrome-
galy, exfoliative epidemic dermatitis, unilateral hy-
pertrophy of the face. The plates illustrative of
acromegaly, taken from a so-called " giantess," are
very characteristic.

Clinical Lectures on Abdominal Hernia ; chiefly in
Relation to Treatment, including the Radical Cure.
By William H. Bennett, F.B.C.S., Surgeon to
St. George's Hospital, Member of the Board of Ex-
aminers for the Fellowship, Royal College of Sur-
geons of England, and Lecturer on Clinical Sui^ry
in St. George's Hospital Medical School. With
twelve diagrams. London and New York : Long-
mans, Green & Co. 1893.

These lectures were delivered at St. George's Hospi-
tal, and include the cases occurring in the author's
wards. The work has the merit of being what it rep-
resents, clinical lectures on hernia. It is a valuable
one, in that it records the ideas of the writer, a man of
ripe experience, who has paid considerable attention to
this subject. It is a book that can be read with in-
terest by all, and may be of value to practitioners who
meet obscure bemise, which are often very perplexing.
A good portion of the lectures is devoted to the symp-
toms of strangulated hernia. Formerly the symptoma-
tology of hernia was of greater importance than now.
The pre-antiseptic fear of opening the sac of a hernia
is gone, we hope never to return. To-day the con-
servative surgeon explores any tumor occupying the
seat of a hernia if there are present any symptoms
suggesting the possibility of strangulation. The dan-
ger of this exploration under modern methods is far
less than the inevitable errors in judgment of attempt-
ing to mentally eliminate strangulated hernia.
* See page 2S2 of the Jonraal.

THE BOSTON

THURSDAY, MARCH 8. 1894.

A J&mnua (tfUedioint, Surgery, and Allied Seitmoei.inMUkei at
Boetom, ttteUt, fry the mido'tigned,

BI7B80RIPTIOK TxKXB : fB.OO per yeca; i» advanee, poitagt paid,
f&r the United State; Canada and Mexico ; $e.t6 per year far aXl fer-
eign eowitriee beUmging to the Poital VnUm.

All eomanmieationt for the Sdtlor, and all boott far Kciew, thnid
be addreeied to the Editor qfthe Bottom Medical and Surgieal Jourmal,
283 Weuhington Street, Botton.

All letteri oontaining tnuineMt commtmieationt. or retarimg (o iht
pyMUxMan, wabeariptiam, or advertiilng departmeiH tff tldt Jimnal,
ihould be addrttied to the ttnderiigned.

Semittanoet ihouid be made by money-order, draft or ngUitni
letter.payable to

DAMRELL * UPHAH,
283 Washixotoh Streit, Bostos, Has*.

CHRONIC ARSENICAL 1>0IS0NIN6 FROM
WALL-FAPEKS AND FABRICS.

The question as to the form in which arsenic enters
the system in cases of chronic poisoning from arsenical
wall-papers has been the subject of much controversy.
The theory that the symptoms are due in some cases
to the irritant action of detached particles of arsenical
pigment has received important confirmation in the
frequent detection of arsenic in the dust collected from
rooms containing arsenical papers. On the other hand,
the occurrence of numerous cases of poisoning under
conditions most unfavorable to the separation of arseni-
cal dust has led to the theory that, under certain con-
ditions, some gaseous or volatile arsenical compound
may be set free from arsenical papers.

Many experiments have been made for the purpose
of testing the latter theory, but the results have been,
for the most part, adverse, until the recent investiga-
tions of Gosio,^ who found that a volatile arsenical
compound could be formed by the action of moulds
on organic matter containing arsenic. Hamberg and
Bischoff alone of the earlier investigators obtained a
volatile compound, which they believed to be arseniu-
retted hydrogen. The results of Gosio's recent inves-
ti^tions suggest, however, that these earlier views as
to the nature of the volatile compound formed were
probably erroneous ; though it seems quite certain that
a volatile arsenical compound of some kind was ob-
tained in the experiments of the two authors men-
tioned.

Two recent papers by Prof. Charles R. Sanger,* of
Washington University, St. Louis, who has repeated
the work of Gosio and proved its correctness, form,
from a chemical point of view, the most important con-
tribution to the literature of this subject which has yet
appeared in this country.

In his first paper the author gives a lengthy bat in-
teresting review of the investigations relative to the

< The Journal, cxxtI, 201 ; cxxrii, 195 ; oxxrtli, MO.
' Proeeediugi of (be American Academy of Arts and Scieaoei,
Tol. xxix.

Digitized by

Google

Vol. CXXX, No. lO.] BOSTON MEDICAL AND SURGICAL JOURNAL.

247

■object which have been made up to the present time,
indading those of Gosio, and describes very minutely
the various experiments which he has himself made,
iDclading some earlier ones hitherto unpublished, the
results of which were, owing to unsuitable conditions,
adverse to the theory of the formation of a volatile
compound.

A description of these experiments cannot be given,
for obvions reasons, in the editorial column. The fact,
however, that Giosio's results have been substantiated
by so careful an investigator as Sanger, justifies the
following brief risume taken from Sanger's papers :

It appears that a volatile compound is generated by
the action of the following moulds on arsenical organic
matter : Penicinium hrevicauU, Mucor mueedo, Asper-
gillrnn virmt, and AtpergiUum glaucum, a few others
having been foand which have a slight action. Of these
the most intense action is caused by the first, a mould
discovered on decaying paper, though Atueor mueedo,
which is more widespread than the first, is only a little
less active. The conditions for development of the
compound by these moulds are moisture, a temperature
from 15 to 86° C. (60 to 95° F.), and a supply of
oxygen, without which no action takes place. A large
amonnt af arsenic retards the growth, which goes on
best in a ground containing 0.01 to 0.05 per cent. The
best nutritive material is a carbohydrate. The devel-
opment may take place in presence of arsenious oxide
or its derivatives, or of arseniates, though the latter
seem to Sanger to have given the best results. Little
or no action is obtained from the sulphides.

The nature of the volatile compound is as yet un-
known. It is not arseniuretted hydrogen, and indeed
it is questionable if any arseniuretted hydrogen is
formed. Sanger is inclined to the opinion that it is an
organic derivative of arsenic pentoxide. It has, bow-
ever, little resemblance to any of these derivatives thus
far isolated.

The author attributes the adverse results obtained
in his earlier experiments, and the similar results ob-
fauned by some of the other investigators to the fact
that there was either too much arsenic for the specific
bacteria to tolerate, or else the latter were not present.
A partial explanation is possibly found in the fact that
many of the earlier investigations were made upon the
assnmptioQ that the volatile compound formed, if any,
most be arseniuretted hydrogen.

The formation of a volatile compound from decay-
ing arsenical matter may now be regarded as settled
beyond any reasonable doubt by the investigations of
Hamberg, Gosio and Sanger. In this formation we
have a complete explanation of those cases of chronic
arsenical poisoning which occur under condition^ in
which the separation of arsenical dust cannot be ad-
mitted. Gosio, while admitting that poisoning from
arsenical papers may at timet be due to the inhalation
of solid particles mechanically detached from the paper,
believes that in a majority of cases the arsenic is ab-
sorbed in the form of the volatile compound.
Sanger's second ^per is made up largely of the

record of published cases of chronic arsenical poisoning
in which analytical work is included, and of cases which
have come to his own notice, in which analyses of wall-
paper and urine were made. The chief value of this
paper is found in the fact that the analyses, both of
paper and urine, in the author's own cases were quan-
titative. He finds that the amonnt of arsenic elimi-
nated by the kidneys is very small, varying from
0.002 mgr. to 0.068 mgm. per litre. These resnlU
are in accord with those obtained by others who have
had experience in this class of cases.

The author concludes that the elimination of arsenic
by the kidneys in cases of wall-paper poisoning is very
slow. He apparently bases his conclusions upon the
fact that, in the cases reported by him, the time during
which arsenic still appeared in the urine was usually
very long. In five gases, for example, arsenic was still
detected after the lapse of 60, 96, 100, 127 and 140
days respectively. The author's conclusions on this
point are justifiable only in case freedom from expos-
ure to other sources of arsenic during the periods
named was secured. There is, however, no evidence
whatever of any such freedom in the history of the
cases reported by him. The existence of other sources
can hardly be denied. There are apparently some which
are as yet undetected. For this reason the settlement
of the question of rate of elimination is, we believe, at-
tended with peculiar difficulties, and much work must
yet be done before the time required for complete elimi-
nation can be determined with any degree of accuracy.
Sanger thinks that the question of the limit which can
be set to the dangerous amount of arsenic in a wall-
paper is one which should be considered very carefully,
since Gosio's work and his own has shown that a very
small amount of arsenic may be quite as good a source
of the volatile compound as a very large amount. He
does not think, with the chances for the formation of
the volatile compound, that 0.1 gr. per square yard
can be pronounced with certainty harmless; and sug-
gests that a quantitative analysis of each arsenical
paper be made, in order that the physician may himself
decide as to whether the paper should be rejected or
not.

A NEW BILL FOR THE ESTABLISHMENT OF
A NATIONAL BUREAU OF HEALTH.

The new bill, prepared by a Committee of the
New York Academy of Medicine, for the establish-
ment of a National Bureau of Health in the Depart-
ment of the Interior, promises, if it meet with favor-
able consideration in Congress, to give to the country
the most satisfactory national health organization that
has yet been proposed.

The Bureau, in accordance with the provision of the
bill, would consist of a Commissioner, appointed by the
President, and an Advisory Council made up of dele-
gates, one from each State, designated for this service
by the respective governors.

I^ as might reasonably be expected, the members

Digitized by

Google

248

JiOSTOH MEDICAL AHJ) SLAGlCAl JOlhUAL.

t^iBcu 8, 1894.

of the Council are selected from the State Boards of
Health, there would theu be brought to the support of
the natioDal organizatiou the influeDce of a body of
men each of whom has a well-recognized position in
his own communitj, and a legitimate influence upon
the representatives of his State in Congress. Their
presence on a national board would go far to remove
the vagae fears that have prevailed in some quarters
as to the tendency of a parely central organization to
nsurp powers, which could more safely and wisely be
left to local authorities.

The duties of the Bureau would be to collect and
diffuse information upon matters affecting the public
health, including statistics of sickness and mortality in
the several States ; the investigation of experimental
and other methods and means of prevention of the
causes of diseases ; the collection of information with
regard to the prevalence of contagious and epidemic
diseases, both in this and other countries ; the publica-
tion of the information thus obtained in a weekly
bulletin ; to prepare rules and regulations for securing
the best sanitary condition of vessels from foreign
ports, and for the prevention of the introduction of
infectious diseases into the United States, and their
spread from one State into another, which rules, when
approved by the President of the United States, shall
have the force of law ; and to ascertain, by a suitable
system of inspection, that these rules are properly
carried out and enforced ; to advise and inform the
several departments of the government, and executives
and health authorities of the several States on such
questions as may be submitted by them to it, or when-
ever, in the opinion of the Bureau, such advice and
information may tend to the preservation and improve-
ment of the public health ; and in general to be the
agent of the general government in taking such action
as will most effectually protect and promote the health
of the people of the United States.

The act provides that this Bureau shall be responsi-
ble for the making of those rules and regulations which
are the foundation of systems of quarantine between
the various States of the Union as well as between
Nations ; yet these rules, having first received the ap-
proval of the President, are to be executed, as hither-
to, under the supervision and authority of the Treasury
Department. While this limitation of the Treasury
Department to purely executive functions may be dis-
tasteful to the Marine-Hospital Service, it can hardly
be claimed, on the other hand, that this body could
adequately perform the multifarious duties above set
forth.

One function is bestowed upon the Bureau, which
is peculiar to this bill, and would probably be of great
benefit — the duty of the Bureau to inspect and report
upon the conduct of the quarantine establishments
formed under the provisions of this act.

State and municipal authorities are permitted to en-
force, if they so elect, such measures as are directed
by the President, in accordance with the recommend-
ations of (he Bureau ; but if such authorities fail or

refuse so to do, then the President shall enforce the
rules by such means as may seem appropriate to him.

The quarantine sections of the bill have, evidently,
been very carefully framed and follow closely the
provisions of Senator Harris's bill. No member of the
Senate has been more interested in public health legis-
lation than the member from 'Tennessee, nor is there
any one whose opinion would have more weight in that
body.

The Bureau is especially directed to take snch action,
by correspondence or conference, as will tend most
effectually to secure the co-operation of State and local,
boards of health in establishing and maintaining accu-
rate systems of notification of the existence and pro-
gress of contagions and infectious diseases ; and to
extend, if possible, such systems to foreign countries.

In general, the motive that appears to have prevailed
in the making of this bill is the one which has led to
the most useful public health bodies which the country
has so far had. That is to say, the intention seemed
to have been to create a central health authority, the
business of which shall be the collection of all sanitary
knowledge and the prompt diffusion of the same.

If this Bureau is able to deserve the confidence of
the country, experience with similar bodies tell us that
executive functions will from time to time be given to it.
The almost hopeless confusion in which the present
Congress is involved, may, possibly, prevent this new
measure from receiving the consideration it fairly de-
serves ; but the bill has been so carefully prepared and
so wisely framed that we hope it may be insistently pre-
sented at Washington until favorable action is taken.

MEDICAL NOTES.

Yellow Fkvee at Rio Janeiro. — Yellow fever
is reported to be rapidly increasing in Rio Janeiro, the
deaths being more than twenty each day.

A New Obifioial Jodhnal. — A new medical
journal has been published in Paris, devoted to orificial
medicine. It is edited by M. D. Magitot and is to be
known as the Bevue MentueUe de Stomatologie.

HoNOKS FOB Profkssob Henooh. — The Em-
peror of Germany has conferred the Order of the Bed
Eagle, of the Second Class, with the crown and oak
leaves, on Professor Henoch who has retired from the
chair of children's diseases in the University of Berlin.

A Pbtsician's House Injubed bt Dtnamitk. —
The house of Dr. J. £. Baker in Lancaster, Pa., was
seriously damaged last week by a dynamite cartridge
which' some mischievously inclined person exploded
under the porch. It is not often that physicians are
thus molested, as even the wantonly malicious seem to
have a little respect for a doctor.

The New York Vegetaeian Society Dinner.
— The New York Vegetarian Society held its second
annual dinner last week, and had a most elaborate
menu. Among the courses were er«Mi of celery soup;

Digitized by

Google

Vol. CXZX, No. 10.] BOSTON MEDICAL AND SDSGICJL JODJtNJL.

249

Brauels spronU, cream sauce ; Nesselroode pudding ;
Stilton, Roquefort, and Camembert cheese. It is to be
presumed that these were all made either with coooa-
not milk or the juice of the milk-weed.

Death of a Hospital Housb-Offiokb. — Mr.
Lewis Borrow, a senior bouse student at St. Thomas's
Hospital, London, died recently from septiosemia, re-
snlting from the inoculation of a scratch on one finger
while making an autopsy.

Thb Tolbdo Medical Collkqe. — In accordance
with the recommendation of the Committee on the
Administration of the Medical Practice Act, the Sec-
retary of the Sute Board of Health of Illinois has
been directed to recognize the diploma of the Toledo
Medical College as entitling the holder to a State cer-
tificate for practice.

The Eighth Imtehnatiomal Congebss of Ht-
oiENB AND Dehoqbapht. — The Eighth Interna-
tional Congress of Hygiene and Demography is to be
held at Budapest, Hungary, in the first week of Sep-
tember next. The following is a list of the subjects
for discussion in the Hygiene Division :

(1) Etiology of Infectious Diseases ; (2) The Pro-
phylaxis of Epidemics ; (3) The Hygiene of the Trop-
ics; (4) The Hygiene of Trades and Agriculture; (5)
Tbe Hygiene of Children ; (6) The Hygiene of Schools ;
(7) Articles of Food; (8) The Hygiene of Towns;
(9) The Hygiene of Public Buildings; (10) The Hy-
giene of Dwellings ; (11) Hygiene of Communication
(Railways and Navigation); (12) Military Hygiene;
(13) Red Cross; (14) Saving of Life; (15) State
Hygiene; (IG) The Hygiene of Sport (Inurement and
Careof the Body); (17) The Hygiene of Baths ; (18)
Veterinary Hygiene; (19) Pharmacology.

BOSTON AND NEW ENGLAND.

AcDTB Infbctiocs Diseases in Boston. — Dur-
ing the week ending at noon, March 7, 1894, there
were reported to the Board of Health, of Boston, the
following numbers of cases of acute infectious disease :
diphtheria 53 ; scarlet fever 28 ; measles 7 ; typhoid
fever 6; small-pox 6, and 2 deaths. On the 3d of
March the steamer Venetian of the Leyland line ar-
rived at quarantine with four cases of varioloid on
board, one of which was fatal soon after being removed
to quarantine. There were no cases in Massachusetts
outside of Boston.

Death at One Hundred and Three Tears. —
Ann Canley, the oldest woman in York County, Me.,
died in South Berwick March 2d, aged one hundred
and three years and seven mouths. She was born in
Ireland.

The Nevt Medical Practice Law in Connecti-
cut.— The first semi-annual examination under the
provisions of the new medical practice law was held
last week in New Haven. Eight candidates were ex-
sminfed by tbe committee appointed by tbe State Board
of Health, and only five were given certificates.

Connecticut Fbbtilitt. — Ayonng married couple
in Roxbury, Conn., have recently been reported to
have had their family increased by the birth of triplets.
Tbe father is sixteen years old, the mother is thirteen ;
and the three new children, a boy and two girls, are
said to have weighed twenty-three pounds I

new tork.

The Board of Health and Fauilt Physicians.
— At the monthly meeting of the Medical So<nety of
the County of New York, Dr. Carl Beck read a paper
on " Pyothorax and its Treatment " ; and Dr. W. M.
Seward one on " Ectopic Gestation." Dr. Daniel
Lewis called up the following resolution, which had
been laid on the table at a former meeting : " Retohed^
That it is the sense of this Society that if the Board of
Health is to preserve its influence in the community in
the highest degree, it should extend to the family phy-
sician the same consideration which one member of the
profession owes to another." In advocating its pas-
sage Dr. Lewis said that, although the wording of the
resolution was somewhat ambiguous, the members pres-
ent knew very well what it referred to. Health inspec-
tors frequently visited patients of practising physicians
and took occasion at these times to prescribe remedies
and counsel treatment at variance with that of the at-
tending physician. This was unprofessional, and should
not be tolerated. The attending physician should, at
least, be consulted before any change in the treatment
of a case was made. In the discussion which followed.
Dr. Joseph D. Bryant took exceptions to Dr. Lewis's
remarks, and denied that the course of the inspector
was, as a rule, such as to warrant the strictures made
by him. He thought, however, that individual cases and
epidemics sometimes occurred where prompt action was
called for, and the exigency of the circumstances com-
pelled the inspectors to violate the letter of the resolution
while they followed the spirit of it. He therefore
proposed the following addition as an amendment:
" Provided that such course shall not conflict with
public policy." This was accepted by Dr. Lewis, and
the resolution was passed as thus amended.

Shall-Pox. — The concealment of cases of small-
pox in tenement-houses continues to give the Board of
Health serious trouble, and on one day recently no
less than ten such cases were discovered. Two or
three cases of the disease have occurred at the State
prison at Sing Sing, and it is thought that it was
brought there by some of the newly-arrived convicts,
or else through the rags taken there for sorting by the
prisoners. During the week ending March 3d there
were reported 30 oases of small-pox in the city, and
six deaths ; against 29 cases and five deaths the week
previous. The total mortality for the week was 857,
against 830 in the week ending February 24th,

A Fatal Case of Singultus. — A case of death
from hiccough is reported from Newark, N. J. The
patient was John Carberry, a bar-tender, thirty-three
years of age, and the affection lasted more than thirteen

Digitized by

Google

250

BOSTON MSDIOAL AND SUSGWAL JOURNAL,

fMAKca 8, 1894.

weeks. At the time the hiccoughing commenced, on
November 29th, he was seated in a barber's chair get-
ting shaved. After a large namber of remedies had
been tried in vain, a novel operation was undertaken
in the hope of saving the patient's life. Under the
hypothesis that the soarce of trouble was irritability of
the inferior dental branch of the inferior maxillary
nerve, which was communicated to the phrenic nerve,
the inferior dental was cat down upon and severed ;
bat this procedure also proved fruitless, although some
temporary improvement in his condition followed. The
only thing that seemed to be of any service in check-
ing the attacks was icecream, which he took freely.
He gradually became weaker, and finally died of ex-
haustion. At the time the hiccough commenced Car-
berry was strong and robust, and weighed one hundred
and fifty pounds, but just before his death he weighed
only eighty pounds. No autopsy has as yet been re-
ported in the case.

MoRTALiTT. — The State Board of Health reports
10,948 deaths in the month of January, representing
an annual death-rate of 19.70 per thousand of the esti-
mated population. In December, the annual death-
rate was 19.20 per thousand. Influenza became epi-
demic ill December, and 1,000 deaths were attributed
to it in December and 1,200 in January. This is more
than twice the mortality from the disease during the
same months in the epidemic of last year. In New
York city, however, influenza has thus far been much
less fatal than last winter.

PROFESSOR TTNDALL AND BOSTON RIS-
SOURCES.

In an account of Professor Tyudall's visit to this
country in 1872, Miss Youmans * publishes some let-
ters of the physicist, which give an interesting revela-
tion of the mental state of even a most highly educated
Englishman concerning the commercial resources of
Boston. Writing for advice as to his arrangements
he says :

Aupst 21, 1872.

Mt Dear Toumams : I am in the midst of my prepa-
rations here, and shall have them ready so as to enable me
to start in the Russia on the 28tb of September.

I shall need your friendly aid in getting my apparatus
through the custom house. . . .

With regard to the lecture rooms, in all of them I must
be able to lower the lights promptly. Most of my experi-
ments will be projected on a screen.

I purpose mixing experiment and philosophy in due pro-
portions.

Do your audiences look down upon the lecturer ?

I suppose I can borrow an air-pump in New York if I
need it.

I suppose if they do not possess ice in Boston, I can
have a clear block sent there from New York.

Acids, of course, are to be had everywhere.

Are they in the habit of using compressed hydrogen and
oxygen in iron bottles in America ; and, if so, could I bor-
row such bottles ?
> Popular Solence Monthly, Febnuuy, 18M.

I am taking one screen with me, but I shall sometimes
require two. Is such a thing to be borrowed?

Now, like a good fellow, answer these questions within
twenty-four hours, and oblige

Yours, ever faithfully,

John Ttrdall.

And again :

Folkestone, September 19, 1872.

Mr Dear Yodmanb : . . . I hope they have clear ice
in Boston, also nitric and sulphuric acid ; if not, I must
stock myself from New York. I have written a line to
Dr. Draper on this point ; but I should be truly thankful
to you if you would malce this point out for me, and if the
acid is not to be had at Boston, send there a carboy of
nitric and one of sulphuric acid.

I am quite shocked at the mass of apparatus I have col-
lected round me. Still I thought it tiest to take light appa-
ratus— batteries, electric lamps and costly optical appa-
ratus— with me, having just given the experiments with
them here. Yours ever,

John Ttndall.

MR. LAWSON TAIT'S USE OF AN.ffi!STHETICS.

In a letter to the Buffalo Medical Journal,^ Mr.
Lawson Tait, in replying to Dr. Robinson's remark
that few English surgeons " engaged in abdominal sur-
gery give much attention to the kidney in their work," '
says that it is the very care he has given to the study
of the effect of anaesthetics on the renal functions whi<^
makes him prefer chloroform to ether for abdominal
and ovarian surgery. He says that the most important
sentences he has ever published in his life are the
following :

" The question of the best anaesthetic for use in abdominal
surgery is one to which, of coarse, I have given a very large
amount of attention ; and it is very singular that in the
class of drugs, the action of which there can be the least
doubt about, we are, as yet, certainly very unsettled in our
views. Like all pupils of Simpson, I began my professional
life with a most profound belief in the advantages of chloro-
form over all other ansesthetics. I have never seen an ac-
cident from chloroform, but, partly by reason of the fear of
inquests and partly by the example and teaching of Dr.
Keith, a belief grew in my mind that ether was preferable
to chloroform, and at first I had the impression that the
sickness after ether was lees marked than after the use of
its rivals. I was not, however, very long in discovering
that ether has special risks for people with a tendency to
bronchitis; and later on I discovered, and have already
published the fact, that during the administration of ether
the secretion of urine is completely arrested. It was sub-
sequently very forcibly impressed on me that, for patients
with damaged kidneys, ether is a dangerous anaesthetic
and although I cannot say that I have seen any fatal results
arising from this peculiarity of its action, I certainly have
had abundant cause to fear it. My first alteration, there-
fore, in my views concerning ether, was to limit its appli-
cation to patients under forty, but even after this I found
my confidence in its safety greatly diminished by the fatal
occurrence of bronchitis in a case of hysterectomy in a wo-
man aged thirty. In this case the patient's breathing was
embarrassed from the moment she recovered from the
anEesthetic, her urine was scanty and became ultimately
albuminous, and she died on the fourth day from suffocative
catarrh, the post-mortem showing that, so far as the oper-
ation was concerned, everything was perfectly satisfactory."

The chief reason why these remarks made little
impression when first printed in 1884 was the fact that
England is emphatically the land of coroner's inquests,

> February, 18M.

> What kiUa aA«r Laparotomy, Boflalo Madioal Jounal. Daoeai-
ber.ISas.

Digitized by

Google

>r.. CTXXX, No. 10.] BOSTOS MBDIOAL AND SURGICAL JOUSNAL.

261

tkicli are things an English practitioner hates above
ery thing else.

** Coronors seem always fond of making public inqairy
to casen of death under an ansesthetic. Lvery such death
. therefore, blazoned abroad until the use ot chloroform
ts l>ecoiiie a hile noire of surgical practice alike for prao-
tioner and patient. Chloroform, when it kills, which it
>es very rarely, kills on the instant, and, in England, there

an inquest. When ether kills, which it does far more
«3«|uently, it kills some days after its administration, and
tere ia no inquest, not even an inquiry.

" To get over the difiSculty, I began to use a mixture
D<1 soon found that it was a great advance over either of
be t'wo anesthetics used separately. I vary the propor-
ions according to age, increasing the proportion of chloro-
orm from one-third to two-thirds rapidly after fortv, and
a c»se there is any suspicion of renal or pulmonary incom-
petency.

** Twelve years' experience has driven entirely out of my
practice all those disasters which ether brought into it. In
a number of administrations, now amounting to a great
many thousauds, not a mistake has occurred, and alarms
occur only where some new and inexperienced administrator
'«rill indnlge in such fantastic tricks as pushing back the
tongue by pressing up the jaw, or violating in some other
foofish way the simple rules for administration laid down
over forty years ago by Simpson, not one of whose methods
1mm yet been surpassed."

UETEOBOLOGICAL BECOBD,

For the week ending Febrnary 21, in Boston, accordlngto ob-
servations famished oy Sergeant J. W. Smith, of the United
Stetes Signal Corps:—

WILLIAM JOHN GORDON FOGG, M.D.

South Boston, March 2, 1894.
At a meeting of the physicians of South Boston the fol-
lowing preamble and resolutions were adopted :

Whereas, Death has removed from our midst our much-
esteemed friend and colleague. Dr. W. J. G. Fo^g, and
whereas, it is fitting that we express our feeling of sorrow
at this great loss, therefore.

Resolved, That we gladly testify to our appreciation of his
great professional skul, bis readiness to advise when called
upon by any of us, his honesty of principle toward his medi-
cal brethren and toward bis patients ; all of which we shall
ever hold in grateful remembrance.

Resolved, That the death of Dr. Fogg is a loss to the
community in which he lived and for which he worked so
many years.

Resolved, That a copy of these resolutions be sent to his
afflicted family ; a copy be published in the local papers,
and in the Boston Medical and Surgical Journal.

" Pkb Committee.

NORFOLK SO. DISTRICT MEDICAL SOCIETY.
SAMUEL MAGNUS DONOVAN, M.D.

March 1, 1894.

1FAere<u, it has pleased Almighty God to remove from
as our beloved friend and co-worker, Samuel Magnus Don-
ovan, M.D.,

Resolved, That we, the Fellows of the Norfolk South
District Medical Society, mourn the loss of a genial friend
and an active member of this organization. Cut off in the
prime of manhood and in the noon-tide of a useful and
DODorable career, we have lost a valued member of this
Society ; the community in which he lived, a trusted coun-
sellor and a skilful physician.

Reiolctd, That we offer our kindly sympatliy to the
family of our deceased brother in this hour of mourning.

Resolved, That these resolutions be entered upon the
recordi of the Society, a copy of the same be forwarded to
the family of the deceased, and a copy be furnished for
poblicatioD to the Qnincy Daily Ledger, Quincy Monitor,
and the Boston Medical and Surgical Journal.

J. WiHTHROP Spoomeb, President.
JoH> F. Welch, Secretary.

B&ro-

Thermom-

Relative

Direction

Veloolty
ot wind.

Wo'th'r.

1

meter

eter.

bumlditT-

ot wind.

•

Dat«.

1

i

1

i

X

ai

i

a

M

a

>i

a

a

3

K

>«

a

■<

ex

>>

4

i

-i

t,

■4

ft!

1

1

d

i

s

!

8

i

S

00

a

i

8. .18

30.00

4.t

51

3K

86

46

66

s.w.

N.W.

26

18

B.

o.

0.28

M..19

80.04

40

47

33

86

100

8.1

8.W.

8.

2

13

O.

B.

0.16

T..»

M.yi

ai

.18

31

6/<

42

K

w.

W.

22

12

0.

o.

0.14

W.21

80.07

.12

.t7

28

72

53

62

s.w.

N.W.

S

10

N.

o.

T..M

30.14

2A

SI

20

BO

62

fi6

N.

S.W.

8

»

F.

0.

F..23

311.16

20

29

12

4«

41

44

W.

w.

14

25

0.

0.

S..M

ao.es

28

6

7

74

4S

61

N.W.

N.W.

22

18

0.

u.

nr

80.17

34

28

<B

.98

•0..oleiid7i CslMTi F.,f«ln a..<«igi H.,huTi S-.tmokji R.,nt>i T-itlirMt-
<alBiiN.,Hiow. «Indlo*tMtnMa(ii3iiftU. «er Heu for VMk.

RECORD OF MORTALTTT
Fob thb Wbbt bitsimo Satobdat, Febbuabt 24, 1894.

Oltles.

New York .
Cbleago . .
PMladelphU
Brooklyn .
St. Louis . .
Boston . .
Baltimore .
Washington
Glnoinnati .
Glevelaud .
Plttiburg .
Milwaukee .
Nashville .
Charleston .
Portland . .
Woroeiter .
FallBlver .
Iiowell . .
Cambridge .
Lynn . . .
Sprlngfleld .
Lawrenee .
New Bedford
Holyoke , .
Salem. . .
Brockton .
Haverhill .
Chelsea . .
Maiden . .
Newton . .
Fttobbnrg ,
Taunton . .
Oloueester .
Waltham .
QuincT . .
Pittsileld .
Everett . .
Northampton
Newbnryport
Ameabury .

1,8»I,S06

1,438,000

1,I16,M2

978,384

560,000

4t<7,397

500,000

308,431

305,000

290,000

263,709

260,000

87,764

69,le6

40,000

96,217

87,411

87,191

77,100

63,666

48,684

48,366

45,886

41,278

82,140
31,396
30,264
29,394
27,666
27,146
26,972
26,688
22,068
19,642
18,802
lf,6s6
16,331
14,073
10,920

4

a s

a *■

I

Peroentage ot deaths tnun

20.04

11.7a

11.65
14.68

6.04

7.11

u
f

20.N
I6.!>6
17.61
24.c0

21.42

21.42

11.70 14.30
14.67 1 23.37
13.63 1 24.60
11.11 33.33
6.66 6.66

20.48
2.17
14 28
37.44
4.65
8.33

8.32
38.46

10.00

18.18
26.00

20.00

20.48
30.38
11.90
8.32
4.66
8.33

16.C4
15.38

23.(0
20.00
9.09
25.00
16.66

14.28

So

8.66
4.80
6.25
7.20

2.62

2.38

6.S0
4.92
7.38

2.66
ISM

8.33

2.40

.48

1.06

1.08

1.68

1.19

2.60
3.69

8.32

7.35

.74

2.10

1.35

1.23

3.69

11.11

10.24

10.00

Deaths reported 3,030: under five years of age 1,149; principal
infections aiseases (small-pox, measles, diphtheria and croup,
diarrhoeal diseases, wbooping-congb, erysipelas and fever) 430,
acute lung diseases 577, consumption 342, diphtheria and croup
183, measles til, scarlet fever 46, typhoid fever 31, cerebro-
spinal meningitis 2H, whooping-cough 28, diarrhoeal diseases
23, erysipelas 17, small-pox 6.

From typhoid fever Chicago 8, Philadelphia and Lowell 4
each. Mew York and PIttsburab 3 each, Brooklyn 2, Boston,
Milwaukee, Worcester, New Bedford, Chelsea and Maiden 1
each. From cerebro-spinal meninadtis Chicago 7, New Yoik
aud Brooklyn 6 each, Holyoke 2, Washington, Cleveland,
Worcester, lynn, Mew Bedford, Chelsea, Pittsfield and Everttt
1 each. From whoopjne-cough New York 9, Philadelphia 7,
Chicago 3, Brooklyn and Boston 2 each, Washington, Pittsburgh,

Digitized by

Google

252

BOSTON MEDICAL AND SURGICAL JOUKNAL.

[Makoh 8, 1894

Milwaakee, Fall Riret and SomerrlUe 1 each. From dlarrboeal
diseases New York 8, Chicago B, Philadelphia, Lowell and Cam-
bridge 2 each, Brooklyn, Boston, Washington, Worcester and
MarlDorouKh 1 each. From small-poz New York 6, Boston 1.

In the thirty-three greater towns of England and Wales with
an estimated popalation of 10,468,142, for the week endinii
February 17th, the death-rate was 18.7. Deaths reported 8,717;
acotediaeases of the respiratory organs (London) 310, whooping-
coagh 133, diphtheria 86, measles 71, scarlet fever 49, diarrhoea
42, fever 29, small-poz (Birmingham 7, Bradford 2, West Ham
1)10.

The death-rates ranged from 11.2 in CroydoD to 27.0 in
Wolverhampton; Birmingham 16.9, Bradford 16.6, Barnley
17.8, Hull 18.9, Leeds 17.1, Leicester 16.0, Liverpool 26.1, London
18.6, Manchester 22.2, Newcastle-on-Tyne 18.8, Nottingham 14.9,
Portsmoatb 17.1, Sheffield 16.8, Sunderland 19.9, West Ham
16.6.

OKFICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. 8. ARMY, FROM FEBRUARY 21, 1891,
TO MARCH 2. 1894.

Leave of absence for twenty days, to take effect opon the ad-
journment of the Eleventh International Medical Congress to
be held at Rome, Italy, March 29 to April 6, 1891, is granted
CoLOMBL Bbrmabo J. D. Ibwih, assistant surgeon-general,
U. 8. A.

A board of medical officers to consist of BIajor Joseph K.
Corson, surgeon; Major Walter Rebd, surgeon; Captain
Julian M. Cabell, assistant surgeon, is, by direction of the
Secretary of War, appointed to meet at the call of the President
thereof, at the Army Medical Museum Building, in this city for
the examination of First-Lieut. Philip G. Wales, assistant
surgeon, to determine his fitness for promotion.

Fibbt^Lieut. Walks will report in person to the President of
the Board at such time as he may designate.

By direction of the President, the retirement from active ser-
vice on the 26th of February, 1891, by operation of law, of
Captain George T. Bkall, medical storekeeper, under the
provisions of the act of Congress, approved June 30, 1882, is
announced.

The leave of absence granted Captain Reuben L. Robert-
son, assistant surgeon, U. 8. A., is extended one month.

Major John Brooke, surgeon, U. S. A., retired from active
service February 22, 1891,

FiRST-LiBCT. Abhton B. Hbtl, assistant surgeon, relieved
from duty at Fort Niobrara, Nebraska, ordered to Uolnmbus
Barracks, Ohio, for duty at that depot, on the arrival of Fibst-
LiEUT. Thomas S. Bratton, assistant surgeon, at Fort Nio-
brara, Nebraska.

The leave of absence on surgeon's certificate of disability
granted Major Edward B. Moselbt, surgeon, U. S. A., is ex-
tended one month.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. 8. NAVY FOR THE WEEK ENDING MARCH
3, 1894.

Richard Ashbridob, passed assistant surgeon, dismissed
from the Naval Service, February 28, 1891, by the President's
approval of the sentence of General Coart Blartial.

A. O. Cabell, passed assistant surgeon, ordered to the U. S.
8. " Michigan."

J. 8. Satrb, passed assistant sargeon, detached from the U.
8. 8. "Michigan" and ordered to the Naval Hospital, New
York.

R. O. Brodbrick, assistant surgeon, detached from the Naval
Laboratory and Department of Instruction, and ordered to the
Naval Hospital, Mare Island, Gal.

THE ASSOCIATION OF MILITARY SURGEONS OF THE
UNITED STATES.

The fourth annual meeting of this Association will be held in
Washington, D. C, May 1, 2 and 3, 1891.

This National Organization is composed of medical officers of
the U. S. Army, U. S. NHvy, National Guard of the United
States and the Hospital Marine Service. The afternoon of one
day will be set apart for an object lesson from the " Manual of
Drill," by the Hospital Corps. The evenings will be given up
to social entertainments.

Gbo. Henderson, Chairman Com. of Arrangements.

Nicholas Sbnn, President.

Eustathiub Chancellor, Secretary,

THE COLORADO STATE MEDICAL SOCIETY.
To THE Members of the American Medical Association.

Members of the American Medical Association are cordially
invited by the Colorado State Medical Society to stop over in
Denver on returning from the coast and attend the meeting of
the Society convening on June I9th and continuing through the
20lb and 21st.

Members who expect to retnm via Denver are invited to cor-
respond with the Secretary, that invitation to participate in the
programme and proper entertainment may be arranged.

Edmund J. H. Roobrs, "President.
A. Stewart Lobinoier, Secretary, Barth Building, Denver.

SOCIETY NOTICE.

Boston Socibtt for Medical Improvement.- A regular
meeting of the Society will be held at the Medical Ubrary, No.
19 BoyTston Place, on Monday, March 12, 1894, at 8 o'clock,
p. M.

Dr. W. F, Whitney: "Cirsoid Myxoneuroma of the Tongue,"
illustrated by lantern slides.

Dr. C. W. Townsend: " Mild Forms of Nasal Diphtheria."
Discussion opened by Drs. A. L. Mason and J. H. MeCoUom.

Members are requested to show interesting cases and patho-
logical specimens.

John T. Bowen, M.D., Secretary.

HARVARD MEDICAL SCHOOL.
Evbnino Lectures.

The next lecture will be given on Wednesday evening, March
14tb, at 8 o'clock, by Dr. John Homans. Subject, " Ovariotomy."
Physicians are cordially invited.

RECENT DEATHS.

JORL Sbaverns, M.D., M.M.S.8., died in Rozbury, March 1st,
aged sixty-five years. He was born in West Roxbury and
grad uated from Harvard College in the class of 1850, of whicli
he has since been secretary. He received his degree of M.D.
from the Medical School in 1864. During the war of the Rebel-
lion he was acting assistant surgeon from May, 1862, to Decem-
ber, 18ii3, when be was commissioned assistant surgeon of the
U. 8. Volunteers. In 1861 he was promoted to be surgeon and
in I8(i6 was made Brevet Lieutenant-Colonel for faiuful and
meritorious service. He had charge of the hospital ships The
New World and De Malay and was for some time post surgeon
at Fort Warren in Boston Harbor. Since 1866 he has been in
active practice in Roxbury. He was for some years a member of
tbe Boston School Committee and has been actively interested in
the work of secret societies, being Medical Examiner-in-Chief of
the Royal Arcanum. He has been a Councillor of the Massachu-
setts Medical Society and President of the Norfolk District So-
ciety. He was a man of scholarly habit, keen perception and
quiet, unostentatious execution. His literary work was marked
by wide research, careful criticism and a clear, attractive style.
He won the professional respect as well as friendship of those
who were his colleagues.

William John Gordon Fooa, M.D., M.H.S.S., died in Booth
Boston, February 27th, aged forty-three years. He graduated
from Harvard College in the class of 1873 and from tbe Medical
School in 1876.

James Parbish, M.D., died In Portsmouth, Va., January
21, 1891. He vas a member of the Medical Examining Board
and of tbe State Board of Health of Virginia.

BOOKS AND PAMPHLETS RECEIVED.

Annual Reports of the President and Treasurer of Harvard
College, 1892-93. Cambridge: Published by the University.
1894.

Manual for tbe Use of Boards of Health of Massachusetts,
Containing the Statutes Relatingto tbe Public Health, the Med-
ical Examiner Laws, the Laws Relating to the Registration of
Vital Statistics and the Decisions of the Supreme Court of Massar
chnsetts Relating to the Same. Prepared by direction of the
State Board of Health. Boston : Wright and Potter Printing
Co., State Printers. 1891.

Lectures on Auto-Intoxication in Disease, or Self-Poisoning
of the Individual. By Ch. Bouchard, Professor of Pathology
and Therapeutics, Member of the Academy of Medicine, ana
Physician to the Hospital, Paris. Translated, with a preface,
by Thomas Oliver, M.A., M.D., F.R.C.P., Professor of Physiol-
oey, University of Durham ; Physician to the Royal Infirmary,
Newcastle-oo-Tynn ; and Examiner in Physiology, Conjoint
Board of England. Philadelphia: The F. A. Davis Co. Lon-
don: F. J. Rebman. 1891.

Digitized by

Google

Vol. CXXX, No. 11.] BOSTON MEDICAL AND SUROWAL JOURNAL.

263

THE TBEATMENT OF PREGNANCY COMPLI-
CATED BY HEART DISEASE.^

BT QBOBOB O. SKABS. K D.,
PAytietoK loiOiU-PaHtmU, Bo$bm OUt BotpUal.

In reporting the followiDg case I realize that I may
lay myself open to severe criticism for hasty action,
bnt I hope to prove that the course adopted was
chosen only after fuIPconsideration bad shown it to be
the best method of meeting a complication of preg-
DkDcy, whose gravity is aniversally recognized, but
whose treatment seems to have been most inadequately
dealt with in the text-books.

The patient was gent to me by Dr. George Haven,
in 1889, when she was twenty-one years old, for the
relief of cardiac symptoms of over three years' dura-
tion. There was no rheumatic history, but she had
bad both scarlatina and diphtheria as a child. There
was little oedema of the feet, considerable dyspnoea on
exertion, cough and slight htemoptysis. The cardiac
dolness extended about one finger's breadth to right
of sternum, while the apex was in the fifth interspace
jaat withiD the mammillary line, where a loud pre-
sjBiolic thrill could be heard and felt. She improved
greatly under treatment, and after a few weeks dis-
cootinned her visits ; so that I saw nothing more of
her until November, 1892, when she again appeared
for advice.

During the intervening three years she bad been
fairly well ; bat on several occasions after exercise she
had had "fainting spells," which were preceded by
tevere cardiac pain. During the early part of the
tDoamer she bad overexerted herself in preparation for
her marriage, which took place in August. Her
catamenia, which in July were attended by an exces-
live flow, occurred last on August 27th, since when
the has been gradually losing ground, cough and
dyspnoea having slowly increased. Haemoptysis now
frequently occurred, vomiting had become very trouble-
tome, and she was very anaemic Always nervous
and somewhat hysterical, her condition had become
greatly aggravated by the recent death of a friend dur-
ing labor, from some cardiac complication, and she
wag haunted night and day by fear of a similar fate.

The lateral area of cardiac dnlness had somewhat
extended, as compared with the last examination ; and
in addition to the preaystolic, a short systolic murmur
was at times heard a little to the left of the apex beat
Except for oedema of both bases, the lungs were nor-
mal, and there was no swelling of the extremities.
The urine had a specific gravity of 1,022 and con-
tained a very slight trace of albumen. The pulse was
regular but very small and easily compressed. While
at rest its rate was only 78, but on the slightest exer-
tion it rose to over 100. Dyspnoea was so great that
ibe spoke only in disjointed phrases, pausing after
every few words to catch her breath. •

After a month's treatment by rest in bed, a restricted
diet, digitalis and tonics, her condition became some-
what better, vomiting grew less frequent, and the
pulmonary oedema cleared up ; but as the dyspnoea
improved but slightly, and the pulse made no gain in
•trength, I asked Dr. Haven to see her with me.

After a thorough discussion of the case, it was de-

' Baad befora the SaoUon for CUnioal Hediolna, Patholnn and
Hjitaieol the Suffolk Dtetrlot Madioal So«t«t7, Janaary 17, ^SSt.

cided to induce abortion; and on December 12th Dr.
Haven dilated the cervix and packed the womb with
iodoform gauze, this method being chosen in preference
to an immediate evacuation as, with her extremely
weak pulse, we feared the effects of etherization on
the heart. Two days later the packing was removed,
and a four months' foetus found in the vagina, the dis-
comfort of the patient having been very slight. Re-
covery was uneventful, but her later condition has
been such as to confirm the wisdom of our action. She
is able to come into town occasionally to report, but
can walk only at a very slow pace, and has since had
several attacks of pulmonary oedema, in which her
condition was critical.

To briefly recapitulate, the problem which con-
fronted us was this : a patient with a double mitral
lesion, between three and four months pregnant, who
has had for several years alarming symptoms of fail-
ure of compensation, and in whom the slightest exer-
tion, after a month's careful treatment, upsets the
cardiac balance, is called upon, after passing through
a farther period of five months, daring which increased
demands are physiologically made on the heart, to
meet the tremendous muscular strain of parturition ;
What advice should be given her ? Or rather, to put
the question in more general terms. What advice
should be given to any pregnant woman with heart
disease? Should she be allowed to proceed toward
term, her strength being carefully supported and her
progress watched with the po'ssibility always in view
of terminating pregnancy if her condition becomes
desperate, or should she be at once delivered ? Mor-
tality statistics drawn from published cases make the
outlook for these patients very bad when nature is
allowed to take its course ; for Porak,' out of 92 cases,
fonud a death-rate of 38.09 per cent. ; and Remy,* out
of 118, found one of 83.8 per cent. Of 77 cases col-
lected by Wessner, 88 died, or 37 per cent. As all
these series contain a number of identical cases, includ-
ing McDonald's, a close similarity in the ratios was to
be expected. More recently, Schlayer has reported
25 cases with 10 deaths, and Ley den 20 cases with 11
deaths. Of SO cases which I have collected, not in-
cluded in the above, 10 died. These percentages are
based upon the number of women, not on the number
of pregnancies, and are drawn almost entirely from
severe cases, and may therefore approximate the
average death-rate when serious symptoms have ap-
peared. That they overestimate the actual mortality
in the rank and file of cases is proved by every-day
clinical experience, which shows that a large propor-
tion of them pass through pregnancy and labor without
the development of any evidence of serious cardiac
embarrassment, or even at times of any signs whatever
which lead the patient to suspect her disability.

One of these seenu of sufficient interest to briefly
report, not only on account of the number of preg-
nancies successfully weathered, but also because the
ultimate fate of the children corroborates the grave
prognosis which is given of their chances of surviving
to adult life. The lesion was one of mitral regurgita-
tion and stenosis. The patient, Mrs. C, thirty-two
years old, had bad three attacks of chorea as a child,
but no diftinct history of rheumatism. Between the
ages of eighteen (when she was married) and twenty-
seven she had six children, and one miscarriage at three

> Thiae de Paris, 1880.

> nitee de Maooy, 1880.

Digitized by

Google

264

BOSTON MEDICAL AND SUBGJOAL JOURNAL. [Uaboh 15, 1894.

months. The first pregnancy was uneventf al, no tronble
being suspected with her heart, hot the second was at-
tended by many stormy symptoms. She then received
treatment for the cardiac condition and had mncb less
difBoalty with the next three, breathlessness and oedema,
however, being more or less troublesome in each ; bat
in the sixth her condition was snch that the gravest ap-
prehensions were felt as to her recovery, and the last
few weeks were spent propped ap in a chair. The
labors were all rapid and easy, being terminated within
an hour. The third child alone sorvives, the others
all dying within a few months after birth.

For the sake of simplifying the original qaestion
cases of pregnancy complicated by heart-disease may
be divided, with reference to treatment, into three
classes, according to the severity of the symptoms:
the first inclading all cases where they are wanting or
slight, the second those in which they are so severe
that the condition of the patient is desperate, and the
third those which occupy a position midway between
the two. The treatment of the two former may be
dismissed in a few words. In the first, general super-
vision over the patient's manner of life, with the ad-
ministration of tonics, will probably be all that is re-
quired to bring the case to a successful termination,
or, at most, it may be necessary to hasten delivery
should danger arise from too prolonged a labor. In the
second class, the condition of the patient is already so
critical that the induction of abortion may seem to
give the only chance, though even here a timely vene-
section may change the aspect of the case, as it has
done in several recorded instances, in one or two of
which it was repeated several times. In the third
class, to which the first case reported above belongs,
as well as most of those in which the statistics pre-
viously given are based, where the patient still has
several months before her, and symptoms have devel-
oped which either do not yield, or only partially so, to
appropriate remedies, conditions are much more com-
plex ; and the question of treatment, whether by hope-
lessly waiting for nature to act, or by sacrificing the
child in the interest of the mother, can only be decided
in an individual case by the most careful study, both
of her material circumstances and of her previous his-
tory and present physical condition, so far as they bear
on the probability of an easy or difficult labor, and the
preservation or loss of cardiac compensation. Many
of these are fully discussed in text-books on heart
disease and midwifery ; so that only those need be
mentioned in which the two conditions react upon
each other, although the advantages of general good
health and the ability to command every necessary
attention may be referred to, as two such circum-
stances had considerable influence in determining us
to induce abortion. These were the intense anxiety
caused by the death of a friend under similar circum-
stances (which was alone exhausting her strength),
and her suburban residence (which prevented prompt
medical attendance should it have been suddenly de-
manded). The following points, however, deserve spe-
cial consideration, namely, the site and gravity of the
lesion, the time at which it was acquired, its station-
ary or progressive character, the period of the present
pregnancy at which serious symptoms developed, and,
in multiparas, the history of previous pregnancies and
labors.

As was to be expected when dealing with a class of
patients, most of whom are under forty, and all of

whom are women, statistics show that mitral disease
largely predominates. Thus, out of Porak's 92 caiea,
there were 22 instances of mitral regurgitation, with 8
deaths; IS of mitral stenosis, with 8 deaths; and 22
of combined mitral lesions, with 10 deaths ; in all, 57
cases, with 21 deaths. There were 13 cases of aortic
lesions, with 8 deaths ; while of 22 cases of complex
lesions, 11 died. Bemy found 29 cases of mitral io-
sufficiency, with 6 deaths; 19 of mitral Btenosia, with
11 deaths; and 15 of double mitral lesions, with 6
deaths ; a total of 63 cases, with 23 deaths. Of the
aortic cases, there were 12 with regurgitation, of
whom 2 died; while 2 with stenosis and 3 with a
double lesion recovered (17 cases and 2 deaths). Of
complex lesions he found 16 instances, with 3 deaths.
Of the cases which I have collected, there were H
of mitral stenosis, with 4 deaths ; 1 fatal case of
mitral regurgitation ; and 2 with combined mitral
lesions, both of the latter recovering. There were 6
aortic cases, with 1 death ; and 7 of complex lesioos,
with 4 deaths. If these latter figures be added to
those of Remy, as the larger of the two series just
quoted, we find the mortality rate to be as follows:
mitral stenosis, 45.5 per cent. ; mitral regurgitation,
23.33 per cent. ; double mitral lesions, 35.5 per cent;
and complex lesions, 80.5 per cent. The mortality-
rate of the pure aortic cases was but 13.67 per cent,
but 3 out of 23 dying, in all of which the valve was
insufficient.

As these figures are drawn from the same source as
those previously given, the same criticism is applicable,
that they represent serious cases ouly, but so far as
any conclusion is justifiable, they show that mitral
cases are more apt to terminate fatally than aortic of
apparently equal severity, and those with mitral steno-
sis than those with regurgitation, a conclusion which
has its value, though a slight one, in estimating the
chances of an individual case.

The means of determining the extent of the cardiac
lesion are not altered by the advent of pregnancy;
but the point was well made by McDonald, that the
probability of its being compensated is much enhanced
if it is not of very recent origin, for if the muscular
substance of the heart has had opportunity to hyper-
trophy till it is able to counterbalance the valvular
defect, it will be much more liable to prove sufficient
under the additional strain than when the double duty
is thrown upon it all at once. The prognosis is also
better if the first appearance of serious symptoms is
postponed until the later months; but in estimating
their gravity it is essential not to confound those
which are due to the cardiac lesion with those which
result from the profound impression eometimes pro-
duced by an uncomplicated pregnancy upon the mater-
nal organism, and which, though threatening, may be
expected to pass off after the third month.

With the development of the uterus and the growth
of its coutents, coincident changes in the circulatory
apparatus take place, and lead to a physiological
hypertrophy and dilatation of the heart, while altera-
tions in the composition of the blood induce a form of
ansemia and so impair the cardiac nutrition that fatty
and other degenerations of the myocardium are not
very infrequent. Such changes occur gradually, and
are not usually sufficiently pronounced to give rise to
symptoms of failing compensation till between the
fourth and sixth mouths ; so that, other things being
equal, little reserve power in the heart may be inferred

Digitized by

Google

'^ox-. CXXX, No. 11.] BOSTON MBDIOAL AND SURGICAL JOURNAL.

266

E they^ appe»r before that time. The reverse of this
>ropoeition, however, that the later the development
>f Bymptoms the better the outlook, is only partially
;rae, sm cases are occasionally met with where the pa>
itent has passed throagh her pregnancy without excit-
\ng any special anxiety, and yet has suddenly died
from aBdem& of the lungs daring labor or even iu the
puerperiana. At times, also, death results from post-
partam haemorrhage, a not very infrequent occurrence
in these cases, though it is possible that its gravity is
often overestimated since it may be a conservative
effort of nature, especially in mitral disease, to relieve
an OTer-distended right ventricle.

In multiparse the histories of their previous experi-
ence may give much valuable information, as the ten-
dency of the cardiac symptoms is to grow more severe
with each sncceedini; pregnancy, owing to the extra
burdens which have been thrown upon the heart, and
also occasionally to fresh attacks of endocarditis, to
which pregnant women seem peculiarly liable. But
little doabt can exist of the necessity of inducing abor-
tion if there is a history of extreme danger in the
previous pregnancy of gravido-cardiac origin, or if,
with serious symptoms iu the present, the lesion is
ioand to be progressive from a rekindling of the endo-
cardial inflammation. As the period of greatest dan-
ger is daring the expulsive stage of labor from the
participation of the abdominal and other mnscles, after
the necessity of terminating pregnancy has been once
determined, the sooner it is done the greater the chances
for the mother, especially if the fcetus is still small
and the expulsive force can be chiefly furnished by the
uterus. The idea that the induction of labor may be
held in reserve until the patient is in a condition of
imminent peril and then be resorted to in the anticipa-
tion of accomplishing any great measure of relief, does
not seem to be justified by facts. Schlayer * says that
all cases in which premature labor was brought on
uuder these circumstances in one of the obstetrical clinics
of Berlin, died either during labor or shortly after,
and in the published oases also recovery followed only
in rare instances.

Regarding the moral side of the question it must be
admitted that the child is apparently sacrificed for the
sake of a mother whose health is permanently im-
paired and whose expectation of life at best cannot be
long, but it is a fair question whether too much im-
portance has not been attached to it, if the ultimate
fate of the child be considered, when nature is allowed
to take its course. Cfaarpentier says that abortion and
premature labor are very frequent and the children
who are born at term do not live long. So sweeping
a statement cannot, of course, be taken without quali-
fication, otherwise it would be an almost imperative
doty to induce abortion at the first sign of danger, but
be quotes Casanova as believing that in more than half
the cases where more or less marked symptoms have
msoifested themselves pregnancy is not completed,
and says that Duroziez noted twenty-one miscarriages
amoDg forty-one women with heart disease, and five
dsliveries at six months, while thirty-seven of the
«Wldren who were born alive died before reaching five
year».

y cannot refrain from referring to a case of advanced
"Mtfal regurgitation which I saw yesterday, as it appears
to illoatrate so well this point ; yet it must be admitted
that the fate of the fifth child may have \)eeo ^n

' ()WM In aem. HAL, Harali 30, US2.

accidental coincidence. The patient was a woman
about thirty-six years old, and had been pregnant six
times, the first four children being still alive. After
the birth of the third child she had an attack of acute
rheumatism, from which the cardiac lesion in all prob-
ability dates, although no sign of it became manifest
until the fifth pregnancy, when she suffered from cough,
dyspnoea and other evidence of cardiac embarrassment,
but was delivered at term after a very rapid labor.
The baby died eighteen months later of some acute
pulmonary affection, which was said to be pneumonia.
During the sixth pregnancy she suffered from serious
symptoms, and miscarried at the seventh month.

There seems to be little question that the mortality-
rate among children bom after serious cardiac symp-
toms have developed in the mother, is high, but statis-
tics are meagre, as the child so often passes from
observation after the lying-in period is over. The
frequency of abortion or premature delivery, however,
can be more closely approximated, though the oppor-
tunities for error in determining the ratio of this
event are great, as in multipara it may be impossible
to tell when the cardiac lesion first developed, and
many of the earlier pregnancies may have been free
from any cardiac complication. However this may be,
Porak found that out of 214 labors 88 were premature,
or 41 per cent. ; while Bemy, in 272 labors occurring
in 112 women, found 87 premature, nearly 32 per
cent., 51 taking place before the seventh month.

The fact that the death of the mother has not al-
ways occurred in apparently the most desperate oases,
has probably had much to do in producing the conserv-
atism which has heretofore prevailed. Yet it is not
enough that the patient should come out alive, her future
must also be regarded : and when one considers the loss
of morale induced by the sense of her critical condition,
the extra burden thrown by pregnancy upon a weakened
heart, and the strain of parturition, so great that in a
case of Simpson's rupture of the aorta occurred, it is
not surprising to find that child-bearing has been the
starting-point in many of these cases of a downward
course soon followed by death, which was as much a
result of it as though it had occurred before the puer-
perium was ended, but which, nevertheless, does not
appear in the statistics.

I do not wish to be considered as holding a radical
position on this question, nor as advocating so serious
a measure as an abortion until other means have shown
their probable futility, but would protest against allow-
ing moral considerations to drive us into too great con-
servatism when the danger to the mother is so great
and the future of the child so doubtful. I am inclined
to believe that when the probable necessity for an
abortion begins to be seriously considered, that in the
long run we shall have less to regret if it is done im-
mediately than if it is postponed till worse comes to
worst uuder the delusive idea that it is an efficacious
measure when employed as a last resort. Certainly
after the seventh month, when the child is viable, the
condition of the mother should be the chief guide for
action.

The question of the advisability of marriage for
women with valvular disease has been the subject of
much ardent discussion. While it is true that many
such patients have passed through numerous pregnan-
cies withoHt apparent harm, yet so many factors have
to be ooq«id«red, for whose estimation we have most
insufficient evidence, that except for very nnosual

Digitized by

Google

266

BOSTON MEDICAL ASD SURGICAL JOVRHAL.

[Masob 15, 1894

oases Feters's dictum seems to be the safest guide,
uamely, that such women should not marrj, that if
they are married they should not become mothers, and
if thej are mothers they should not nurse their children.
The points which I have wished to emphasize may
be summarized in the following propositions :

(1) That many women with valvular disease, even
when situated at the mitral orifice, pass through re-
peated pregnancies without the development of serious
symptoms, and at times without suspecting that they
are victims of such disease.

(2) That as miscarriages are very frequent, and the
chances of the child's surviving more than a few years
are doubtful, if the mother's condition during preg-
nancy has been serious, the probable fate of the latter
should take so much more prominence in deciding the
question of abortion.

(3) That the necessity of inducing abortion is very
probable if grave symptoms have appeared during the
early months or are present with an advancing lesion,
or if there is a history of extreme danger in the pre-
ceding pregnancy.

(4) "That if the necessity for an abortion becomes
apparent, the sooner it is done the better, while the
foetus is still small and the expulsive force chiefly fur-
nished by the nterus.

(5) That the hope that relief may be given when
the case has become desperate by inducing abortion is
delusive, as it is possible that it only increases the
danger.

(6) That marriage should be forbidden, except per-
haps in very unusual cases, to women suffering from
cardiac disease.

SIX CASES OF EXTRA-UTERINE PREGNANCY.*

Onb a Preonanot in Both Tubes at the Same
Time, with the Possibility of there also bbimo
A Twin Pbeonancy in the Left Tube. — C<eli-
otomy. — Recovery in All.

BY F. W. JOHXSON, MJt.,

FitttifV OtneeologUt, Camev SbtpUal; VUMng Ofnecoioffitt, St.
Blizabeth't HotpUcU.

Case I. 6. F., married, aged twenty-eight, con-
sulted me on Tuesday, September 29, 1891. A diag-
nosis of extra-uterine pregnancy was made, and 1
operated on her at the Carney Hospital. The follow-
ing is the history of the case and the result of the ex-
amination :

Dysmenorrhoea since puberty. The pain, situated
in front and low down in the abdomen, comes on
several days before the flow, and lasts throughout
menstruation. For the past year has had quite severe
pain in the right ovarian region when unwell. Flows
five days. Flows quite freely. Lenoorrhcea for years.
Had always been regular to the day until August 9th.
Instead of menstruating at this time, she went to
August 16th, just one week over her time. August
16th flowing began, and continued, at times profusely,
for two weeks. In two weeks the flowing again
began, and has continued up to the present time.
Since August 16th, when the flowing began, until
September 20th, has had a dull pain in right ovarian
region. The breasts have enlarged.

Sunday, September 20th, was suddenly seised with
severe, cutting pain in right ovarian region. This

> Bead before the Obatetrloal Section of the Suffolk District Med-
ical Society, December 28, 1883.

pain lasted one hour, and produced fainting. This
severe pain was repeated September 28th, and lasted
two hours. Formerly the pain in the right ovarian
region was doll in character, but since the severe at-
tack of pain it has been more cutting in character.
From August 9th to August 16th, the week following
the date of expected menstruation, there was a dull,
heavy dragging-down in lower abdomen.

&eaminali<m. — From half-way between umbilicus
and pubes, extending over the whole of the lower part
of the abdomen, there was marked sensitiveness on
pressure. By vagina, a soft mass, the size of the fist,
excessively sensitive, was found in Douglas's pouch,
and on this the uterus rested in a position of retrover-
sion. Bright red blood flowed from the cervix.
Uterus measured three inches in depth. Temperature
99°, pulse 110.

Operation. — On opening the peritoneal cavity, dark-
colored blood welled up through the incision. The
abdominal cavity below the incision contained fluid
and clotted blood of a dark color, aud no bright blood
was found until the right tube and ovary were brought
into view. A portion of the right tube towards the
ovary was found dilated. This dilatation was about
the size of a small English walnut, and from the
upper part of it fresh blood oozed out through an
opening the size of a pin's head. The right tube and
ovary were ligated and removed. On the left side a
cystoma of the ovary was found, and it, with the tube,
was ligated and removed. The peritoneal cavity was
thoroughly washed out with a salt solution, and the
abdomen closed. About a quart of fluid and coagulated
blood were removed. The mass in Douglas's pouch
was composed of coagulated blood, and was dug out
with the fingers. Convalescence was uninterrupted.

Twenty-three days after the operation she was dis-
charged well. December 2d, she reported that she
felt perfectly well.

2>r. Whxtne^* Report. — " The following is the de-
scription of the ovaries and tubes from the case of
Mrs. G. F., received from you October 1, 1891 :

"(I) Ovary and Tube. The portion of the tube
measured about six and one-half centimetres. About
two centimetres from the fimbriated end, which was
normal, was a rounded enlargement measuring about
two and one-half centimetres by two centimetres, dark
red in color, and covered with shaggy, thin adhesions.
About the middle of the nodule, opposite the side of
the ligament, was a very small rent with a hemor-
rhagic, infiltrated edge. The remainder of the tube,
about two centimetres, was of normal size and calibre.
Sections made through the nodule, and examined mi-
croscopically, showed the greater part to be made up
of blood clotted among small, villous projections,
fibrous in character, and covered with a low epithelium,
similar in every way to the villi of an immature
placenta. Just beneath the outer surface were large
and very thin-walled vascular sinuses. The cavity of
the tube was dilated, and its lining membrane was appar-
ently reflected up on to the mass of blood and villi ; but
whether it was continuous entirely over it could not
be determined. Apparently, however, it was not.
From the distal end of the nodule there opened a dis-
tinct diverticulum from the tube, which could be fol-
lowed almost to the fimbriated end, where it stopped.
The relations were such as to show that the nodale
had developed entirely in the main tube, and not m
the diverticulum. In none of the sections ww 4?*^

Digitized by

Google

Vol. CXXX, No. 11.] BOSTON MEDICAL AND SVBOJOAL JOURNAL.

267

any evidence of a foetos found. The ovary attached
to this tobe measured two by two and one-half centi-
metres, was irregularly abaped, and from one place a
reddish nodale projected, which, on section, showed an
irregularly festooned outline enclosing a yellow mass
of large cells (corpus luteum).

>'(2) Tube and ovary. The piece of tube meas-
ured about six centimetres, and was of normal size
and structure. The ovary measured about three by
four centimetres, and was mostly made up of a cyst,
filled with thin fluid, extending deeply into the hilus,
where there was a layer of ovarian tissue gradually
thinning out over the cyst.

" The case is one of tubal pregnancy with rupture.
There are no positive data as to the length of time,
but from its size it is probably within two months."

Cask II. B. K., married, aged twenty-eight, en-
tered the hospital September 80, 1892.

Menstruation began at thirteen. Regular every
four weeks. (Eleven years ago went three months
without menstruation.) Flows five or six days. Flows
very freely. No dysmenorrhoea. Three children.
.No abortion. First confinement October 1, 1889.
Last coofinement March 1, 1892. Nursed her child
op to the time of entering the hospital. She had had
a bloody discharge from the vagina for four weeks.
This had increased very much since the last of August.
Since the flowing began there had been bearing-down
pains in the back, side and abdomen. There had been
interrupted, sharp pains in the left ovarian region for
three weeks. Urine and defecation cansed pain in
left ovarian region.

Examination showed a large movable tumor on the
left side, in the region of the left broad ligament.

Operation, October 10th. On opening the perito-
neal cavity, a large, grayish-white cyst presented.
Eleven and one-half pounds of dark, bloody-looking
fluid were removed by tapping. At the upper part of
the cyst inside, there was a solid mass as large as a
goose's egg, which was papilloma. Directly opposite
this, on the outside of the cyst wall, the mesentery,
omentum and intestines were adherent. No papillo-
matous disease could be seen on intestine or omentum.
The pedicle was tied, cut and cauterized. There was
au htemetocele between the layers of the left broad
ligament, containing eight to ten ounces of dark,
clotted blood and dUbrit. This was emptied, and as
much of the broad ligament as possible was tied off
and removed. The cavity was washed out with salt
solution and packed with sterilized gauze to stop the
bleeding, which was quite free. The right tube and
ovary looked healthy, and were left. So much shock,
lasting for hours, followed the operation that the
ganze was not removed for forty-eight hours. In con-
sequence, a sinus was left; otherwise her convales-
cence was perfect.

Dr. WkUney't Report. — ''The specimen consisted
of a portion of the tube and ovary, with a considera-
ble mass of dark, clotted blood. The specimen was
considerably torn, and the relations were not readily
evident to the eye. Microscopical examination showed
the tube to be normal wherever seen ; but the layers
of the ligament were infiltrated with blood, and there
were numerous newly-formed vessels and thin-walled
sinuses. A few large, fiat cells were found mingled
with the blood-clot, recalling the so-called decidual
cell). A definite diagnosis cannot be made iu this case
from the histological condition."

Cask III. H. J. O-; married, thirty-eight years of
age, was operated on October 17, 1892. Had had
three children. One abortion with twins, eight years
ago, at five months. Two living children since. Men-
struation began at sixteen. Always regular every
four weeks. Flows seven to eight days. Always
flowed excessively, soaking twenty-five to thirty nap.-
kins. Until birth of first child had severe dysmenor-
rhoea, beginning with the flow and lasting the first day.
Since first confinement absolutely free from all pain at
menstrual periods. Last child was born November
12, 1891. Grood getting-up, except that it took her a
long time to get her strength. There was a bloody
discharge from the vagina for three weeks after con-
finement. There had been a great deal of leucorrhoea
since marriage. March 6th, four months after con-
finement, menstruation returned. Flowed eight days.
No pain. Flowed profusely. Unwell every five weeks
until the menstrual period was due in October. When
four days over her time, October 10th, was taken with
severe pain in the lower abdomen. Fell to the fioor,
and was unconscious for several minutes. Large doses
of morphine were required to relieve the pain. The
face was pale, and she felt faint and was very thirsty.
Wednesday, Octtfber 12th, she was taken with severe
pain in both ovarian regions, and begun to flow. There
was but a show, and the pain lasted but five minutes.
There was no return at all of a bloody vaginal dis-
charge. Saturday, October 16th, during the evening,
she had a return of the severe pain in the lower abdo-
men. She grew very pale, felt faint, and was thirsty.
The pain lasted one hour, although morphine was
given twice. Monday, October 17th, during the fore-
noon, she was seized with severe pain in the lower
abdomen. As before, she grew pale, felt faint, and
was very thirsty. On the arrival of the family physi-
cian. Dr. E. S. Boland, the feet, hands and nose were
cold. The face was white, the lips colorless. She
was restless, with now and then sighing respiration.
Temperature 99°; pulse 120. Dr. Boland made a
diagnosis of internal hssmorrhage, probably a ruptured
extra^uterine pregnancy.

Dr. Fogg saw her in consultation, and agreed with
Dr. Boland. ' I saw her with Dr. Boland a few hours
after the onset of the pain and collapse. Reaction had
set in. The temperature and pulse were normal. The
severe pain in the abdomen had ceased, although there
was marked tenderness on pressure over the abdomen
below the umbilicus. Resonance was present, but over
the right ovarian region there was slight dulness. On
the right side, nearly on a line with the umbilicus,
there seemed to be a line of resistance, but this was
less marked when the patient was etherized. Nothing
could account for the symptoms more perfectly than
an ruptured extra-uterine pregnancy. She was sent
into St. Elizabeth's Hospital, and a celiotomy was done
as soon as she reached there. The abdomen was full
of blood, fluid in the region about and above the inci-
sion, clotted in the lower abdomen and Douglas's
pouch. Owing to the dulness over the right ovarian
region I expected to find the rupture on the right side;
but it took but a minute or two to run the right tube
between the thumb and finger, and thus prove that
there was no rupture on the right side. On feeling for
the left tube, the fingers came in contact with a shaggy
mass. On drawing this up to the incision the rupture
in the tube was seen, from which was squeezed out an
embryo in an unbroken sac filled with dear fluid. It

Digitized by

Google

258

BOSTON MEDICAL AND SUROIOAL JOURNAL. [Mabch 15, 1894.

was a beautiful specimen. Tbe right tube and ovary
were not removed. On entering the hospital the tem-
perature was 100°, and the pulse 115. Owing to her
very weak condition, no attempt was made to wash
out the peritoneal cavity. The clots and fluid blood
that could be easily reached were sponged out. No
drainage. For hours after the operation, shock de-
manded constant attfintion. Her recovery was unin-
terrupted, and she was discharged twenty days after
the operation.

Dr. WAitney't Report. — " The specimen consisted
of about six or seven centimetres of the Fallopian tube
with the ovary attached, and an embryo about three
centimetres long in an unbroken sac filled with clear
fluid. About two centimetres from the fimbriated end
the tube was dilated into an egg-shaped enlargement
about three centimetres in its longest diameter. The
free surface was torn, and from this a shaggy tissue
infiltrated with blood projected. Microscopic exami-
nation showed this to be made up of branching fibrous
filaments (chorionic villi). The ovary, to which the
end of the tube was slightly adherent, contained a
large corpus lutenm."

Casb IV. S. F., married, aged twenty-nine, en-
tered the hospital November 20, 1892. Has had seven
children, the youngest being six years old. Nine years
ago had two miscarriages at about six months. Ten
years ago miscarried at eight months. After her first
labor bad puerperal trouble of some kind, and was in
bed seven weeks. From her first pregnancy until six
years ago never menstruated, as she was either preg-
nant or nursing. Since then she has been regular
every thirty days. Has flowed two to three days, and
the amount has been small. Constant leuoorrhoea
since her last confinement. Last unwell four months
ago. During the first two months of this period had
no trouble except "morning sickness." Then came
loss of appetite, epigastric pain and constipation. Six
weeks ago begun to have attacks of sharp pain in the
lower abdomen, chiefly in the left ovarian region.
About this time a bloody discharge made up of fluid
blood and clots begun from the vagina. The abdomen
was distended, and everywhere below the umbilicus it
was sensitive to pressure. Pulse and temperature
were elevated. She had lost much flesh and strength.
By vagina, a soft elastic mass, the size of a small
orange, was felt in the right ovarian region. On
opening the peritoneum dark-colored blood welled up.
There was a large quantity of fluid blood and clots in
tbe abdominal cavity, but it was dark-colored. On
pressing the band down to the right tube, an embryo,
head presentation, was grasped, and drawn out of a
rent in the tube. When placed on tbe table, it moved.
Both tubes and ovaries were removed. The perito-
neal cavity was thoroughly washed out with a salt
solution. No drainage. She made a good recovery.

Dr. Whitney's Report. — •' The specimen consisted
of both ovaries and tubes. The right tube measured
about ten centimetres in length. Tbe outer eight cen-
timetres of this was occupied by a flattened oval en-
largement about six centimetres in diameter. On the
free border there was a small opening with a bsemor-
rhagic, infiltrated edge connected with an irregular
rent (made by the finger at the time of operation).
This opened into a cavity lined by a smooth membrane.
Microscopic examination showed the lumen of the
uterine end of tbe tube partially closed by a fibrous
mesh-work, the partitions of which were covered on

either side by a layer of columnar epithelium. The
enlarged part of the tube showed villi of the chorion
mixed with blood-clot. The embryo which came with
this measured seven and five-tenths centimetres. Tbe
ovary connected with this measured two centimetres,
contained a small dark cyst, and a large corpus luteum.
The other tube and ovary showed little chauge from
the normal."

Case V. W. W. R., married, aged twenty-four,
was sent to me by Dr. J. F. Croston, of Haverhill,
January 24, 1893. The following is the history of
the case :

Never pregnant. Menstruation began at thirteen.
Regular every five weeks. Flows seven days. Flows
moderately. Never any dysmenorrhoea. September
11th menstruation began, but the quantity was less
than usual. Seven weeks after this menstrual period
she was seized with severe, excruciating pain in the
lower part of the abdomen, in the median line, ex-
tending through to the back, and vomiting. The pain
lasted one hour. In two weeks the pain and vomitiug
returned, and lasted two hours. Between these attacks
there was nausea and vomiting, but they were not con-
fined to the morning. The third attack came on ten
days after the second. When three months over her
time ptyalism began, and lasted six weeks. The fourth
attack came on twelve days after the third. The fifth
attack began seven days after the fourth, and was ac-
companied with a show. November 26ib, pain with
flowing. December 3d, began to flow quite freely.
Went to bed, and flowed one week. December 10th,
severe pain and profuse flowing, followed by collapse.
Four weeks later, with no flowing, passed a " cast of
the womb." Stayed in bed until January 10th. No
flowing since the collapse. Sore feeling in the left
ovarian region. If pregnant, would be four plus
months. Nausea and vomiting lasted until the cast
of the womb came away. Six years ago she was in
bed six weeks with peritonitis, and has had several
less severe attacks since.

The history of the case was so typical that I made a
diagnosis before examining her.

A smooth, elastic tumor was found behind and to
the right of the uterus. Uterus was quite firmly fixed.
The examination caused considerable pain.

Sunday, January 29th, the abdomen was opened.
There was no blood in the abdominal cavity. Between
the layers of the right broad ligament there was a
tumor the size of an orange. I tried to tie ofi the
ligament so as to remove the tumor intact, but I was
unable to get more than half round owing to very
thick abdominal walls, and a poor light. A hole was
then dug through into the tumor, which contained a
foetus, placental tissue, and blood. The cavity in the
broad ligament was thoroughly cleaned out with fingers
and spouges, then washed out, and packed with gauze
to arrest the oozing. The tube had ruptured on the
under side, and the ovum, as it grew, made for itself a
place between the layers of the broad ligament A
small cystoma was removed from the left side. The
tube and ovary in the right side were removed. She
returned home in about three weeks. Menstruation
returned two months after the operation, and has been
regular every four weeks.

The foetus was given to Dr. Whitney, who was
present at the operation.

The blood and dibrU had begun to break down, and
had so softened tbe foetus that it was not preserved.

Digitized by

Google

yoL. CXXX, No. 11.] BOSTON MEDICAL ASD SUSGIOAL JOUBNAL.

259

With 8ome difficulty the sex was made out. This
woDld bring tbe age of the foetas up to aboat the fourth
mouth.

Case VI. This is the only ewe on record, as far
as coold be found in the literature on the subject, of
pregnancy in both tubes at the same time.

Mrs. H., aged thirty-six, entered the Carney Hospi-
tal November 16, 1893. No children. Had aborted
three times at about two months. There had been an
ioterral of about one year between each abortion.
Last abortion two years ago.

Menstruation began at sixteen. Always regular.
Flows three to four days. Uses five to six napkins.
Only slight discomfort when unwell.

October 25th, having gone six weeks without men-
struating, passed a small blood-clot. " Labor " pains
were present to a slight degree, being mostly in front.
October 27ih, had a severe attack of colicky pain in
the lower abdomen, obliging her to go to bed. The
pain was severest in the right ovarian region and ex-
tended Dp the side under the ribs. This pain was re-
lieved by applications of heat. There was slight flow-
ing. October 28tb, she was up and about. October
29th, the severe pain again returned, and she was
obliged to stay in bed until November 1st. During
this time she was in constant pain. On getting up
November 1st, she was seized with severe colicky pains
in the lower abdomen and fainted. At this time she
began to flow quite freely, ^nd had a " pressing-down "
feeling in the rectum. From this time until Novem-
ber 16th she was in bed. The pain was less, but at
times it was severe and of a colicky nature. Exami-
nation showed an enlarged uterus (four inches in depth),
chronic endometritis, a smooth elastic mass in the left
ovarian region, and a soft boggy feeling mass in the
right ovarian region.

Operation. — The uterus was first thoroughly cu-
retted. About one-half pint of dark-colored fluid blood
was fonnd in the peritoneal cavity. On the right side
a ruptured tubal pregnancy was found, and it was from
this rupture that the hsemorrbage had taken place.
The dilatation of the tube was at the fimbriated end.
On the left side the fimbriated end of the tube was
occupied by another extra-uterine fcetation. This was
removed unruptured. Both tubes and ovaries were
ligated and removed. The abdominal cavity was thor-
oughly washed out. No drainage. Her convalescence
was uneventful.

2V. Whitney't Rvport. — " The specimen from the
case of Mrs. H., removed by you at the Carney Hospi-
tal, November 21, 1893, consisted of a portion of both
Fallopian tabes with the ovaries attached.

" (1) Right tube and ovary.

"Tube. A piece about five centimetres long had
been removed. This was about normal for one centi-
metre from the cut end, when it suddenly enlarged to
a dark-red, egg-shaped mass, four by three centimetres
in diameter. The fimbriated end was drawn up against
the swelling and spread out upon its surface. There
was no free blood coming from it. The surface of the
mass was marked by small, arborescent, injected blood-
vessels, and was more or less covered by a thin layer
of dark, coagulated blood.

"The right ovary measured four by two centimetres,
was flattened and very much corrugated, and covered
on the surface by thin, quite adherent blood coagula.
At the end nearest the fimbriated end of the tube was
a yellow opaque body with a more or less convoluted

outline. This measured about one centimetre in
diameter.

"Microscopic examination showed that the blood-
clot contained thread-like masses, which were evidently
villi of a chorion.

" (2) The left tube and ovary.

" Tube. About four centimetres had been removed.
Tbe cut end was normal, and the tube continued so for
about one centimetre, when it dilated into an irregularly
rounded mass about two and a half centimetres long
by one and a half in diameter. It contracted again
just before the fimbriated end, which was normal. The
surface of the enlargement showed injected arborescent
vessels like the other, and was also roughened by thin
adherent coagula. But quite close to the fimbriated
end was a rounded projecting clot about one centimetre
high, which section showed to be directly continuous
with a dark-red mass filling the interior of the tube.
Section through the tube showed a small blood-clot in
the wall of the tube near the uterine end, which con-
tained numerous small, branching villi, like those of
the chorion. This clot was continuous into the cavity
of the tube. The clot which projected from the sur-
face was not connected with this one iu any way, and
was a perfectly independent affair, which had passed
entirely through tbe wall of the tube. In this were
structures recalling very poorly-formed chorionic villi.

" The left ovary measured four and a half by two
centimetres, and was of the same flattened and cor-
rugated shape as the right. Its surface was also covered
with blood-clot and some fibrous adhesions. At the
end next the fimbriated end of the tube was a corpus
lutenm one centimetre in diameter. The other end of
the ovary was occupied by a cyst with bloody contents,
the size of a small cherry.

" January 5, 1894. Further study of this remark-
able specimen is necessary. But as far as the investi-
gation has gone, it shows with certainty the fact of a
pregnancy in each tube, with the possibility of their
also being a twin pregnancy in the smaller tube. It
is probable that the age of the pregnancy in the two
tubes is not the same."

(1) The cause of extra-uterine pregnancy seems to
be due to an absence of the ciliated epithelium in the
tube. This condition allows the spermatozoa to ascend
tbe tube and there meet with the ovum. It also re-
tards the ovum in its downward migrations. This
theory will not hold if the modern idea is true, namely,
that normcUly impregnation takes place in the tube.

(2) All extra-uterine pregnancies are primarily
tubal, the point of rupture and circumstances deter-
mining the variety that will be found after the rupture,
provided gestation goes on after rupture takes place.

(3) Rupture of the tube takes place when tbe limit
of its expansibility is reached, and this is usually be-
tween the second and third mouths of pregnancy,
usually at the second month.

(4) in this class of cases there should be no delay
in opening the abdomen.

Nkw Potbnoies fob Pkrmanganate of Potash.
— Permanganate of potash is fast becoming a popular
antidote for all kinds of poisons. Not only is it effica-
cious against snake-bite and morphine, but now an
Alsatian, M. J. Austal, claims that it acts as an anti-
dote for phosphorus, muscarine, strychuiue, colchicine,
oil of sabine and oxalic acid ; at least in dogs, rabbits
or frogs.

Digitized by

Google

260

BOSTON MEDICAL AND StJRQtOAL JOVRHfAL.

[Mabcb 15, 1894.

CASES OF EXTRA-UTERINE PREGNANCY,
WITH OPERATIONS.

BT J. W. ELUOT, K.D.

Case I. Unruptured tubal pregnancy.

This case was reported in part in the Boston Medi-
cal and Surgical Journal, February 2, 1893, by Dr.
Prior, of Maiden, with whom I saw it. An abstract is
here included to make my report complete.

The patient, aged thirty-fire, was married to a
second husband. She had had pelvic peritonitis sev-
eral years before her present illness. She finished a
normal menstroation at the end of June, 1891. About
six weeks later, at the end of August, she had a show
of blood, which lasted a day or two and ceased. This
sort of flowing continued intermittently to the end of
September. She had the same pain she usually had at
regular mensiruation, and thought this was simply a
prolongation of that process.

She consulted Dr. Prior for a nose-bleed on October
18th. He found the uterus slightly enlarged, and the
left Fallopian tube large and tender. One week later
the flowing returned. She was put to bed with more
pain and a temperature of 100°. There was no nausea.'

I saw her, in consultation, on November Ist. There
was a boggy swelling in the region of the left tube.
The diagnosis was chronic tubal disease, either gonor-
rhceal or tubercular, with hsemorrhage from the tube
coming ont through the uterus. Eztra-aterine preg-
nancy was considered and thought less probable.

Operation, November 25th. The abdomen being
opened, the pelvic contents were found matted together
by old and new adhesions. Both tubes were found
inflamed and enlarged, especially at their outer ends,
forming with the ovaries the so-called tobo-ovarian
cysts. In dissecting out the left side I noticed that it
was very vascular ; four or five arteries spurted in dif-
ferent directions. When removed, this proved to be
the unruptured sac of a tubal pregnancy. The patient
made a good recovery.

The following is Ur. Whitney's report on the speci-
men:

" The specimen consisted of about three inches ot
the Fallopian tube with an ovary attached. The tube
was of normal size and appearance, till close to the
fimbriated end, where it suddenly dilated into a round
mass about the size of a robin's egg. The color was
a dark red, and the surface was slightly roughened.

" Sections made at right angles to the long axis of
the tube showed greatly dilated and sinus-like blood-
vessels among the clots, in which were portions of
chorionic villi ; and in the midst of the mass which
occupied the centre of the tube an embryo, slightly
curved, and measuring about four millimetres in length,
which would place it between the eighteenth and twen-
tieth days.

"In the ovary a well-marked corpus luteum with
deeply festooned edges."

Case II. Tubal pregnancy of five months' stand-
ing ; rupture, causing pelvic peritonitis.

The patient, aged thirty-two, had been married
several years, and had had no children. The catamenia
had always been regular. In September, 1892, she
passed her period, and had occasional nausea in the
morning during the last of the month. Two or three
weeks later she had an attack of pain in the abdomen,
with flowing, and went to bed. After a fit of cough-
ing a membrane came away from the vagina. 'The

flowing continued through October, and in November
she had an attack of pain and tenderness in the abdo-
men. During December she felt somewhat better, but
still had slight flowing and pain.

She entered the Massachusetts Greneral Hospital
January SO, 1893. She was well nourished, fat and
ruddy. On examination, s tender, fluctuating mass
was found on the right side of the uterus extending
down into Douglas's fossa. There was also a smaller
mass on the left side.

Operation, February 6th. The patient was placed
in the Trendelenberg position. When the abdomen
was opened, the pelvic cavity was found walled off
from the general peritoneal cavity by old and new ad-
hesions. When opened, it was found full of dark,
clotted blood, with a quantity of shreddy, placental-
looking tissue. The right ovary and tube dilated,
tortuous and ruptured, was tied oS and removed. The
left tube, being diseased, was also removed. The pel-
vis was sponged out, and the abdomen closed with a
glass drainage-tube in the pelvis. The patient made a
rapid recovery.

Unfortunately, I have been unable to find the patho-
logical report on this specimen, but have a record from
the hospital, that it was evidently a case of ruptured
tubal pregnancy of several months' standing.

Cask III. Tubal pregnancy; sudden rupture, with
alarming symptoms and collapse.

The patient, aged thirty^wo, was unmarried, bat
was exposed in the last of December, 1893, about one
week after the cessation of a period. She then went
five weeks without any menstruation. A flow then
began, which continued each day for three weeks, and
was always preceded by pain.

,0n February 11th Dr. Lena Ingraham examined
the patient at her office, and made a diagnosis of extra-
uterine pregnancy. The next morning the patient was
suddenly taken with weakness and vomiting and a pain
in her left side. The pulse became rapid, and she was
in a critical condition. She was sent to the Massachu-
setts General Hospital on February 12th. When
seen there she was pale, with sunken eyes and a bad
expression. The abdomen was swollen and tympanitic,
and slight pressure caused pain. The uterus was en-
larged, and there was a fulness in Douglas's fossa.
During the night she vomited frequently, and the ab-
dominal tenderness and distention increased, but the
pulse improved. February 13th, the patient looked
badly, being of a yellowish-white color.

The operation was done in the Trendelenberg posi-
tion. The abdomen was found full of black clotted
blood. The bleeding came from the right tube, which
was markedly dilated. The ovarian artery was en-
larged. In the clots removed from the pelvis there
was a little sac the size of a bean, which looked like
an embryo, (unfortunately this was not examined mi-
croscopically). Both tubes and ovaries were removed
The abdomen was sponged out, and a glass drainage-
tube placed in the pelvis.

The patient rallied from the operation, and made a
slow recovery. One year after the operation she was
found to be in excellent health..

The following is Dr. Whitney's report on the tubes
removed : " The specimen consisted of both tubes and
ovaries, and a mass of blood-olot, at one part of which
was a more or less shaggy membranous patch. One
tube and ovary presented nothing markedly abnormal.
The other ovary had a portion torn away from it,

Digitized by

Google

OL. CXXX No. 11.] BOSTON MBDWAL AUD SUROlOAL JOURNAL.

261

liich on section wae found to be a corpus luteum.
'he tobe was thickened and dilated towards the fim-
riated eud. lu the walls there were no greatly dilated
lood-Tessela or hemorrhagic infiltration. The section
hroagh the clot showed masses of well-marked chori-
■nic villi.

** Although there is no absolute microscopic evidence
hat the conception had taken place iu the tube, still it
B probable that the ovum developed there to a degree
ind then an abortion took place into the abdominal
Mivity, BuflBcient time having elapsed to allow retro-
pade changes to have taken place in the tube."

Ca.sk IV . Tubal pregnancy ; rupture, with serious
tymptoms.

The patient, aged thirty, entered the Massachusetts
General Hospital in November, 1898. She had had
two children, the youngest being six. years old. Her
catamenia had continued regularly throughout her
second pregnancy. From that time on there had been
no irregalarity. The month before entrance the regu-
lar flow had been much more profuse than usual, and
had been accompanied with darting, cutting pains in
the lower abdomen. This pain had recurred every
three to four days since that time. The week before
coming to the hospital the pain had become very severe,
and the uterus had been curetted. Catheterization then
become necessary. She had had occasional slight
chills, one quite severe. She thought herself three
mouths' pregnant, and had cravings and a great appetite.
On examination the uterus was found to be some-
what enlarged, and there was a tender mass, the size of
a fist, in Douglas's fossa. On the following day thic
mass was found to have filled the pelvis and to have
extended nearly up to the umbilicus. The patient was
suffering great pain, had a poor pulse and a very bad
general expression. As Dr. Warren, in whose wards
she wsLS, happened to be out of town, I operated at
once, fearing that any delay might be fatal.

The patient being placed in the Trendelenberg posi-
tion the abdomen was opened by a large incision. The
whole pelvis and lower third of the abdominal cavity
was lull of dark, clotted blood. This hsematocele was
walled off from the rest of the abdominal cavity by
recent adhesions ; the enlarged, flattened and much dis-
placed uterus formed a part of this barrier. The adhe-
sions were separated and the blood scooped' out. The
right tube, enlarged to the size of a lemon, and contain-
ing a mass of tissue and clotted blood had been ruptured.
The other tube showed the effects of chronic salpingitis.
They were both removed. The ligated pedicles were
markedly oedematons. The blood cavity was sponged
out, and the abdomen closed without drainage. The
patient made a good recovery.

Ih, Whitnejf's Report. — " Specimen consisted of
about fourteen centimetres of the Fallopian tube, with
part of the ovary attached ; two centimetres of this
were of normal size, then dilated suddenly into an elon-
gated sac about three centimetres in greatest diameter,
and then contracted again at about two centimetres
from the fimbriated end, which was quite open. In
the dilated part of the tube was a firm, dark-red mass
intersperged with whitish, fibrous- looking things, and
10 the centre a cavity, one centimetre in diameter, lined
with a smooth membrane. This mass was adherent at
the part next the normal tube, and was only slightly
Utached elsewhere ; it was directly continuous with a
clot the size of the end of the thumb protruding from
the rent in the tube opposite the line of attachment of

the tube and close to where it commenced to contract
again at the fimbriated end. There was no blood
found in this part of the tube. Microscopic examina-
tion showed the white strings to be made up of branch-
ing and club-shaped villi of the chorion. No remains
of an embryo were found. Tubal pregnancy, with
rupture."

Cask V. Probable tubal pregnancy ; rupture, with
sudden and alarming symptoms.

The patient, aged thirty-seven, gave the following
history : She had one child fourteen months old. Since
the birth of the child she had been regular until four
months before I saw her, since which time the monthly
flow had not appeared. She had a large appetite and
the breasts were large and tender ; she therefore
supposed that she was pregnant. One month before I
saw her, she was taken with sudden and severe pain iu
the lower abdomen, and with vomiting; while kin-
dling the fire she fell on the floor in a faint. After
this she remained in bed for a week or ten days, suffer-
ing much pain. When she got up she bad a heavy
and sore feeling in the lower abdomen, and there was
au irregular, bloody discharge from the vagina.

The night before I saw her, she had another attack
like the one just described. She again fainted, with
sudden severe pain in the epigastrium ; there was also
vomiting and diarrhoea. Dr. F. B. Lund saw her, and
considering it ,a case of extra-uterine haemorrhage, sent
her to the Massachusetts General Hospital, where I
saw her and operated a few hours later.

On entrance the patient had a yellowish-white color;
was languid and sluggish in her movements ; and could
not talk intelligently. She had the look of a person
in a critical condition, although the pulse and tempera-
ture were about 100.

When the abdomen was opened, the pelvis was
found to be filled with an hsematocele, which had rupt-
ured (causing the second attack of pains) and was fill-
ing the abdominal cavity with blood. About a quart
and a half of blood was scooped and washed out of the
pelvis and abdomen. Fresh bleeding was seen coming
from the region of the right tube. Both ovaries and
tubes were involved in the adhesions of the hsematocele,
and were therefore removed. The abdomen was closed
without drainage. The operation was quickly finished,
and the patient suffered no shock ; a large amount of
salt solution was given by rectum. The patient made
a slow recovery, convalescence being interrupted by a
pelvic abscess.

Dr. Whitney has not finished the report on the
specimen.

IMPURE IC£.>

BT F. A. DmtBAS, M.D., OAMBBIDOE, MASS.

Ddrino the past year my attention has been drawn
to the purity, or rather impurity, of the ioe supplied in
this city, and 1 have made quite a number of analyses
of ice taken from the ice-wagons while they were de-
livering to customers their daily supply, as well as
from the ice stored in the ice-houses. I have also
looked over the sources of supply of many of the
companies who cut ice near by, and as the results of
these examinations have been quite interesting to me,
I thought the Society might be interested by a short
account of the present condition of ice as supplied here
for domestic use.

< Beadbefors theOunbridge Sooiet; for Hadlosl Improvemeat.

Digitized by

Google

262

BOSTON MEDICAL AND SVttGICAl JOVBNAL

[Mabch 15, 1894.

The first thing I had to determine was bow many
companies deliver ice, and where they get their annual
supply ; this after considerable inquiry I was able to
find out. The companies are the Fresh Pond Ice Co.,
the H. D. & W. S. Dnrgin Ice Co., the Boston Ice
Co., the Independent Ice Co., the Drivers' Union Ice
Co., the Harvard Ice Co., and the Cambridge Ice Co.

On writing to these different companies, asking them
to give the source of supply of their ice, I received re>
plies as follows :

The Fresh Pond Ice Co. cut all their ice at Berlin,
N. H. The Durgiu Ice Co. get their supply from Spy
Pond in Arlington, and from Smith Pond in Belmont ;
the latter pond is only a few hundred yards from Spy
Pond. The Harvard Ice Co. buy their supply from
the Fresh Pond Co. The Cambridge Ice Co. cut their
ice on Spy Pond in Arlington, and on Little Fresh
Pond in North Cambridge. The Boston Ice Co. cut
their supply at Milton, N. H., Woburn, Mass., Wake-
field, Mass., N. Chelmsford, Mass., and South Wey-
mouth, Mass. The Drivers' Union Ice Co. cut on
Wenham Lake in Beverly, Chebaoco Lake in Essex,
Wausbakum Lake, South Framingham, and Lovell's
Pond in Wakefield, N. H. The Independent Ice Co.
cat on Mirror Lake in Hudson, Mass.

Thus it is seen that the ice sold here comes not only
from ponds within a few miles of Boston, but also
from points more or less distant, both in this State and
from New Hampshire. I also discovered that each
company seems to have a certain district which it sup-
plies ; and though in some parts of the city these dis-
tricts overlap, in other parts only one company fur-
nishes ice ; and there seems to be a sort of understanding
between the different companies that each one will
keep to its own district.

I next proceeded to collect and analyze samples of
ice. The samples were taken, if possible, from a block
of clear ice, broken up, washed under a faucet, and
put into clean glass jars. When the ice had melted,
the appearance of the water was noted, and it was then
submitted to an ordinary water analysis. The amount
of solids, organic and inorganic, was determined by
evaporating to dryness a known quantity of water in a
platinum dish, over a water bath, weighing and sub-
tracting the weight of the dish ; then heating the dish
to redness for a few moments, and again weighing
when cool.

The amount of chlorine, which occurs almost entirely
in the form of chloride of soda, was determined by add-
ing to a known quantity of water a few drops of a so-
lution of potassic chromate, as an indicator, and then
adding, drop by drop, a standard solution of nitrate of
silver until the yellow color of the water changed to
red ; from the amount of silver solution used to de-
compose the chlorides, as shown by the change of
color, the amount of chlorine was calculated. Free
and albuminoid ammonia was determined by distill-
ing a known quantity of water, until a certain amount
had come over and Nesslerizing this distillate, then
continuing the distillation of the same sample after
adding a solution of potassic permanganate and potassic
hydrate and Nesslerizing this second distillate the
same as the first. The full details of this analysis may
be found in Wanklyn's Water Analysis.

I made a good many such analyses during the sum-
mer and fall, and the results were as varied as possible.
The ice coming from New Hampshire was mostly
quite pure, the analyses showing water of such purity

as is considered suitable for drinking; some oT that
cut in this State and even from ponds quite near by
was also of excellent quality ; but other samples were
evidently cut from ponds contaminated with sewerage,
or filled with decomposing vegetable matter ; the water
from the melted samples in some cases smelt badly; in
others where there was no bad odor, there was so much
dirt of one kind and another floating through it, that
no one would for a moment think of drinking such
water. One small pond quite near by which I visited
in the summer, has no apparent outlet of any kind,
and is used for bathing during the warm weather by
the people living around it ; an analysis of the water
of this pond showed it to be contaminated with sewer-
age. Other ponds are situated in the midst of thickly
settled districts, so that the e^rly winter rains must
necessarily wash filth of one kind or another into them ;
and still others have already been condemned as sources
of water-supply, though still considered good enough
to furnish ice. In fact the ice offered for sale seems
to be of all degrees of purity, from that of excellent
quality to that so much contaminated that it must be
considered wholly unfit for domestic use.

A few of the analyses may be of interest ; they are
as follows :

Loeallty.

Parte par 100,000.

SoUda.

Chlorine.

Free
Ammon.

Alb.
Ammon.

Spy Pond. ArUiu;ton. Haw.,
a. D. & W. sTd. lee Co. .

Smith Pond, Belmont, MaM.,
H.D.*W.S.D.IoeOo. .

Brookllne, N. H., F. P. loe
Co

5.00
3.00
B.70
3.00
4.00
4.30
S.TO
4.20
3.40
15.70
7.10
3.00
6.70
5.70

0.87
0.70
0.43
0.35
0.60
0.43
0.43
1.30
0.70
1.10
0.43
0.69
1.90
0.43

:.004 1

|.b02.V

.OOll^

:, .0011

•»-
.-.oo3j;

«

.001
.001

r.oo2

--006?
.003
.001
.020
.030

.oos

.006
.010

006

Wolfboro' Jane., N. H., D.
U. lee Co .

loe Co

.006
006

New Hampehlre, 0. lee Co. .

New Hampehlra, H. loe Co. .
LIUle Freeh Pond, N. Gwnb.,

Man., C. Ice Go. ... I
Horn Pond, Wobnm, Haas.,

B. lee Co

Hudaon, Haaa., I. loe Co. . .

N. Chelmatord, Haaa., B. loe

Co

.006
.008
.006
.063
.063
Oil

New Hampahlre, H. Ice Co. .
Mirror Lake, Hodaon, Maaa.,

I. loe Co

Spy Pond, Arlington, Haaa.,

H. D. & W. sTd. loo Co. .

.OSS
.020
.014

Of course, if ice never came in contact with food or
drink, its condition of purity or impurity would be a
matter of no consequence ; but during the summer, at
any rate, it is almost universally used so as to contami-
nate certain articles of food. Water and milk are
cooled by placing pieces of ice in the vessels contain-
ing them ; butter, tomatoes, lettuce, etc., have pieces
of ice placed directly upon them ; and doubtless every
one can think of further examples of its direct use.
Now, some recent examinations of Hudson River ice
made by Prudden have shown that many kinds of
bacteria are not much affected by freezing; in some
samples they were found to be very numerous, and,
when placed in favorable conditions for growth, none
the worse for their imprisonment. We also know
from this and other sources, that many harmful kinds
of bacteria, among them the bacillus of typhoid fever,
can survive freezing, often for long periods ; and even

Digitized by

Google

Vol. CXXX, No. 11.] BOSTON MEDICAL AND SURGICAL JOURNAL.

263

vben the bacteria themseWes may be destroyed, it is
probable that their spores may be more resistant than
the bacilli to cold, just as they are to heat. Cases of
typhoid ferer, as we all kDOW, are most namerous '\a
the fall ; and some epidemics have already been traced
to the nse of water contaminated by previoas cases.

It does not require a great stretch of the imagina-
tion to soppose a small pond contaminated in the late
fall or early winter by the washing into it of typhoid
discharges from cases occarring on its banks. If this
pond should shortly after freeze over, it does not seem
beyond the bounds of possibility that the ice cut from
it might give rise to fresh cases. I do not know that
any cases of typhoid or other diseases have been traced
directly to the use of impure ice, and indeed the diffi-
culties iu the way would be so great that it may never
be done ; but it seems to me that until we have fewer
cases of infectious diseases, for which we can ascribe
00 cause, the chance of some of them originating from
the ice-snpply should not be ignored, and if it is con-
sidered Decessar} for a town to have a pare water-
supply, the source of its ice should no longer be left
to chance.

The State Board of Health have made an investiga-
tion into the condition of the ice-supply throughout the
State (an account of which may be found in the report
of 1890), and have also made numerous experiments
to see how far water could purify itself by freezing.
These experiments resulted somewhat as follows :

Different parts of the same cake of ice may differ
greatly in purity ; the snow-ice is always the most im-
pure ; and of the clear ice, the more air-bubbles it con-
tuns, the more impure the ice is found to be ; more-
over, the bacteria are found to be far more numerous
in tnow-ice and around a layer of air-bubbles in clear
ice. When a pond freezes over, the first inch of ice
seems to be about as impure as the water; if snow
falls on the ice so as to sink it, and then holes are cot
■o as to flood the snow, as is generally done, this
upper layer is found to be as impure as the water, plus
whatever impurities the snow may have derived from
air. If DOW the ice forms rapidly anderoeatb, so that
few air-bubbles collect, it is found to be much more
pore than the water from which it is formed ; what-
ever impurities it contains are largely composed of the
matter held in suspension by the water, the matter in
toiution being more or less completely removed. As
a result of the experiments made, the Board concluded
that while clear ice from polluted sources may contain
so small a proportion of impurities as not to be con-
lidered iujarious to health, the snow-ice — and any ice,
however clear, formed by flooding — is likely to con-
tain so large a percentage of the impurities of its
source, together with some of the disease germs that
may be in its source, that no ice can be recommended
for domestic use that is cut from a source which would
not be considered as suitable for drinking-water.

When one comes to the question of how best to
prevent the use of impnre ice, and what legal restric-
tions have been put upon its sale, it is found that
scarcely anything has been done in this respect.

There is a statute, passed some years ago, to the
effect that if twenty-five consumers of ice supplied by
one dealer, and cut in this State, think the ice unfit
for use, they may ask the State Board of Health to in-
vestigate the matter. The Board may then order a
hearing, and put whatever restrictions may seem ueces-
nry on the sale of such ice. If the ice-dealer feels

aggrieved, be may take the matter into court and have
it tried before a jury. Dr. Abbott, the Secretary of
the State Board of Health, tells me that only one such
complaint has ever been brought before the Board;
and this one was brought by an ice-dealer in order to
enable him to break a contract.

There is also a city ordinance on this subject, to the
effect that all persons intending to sell ice for domestic
use must give uotice to the Inspector of Milk some
time during the month of April of each year, together
with information as to the source of the ice. A
penalty of twenty dollars is imposed for non-compliance
with this order. The inspector is then directed to
make such analyses and examinations of the ice and
its source as he may deem necessary, in order to deter-
mine its purity, and to give copies of such analyses to
the Board of Health and the City Clerk, the latter to
be kept open for public inspection. This gives no one
the power to prevent the sale of ice, however impure ;
probably not one person out of one hundred knows
that ice analyses can be seen at the City Hall ; and
even if it were known, not one person oat of one hun-
dred would, after looking at them, be any the wiser.
As a matter of fact, no one has ever asked to see them.
This is not a very good showing, either for the public
interest in the matter of impure ice, or for the means
at hand to prevent its sale.

fli^tintal l^rogcejecjsc.

REPORT ON DERMATOLOGY.

BV JOan T. BOWIB, ILO,, BOSTON.

(Oonoladad from No. 10, pace 244.)
CrSTIOBBOI IN TBB SKIN Or MAN.

Lbwin's article on cysticercus cellulosse, in Eulen-
berg's " Real-Encyklopiidie," has remained up to the
present time the most complete exposition of the sub-
ject that we have. In the Archiv. fur Dermatologxe
und Syphitit, Heft 1 and 2 for 1894, he again takes up
the pen on this subject. He repeats what he has pre-
viously said, that cysticerci in the skin often simulate
tumors of a different nature, for example, gummata,
and are not always recognized. He also asserts that
few cases have been recorded where the recognition of
the cysticercus in the skin has made the diagnosis of
the parasite in other organs possible, although he has
had numerous instances of this in his own practice.
His cases, which are described in this article, he
divides into (1) those in which the cysticerci cause
little or no local disturbance; (2) those which have
been taken for gummata, and treated by antisvphilitic
remedies ; (S) those which also caused disturbances of
other tissues or organs, especially of the brain, and
which have been considered of syphilitic origin also.

Lewin concludes, from his historical researches, that
from the discovery of the cysticercus down to 1875,
uamely, during two centuries, it was only found eight
times in the living subject. Since 1875, about 50
cases have been published, yet this number falls below
its actual occurrence.

The eggs of the tapeworm inhabiting the small in-
testine contain the numerous embryos of the future
cysticercus. The infection of man with these embryos
may take place directly through the eggs of the tenia
of bis own intestine, or indirectly through the eggs of

Digitized by

Google

264

BOSTON MEDICAL ASD 8VROIOAL JOURNAL.

[March 15, 189 4

a tapeworm belonging to another person, although the
direct mode is denied by Virchow.

The comparative in frequency of the discovery of
cysticerci in the skin is partially doe to the slight
symptoms caused, which do not lead the patients to
seek medical help. Symptoms do, however, occur,
hut their appearance is very gradual. They may
cause more or less severe rheumatio pain, sometimes
even suggesting the paroxysms of gout, or numbness
or neuralgic pain, stiffness of the affected part, etc. ;
sometimes there are also inflammatory appearances.
These are indicated by pallor, or sometimes a dark
brown color of the affected tissue, and capillary haemor-
rhages. This inflammation may result in abscess ; but
whether the suppuration is caused by organisms trans-
ported l>y the cysticercus, or by ptomaines produced
by the parasite, can only be conjectured.

With regard to diagnosis, the tumor formed by the
cysticercus surrounded by its connective-tissue capsule
is always more or less movable. The degree of this
depends upon the depth of its location, and whether it
is fastened by fibres from an adjacent muscle. The
nodule is sometimes prominent, often not. The size
is variable. On the average they are from a lentil to
a hazel-nut in size. It is either roond or oval in shape,
the former especially in those lying in the subcutane-
ous tissue, the latter in those contained in the muscles.
The consistency of the tumors is characteristic, being
almost as hard as cartilage, and in this way it is dis-
tinguished from syphilitic gummata. Its surface is
smooth. The parasite appears in man both singly and
in great numbers. In most instances, there are at
least several. The extirpation of the tumors is the
decisive test The bladder-like covering is seen, with
a firm, whitish, round body, the size of a pin's head, in
its interior, the embryo itself.

Cysticerci may be confounded with tnmors of vari-
ous kinds. Gummata, however, are most frequently
diagnosticated, and several cases are related of tumors
in syphilitic subjects, which were at first taken for
gummata and afterwards proved to be cysticerci. In
some cases the differential diagnosis may be extremely
difiicnlt, if not impossible. The writer believes that
many of the cases of intractable gummata may have
been cysticerci, and mentions the fact that Hebra de-
scribes no case of the disease in 80,000 cases of skin
affections, and makes no mention of it in his work on
dermatology. The hand-books on pathological anat-
omy also accord it scant recognition.

The recognition of the cysticercus in the skin is
often of great importance in the diagnosis and treat-
ment of diseases of the internal organs. Sometimes it
occurs both in the skin and in the viscera, and its dis-
covery in the former will often lead to its diagnosis in
the latter situation. This is especially true of cysti-
cercus of the brain, which is comparatively common,
as statistics show, and which cannot be diagnosticated
unless cysticerci are found externally. A number of
such instances are related.

A cysticercus in the eye is naturally of equal impor-
tance in the diagnosis of visceral troubles. Von Grafe
was the first who made this diagnosis, followed later
by others.

HIDB0CT8TOMA.*

In 1884, in a paper upon malaria and sudamina. Dr.
Robinson described a peculiar affection, seen especially

^ A. R. Kobloson : Joomal of Cutmueou and Osnito-U'rlnary Dii-
eaaea, Augoit, 1898.

upon the faces of washerwomen and those who per-
spire freely upon the face, which was evidently related
in its anatomy to the sweat-glands. The affection was
described, in his manual of dermatology, under the
heading " Sudamina," hut has been since referred to
by Jackson and others as " dysidrosis."

Robinson has found the affection of not infrequent
occurrence in New York City, as he has seen not less
than thirty or forty cases since 1884 All these cases,
with one exception, have been in women of middle age
or older, although he can give no reason for this restric-
tion. In one case it occurred in a young man of
twenty -eight, on the lower half of the right side of the
nose. Most of the women had been " doing general
housework," and most of them attributed it to wash-
ing; although some did very little of this work. It
occurred also in cooks who did not wash, and in people
who neither cooked nor washed ; but in the majority
of cases the subjects were middle-aged women who
perspired freely and did considerable washing over
tubs. The cases were all worse in summer than in
winter, and in some the affection almost entirely dis-
appeared in cold weather. The lower part of the fore-
head, orbital region, the nose and cheeks, are the
favorite seats of the eruption. The lesions are either
discrete or situated closely together, and are " tense,
clear, shiny vesicles, obtuse, round or ovoid in form
and varying in size from that of a pin's head to that of
a pea." They are rather deeply seated and project
somewhat above the level of the skin. The smaller
ones look like boiled sago-grains, the larger have a
dark bluish tint. - There are no signs of inflammation.
The subjective symptoms are slight or wanting. These
vesicles contain a perfectly clear fluid, which never be-
comes turbid, and is of a slightly acid reaction. The
lesion, if unruptured, dries up and disappears after last-
ing from one to several weeks.

A careful microscopical examination of a number of
these lesions showed them to be due to a cystic dilata-
tion of the sweat-duct within the corium. The epi-
dermis was not concerned in the process. A cyst is
found in ihe corium, whose connection with an ex-
cretory sweat-duct may be verified by the sections.
As the vesicles always contain a clear acid fluid re-
sembling sweat, and as the connection between these
cysts and the sweat-duct may be traced, we have here
a proof that the theory that the sweat-glands are only
fat-producing and not sweat-producing glands, is not
true.

Robinson is not able to explain why the lesions
form, but he assumes that there must be some abnoi^
mal condition in the excretory tube, or surrounding
connective-tissue, causing obstruction to the outflow of
sweat.

The word sudamen has been used to describe the
condition caused by retention of sweat within the cor-
neous layer of the epidermis. This condition rarely
appears on the face and is very superficial. As in
sudamen the sweat is not retained within an excretory
duct, and as in the disease that has been described
there is a proliferation of epithelial cells so marked as to
cover the whole inner lining of the cyst formed by
dilatation, Robinson considers that it is entitled to a
distinct name and proposes the term " hidrocystoma "
as unobjectionable and fairly descriptive.

The term " dysidrosis " that has been applied to this
condition is deplored, as tending to confuse it with the
dysidrosis of Fox and Hutchinson, or pompholyx,

Digitized by

Google

»r.. CXXX, No. 11.]

BOSTON MEDICAL ABD SURGICAL JOVRSAL.

266

lich is an acnte inflammatory affection occurring
ton the palms and soles.

IB X&BA.'rBCBNT OF CERTAIN SKIN AFFBCTION8 BT
THYROID FEKDINO.

In the Dermatological Section of the British Medical
.Bsociation held at Newcastle-on-Tyne, August 2,
393, £>r. A. T. Davies read a paper on the above
ihject, which is printed iu the British JourtuU of
>er^€Mtoloffy for September, 1893.

It has been noticed that when the thyroid gland is
iven medicinally in myxoedema, the skin and glands
egain their normal condition and there is a new
.Towth of hair. In illustration of the influence of thy-
'oid feeding on the skin, a case is cited that was
hown at the Hanterian Society in April, 1893. The
voman had, by accident, taken ten thyroids at once.
The result was an acute dermatitis, with a " peculiar
»t\cky secretion," followed by peeling of the entire
hands.

The following four cases of skin disease were treated
by Davies with tablets of thyroid extract :

Case I. A blacksmith, suffering from psoriasis,

which had begun three weeks previously on his left

arna aud had gradually affected the rest of the body.

Ons tablet of thyroid extract a day was given, and the

improveuieut was immediate. In eight weeks the

p«tieDt was cured. He had taken, before the thyroid

extract, a simple alkaline tonic for three weeks, which

had bad no effect upon the skin. There has been no

relapse.

Case II. A boy of sixteen, with psoriasis of three
gears' duration. This patient had been for some time
nsing cbrysopbanic acid externally and taking arsenic
intenially, bat in April, was put on thyroid tablets
also. There was so marked an improvement after the
thyroid was added, that the arsenic and ohrysophanic
acid were discontinued. After taking the tablets for
three months he was practically cared.

Case III. A woman of forty-three, with ichthyo-
sis ; which is congenital, and other members of ber
family are affected. After taking a thyroid tablet every
day for a month, she was very much improved. At
first the desquamation was increased, but soon began
to diminish, and the skin generally to assume a more
natural condition. Perspiration of face and head has
also increased.

Case IV. A woman of fifty-nine, who had had a
chronic eczema for twelve years, with acnte exacer-
bations, aud who bad been treated by Davies for seven
years. During the last acnte attack one thyroid tablet
a day was given in conjunction with the otber remedies,
and the improvement was much faster than it had ever
been before. Davies concludes that thyroid extract
W a powerful effect in altering the condition of the
akin, aud hence of assisting the action of the remedies
nted.

At the same meeting Dr. Byrom Bramwell presented
» paper on the " Value of Thyroid Feeding in Psoria-
M and Skin Affections," illustrated by photographs
of the cases. Seven cases had been treated, and there
had been great improvement in all but two.

1

AChaibop Public Health at Edinbdrgh. —
The University of Edinburgh has recently establfshed
» chair of public health with an endowment of five
thoostnd pounds.

Vitpnttfi of Jtntittit0.

OBSTETRICAL SECTION OF THE SUFFOLK
DISTRICT MEDICAL SOCIETY.

O. H. WASHBUltK, U.V., BKCBETABT.

Regular Meeting, Thursday, December 28, 1893,
Dr. Edward Rbtnolds in the chair.
Dr. F. W. Johnson made a report of

SIX OASES OF KXTBA-UTERIME FREONANCT.'

Dr. W. F. Wbitmet : These cases of Dr. Johnson's
are most interesting and he has kindly placed them at
my disposal for microscopic examination. With one
exception there was no doubt of the diagnosis. In
the others there were evidences of the foetus itself or
the chorionic villi which showed them to be cases of
tubal pregnancy. As regards the case of double preg-
nancy, there is an abstract of one iu the Gyneecological
Centralblat, in which, however, the account is not per-
fectly clear that it is of pregnancy occurring in both
tubes. So that as far as the literature goes, throwing
out this possible double case. Dr. Johnson's statement
that his is unique, is correct ■

Dr. E. W. Gushing : I think we have to thank the
reader of this-paier for the very lucid exposition of
the subject. It is a pleasure to listen to it as a paper
apart from the facts, and the facts are of such great
importance that I sincerely hope they will receive the
attention from the profession in general which they
deserve. It has often been said to me by my friends
in Philadelphia, " What are the men of Boston doing
that they do not have more extra-uterine pregnancies
reported ? " There is hardly a meeting of the Philadel-
phia Obstetrical Society but one or two are reported.
There is no great reason to suppose that more cases
occur in Philadelphia in proportion to the population
than occur in a city like Boston. The inference is
that there are many in this part of the country which
are not diagnosed and not operated upon, and which
die unrelieved. Dr. Johnson evidently is doing his
share ; and if all the practitioners in alt parts of the
State, or in this part of the State, would find them as
readily, and report them, and get them operated on, I
think we should see a good many more.

My own experience is comparatively limited. I
have had in years gone by several cases of what we
then called haematocele, which I have no doubt now
were really extra-uterine pregnancies. In 1887 I had
and reported s case which was not 0|)erated on, but
got well without operation. It came very near my
household, and attracted my attention very much to
this subject. The lady was taken in the theatre
suddenly with pain and collapse ; got home with dif-
ficulty; went from one collapse into another; and
nearly died after various attacks of severe pain in the
side. Nevertheless convalescence occurred, with slight
elevation of temperature, and formation of a collection
of fluid in the left iliac region. Dr. Fitz thought that
the mass which formed at that time was a serous cyst.
On the itrength of that case I went into the Museum
at Harvard, and picked out every specimen there.
These I photographed, with Dr. M. B. Parker, and
published in the AnnaU of Gyntecology, February,
i 888. Since then I have been in the way of seeing
and publishing a good many cases ; and, as far as 1

> See pace 296 of the Jounal.

Digitized by

Google

266

BOSTOJf MBDICAL AND SURGICAL JOURNAL.

[March 15, 1»94

have been able, I have oontinaally (urned attention to
this question.

In regard to the escape at the end of the tobe, I re-
member distinctly at least two of Price's cases where
the blood was escaping from the end of the tabe in
large amoaut.

My own operated cases namber three. One, which
I have published ' was at nine months. I will not
devote attention to it here except to say that the pla-
centa there lay in the end of the tube, implying that
the tube must have been open at the end and the pla-
centa lay in the middle of it. That was done in Pea-
body two years ago, and the woman made an excellent
recovery. I have had two other cases. One was
brought to me by Dr. Galvin, where the principal
symptoms were supposed to be probably caused by a
pus-tube, namely, pain and high temperature ; there
was a skipping of the menstruation, irregular hemor-
rhages ; aad it is not always easy to make a diagnosis
in such cases. Oa opening the abdomen blood was
not free, but was encapsulated on the side. Separat-
ing the intestines, I got into a mass of blood, and re-
moved a tube, which I have here, and which I presume
is an extra-uterine pregnancy, I also removed a num-
ber of old clots of blood. The other case was brought
to- me by Dr. Garceau, Jr., and had been seen by Dr.
Chatlwick and Dr. Homans. Dr. Homans was to
operate ou it, but had to go to Chicago ; and so the
case came to me. It proved to be an extra-nteriue
pregnancy, and the sac unruptured ; bat it shows that
the contention that H. A. Kelly made before the British
Medical Association, namely, that a case could be
diagnosticated before rupture, at least with great prob-
ability, is well founded. I believe Drs. Chwlwick and
Homans agreed with Dr. Garceau that it was in all
probability extra-uterine pregnancy. Of course, if the
tube is not ruptured, it is the easiest thing in the world
to remove.

The only thing of interest which I should wish to
bring up for debate is the question as to the location
of this blood. Dr. Johnson reports in one case that it
was between the layers of the broad ligament. Dr.
Whitney also refers to the same, and I know it is
Tail's theory that in the cases which do not die the
rupture occurs between the layers of the broad liga-
ment, and that the blood is coagulated there. The
pregnancy may go on further ; or if the foBtus lives,
the broad ligament forms a nest for it, in which it can
grow, the layers of the broad ligament being separated.
The question is, whether that is so in anything except
a very rare number of cases. It is, of course, a very
beautiful and ingeuious theory ; but those who have
done a great many of these operations have not found
that that condition existed. Price reports that he has
never found it so, and at last accounts he had had
ninety cases. He says that in all cases, whether the
foetus was big or little, the broad ligament was not
separated, but the blood was behind the broad liga-
ment, roofed off by adhesions to the bowels, and was
free, or in fact a hsematocele ; that the old division of
haematocele into that which is in the cavum peritoneale
and cavum subperitoneale does not exist in his experi-
ence as been at the operating-table in a large number
of cases. Others have told me the same thing. In
my own case, where it had gone on to nine months, it
was not in the broad ligameut; it was free in the ab-
domen, and the end of the tube was a cup. In those
' Anoal< of Ojnoioolog; and tttdialai, Jaaour, ISSl.

cases where the symptoms were not those of acute
rupture, but those of high fever from the beginning of
the deposition of this dot, the blood being firmly
coagulated, it was in the same place that you get a
collection of pus such as was formerly supposed to be
in the folds of the broad ligament ; it is now agreed
that it is in the tube or leading from the tube. I throw
out the question for discussion, whether we are passiog
through the same change of theory in regard tq^the
location of this mass of blood, and instead of believiug
that it is between the folds of the broad ligament that
we shall recognize the fact that the blood has escaped
from the tube, that not all cases bleed to death, that in
the cases we used to call htematocele the haemorrhage
was a small one. Tatt states that if it is between the
folds of the broad ligament they may not bleed to
death. He implies that if it is free in the cavity, they
are sure to bleed to death ; but, in point of fact, there
may be a little opening, leaking enough to start up a
little inflammation ; it may roof itself off ; aud the
very tubes in which this occurs are apt to be tubes iu
which there is adhesion about it. So that you get your
collection of blood behind the broad ligament ; at any
rate, that is where I have found it ; and other men have
found it there without exception. I would like to
ask Dr. Johnson if he feels very sure in regard to the
point as to where the blood was located in that case,
because it is a matter of urgent debate at present.

Dr. Johnson : In both those cases where there was
what I called htematoma in the broad ligament, there
was no question about it at all. Seven or eight saw iL
There was uo blood in Douglas's pouch at all. It was
bulging out on both sides of the broad ligament. When
1 bored through, I bored through cellular tissue. It
was in the broad ligament in both cases, and those
present agreed with me.

Dr. Inorahau : I desire to say a few words as to
the early symptoms which were observed in my case
operated on by Dr. Elliot. A woman, thirty-two,
single, came to my office one evening about nine
o'clock, and said she was suffering very severe pain in
the lower part of the abdomen, and had been flowing
profusely for one week. She had been regular in her
menstruation up to six weeks before her visit. At
this time, six weeks before, the menstrual period was
delayed one week ; then she began to flow every day
about an hour. This, I think, continued about three
weeks ; then she stopped flowing, and did not flow
again until a week before she carae to the office. The
flow at this time was very profuse, and she was so
weak that she could not do her work. On examina-
tion, I found a good-sized mass on the left, with the
uterus quite a little enlarged and the cervix pushed
down. The abdomen was so tender that I could make
very slight counter-pressure. I told her to go home
and report at once if she had pain or felt faint. I sus-
pected it might be an extra-uterine pregnancy. At
seven o'clock the next morning she sent for me. I
found she fainted at midnight, when she got up to go
to the water-closet, and when she recovered she did
not know how long she had been on the floor. She
was chilly when she got up, and crept into bed.
When I saw her, her pulse was 150, temperature 97°,
and she had all the symptoms of collapse. That was
Sunday morning. We bad no bed vacant in the Vin-
cent Hospital, aud I telephoned to Dr. Pratt of the
Massachusetts General Hospital. He sent an ambu-
lance, and we moved the woman there. Dr. Elliot

Digitized by

Google

Vol. GXXX, No. 11.] BOSTON MEDICAL AND SVSOIOAL JOV&HAL.

267

operated the next morning. The abdomen was fall of
blood. The case was one of extra>aterine pregnancy.
I think that such cases should be reported, to impress
apon the minds of physicians that the symptoms of col-
lapse from any intra-abdominal hiemorrhage are jast
the same in the case of haemorrhage in tubal preg-
naucy. It is diflScult, I think, to make a diagnosis of
tobal pregnancy unless one takes into consideration all
the circamstaaces. This yoang woman was single,
and stoutly denied any cause. She had been ill so
long, that is, she meant she had suffered severe pain
every time she was unwell, she thought she had some
tumor, and tried to impress me with this idea. The
mass was very soft and doughy. When I examined
her the next morning at seven o'clock, I found that
the abdomen was dull on percussion in the lower part ;
there was distinct bagging of the walls of the vagina ;
and the change from the night before in the relation
of parts in the vault of the vagina convinced me there
was no question whatever of the trouble.

Db. Edward Rbtnolds : The Chair thinks Dr.
Ingraham's remarks raise an important point. We hear
frequently accurate rules for the diagnosis of extra-
uterine pregnancy. The specialist and operator knows
there are a very large number of cases in which the
diagnosis is determined principally by the operation.
I think a great many cases are lost because the gen-
eral practitioner feels that before turning them in for
operation he ought to make a more accurate diagnosis
than is in reality possible ; and I hope we shall hear
something on that point.

Db. J. W. Elliot : The case Dr. Ingraham men-
tions was certainly a very good case and a very good
diagnosis. She came to the hospital in the condition
Dr. Ingraham describes. The next morning she re-
acted somewhat. I opened the abdomen in the Tren-
delenberg position, and found a large amount of blood
and a ruptured tube which had ceased bleeding. After
washing out the abdomen and taking out all the clots,
1 pat in a drainage-tube, aitd she made a slow but per-
fect recovery.

Dr. Johnson's paper interested me very much in
various ways. One was that he seemed to have made
the diagnosis in four out of six cases ; which I think
is very encouraging, because when the subject came
up a few years ago our ideas were so vague that very
few diagnoses were made. As time goes on the diag-
nosis seems to be easier ; in fact, I begin to feel now
that it is moderately easy to make in most cases. I
do not mean to say there are not extremely difficult
cases for diagnosis. In the last year I have operated
on three cases and the diagnosis was made in two out
of the three. One other case was diagnosed as bsBm-
orrbage from the tube with probable extra-uterine
pregnancy, which it was. Another case was of long-
standing, and the diagnosis was not made and probably
could not be made. The prognosis, also, is much more
favorable than we used to think. All of Dr. John-
son's cases got well. The four I mentioned got well.
They all should get well, of course, for haemorrhage is
not a disease but an accident, and- should get well if
the antiseptic precautions are observed. Cases like
the one described by Dr. Ingraham, where the haemor-
rhage is severe and stops of itself, are wonderfully
tolerant of the haemorrhage as well as of the operar
tion.

The diagnostic point that impresses itself on me
most of all, is the pain they have. All the cases that

I have seen have had pain. Pain with collapse and
tenderness, even if one cannot feel anything in the
vagina, would be sufiRcient reason for opening the ab-
domen if there had been the slightest irregularity of
menstruation. In the cases where the rupture has
taken place, one cannot feel anything by vagina, for
there is simply extravasation of blood in every direc-
tion. As to the question of whether rupture takes
place into the broad ligament or not, I have never had
a case where it did ; but I have supposed it did, be-
cause I have read so many cases described by good
observers. I do not see why it should not escape into
the broad ligament.

This subject is a very important one and I think
every one ought to report the cases they see, so that
the community may become familiar with the subject,
because it is a kind of malady where lives can be saved
by good knowledge and prompt action.

Dr. W. L. Bcrragk : I have operated on five cases,
all of them since October of last year. My first case
was a neglected one, and the blood had gone on to
suppuration and septic infection. The case was septic,
and the specimens were so disorganized that they were
in no condition for pathological examination. * The
specimens of the other cases are in Dr. Whitney's
hands ; and he has said with reference to them that in
two be has completed the examination, and there is no
doubt aa to the diagnosis. Of the other two, from the
preliminary examination and the gross appearances, he
thinks there is little doubt. The cases all got well.
The first case I reported before the Alumni As-
sociation of the Woman's Hospital in New York last
January, and published in the New York Journal of
Gyneeeology for May. The second case I saw with
Dr. G. W. Townsend, and operated for him afterwards.
That case he reported before the Obstetrical Society
of Boston ; and it was reported in full in the Medical
and Surgical Journal., November 2d, last. The other
cases have not been worked over enough yet for re-
port. In three of the cases I made the diagnosis. In
the fourth, extra-uterine pregnancy was thought of,
but nothing at all sure ; and in the fifth it was quite
unexpected.

As regards the situation of the haemorrhage in my
cases, I do not think it was in the broad ligament in
any of them. It seemed to me to be behind and en-
capsulated in some, and in others, free ; but, as Dr.
Elliot says, I can see no reason why it should not be
in the broad ligament.

I quite agree with the other speakers in the impor-
tance and gravity of the condition, and that the cases
should be operated on as soon as the diagnosis is made.
Of course, it ia very diflBcult to make a diagnosis in
this affection. Pus-tubes are the principal condition
with which it is likely to be confounded, but the opera-
tion is generally indicated in either event; and, of
course, in the case of acute abdominal emergency, op-
eration is the only thing.

The case in which the diagnosis was not made was
a hospital case. The patient was thirty years old,
married one year for the second time, mother of four
children ; catamenia always regular, lasting three days,
using four or five napkins; backache constantly, worse
at catamenia. Entered the hospital August I5tb. In
July flowed three weeks, passing a great many clots,
and had sharp pains in the left lower abdomen that
lasted one-half to one hour at a time. Ever since that
time she had had, once or twice every week, rather

Digitized by

Google

268

BOSTOJf MEDICAL A£ID SVRGIVAL JVIHHAL. [Mabch 15, 189i

bad pains ; but in her estimatioD the pain was lecond-
ary in importance to a feeling of prolapee at the vulva.
There was a mass iu the pelvis on the left side, the
size of a closed fist ; and I thought more than likely it
was a pus-tube. The abdomen was very sore. She
complained of bearing-down feelings. She had a bad
tear in the cervix and another in the perineam. I
found this mass in the pelvis, and advised operation.
She consented, and we found extra-uterine foetation of
about six weeks. When she went home, I believe
she complained bitterly because she still bud the feel-
ings of prolapse for which she came in, and thought
the right thing had not been done.

Db. W. M. Conamt: Since November, 1893, I
have seen seven cases of what 1 thought were extra-
uterine pregnancy. Six of them have been pronounced
extra-uterine by the pathologist's report ; the other
one, which was a fatal case, I supposed without ques-
tion was extra-uterine. It proved to be a htemorrhagic
condition in the tube with pus. That case at the end
of a week developed septic peritonitis, and died. The
other six lived, and got well. In four the diagnosis
was -made before operating. The first case which I
saw was sent to me as a simple cyst of the ovary, and
I so diagnosed, and operated and found a simple cyst.
On the other side, I found something which looked like
an extra-uterine pregnancy as large as the thumb. So
it proved. The other case, perhaps, ought to have
been diagnosed, but was not ; it was an unruptured tube,
and I have been in the habit, from my own experience
and the cases I have been able to collect, of dividing
the subject into two heads : those that are acute, (and
1 agree with Dr. Elliot that in the majority of these
acute cases you can readily make the diagnosis) ; and
those iu which the tube is not ruptured, and are not
acute. The diagnosis oftentimes is not accurately
made until it is in the hands of the pathologist. The
case I lost presented the symptoms which Dr. Elliot
spoke of as being the cases he would operate on with-
out question, — there was irregularity of flow, tender-
ness and a mass in the pelvis. The last case I had
was one in which I very nearly made a mistake. The
woman presented all the symptoms of acute rupture.
I saw her in consultation about ten days before I oper-
ated. She had had two or three previous attacks of
sharp pain, relieved by rest in bed and opium. I made
an examination, and found a mass which fell much
like a pelvic abscess. I think this is the only case in
which I have been at all tempted to aspirate in the last
three years. She was not iu a position to have proper
care at home, and 1 advised immediate removal to the
hospital. She waited about ten days, and then entered
the hospital. I got a history of more or less continu-
ous flow since my last visit.

I found the mass much enlarged, and at once changed
my diagnosis from pus-tube to extra-uterine pregnancy,
and advised immediate operation. She had that night
another attack of sharp pain, with fresh exudation;
and the next morning when we opened the abdomen,
the blood was fresh. I can verify the statement Dr.
Elliot made, that the blood comes out in spurts, be-
cause I felt as if I had torn away a part of the iliac
vein. It was not until I got hold of both tubes and
applied a clamp, that I could get a look. In this case
there was a very speedy recovery, in spite of the fact
that at the operation the pulse was at 160. She rallied
immediately, and now, two weeks afterwards, she is
sitting up. We must remember the possibility of so

profuse bsemorrhage that death may follow from ex-
haustion.

Dr. W. F. Whitnkt : In regard to the bleeding
from the end of the tube, I do not wish to lay that
down as an absolute fact, that it does not occur. Bat
I have found in some cases, where the ovum is situated
at a distance from the fimbriated end, there has been a
space perfectly free from blood. In the case Dr.
Elliot referred to, I also think there is the possibility of
mistaking blood which has gone into the fimbriated
end from that which has come out. As to the occur-
rence of blood or pus in the layers of the broad liga-
ment, I do not see any anatomical reason why it may
not occur. Of course, as Dr. Gushing rightly states,
a great many of the old hsematoceles are so walled off
by thick layers of fibrin and partly organized tissue
that it is difficult always to recognize the difference
between that and the true connective-tissue of the broad
ligament. I have had one case where, I am positive,
the pus entirely surrounded the tube and was entirely
beneath the peritoneum.

MASSACHUSETTS MEDICAL SOCIETY.
SUFFOLK DISTRICT.
SECTION FOR CLINICAL MEDICINE, PATHOL-
OGY AND HYGIENE.

HEKBV JACKSOK, If.D., SBCKETABr.

Reoulak Meeting, Wednesday, January 17, 1894,
Db. F. C. Shattl-ck in the chair.
Db. G. G. Sbars read a paper on

PREGMANCr AND HKABT DISEASE.*

Dr. Gbobge Haven : I had the pleasure of seeing
this case with Dr. Sears, and the fact that after a
month of care and rest this woman bad grown worse
instead of better, and that her condition seemed to be
a very critical one, led me to think the safest thing
was to empty the uterus. It bas always seemed to
me that where the life of the mother was in imminent
danger, the life of the child should be sacrificed. It is,
I think, a mistaken idea of humanity to wait until the
mother is in the last stages of disease before the opera-
tion is undertaken in cases where pregnancy is a
serious complication of her trouble. This, I think, is
true, not only in cases where the heart may cause the
trouble, but also where the trouble is due to kidney
disease, or the complication is such as eclampsia oc-
curring in pregnancy, so that I have always considered
the better thing to do, where the opinion is very dis-
tinct that the life of the mother can be saved by sacri-
ficing the life of the child, to sacrifice the life of the
child. I think in this case the after-result proved the
wisdom of her delivery.

It seemed to me that, in this case, it was unwise to
give ether, and Dr. Sears thought so also. The cervix
was ratber soft and patulous, and was dilated suffi-
ciently to put in a certain amount of iodoform gauze.
The vagina was washed with soap and corrosive before-
hand, and gauze introduced into the body of the uterus
and the vagina packed with iodoform gauze. This
was left in the vagina two days, when, upon removing
it, the foetus and the placenta were found in the
vagina. I should prefer this to the introduction of a
catheter or any foreign substance of that kind, believ-
ing, as I do, it is a much cleaner method and a much

' See page ilS3 of the JoonuU.

Digitized by

Google

Vou. CXXX, So. ll-l BOSTON MBDIOAL ASD SV&GWAL JOVkHAL.

269

surer method. I have seen cases where catheters
have been put in, and left in position forty-eight hours,
w^ithout any result whatever. I have seen cases where
the resalt was disastrous. They are tied outside, and
may lead to septic condition of the uterus which may
prove fatal to the mother.

Very little mention is made in any text-book on ob-
stetrics or gyuaecology which I have seen, about the
complication of pregnancy and heart disease; and for
that reason Dr. Seara's paper is of peculiar value.

Db. EdWARD Reynolds: I wish to speak particu-
larly of the question of interrupting pregnancy or of
Allowing it to go on, not of the conservative treatment
of the heart lesion. I would divide the question, for
convenience of discussion, into the three periods of
pregnancy ; when serious symptoms appear in the first
three months, there will always be a strong probability
of an ultimate necessity for a resort to interference ;
bat in that period due care must be taken to eliminate
the depressing effects of the nausea, salivation and
other troubles of early pregnancy ; to estimate prop-
erly the fact that the first three months of pregnancy
is a period of depression of the general health in the
majority of cases of normal pregnancy, and that after
the woman has passed three or three-and-a-half months
her condition normally becomes better, so that if the
woman with heart disease can be carried successfully
past that period, there is then some prospect of an im-
provement in her general condition, and from that of
better toleration of the heart lesion ; remembering
what I believe to be the fact, that the question is how
fully compensation takes place.

In view of the effect of pregnancy upon the normal
heart, in which the increase of compensation is neces-
sary to overcome the normal added load, if the serious
symptoms first appear in the second three months, I
think the prognosis will always be tolerably grave.
That is the period of well-being in normal pregnancy.
If the heart gives out then, it gives out under a load
which must be expected to increase constantly towards
the end of pregnancy.

In the third three months I should feel inclined to
give the benefit of doubt towards letting the pregnancy
go on undisturbed. Jf the woman has come up to the
full six calendar mouths in tolerably good condition,
there must certainly be a good prospect of carrying
her to the viability of the child at seven months.
After she has reached seven months in anything like
good condition she does better, as far as my experience
goes, than one would expect. I should be inclined
toward conservatism during the last three months.

if it is necessary to interfere with pregnancy in
heart disease, a word must be said as to the method.
1 do not think that it would be wise in cases of heart
lesion sufficiently serious to require operation to adopt
the method which I should prefer for most other con-
ditions— etherizing and finishing the operation, to the
removal of the last atom of the ovum, at a single sit-
ting. I think the method by introduction of a foreign
body, and preferably of a strip of iodoform gauze, into
the uterus, followed by a tamponade of the vagina,
almost invariably works well. A tamponade of the
vagina is not sufficient by itself, but with the introduc-
tion of a foreign body into the uterus, tamponade of
the vagina, in my experience, has always resulted in
the favorable and tolerably rapid progress of labor.
1 remember especially a case I saw a year or more ago
with Dr. Folsom, where a woman with a serious heart

difficulty, which rendered etherizatiou distinctly inex-
pedient, started to miscarry spontaneously at about the
sixth month. I inserted a little iodoform gauze, and
packed the vagina, and at the end of about twelve
hours, there being some labor pains present, and the
woman becoming greatly distressed, I removed the
packing, and found that the os had dilated so far that
it was easy to remove the ovum with the curette with-
out paiu to the patient and without ether. Even if
labor under such circumstances should become distress-
ing, the fact that there has been a preliminary attempt
at the induction of labor would probably render it pos-
sible to clean out the uterus with the curette, with a
moderate amount of pain, without ether, and much
more easily than if there had been no preliminary
tamponade.

As to the general principle of the treatment of
pregnancy complicated by disease of serious import to
the mother, I think that the profession in the past,
one and all, its most prominent as well as its less
prominent members, have been misled by an undue con-
cern for the prospects of immature foetuses. The his-
tory of the profession teems with examples in which,
when the question of abortion came up, conservatism
has been persisted in until still more threatening
symptoms supervened ; then the abortion has been
undertaken, and both mother and foetus have been
lost. I think that when this question comes up, that
it is usually not. Shall abortion be done now or at
some future time ? it is almost always. Shall abortion
be done now, or shall pregnancy go on to term?
Taking the condition I refer to, cases in which the
question is properly before us, in which the symptoms
are sufficiently grave to bring up the question whether
abortion shall be done, it must be decided whether abor-
tion shall be done early. Abortion done for any
serious complication of pregnancy is a very simple
and safe matter if it is done early ; it is followed by
the promptest relief to the condition, so far as that is
dependent on pregnancy. Abortion done after the
woman is anything that approaches moribund is almost
hopeless; and the physician should never shirk the
responsibility of doing the operation while, the mother
is in good condition. I think that when we consider
the difference between the value of the life of a
woman, mature, occupying a place in society, the
mother of children, the wife of a man dependent on
her for the comforts of bis home ; when we compare
the value of her life with that of a foetus at three
months, which is exposed to especially great danger
from the condition of the mother, which, even though
it be born, runs a strong risk of never attaining
maturity, and in heart disease a risk which is again
already compromised by the condition of the mother,
— I think, under those circumstances, a serious risk
to the life of the mother is of far more importance
than the termination of the life of the child.

Dr. a. L. Mason : The case of Dr. Sears is very
interesting, and I have no doubt his course was wise.
It must be easy in such cases to wait too long, as it is
in the dangerous vomiting of pregnancy, until the
operation is too late. When the question arises
whether a woman with heart disease should marry, it
sometimes is very difficult to decide that in the nega-
tive. The cases Dr. Sears has referred to were prob-
ably of a very severe description, because the milder
cases of cardiac lesion, in which pregnancy occurs and
labor goes off without accident, are not reported, and

Digitized by

Google

270

BOSTON MEDICAL AUD SURGICAL JOVRHAL. [Maboh 16, 1894.

there must be very many such. The existence of a
murmur, prorided that there is a good compeosatioD,
and has been for a long time, 1 should think might
frequently be no bar to matrimony. Advice is not
always asked in such cases ; sometimes it is, and
it may be hard to decide. The murmurs, which, per-
haps, are congenital, or those with perfectly good com-
pensation of many years' standing, where patients are
able to take the usual amount of exercise, and can
walk up hill without dyspnoea, must be present in
many women who can marry with comparative safety.
It seems to me Dr. Sears's statement was a little
sweeping. I think he said that women with heart
disease should not be allowed to marry ; if they mar-
ried they should not become pregnaut, and they should
not nurse their children. The question is, what degree
of heart disease or what conditions of the heart would
be sutficiently grave to oblige us to advise that women
should not marry.

Dr. Reynolds: Although I did not have the
pleasure of seeing this case of Dr. Sears, I was con-
sulted about it by Dr. Sears and Dr. Haven shortly
before the operation was done ; and then, as now, I
said that whUe it is always difficult to judge of a case
without seeing it, yet, from the symptoms detailed, 1
should support abortion in that case.

Ds. F. C. Shattcck: The paper reminds me
strongly of a bit of my own experience. Five years
ago I was asked to go out of town to see the wife of a
gentleman, the subject of mitral disease. She had one
child a few years old, and had had a very alarming
time at its birth. She seemed to be so well — I think
it was in November or December I saw her — that in
the previous spring she bad been authorized by her
family physician to become pregnant. The murmur
was reported as slight, the cardiac condition as com-
paratively unimportant at that time. When 1 saw ber
I think she was four months' pregnant. She had then
serious cardiac symptoms. Her husband said they
had been distinctly advancing — shortness of breath,
inability to walk, etc. The murmurs and the evi-
dences of insufficient compensation were distinct ; and
it was my opinion, which I expressed, that it was beat
to terminate the pregnancy. That opinion was based
upon the belief that we had to do with an advancing
cardiac lesion as far as could be told from the symp-
toms. This woman was so well the previous spring
that her heart lesion was considered trifling. It was
not trifling when I saw her. They were extremeFy
anxious to have children, and in this matter other
counsels prevailed. Soon after she bad an attack of
influenza with pneumonia, and miscarried without diffi-
culty. Then she went along pretty well ; and a year
or two later she became pregnant, went to term, was
delivered without very serious trouble, but died within
two weeks after the labor from cardiac failure.

To-day I saw a lady with a very bad heart who is
said to have had valvular disease all her life, as long
as anybody knew anything about it. She is about
forty years of age. She has had two children, the
youngest twelve, both children born without any great
difficulty. The doctor was very much alarmed about
her first confinement, but she went through it perfectly
well. At her second confinement she had one pain,
and that lasted three-quarters of an hour without in-
terruption ; otherwise the confinement was uneventful,
and the symptoms of failing compensation she now
presents are of comparatively recent origin.

THE BOSTON

lEeDfcal aiU) ^utgical 3Iounial

THURSDAY, MARCH 15. 1894.

A Journal e/Medieine, Swrgtrf. ami Allird Seieuea,p*blUted al
Sotion, w*tklf, bf the mulenigned.

SOBSCRiPTiox TxaifS : 96.00 per year, in advance, poetagt foid,
for the United Statee, Canada and Mtxico; fS.86 per ytar for all /lir-
eigncowitrieelieUmging to the Pottal Union,

All eomrnnnieatione for. the Editor, and all bookt for review, thotJi
be addreued to the Editor of the Boiton Medical and Surgical Jommal,
283 Waehington Street, Botton.

All lettert oonlaining butinesi eommunieatiom, or referring to the
pnbliaation, tnitcription, or advertuing department of thi* Jommal,
thonld be addreued to the undersigned.

Bemittamoee ehonld be made by numef-order, draft or regittered
letter, patiable to

DAMBELL & CPHAH,
S8S WASHUfOTOM Stbbst, Bobtoh, Hajii.

ECTOPIC GESTATION.

The report of a large number of cases of tubal
pregnancy occurring in this vicinity * brings up the
pertinent question whether this peculiar condition is
really more frequent now than in years past.

This can be surely answered in the negative, as it
is not only from here but from all over the world that
a great increase in the number of cases has been re-
corded. During the past fifteen years, seven hundred
and eighty cases have been reported, of which about
five hundred occurred within the last four years.
This great apparent increase is due simply to the at-
tention which has been directed to the subject (just as
in the case of appendicitis) and to aseptic surgery,
which has rendered successful abdominal operations

The study of the cases from the clinical and anatom-
ical sides has added much to the ceruinties of diagno-
sis, the best line of treatment and points of theoretical
interest in the way the ovum acts on the surrounding
parts.

The diagnosis is often very difficult, especially in
the early stages, when it is all important But the
cardinal points of irregularity of menstruation,' in a
person previously regular, often with a slight persistent
flow from tbe uterus, one or more attacks of sharp
pain and syncope, and a tender swelling on one side
of tbe uterus, are now beginning to be so well unde^
stood that fewer cases will be overlooked in the future.

There are but two lines of treatment, either the ex-
pectant or operative. The real mortality under the
former cannot be surely determined. In a series of
two hundred and sixty it was found to be sixty-three
per cent. ; but from the difficulty of diagnosis we are
inclined to think a disproportionate number of fatal
cases is always recorded. But even placing it as low
as fifty per cent., the patient has then but an equal
chance. The statistics from the operated cases are
more reliable, as the diagnosis always can be verified.
> Sea paee* i2B6, 2<0 of Ura Jonnial.

Digitized by

Google

Tos.. CXXX, No. 11.1 BOSTON MEDIOAL AND SURGICAL JOURNAL.

271

[n a series of five handred and fifteen cases there was
i mortality of twenty-three per cent., thus showing
;wice as many recoTeries as under the expectant treat-
naent ; and, moreover, the period of oonvalesceuce is
^eatly shortened. If the zeal of the operator can be
restrained from removing everything in the pelvis
when he has it once open under his hand, the chances
of future sterility are no worse in one case than the
i>tber.

The anatomical study has brought out many inter-
estiug facts. The most important to the patient is
that the first haemorrhage is rarely fatal, and if the
warning thus given is early heeded, the life can be
saved. The bleeding occurs in two ways, either from
one of the thin-walKd sinuses in the wall of the tube
directly into the abdominal cavity, or indirectly, first
into the fcetal membranes and then through the open
fimbriated end of the tube or a hole in its thinned
wall into the abdominal cavity. But in none of the
cases which we have bad an opportunity to examine,
now over fifty in number, has the hemorrhage been
from elsewhere than the placental site, about which
there was formed no protective thickening of the wall.
The rapture directly into the abdominal cavity is natu-
rally the more serious for the patient. When it occurs
into the membranes, the death of the foetus results,
bat this does not prevent a repetition of the haemor-
rhage. This is proved from the examination of speci-
mens showing that the period of development of the
embryo corresponds to a much earlier date than would
be the case if it had lived during the entire time the
clinical symptoms had indicated. This shows how
irrational auy treatment is, which is directed alone to
killing the foetus (morphine, electricity) ; for, granted
the death is brought about, there is no proof that the
tendency to subsequent haemorrhage will be stopped.

As yet no satisfactory cause has been found that
covers all cases ; various theories have been advanced
to be abandoned. The first thing that bars the way is
our ignorance of the place where the ovum is fecun-
dated in the human species. If, as is generally
assumed, this is in the uterus, then the accidental
meeting of the vitalizing elements at a point elsewhere
is a sufficient explanation. If, on the other hand, this
should be shown to occur normally before the uterus
is reached, as is the case in some of the lower animals,
then a hindrance to the onward passage of the egg will
be the best explanation. Under any circumstances a
normal mucous membrane will be more favorable for
the future development than a diseased one. And the
facts bear out this assumption.

The possibility of the migration of the ovum from
the ovary of one side into the tube of the other side,
has been proved by the cases of tubal pregnancy. The
^t explanation is that by Hasse, who finds that the
ends of the tubes are closely approximated behind the
uterus during life in many cases, and not widely sepa-
rated as they are usually described and figured by the
anatomists.
The majority of observers agree that wbep preg-

nancy occurs in the tube there is very little, if any,
decidua formed, and but a minimum hypertrophy of
the wall, and in most cases a decided atrophy. The
examination of our specimens makes us coincide with
this view. At the same time the decidua is formed in
the uterus, and it hypertrophies as if the ovum was
present there. This has suggested to us that the
fecundated ovum exerts a double action on the organ-
ism, which may be designated as sympathetic and local.
From the former would come the uterine decidua and
hypertrophy, the true corpus luteum, and changes in
the mammary glands. It acts, no matter where in the
body the ovum is vitalized, but by what subtle influence
is unknown. Niiturally a reflex action of the nervous
system would be the first to suggest itself. The second
action, which may be regarded as the local one, is
shown by the rapid development of vessels at the point
where the ovum locates. In the uterus this action has
been lost sight of from its association with the other
changes due to the sympathetic action. But it comes
clearly into the foreground when we study the condi-
tion in the tube, for here an atrophy of the wall and
adjacent mucous membrane are the associated phenom-
ena, due to the mechanical pressure of the growing
ovum, while it is in the blood-vessels alone that there
b any indication of a marked increased activity in
growth, which may be best classed as a process due to

an irritation.

•

THE BACTERIA OF PERITONITIS.

The interesting subject of the bacteria associated
with peritonitis- has received a new and important con-
tribution in a monograph by Drs. Tavel and Lauz,
ill a recent issue of the Mitteilungen mu KUniken und
Medicinitchm Irutitulen der Sehweiz.

The authors have given in this report the results of
their study of seventy odd cases of inflammation within
and about the peritoneum or neighboring organs. But
only a part of this number fall within the usual accep-
tation of the term peritonitis. The material for this
study, with the exception of a very few cases, has been
obtained at operations in the clinic of Professor Kocher,
and has, therefore, the great merit of having been se-
cured intra-vitam, thus excluding the possibility of a
post-mortem migration of intestinal bacteria into the
peritoneum, a possibility which has been brought for-
ward as an objection to the results of E. Fraenkel and
Predohl in their work on peritonitis.

The cases have been of the most varied character
and diverse etiology ; but if considered analytically
they may be fairly well divided into several groups,
lu considering the bacteria met with in their examina-
tions we shall only mention those which are recognized
as having pathogenic significance, and shall neglect the
less important forms of which as many as a half-dozen
or more species have been observed occurring together
in some cases.

Perhaps the most important class of cases are those
in which there is inflammation in or about the vermi-
forq) appendix. Of these, uineteeo cases were studied.

Digitized by

Google

272

BOSTOH MEDICAL AHJ) HLMGICAL JQlhhAL. [AIabcb 15, 1894.

The resnlts maj be given as follows : of seven cases
of paralent formation within the appendix, the bacil-
lus coli communis was found in >ix, the streptococcus
in two, and the pneumococcus in one case. None of
the cases were sterile. In fifteen cases of peri-appen-
dicitis, the examination of the exudate or abscess showed
the presence of the bacillus coli communis in eight ;
the streptococcus in five; the staphylococcus citreus in
one; the pneumococcus in one, and actiuomyces in
three cases. Two cases were sterile. The number of
species found varied in the different cases from one to
nine io number. It is interesting to note that the ex-
amination in seven cases of the interior of the appen-
dix, where the contents were to be considered as
normal or not affected with the inflammatory process
in the neighborhood, showed no bacteria in two cases.
This result is surprising in view of the enormous num-
ber of bacteria always present in the large intestine.
Of three cases of peritonitis diffusa, secondary to ap-
pendicitis or peri-appendicitis, the bacillus coli comma-
nu was found in two, the bacillus pyocyaneus in one,
and one case was sterile. In this group of peritonitis
diffusa are also three cases which had their origin in
the gall-bladder, one being secondary to a choledochot-
omy. In two of the cases the bacillus coli communis
was found, and in the third the staphylococcus albus.

In this connection it may be mentioned, that of
three cases of gall-stones, the bile contained staphylo-
coccus albus in one case, bacillus coli communis in one
case, and the remaining case was sterile.

Of six cases of peritonitis from various causes, in
two bacillus coli communis, in two streptococcus, in
one bacillus pyocyaneus were observed. In a single
case no bacteria were present. Four cases of intesti-
nal obstruction formed another group of cases, in three
of which there was a fibrinous exudation in the perito-
neum. Of the four cases but one yielded an organism
of any significance, namely, the staphylococcus albus.
Two were apparently sterile.

The last group of cases are those in which the fluid
of hernial sacs was examined for bacteria. Of seven-
teen cases all were sterile except two, and these posi-
tive cases were from four of beginning or advanced gan-
grenes of the gut. The absence of bacteria in the
other two cases of gangrene, where the conditions for
their migration through the wall of the gut were ap-
parently favorable, is surprising. On the other hand,
in the sac fluid of two out of three epiploic hernise,
where bacteria from the intestine were scarcely to be
expected, bacteria could be demonstrated. In two her-
nial hydroceles the fluid was sterile. These results are
of interest as showing that we are as yet ignorant of
all the causes which determine the migration of bacte-
ria through the intestinal wall. It is also interesting
to note that the examination of the conteota of a her-
nial loop of the small intestine accidentally opened at
operation showed few bacteria. This is another proof
of the relatively small number of organisms in the
small intestine as compared with those in the larger
gut.

In addition to the foregoing cases, the authors have
included in their list of examinations a number of other
cases more or less germane to the subject of peritoni-
tis, but which have uo special interest. Among thess,
however, should be mentioned a case of sub-peritoneal
abscess, and a case designated as empyema of a her-
nial sac, in both of which tuberculosis originating in
the vertebrse has not been saflSciently excluded. The
latter case especially serves to emphasize how desira-
ble it is for the bacteriologist who works with patho-
logical processes to have some knowledge of pathology.

The technique employed in the work is, on the
whole, satisfactory. The study of the biology of the
different bacteria is perhaps, in general, as thorough
as is necessary. A feature of their investigation,
which is of especial interest from a bacteriological
point of view, is the study of thirty representatives of
the bacillus coli communis with reference to their vari-
ous cultural peculiarities, number of locomotor organs
and other characteristics.

The results would seem to show that scarcely any
two of them are exactly alike. The differences, how-
ever, in many cases, are only such as one would en-
counter in studying parallel cultures of almost any
organism, and we do not think that the writers are
justified in considering many of such differences as
constant. It is well known that different varieties of
the bacterium coli exist, but the division of these thirty
representatives of that group into as many as twenty
varieties does not seem warranted from the observa-
tions. Of the thirty, two at least are clearly not to be
classed within this group of the bacterium coli, as
would appear from a consideration of their cultural
peculiarities as given by the writers. Io several cases
bacilli somewhat resembling the Elebs-Ldffler organ-
ism have l>eeu observed. To these, however, no path-
ogenic significance is ascribed. We cannot agree with
the writers that this is probably the pseudo-diphtheria
bacillus of Loffler. The cultural peculiarities of that
organism are too little known for it to be identified,
and our own experience has seemed to show that there
may be nearly as many pseudo-diphtheria bacilli as
there are observers.

In addition to the results of their own experimental
work, the speculative and historical aspects of various
questions connected with the subject of peritonitis have
been well considered by these investigators. As to
prognosis, they state that no conclusion can be drawn
from the species of bacteria present. In those cases,
however, where no bacteria are to be demonstrated, it
would seem that the result is, in general, more favora-
ble than in those where bacterial forms are present.

Therapy also receives due attention. Especially
valuable and noteworthy features of this contribution
are thirty-two excellent reproductions of micro-photo-
graphs of some of the bacteria observed.

" Man is a part of collective nature ; his develop-
ment proceeds not bv leaps and bounds, but slowly out
of past and present." — BiUrotKt Autobiography.

Digitized by

Google

^oi.. CXXX, No. 11.] BOSTOH MBDICAL JUJJ SURGICAL JOVHhAL.

278

MEDICAL NOTES.
Cbicaoo Small-Pox Statistics. — During the
aonth of Janaary there was 128 cases of small-pox in
yhicago, 29 of which were fata!, some before they
lould be removed to the hospital. There was seven
ases of hsemorrhagic variola, nooe of the patieuts
laving ever been vaccinated. There were many con-
laent cases, all in nnvaccinated persons. A few of
>he fatal cases had been vaccinated in infancy, but
lever re-vaccinated.

A Hospital for Tuberculosis in Vienna. —
The Emperor of Anstria has made the anniversary
[>f the death of the late Crown Prince Rudolph the
oocasion of giving a sum of 10,000 gulden towards
the establishment of a home for tuberculous patients
in Vienna.

The Royal Commission «n Vaccination. — In
an editorial upon the first volume of the long-expected
report of the Royal Vaccination Commission, the lAincet
Bays : " The evidence published to the volume shows
that the difficulty that really has to be met is the
readiness with which well-intentioned people can be
misled. Perhaps one thought impresses the reader
more than any other in studying the volume which has
been issued. If one tithe of the pains had been taken
to make known the risks of small-pox and the value of
vaccination that have been expended on endeavors to
prejudice the public against vaccination, it is not prob-
able that the appointment of a commission of inquiry
would ever have been deemed necessary."

boston and new ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon, March 14, 1894, there
were reported to the Board of Health, of Boston, the
following numbers of cases of acute infectious disease :
diphtheria 30, scarlet fever 36, measles 12, typhoid
fever 5, small-pox 7 (no deaths). Two cases of small-
pox have been reported to the State Board of Health
from places outside of Boston ; one from Waltham and
one from Lynn (which is the first case in that city
since 1873).

A Warning to Boston Phtsicians. — During
the past week a sneak-thief has been plying his trade
among physicians' bouses, if given an opportunity to
be left alone in the reception-room. He is a man
aboot forty-five years old.

Notification op Chicken- Pox in Boston. —
The Board of Health of Boston has given notice that
in addition to Asiatic cholera, small-pox, scarlet fever,
typhus fever, diphtheria, measles, typhoid fever, yel-
low fever and membranous croup, chicken-pox will here-
after be regarded as a disease within the meaning of
Section 79, Chapter 80, of the Public Statutes, and that
phyaicisns will be expected to report all cases coming
under their notice within the city.

A Centenarian. — Mrs. Abigail Hobart, Nashua,
N. H., passed her hundredth birthday last week, and
with the exception of slight deafness is in possession

of all her faculties. She has had nine children, five
of whom are living, with sixteen grandchildren and
twenty-five great-grandchildren.

Death at nearlt One Hundred and One. —
Mrs. Sally Sawyer Case, who died in Wellesley Hills,
Mass., last week, was one hundred years and ten
months old. She was present at the funeral services
of George Washington.

AMERICAN GOUT.

LiTHAMiA is 80 preeminently the form in which gout
shows itself in this country, that Da Costa has char-
acterized it as " American Grout." As he has, by his
former contributions to the subject, done very much
towards giving us clearer views upon the pathology
and therapeutics of this hydra-headed morbid state, a
brief abstract of an unpublished address which he re-
cently delivered, by request, before the students at
the University of Pennsylvania, will prove especially
interesting at this time.

By the term lithsemia is understood the morbid con-
dition closely allied to gout, in which litbic or uric acid
and other waste products, accumulate in the blood, and
cause certain toxic effects, as well as interfere with
normal metabolism. Symptoms like those of lithaemia
have been found where the urine shows neither uric
acid nor urates in excess, nor oxalates. They might
be accounted for, perhaps, by the presence of waste
products in the urine, such as acetones and pep-
tones, though as yet no accurate chemical researches
have been made on this point. It is convenient to re-
tain the term lithsemia as broadly covering the state of
the system associated with waste products, even though
not specifically uric acid until we find a better name
for the whole malady. The title " nricsemia," or even
" uric-acidsemia," which has been suggested as a syno-
nym for the older term, is not an improvement, since
it implies that the symptoms are due entirely to excess
of uric acid, which is taking quite too limited a view of
its pathology. In fact, after referring to the theories
of Murchison, Roberts, Haig and others with regard
to the pathology of the litheemic or gouty diathesis.
Professor Da Costa declared that we must return to
neuro-humoral views like those of Sydenham, which
are more in consonance with the clinical plienomena
than any of those recently proposed. The suggestion
of Roberts that a less soluble form of uric acid salts is
formed in gouty states (that is, bi urates instead of nor-
mal quadrurates) is highly plausible, and may well ac-
count for the tendency to uric acid deposits, which,
however, are very much less liable to be encountered
in lithsemia than in typical gout. The urine of lithee-
mic patients, moreover, does not present exactly the
same characters which it does in typical gout. It is,
as a rule, dense, high-colored, and of higher specific
gravity than normal urine. After over-indulgence at
the table, the urine may deposit lithates and oxalates,
and become darker in color and of higher specific
gravity. It may become less abundant than normal,
and, by concentration, cause albumin and even casts to
appear for a time. This does not, however, indicate
the presence of the well-known form of gouty, or con-
tracted, kidney; on the contrary, the kidney is re-

Digitized by

Google

274

BOSTON MEDIOAL AND SUROWAL JOVBNAL.

flfABOB 15, 1894.

markably free from inflammation in lithgemia, and both
albumin and casta rapidly disappear under appropriate
treatment. The heart may be irregular and palpita-
tion be complained of. It is apt to have a weak or
muffled first sound ; and this is followed by an accentu-
ated, valvular second sound, due to increased arterial
tension, which is also indicated by the sphygmograph.
In litbsemia, however, cardiac degeneration and valvu-
lar disease, such as is common in gout, are remark-
ably rare, aud cannot be said to belong to the clinical
history.

The nervons and cerebral symptoms of lithsemia
commonly found, are gloom, depression of spirits,
irritability of temper, restlessness at night, drowsiness
during the day, with disinclination to intellectual effort,
jerking of muscles, myalgia, pains in tendons and neu-
ralgia. There is also indisposition to muscular exer-
cise, and the patient is quickly tired ; flying pains may
appear iu various portions of the body, or actual cramps
occur. Dyspeptic symptoms are common, though not
constant, and there is a tendency to excess of acid in
the stomach. Functional derangements of the liver
are of frequent occurrence. Vertigo and migraine are
prominent symptoms; and the vertigo, like that of
stomach disorder, usually appears early in the day ;
while to increase of acid in the system the attacks of
migraine may be ascribed; and the lecturer stated
that, for prompt relief of the latter symptom, nothing
could excel the effects of administration of hydro-
chloric acid. This, however, might be like applying
ice-water to a gouty inflamed joint, which would
promptly relieve the pain, but was attended by some
risk of further injury to the patient.

The most prominent causes of lithsemia and gout are
excessive eating and drinking, the body is burdened
by an uudue amount uf nitrogen and carbo-hydrates,
which the excretory organs cannot remove as fast as
supplied, and waste material accumulates in the blood.
This is less apt tp occur, when active open-air exercise
is kept up, than when the life is sedentary or inactive
aud oxidation is imperfect. The gastronomic achieve-
ments of the Emperor Charles V, as detailed by Roger
Ascham, were quoted ; and the gloom, depression o(
spirits and increasing melancholy, which finally led to
his abdication and retirement to a monastery, were
shown to be directly due to lithsemia and gout from
excessive eating. Here, gluttony and consequent dis-
ease had an important influence upon history. If the
emperor had not been lithsemic aud gouty, he would
not have been so gloomy and melancholic, and he
would not have retired to a monastery ; if he had not
thus retired the Netherlands would not have been
given up, and there would have been no Armada.
And so great results may be traced to a monarch's
self-indulgence.

Lithsemia may be inherited as well as acquired. It
may be manifested early in life, aud among adults is
as frequent among women as men. Exceptionally
the symptoms become those of ordinary gout, but
joint inflammation does not, as a rule, occur, though
there may be some painless enlargement of a distal
joint of the little fingers of slow development, pos-
sibly several joints may be affected, or the finger-ends
may become clubbed.

In the treatment, diet occupies the first place. In
many cases restricting the diet to vegetables, especially
the grteu vuj:eubk-s, will be sufficieut to dissipate all
the symptoms. In most cases, it will not be advisable

or necessary to adhere strictly to a vegetable diet, and
a moderate allowance of meat, if exerciee be taken,
is permissible, especially the white meal of poultry sad
fish, may be indulged in without harm. Fats are to
be restricted in amount, and carbo-hydrates are to be
excluded as much as possible, allowing patients to take
only a small quantity of stale bread or biscuit. Most
lithsemica declare that sugar does them barm. It la
advisable to use especial caution against all articles
which the patient finds by experience readily undergo
fermentation in the stomach, as the acid aggravates
the condition. The drink of the lithsemic should be
water only, and enough water should be drunk to keep
the kidneys flushed. All forms of alcoholic drinks are
bad; but iu elderly subjects, accustomed to their use,
a very moderate quantity of old whiskey, or of a good
claret, may be allowed with the meals. Champagne
is particularly bad because it is generally acid in reac-
tion, besides containing much sugar. The importance
of fresh-air exercise has been already insisted upon, ss
the means of increasing metabolism and oxidizing
waste. The skin should be kept in good condition,
and the sweat-glands rather active. Woollen clothing
is advantageous.

In conclusion, the medical treatment may be sum-
moned up in a few words. Laxatives, ' especially
salines, are highly useful. Mineral waters are impor-
tant adjuncts, these waters being better diuretics for
these cases than drugs, which irritate or increase, still
further the blood-tension in the kidneys. To neutral-
ize waste matters in the blood, carbonate of lithia
(gr. ii) in capsules, with extract of nux vomica (gr. \),
given several times a day, had been found very efficient,
the nux acting as a general tonic, as well as affecting
the heart. Piperazin is still under trial ; it has been
found of some service in lithsemic conditions.

As regards prognosis, a very favorable view can be
taken. Living in accordance with the regimen above-
indicated, reducing the quantity of the food to the
actual demands of the system so that the in-come shall
not be greater than the ont-go, restricting the nitro-
genized food, carbo-hydrates and fats; drinking only
water, avoiding alcohol, and taking daily out-door ex-
ercise — this is the road to health for lithsemic sufferers,
by pursuing which they will escape their threatened
ills, and may in time feel themselves entirely cured of
their maladv.

THE INTERNATIONAL SANITARY CONFER-
ENCE.

The result of the International Sanitary Conference
thus far has been to make more evident than ever
before the difficulties attending any satisfactory control
of the out-put of cholera from Mecca at the time of
the pilgrimages. The committee on this subject has
recommended that a system of medical inspection of
pilgrims landing at ports of the Persian Gkilf be estab-
lished ; but how it is to be organized, or in what way
it is to be controlled, was not mentioned. The chief
attention has been directed to the sea routes, although
the greatest danger has in most years been from the
land routes, over which there has been little or no
control thus far.

The French and English delegates have differed a
good deal over the conditions of port quarantine, the
position of the British representatives, that to stop
healthy passengers and a healthy ship does not prevent

Digitized by

Google

Vol. CXXX, No. 11.] BOSTOS MEDICAL AND SURGICAL JOURS AL.

275

bat actually creates danger, being strengthened by Dr.
Arnaad's description of the qaarantine station at the
idsiid of CamaraD in the Red Sea, where the accom-
modation is so bad that the disease is spread to passeo-
gers aud crews detained there. *' It is simply a d^pdt
of cbolera, and there have been more epidemics since
the opening of this quarantine station than there were
previously." Great distrust is felt as to the intention
or willingness of Tarkey to carry out any agreement
sod as to the ability of the Persian Government to do
so.

The inquiry of one of the United States delegates
whether the Conference could uot establish rules by
which emigrants could be watched, examined, or con-
trolled in such a manner as should prevent them from
carrying over to the Uuited States the germs of cholera,
small-pox, and kindred diseases, opened up a wide field
for discussion. He said, very fairly, that it wad all
very well to impose medical inspection on Mahom-
medan pilgrims embarking for Mecca, but why uot
take similar precautions with respect to emigrants em-
barking for America? The action of the Conference
on this proposition will be watched with interest.

Socially the Conference has been an unprecedented
sQccess. The delegates have been entertained at
dinners, balls and f6tes by public and private persons,
with untiring hospitality.

€orrej(|)ottDetice.

THE DIAGNOSIS OF SMALL-POX.

Boston, March 13, 1894.

Mr. Editor : — The rare occurrence of small-poz in
Massachaaetts during the past twenty years (and since the
great epidemic of 1872-73} makes it more than probable
that scarcely one in ten of the physicians now in active
practice has ever seen a case of this disease. When cases
occur in the practice of young physicians, it not unfre-
qnently happens that an error in diagnosis is made, espe-
cially during the first week of illness and when the disease
is <rf a mild type. In consequence of such mistaken diag-
nosis, undue exposure has occasionally taken place, and the
health of the community has suffered.

The writer has known several such instances during the
past six months, and would therefore respectfully suggest
to all young practitioners who have not had a considerable
experience with small-pox, that they should in every doubt-
ful case, request a consultation with some older practitioner
who has bad opportunity to see cases of this character.
°— *- -, course might not only prove advantageous to the

Soch :

young practitioner, but also to the community at large.
Respectfully yours, Semex.

ARRANGEMENTS FOR ANNUAL MEETING OF
THE AMERICAN MEDICAL ASSOCIATION.

Boston, March 10, 1894.
Mr. Editor : — Elaborate arrangements are being made
in San Francisco for the reception and entertainment of
the American Medical Association at its annual meeting in
June. Special trains will run from Chicago, leaving on
ilay 28th. It is expected that round-trip tickets will be
{nrnisbed at the price of a single fare, with choice of return-
ing by other routes. If a sufficient number attend from New
England, special cars will be furnished from Boston. Mem-
ber* may be accompanied by friends.
Further information may be obtained by addressing,
Henrt O. Marct, M.D.,
180 CommoniBeakh Awnue, Boston,

METEOROLOGICAL RECORD,

For the week ending March 3, in Boston, accordinfc to ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corps:--

Baro-

Thermom-' Belatlve

Direction

Velooitv
of wind:.

Wo'th'r.

•g

Dat«.

meter

eter

. hnmidlty*

pi wind.

•

1

S

i

a

1

1

X

f

a'

a

91

a

ai

M

a
1

~ 1 <

».

>,

<

■^

■<

0.

t

H

.5 S

g

«

5?

s

S

g

s

i

Q

ii

S »

»

C

ao

OC

er-

»

«

go

8. .211

80.70

A

23

6i 33

47

40

N.W.

S.W.

7

7

c.

O.

M..2e

30.14

23

2<<

17 W

50

6S

N.K.

N.

10

IS

().

o.

0.11

T..27

30.43

26

31

■J(. 153

72

62

N.

.S.E.

12

7

c.

c.

W.M

30.34

34

4l

J.i 74

SO

77

SW.

S.W.

R

10

<>. 1 c.

T.. 1

30.16

39|4>

;ii 1 ;6

('2

79

S.W.

S.W.

6

4

p. c.

P.. 2

28.9i

44

isr.

32 1 74

61

as

s.w.

W.

6

■*

F. |C.

S.. 3

SU.16

«

an

3a

Bfi

61

60

N.W.

N.W.

16

16

C. 1 C.

W

30.2S

39

23

»

1
1

o.n

•O.,alouaji CelMTi r.,<siri O.. foe: H.,bu]Pi E.,iinok7i H.,niiii T.,thre*l-
tnlngt Il..n>o«. « IndiotM tnra of nilnfiU. av Mmb for VMt .

RECORD OF MORTAUTY
Fob tbb Wuk xHDiNa Saturdat, March 3, 18i<4

Oltlei.

New York .
GMoago . . .
PhiladelpbU ,
Brooklyn
St. Louis . .
Boston . .
Baltimore .
Wa»liiugton
Glnoinnatl .
Cleveland .
PltUbnrg .
Hilwaakee .
Nashville .
Charleston ,
Portland . . .
Worcester .
Pall River . ,
Lowell . , ,
Cambridge .
Lynn . . .
Springfield .
Lawrence .
New Bedford
Holyoke , .
Salem ...
Brockton .
HaTerhill .
Chelsea . .
Maiden . .
Newton . .
Pltohburg .
Taunton . .
Qlonoester .
Waltham . ,
Qolncy . . .
Pittsfleld .
Everett . , ,
Northampton ,
Newburyport ,
Amesbury . ,

If
II

1,891,306

1.438,000

1,116,662

978,394

6ti0,U00

487,387

600,000

308,431

3UG,U00

200,000

263,709

260,0(10

87,764

65,lt>6

40,000

96,217

87,411

87,191

7;,10U

62,666

48,684

48,366

46,886

41,278

32,233

32,140

3I,39«

30,264

29,394

27,686

27,!4«

26,972

26,688

23,068

19,642

18,802

16,686

16,331

14,073

10,920

867

^1

a 9

a ►

343

Percentage of deaths from

16.61

16.79

is

18.81

23.46

12.47 10.81

4.14 26.22
7.60 I 18.76
18.64 I 18.64

11.20 I 13.44
9.39 12.62

7.40
16.40.
18.78

6.12
21.04

9.09 1

40.70

ut.-a

18.78
22.01
10.62
18.18

S2
So

■§.•0
■9'S

6.93

7.82

7.74

1.38
3.76
6.16

2.24

9.10
16.66

12.60

11.11
11.11

60.00

9.10

26.00

8.33
22.-22

16.66
«6X6

^.(0
60.00

7.70
3.13

12.60

60.00

•Eft

1.65

1.84
.13

2.06
2.24

i 2.76

.43

1.03
8.36

).70

8.13
6.12

9.10

Denths reported 2,303: nnder five years of age 840; principal
infections diseases (amall-pox, measles, diphtheria and croup,
diarrhoeal diseases, whooping-cough, erysipelas and fever) 3^2,
acute inng d iseases 4tS9, consumption 268, diphtheria and croup
137, measles 34, scarlet fever 34, diarrbcaal diseases 27, whoop-
ing-cough 20, small-pox 18, cerebro-spinal meningitis 18, typhoid
fever 18, erysipelas It, maliirial fever 3, puerperal fever 1.

From diarrhoeal diseases New York 10, Cleveland 4, Milwaukee
3, Washington and Fall River 2 each, Brooklyn, Boston, Spring-
field, Somervilie, Salem and Fitchburg I each. From whooping-
cough New York 7, Brooklyn 4, Cleveland and Nashville 3 each,
Washington and Cincinnati 2 each, Boston 1. From small-pox
Brooklyn 8, New York 6, Boston 4. From cerebro-spinal menin-
gitis New York 7, Brooklyn and Lynn 4 each, Boston, Worcester
and Marlborough 1 each. From typhoid fever New York 5,

Digitized by

Google

276

BOSTON MEDICAL AND SUMGtOAL JO USUAL.

[Mabob 16, 1894.

Brooklyn and Lowell 4 «acb, Boston 3, Cleveland 2. From ery-
sipelas Brooklyn 1, New York 3, Boston 2, Cleveland and Tann-
ton 1 each.

OKFICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS 8EBVINO IN THE MEDICAL
UGPART.MEMT, U. S. ARMT, FROM MABCH 3, 1891, TO
UABCH 9. 1891.

Leave o{ absence for one month is hereby granted Captaxm
B. B. Ball, assistant surgeon, U. 8. A., Fort Monroe, Vh.

Captain K. W. Johmsok, assistant sargeon, U. S. A., will
proceed to Fort Monroe, Va., for temporary dnty, during the
absence on leave of Captain B. B. Ball, assistant lurgeon.
Upon the return of the latter from leave. Captain Johnson will
return to bis station, Washington Barracks, D. C.

FiBST-LiBUT. Chablbs WiLLCoz, assistant surgeon, U. S. A.,
is relieved from temporary dnty at Boise Barracks, Idaho, and
ordered to return to his proper station, Presidio of Ban Fran-
cisco, Cal. Par. 7, 8. 0. 81, Hdqrs. of the Army, A. O. O , March
&, 1891.

Leave of absence for one month is granted Majob Tdiotbt
E. Wilcox, sargeon, O. 8. A.

The leave of absence granted Majob John D, Hall, surgeon,
U. S. A., is extended one month.

Leave of absence for four months, to take effect on or about
August 10, 1891, is granted Captain Hbnbt I. Raymond, assis-
tant surgeon.

Major John Van B. Hoff, surgeon, U. 8. A., is hereby
assigned to the charge of the olflce and duties of the medical
director, Hdqrs. Department of the East, during the temporary
absence of Colonbl Jobbph B. Smith, assistant surgeon-gen-
eral, medical director of the Department.

OFFICIAL LIST OF CHANGES IN THE MEDICAL COBPS
OF THE U. 8. NAVY FOB THE WEEK ENDING MABCH
10, 1894.

F. W. Olcott, passed assistant snrgeon, from Naval Hospi-
tal, New York, and to the " Bichmond.*'

8. 8. Whitr, passed assistant surgeon, from the " Richmond "
and to the Naval Academy.

L. W. Curtis, passed assistant surgeon, from the Naval
Academy, Annapolis, and wait orders.

G. T. LuHSDKN, passed assistant surgeon, from the " Kear-
sarge " and wait orders.

W. H. Jonbs, medical inspector, ordered before the Betiring
Board.

C. E. Rioos, assistant surgeon, from Naval Hoapitai, Mare
Island, Cal., and to Naval Laboratory and Department of In-
struction, New York.

D. N. Bkbtolbttb, surgeon, and J. M. MooKX, assistant
snrgeon, ordered to the " Atlanta."

J. E. Paok, assistant sargeon, ordered to examination pre-
liminary to promotion.

HABVARD MEDICAL SCHOOL.
Evening Lecturxs.

The next lecture will be given on Wednesday evening, Blarch
21st, at 8 o'clock, by Dr. J. J. Putnam. Subject, "The Present
Status of the Therapeutics of Nervous Diseases." Physicians
are cordially invited.

AMERICAN SURGICAL ASSOCIATION.

The annual meeting of the American Surgical Association
will be held in the lecture-room of the Medical Department of
the Columbia College, Washington , D. C, May 29, 30, 31 and
June 1, 1891. The special subjects for discussion so far ar-
ranged are:

I. " The Surgical Treatment of Empyema." by John Ashhurst,
Jr., M.D. DiscuBsion opened by Dre. N. P. Dandridge, C. B.
Nancrede, T. F. Prewitt and DeF. Willard.

II. " Methods of Teaching Surgery," by J. 8. Billings, M.D.
Discussion opened by Drs. J. C. Warren, N. Senn, W. W Keen,
E. M. Moore, W. T. Briggs and Hunter McGuire.

III. "The Surgery of the Kidney." by L. M. Tiffany, M.D.
Discussion by Drs. M H. Bichardson, U. H. Mudd, C. U. Mastin
and Ford Thompson.

IV. " Methodsof Controlling Haemorrhage in Amputation at
the Shoulder," by W. W. Keen, M.D. Discussion by Urs.
Boswell Park, C. B. Porter and J. William White.

Fellows who desire to present volunteer papers are requested
to send the titles of the papers to the address of the Business
Committee, 1129 Walnut Street, Philadelphia, not later than
April 18, It^. J. R. Wbibt, H.D., Secretary.

AMERICAN MEDICAL ASSOCIAHON.
8ak Francisco Mbbtinq, Junb 8-8, 1891.

The Committee of Arrangements has secured Odd Fellows'
Hall Building, Corner of Market and Seventh Streets, for the
meeting June 6, 1891. Assi^mbly Hall will be need for the gen-
eral meeting, the twelve smaller halls for Section work. The
engagement carries three of these rooms on Monday for accom-
modation of associate organizations, as that of the Editors,
Colleges, etc.

Headquarters for the Association have been located at the
Palace Hotel, comer of Market and Montgomery Streets, only
four blocks from the place of meeting.

Post-Offlce Section K is located in the Palace Hotel, on the
office floor, adjacent to the registration room, where members
can receive all mail matter by having it so addressed.

B. H. Plummbb, Ckairman.

Sbction on Subobbt and Anatomt.

It is proposed to devote a portion of the time of this Section
to the systematic consideration of a few selected subjects, upon
which papers, each not occupying more than ten minutes will
be read. It is hoped that speakers discussing these papers will
confliie their remarks to brief addresses of five minntes length.

The topics and papers to be so presented are as follows:

(1) Malignant Growths; (2) Tabercalar Disease of JoinU; (3)
Hernia; (1; Hemorrhoids, Fistule and Fissure; (5) Fractures;
(6) Obstruction to Urination in the Male."

Members who have specimens or patients to exhibit beating
on these topics or who wish to make remarks in the discussion
of tbem are cordially invited to be present daring the meetings
of the Section. The titles of other papers to be presented to
the Section will be published when the programme of the meet-
ing of the Association is issued by the Committee of Arrange-
ments. John B. Robbbtb, Chairman,

1627 Walnut Street, Philadelphia.
Llotd W. McRab, M.D., iSeeretary, Atlanta, Ga.

RECENT DEATHS.

Fbancib Flint Fobsaith, M.D., M.M.S.S., formerly of Wey-
mouth, Mass., died in Providence, R. I., Much 10, 1891, aged
sixty-niue years.

Db. Albbbt Locke, Professor of Surgery in the University
of Strassburg and the colleague of Billroth in editing the
DeuUche Chirurgie, died February 28th.

Db. Don Vincent A. Gabcia, President of the Medical and
Natural Science Society of Bolivar, Columbia, died recently.

BOOKS AND PAMPHLETS RECEIVED.

The Young Man in Business. By Edward W. Bok. Phila-
delphia. 1891.

The Forms of Peritonitis, Their Belation to Appendicitis and
the Etiology of Each. By Boswell Park, A.M., M.D. Beprint.

A Critical Beview of the Seventh Decennial Bevision of the
Pharmacopoeia of the United States of America. By George H.
Beringer, A.M.. Ph.G. Reprint. 1891.

A Practical Treatise on the Diseases of the Hair and Scalp.
By George Thomas Jackson, M.D. New, revised and enlarged
edition. New York : E. B. Treat. 1891.

A Speech on the Principles of Finance. By Victoria C. Wood-
hull, delivered at Cooper lostitate. New York City. Thursday,
Augusts, 1871, and throughout the United States of America.
London. 1891.

The Strike at Shane's. Goldmine Series No. 2, Sequel to
Black Beauty. A Prize Story of Indiana. Written for, and re-
vised, copyrighted and published by The American Human
Education Society. Boston, 189J.

The Physician's Wife and the Things that Pertain to Her
Life. By Ellen M. Firebaugh. Illustrated with forty-four
photo-engravings of sketches from life. Philadelphia: TheF.
A. Davis Co. London : F. J. Bebman. 1891.

Atlas of Clinical Medicine. By Byron Bramwell, H.D.,
F.B.C.P., Edln., F.R.S., Edin., Assistant Physician to the Edin-
burgh Royal Infirmary, etc. Vol. II, Part III. Edinburgh:
Printed by T. & A. Constable at the University Press. 1893.

Supplement to the Reference Handbook of the Medical
Scieui'es. By various writers. Illustrated by chromolithographs
and fine wood-engravings. Edited by Albert H. Buck. M.D.,
New York City. Volume IX New York: William Wood &
Co. 1891.

A Treatise on Headnche and Neuralgia, including Spinal Irri-
tation and a Disquisition on Normal and Morbid Sleep. By J.
Leonard Coming, M. A., M.D. With an appendix. Eye-strain,
a Cause of Headache. By David Webster, M.D. Illustrated.
Third edition. New York : E. B. Treat. 1891.

Digitized by

Google

Vox.. CX3X, No. 12.] BOSTON MEDICAL AND SURGIOAL JOURNAL.

277

Original S&rticitjt.

THE DIAGNOSTIC AND PROGNOSTIC IMPOfU
TANCE OF LEUCOCYTOSI8.*

BT BICHABO C. CABOT, lf.D.,
■Bfcaieal littenu, MauaehmtUt QtMtral Bovital.

Thb material for this paper consista largely of blood-
ooanta, 33:2 in all, which I have made at the Maaaachu-
aetta General Hospital within the last year ; and for all
of it I max indebted to the kindness of the visiting physi-
cians and surgeons of the hospital, who have given me
the freest access to their cases at all times. I am
under special obligations to Dr. F. C. Shattack and
X>r. R. H. Fitz.

It ia important to know exactly what lenoocytosis is
before we attempt to estimate its diagnostic or prog-
nostic value. It is a very difficult idea to define. Not
one of the aathors whom 1 have consulted have seemed
to n»e to give a satisfactory definition, that is, one which
•afficiently distingniabes it from leuctemia. Von
Jakach,* for instance, distingaishes it from leuoemia
by its transitorinesa, bat it may last as long as leucn-
mia. Vircbow defined it as ao increase iu the white
cells of the blood due to a stimolation of the lymph
glanda, bat in typhoid the increast;d glandular activity
caaaea no leococytosis.

EUchborst, JUrgenaen, Seifert, Miiller, Striimpell,
Vierordt and P^e' iu their text-booka give it to be
anderstood that leacocytosia is transitory, symptomatic,
and less in degree than leucssmia ; bat counts as large
as those in leucaemia have repeatedly occarred in cases
where none of the characteristic lesions of leocemia
were present, especially in connection with malignant
disease and the ansemiae of children (Von Jaksch).

Very probably many of the reported cases of acute
leucaemia where nothing was found at aatopsy, were
simply leucocytosis. The reported developments of
pseudo-leucaemia into leucasmia were probably all
leucocytosis. At any rate, I have not been able to
oome across a single such case where the crucial test
of the differential count was applied. The mere in-
crease in the white was held to constitute leuctemia.

Ou the whole, the best definition that I have been
able to arrive at is this : Leucocytosis is the presence
in the blood of ao increased number of white cells of
the same varieties morphologically as those in normal
blood, a plurality and generally an overwhelming
plurality being polynaclear.

In leuctemia many of the varieties of white cells
present have never yet been found in normal blood,
although every one of them has now been found in
diaeasea other than leucaemia.

In leucaemia the poly nuclear cells are never increased,
sod are generally in minority, in leucocytosis the
polyDQclear cells are generally much increased, and
are never in a minority.

Bat we cannot say, as Friedlander* does in his
ihort and pungent definition, that: "Leucocytosis is
so increase in the polynnclear or other varieties of
white cells present in normal blood"; for in pure
lymphatic leuosmia there are no varieties other than
thoae found in normal blood, the diagnosis being made

■ B«td before tbe Seetton for Oliniesl Medlelne, Pathologr end
^^n* of tbe SoSolk Ototriet Medleal 8oelet7. Janiurj IT, IsM.
' VOD JakMh : Klinlwbe l>lasiio*tik, 1889.
^M : UnieniMhaiigeii Uber LenkooTtoee ; iBsag. Dtaert , Barliii,

< IriwUlnder : MlerosMVlMhe TeehnUc.

on the overwhelming majority of lymphocytes, or
small mononuclear white cella, taken in connection
with the other physical signs.

Practically, 90 oat of 100 lencocytosesare perfectly
easily distinguishable from lencaemisby their enormous
percentage of the polynaclear varieties, 90 to 98 per
oent. being the rule.

We cannot, then, make tbe distinction from lea-
caemia simply by the count. As an example of this, let
me cite a case occurring in the wards of Dr. Maurice
H. Richardaon last summer, in which a mistaken
diagnosis was made for lack of a differential count.

A. M., single, age twenty-one, entered with a diag-
nosis of malignant tumor. She was so pale that an
examination of the blood was made. This showed an
overwhelming number of white cells, 1 to 89 red ; and
taking this fact in conjunction with the position and
nature of the tumor, a diagnosis of leucaemia was
made. The tumor was in the region of tbe spleen,
projecting below the left ribs, and it was thought that
a notch was felt upon its upper surface. Tbe patient
was transferred to a medical ward; and here, after
considerable delay, a triple atain and differential count
of the blood was made, which at once showed that it
was not leucaemia, for 95 per cent, of all the white
cells present were of the poly nuclear type< Not long
after tbia, the tumor began to assume a position near
the median line, and a sone of resonance appeared be-
tween the left ribs and the tumor. Daring her stay
on the medical side she had several well-marked chills.
She was transferred to the surgical wards again, and
the tumor was tapped in several directions, nothing
but a little faecal matter being obtained.

She failed rapidly, decided to go home, and was lost
sight of; but her death was reported in the papers
within a few weeks. No autopsy. This was probably
a case of large malignant new growth and the connt, I
to 39, was not higher than has been repeatedly found
in large abdominal tumors. I have collected eight
cases of malignant growths from literature in which
the count was I to 50 or greater.

On the other hand, we may have leucaemia with no
increase in the number of white cells. A few months
ago Dr. Hubbard, of Tannton, sent me some blood-
slides from a case of leucaemia. Mrs. S., which I had
seen and counted in the hospital a year before in the
service of Dr. Sbattuck and which is now under Dr.
Hubbard's care in Taunton. TAejf $hoto*d no inenase
at allinOM white eell$; but on making a differential
count, a large proportion of the white cells present
were found to be myelocytes, so large a proportion
as could only occur in leucaemia. The patient has
still all the other signs and symptoms of leucaemia.
In leucocytosis then, as distinguished from leucaemia,
we have only those varieties of white cells present
which are found in normal blood.

We have said that leucocytosis is an increase in the
white cells over the normal number. This normal
number has been somewhat disputed ; but the majority
of careful observers in late years agree in placing it at
or near 7,500. Any variation, of more than 1,500
above or below this namber is to be considered abnor-
maL

Now, leucocytosis is found in a considerable number
of physiological conditions. This must be carefully
borne in mind if we are to rightly interpret its signifi-
cance in disease.

DigettioH, — We have in the first place leucocytosis

Digitized by

Google

278

BOSTON MEDICAL AJfD SUBGIOAL JOVRSAL.

[March 82, 1894.

daring digestion. Thii haa been doubted by many
aathora ; bat the weight of anthority i« in favor of it,
at any rate nnder certain oonditions. Two and one-
half houra after a meal rich in proteids the blood of
most normal persons shows an increase of white cells
varying from 1,000 to 7,000 above the normal.

Rieder,' who has made a most thoroagb investiga-
tion of the subject, says that in adults the digestion
leucocytosis rarely if ever goes above 18,000. Von
JalcBch states that it may be so great as to canse a
ratio of 1 white to 100 red, but he gives no cases in
support of his assertion ; nor does Klein,* who asserts
that the white cells may reach 20,000 limply from
digestion.

In children it may be a good deal higher, bat never,
I think, so high as the estimate of von Jaksch. My
own investigations of this matter agree entirely with
those of Rieder. In 21 cases, on varioas diets, I have
never seen it rise above 18,000. In IS of these it was
absent altogether.

Pregnancy: — Next may be mentioned the leucocy-
tosis of pregnancy and the puerperal state, which oc-
curs in about two-thirds of all cases ; it is generally
moderate, not over 14,000. The leucocytosis of preg-
nancy might be of value in excluding those cases of
phantom tumor simulating pregnancy. This has not
been done as far as I know.

ChUdnn. — New-born children have a very consider-
able leucocytosis; which falls gradually, until at the
sixth year the count becomes normal. At no time
daring the first year is 12,000 abnormal. Besides
these physiological conditions, we must liear in mind
hemorrhage, which, if large, may cause considerable
increase soon after the loss of blood ; also the leucocy-
tosis occurring just before death, so-called leucocytosis
of agony. If these causes are excluded, any leucocy-
tosis may be called pathological.

J^U^utid. — Taking up now the diseases in which
the count of leucocytes is important, I shall begin with
typhoid. Most febrile diseases are accompanied by
leucocytosis ; and Striimpell, in the edition before the
last, of his "Text- Book of Medicine," makes the mis-
take of saying that leucocytosis is present in typhoid.
In this he only follows the lead of such authorities as
Virchow, Yierordt and others, who, judging apparently
from a priori considerations, have stated that in all
diseases accompanied by increased activity of the
lymph glands, increase of white cells should be found.
As a matter of fact, however, the overwhelming ma-
jority of observers, and almost all the facts, are on the
other side. As mentioned in Osier's text-book, Thayer
has counted nearly 150 cases, not reported in detail as
far as I know, in which no increase was found.
Bieder, v. Limbeck,^ Pick * and others have come to
similar conclusions. Leucocytosis occurring in typhiod
points to some complication, such as thrombosis, pneu-
monia, abscess, etc. The diagnosis between relapse
and some of these causes of temporary rise of tempera-
tare may, perhaps, be assisted by the blood-count. In
a patient of Dr. Sbattuck's, who had just recovered
from a thrombosis during convalescence of typhoid,
the temperature began to rise again. The question
arose, whether this was due to the smouldering re-
mains of the thrombosis (which, when active, had

• Sled«r : Beitrilce zor Eantnln der Lenkoortoae, Leipzig, U92.

• KMa : Yolkmuui'i SammloDg KllnUoha Vortnge, Dm. 18SS.

' Von Limbeck: GntndrlM eiiMr Kilo. Patb. dec Blates, Jen*, 1892.

• Plok: Klin. Beobaohtongen ttber die Entznndl. Lenkoonote
Png. Hed. Woobemclirift, leso, TSo. it.

caused both fever and leucocytosis), or whether the
patient was having a relapse. The blood-count was
normal ; two days later rose-spots appeared, and the
subsequent coarse of the case confirmed the diagnosis
of relapse as indicated by the blood-count.

In the last few months I have counted 79 cases of
typhoid fever. In only one was leucocytosis present,
and that was in a child of four, where the normal
number of white cells was so great that the count in
this case, 1 to 800, may not be really leucocytosis at
all. In 49 of my cases the number of white cells was
less than the normal, and this agrees with most of the
latest observations. Lack of time prevented my mak-
ing more than one count in each case of typhoid.

Cold baths, as recently observed by Thayer, may
produce a temporary increase. In two of my cases I
was able to confirm this observation.

Now this fact, the absenoe of leucocytosis in typhoid,
is a very important one in the diagnosis of that dis-
ease, for a large number of affections with which
typhoid is likely to be confounded do show leucocyto-
sis. Local suppurations, for instance, which are some-
times difficult to distinguish from typhoid fever, almost
always produce leucocytosis. Purulent meningitis has
shown in every case which I have been able to find in
literature (only seven in all) a very marked leucocyto-
sis. I have only one case to add to this.

Last September, a man entered the Massachusetts
Greneral Uospitsd with a diagnosis of typhoid fever.
He had the typical " typhoidal " aspect. Low, mut-
tering delirium, heavy coated tongue, temperature
104.2°, pnlse 115, respiration :S2. Ue could give no
account of himself, and complained of nothing in par-
ticular. Physical examination was generally negative.
No rose-spots were present, no spleen was felt, and
there was no distention. The diaso reaction was
present. In the absence of any other obvious diagnosis,
the case was considered one of typhoid. The blood-
count, however, showed 22,000 white cells. Next morn-
ing the patient's brother arrived, and stated that the
patient had been suffering for years with middle-ear
catarrh. There was no discharge from the ear ; but
Or. Green found paralent otitis, with perforation in
the left ear, and made a diagnosis of meniDgiiis. The
patient became unconscious within a few hours, and
died two days later. No autopsy.

Ewing reports a number of cases in the New York
Mtdieal Journal, December 16, 1898, where the diag-
nosis was very difficult between pneumonia and typhoid
uniil an examination of the blood cleared it up. No
such difficulty has oocarred in the cases I have seen,
but, should it arise, the blood would undoubtedly
decide in the great majority of cases.

Typhoid vt. Appendicitii. — A diagnosis between
typhoid and appendicitis has presented considerable
difficulty in several cases which I have seen at the
hospital this year. As is well known, the pain of ap-
pendicitis may be very slight, and the tenderness no
greater than is occasionally found in typhoid. The
histories in a certain number of cases are not markedly
different. In two such doubtful cases where I have
found no leucocytosis, a diagnosis of typhoid has been
confirmed by the subsequent course of the disease.

Three years ago, I saw in the hospital, iu the ser-
vice of Dr. Shattuck, a case in which the diagnosis
between typhoid and some internal supparation was
for several weeks doubtful, until at last an abscess of
the liver came to the surface and was opened. In

Digitized by

Google

7oL. CXXX, No. 12.J BOSTON MEDICAL AND SURGICAL JOURNAL.

279

mch a cue as this I think the blood examination
Tonld have settled the difiSculty at once.

Gripp«. — Between grippe and typhoid the blood
doM not help as, for in neither are the white cells
markedly changed. I have connted but five cases of
ancomplicated grippe, but in none of these, and in but
few of those which I have fonnd in literature, has
increase been presenti

Between general sepsis and typhoid a blood-exami-
nation was of ralae in a case occurring this autumn in
Dr. Shattnck's service. Patient presented symptoms
and aigos of acute polyarticular rheumatism with fever.
The fever came down under salicylates, but soon rose
again, and the man became wildly delirious. His de-
lirium persisted after the salit^late was stopped.
Several joints continued swollen and tender. The
fever was very moderate, ranging between 99° and
101°. There were uo rose-spots and uo spleen. The
qaestioQ arose as to whether it was a case of sepsis
with localization in the joints, or whether it was a case
of typhoid supervening on an arthritis of some kind.
The blood-count, which was repeated several times,
•bowed always a perfectly normal blood except for a
(light anaemia. The subsequent coarse of the case,
daring which he remained for nearly three weeks more
or less delirious, convinced Dr. Shattuck that it was a
case of typhoid fever.

Tubereie. — As between typhoid and incipient pul-
monary tnberoulosis or tubercular meningitis, the
blood does not give us any help. For in pulmonary
toberculoais all observers agree that leucocytosis is
present only in advanced cases with high fever -(that
u, I suppose, in those where the infeotion is mixed)
and in tubercular meningitis there is no leucocytosis,
•0 far as observed. My own counts in tubercalosis in
eleven cases have coincided with the results obtained
by others. In two cases of galloping consumption
and two cases of empyema with phthisis, leucocytosis
has been present. In the other cases, consisting of
two cases of tabercular peritonitis, two of early phthisis,
two of tuberculosis of the kidney and one of general
miliary tuberculosis, no increase has been present. I
have only been able to find four cases of miliary tnbei^
culosis in literature where counts have been maide. In
none of these was there any increase, so that in these
cases of tuberculosis which would be likely to be con-
founded with typhoid the blood does not help us. The
■ame is true of malaria, where a normal blood-count is
found.

I stated before that the majority of cases of typhoid
show by the second week lencopenia, or lack of white
cells. Cases of debility with fever, and with or with-
out gastro-intestinal symptoms, which are sometimes
difficult to tell from typhoid, may, perhaps, be distin-
guished from it in some cases by their normal count.
Two cases of acute gastro-intestinal catarrh with fever,
which I connted with a view of finding out the cause
of the fever, both showed a decided increase in white
cells. This might be of use in a diagnosis of typhoid.

Pneumonia. — It has long been known that pneu-
monia shows a marked increase in white cells. I pub-
lished the blood-counts of 48 cases last summer, in all
bat 5 of which leucocytosis was present.* I dwelt
then upon the prognostic significance of the absence of
increase in the white cells, for all of the 5 which had
no increase died. Since then I have counted 24 more,
or 72 in all.

' Cabot: Boston Xadlosl ud Snrgtoal Jounua, Aoffntt 8, ISSg,

I will speak first of the diagnostic importance of
blood in pneumonia. In the cases that I have seen it
has helped mostly in distinguishing pneumonia from
grippe, or rather in anticipating the complication of
pneumonia in grippe. In three cases seen last month
where no physical signs of pneumonia were present,
where the history might do either for grippe or pneu-
monia, the high leucocyte count made me suspect pneu-
monia, and this was verified in each case by the appear-
ance of signs of consolidation within thirty-six hours.

It is important before any treatment or any prog-
nosis to make this distinction between grippe and pneu-
monia as early as we can, especially if we are in the
habit of treating grippe with phenacetine.

Ewing, in the article mentioned above, says that he
found a connection between the count and the amount
of physical signs, and also between the count and the
vigor of the systemic reaction. In my cases I have
not been able to establish any such connection. High
counts have been present in sthenic and in fatal cases
repeatedly ; low counts in those with much lung sub-
stance involved. Of the 24 new cases since my last
report on pneumonia, two have had no leucocytosis.
One of these died. The other did not ; bat the course
of the case was so interesting that I think it will be
worth reporting in a little more detail.

The patient, L., was seen in Dr. Fiu's wards a few
weeks ago, and was evidently a very mild case of
pneumonia. Temperature and pulse were not high ;
there was no cyanosis, and bnt little lung involved.
The man was perfectly sensible ; and after the count,
which showed a normal number of leucocytes, I felt
as if the theory were certainly at fault in this case.
The man was evidently going to get well. Within
twelve hours the temperature rose to 105° ; the pulse
to 160, and became so weak as to be almost uncount-
able. The nutn became much cyanosed and wildly
delirious. He seemed almost moribund, and remained
in this condition for forty-eight hours. At the end of
this time he began to improve a little. The count was
repeated, and found to show a marked increase in the
white. He ultimately recovered. Now here was a
case where from ordinary appearances a good prognosis
would have been given ; but if we could have antici-
pated what his condition would be twenty-four hours
afterwards, the prognosis would have been the very
reverse. The blood did antieipcttt it ; so that this case
does not seem to me to be one which tends to upset
the prognostic importance of the absence of leucocyto-
sis in pneumonia. Of my 72 cases, 7 had no leuco-
cytosis ; 6 of these have died ; and the other came so
near it that if it had been foreseen what his condition
would be, a very unfavorable prognosis would have
been given. It is interesting here to see that when his
condition began to improve, the leucocyte count rose.

Phtkint and Pneumonia. — Between pneumonia and
phthisis in the early stages the blood-count might be of
value, but it is not in this stage of phthisis that the
difficulty of diagnosis would be likely to occur. Pleurisy
with serous effusion shows, according to v. Limbeck
and Pick, moderate leucocytosis in febrile stages, none
in the quiescent afebrile stage. I have counted six
cases, two in the febrile stage and four in the afebrile
stage ; and my results are entirely in accord with those
of the writers above mentioned. Rieder thinks (on
the evidence of a very small number of counts) that
tubercular effusions give no increase in leucocytes, eveu
whep febrile.

Digitized by

Google

280

hOSTOJf MEDJOAL ASD SURGICAL JOUBHAL. [Mabcb 22, 1894.

In three caaea of empyema, I have fonnd moderate
lenoocytosU, bat not greater than that present in the
febrile stages of serous effusions, so that no help is given
by the blood-count, as between empyemas and serous
effusions in the febrile stage.

Scarlet fever and Meade*. — Between these two
diseases the blood is said by several authors to be of
greater diagnostic importance, lencocytoais being pres-
ent in scarlet fever and not in measles. I have had no
personal experience in these diseases. Aooording to
Koozetkow, leucocytosis is present in scarlet fever in
the incubation stage early as six days before the jorup-
tion.

In RhetimatUm but few counts have been made. In
the febrile stages the white cells are apparently in-
creased. The same is true of erysipelas. In two cases
I have found marked increase.

Diphtheria shows as high a oonnt as any felMile dis-
ease. According to v. Limbeck the higher the ooont
the worse the prognosis.

In FoUieular ToneiUitiM Halla has foond moderate
leucocytosis ; and 1 have fonnd the same in three oases,
all febrile ones.

Experiments in the inocalation of animals with oalt-
ares of various pyogenic oooci show that those animals
in which no leucocytosis is present generally die. This
has been observed in a number of cases in the inocu-
lation experiments at the Pasteur Institute last year.

MaUgnamt Diseaam. — Lenoocy tosis occurs in a cer-
tain proportion of cases of malignant diseases. Just
what that proportion is and what relation the count
bears to the presence of the disease in one or another
organ, or to the kind of disease, does not seem to me
to have been settled as yet.

V. Limbeck found it most frequently in soft, grow-
ing tumors, and constantly in osteo sarcoma. Here
the count may be of great importance in helping the
diwnosis between malignant disease or some other form
of joint affection. Tuberculosis, for instance, as before
mentioned, does not cause an increase in the white
cells ; nor does chronic arthritis sicca., nor gonorrhoea!
arthritis.

Oaalrie Oaneer and VIeer. — Schneider has, during
the last year of two, maintained the thesis that the
examination of the blood is of great importance in the
diagnosis between cancer and ulcer of the stomach.
He has found leucocytosis in all of 12 cases of cancer
of the stomach and failed to find it in a number of
ulcers. It is important here, however, to rule ont all
these cases of ulcer where profuse hnmorrhage has
taken place, or where a long-standing chlorosis is pres-
ent, for chlorosis and haemorrhage both may cause
leucocytosis. In cases of ulcer not dependent on these
oaoses, it seems that the count might be of diagnostic
value. I have counted only two cancers of the stomach,
and there leucocytosis was present. I have counted
no ulcers. In the diagnosis between anasmia second-
ary to malignant disease, and the simple primary or
pernicious anaemia, the count is certainly of importance ;
for in these latter forms of aneemia, no considerable in-
crease is often found, and although the absence of leuco-
cytosis would not be of any great diagnostic importance,
its presence might be. Moreover, Klein, the latest
and most enthusiastic writer on the subject, states that
in malignant disease, even where no leucocytosis is
present, a differential count shows a marked increase
in the percentage of polynudear cells. In canoers of
the uterus- it has been found less often, and in cancer

of the gullet it apparently does not occur, the white
cells being decreased.

I have counted 19 cases of malignant disease and
found leucocytosis in 12. In my cases a leucocytosis
was present wherever cachexia was present, without
any particular reference that I can trace to the posiuon
or nature of the tumor. The 7 cases where no increase
has been present have been mostly small tumors, and
all in persona where no ctM^exia waa present. Thus,
in a small cancer of the lip, a sarcoma of the testis,
and a sarcoma of the abdominal wall, there was no in-
crease. In all of these cases the tumors were smsll,
and there was no cachexia. In one case of cancerous
growth filling the whole pelvis, and in another case of
very large sarcoma, probably of both suprarenal
capsules, both without cachexia, there was no increase.
The last of these two cases became cachectic, and sev-
eral months after the first count the leuco«3ytosis rose
proportionally. In one case of multiple sarcoma of the
skin where the tumors were very small, although
fairly numerous, there was a large increase ; but here
again the patient was markedly cahectic.

Apptiidieiti*. — I have counted 24 cases of appen-
dicitis, and have been specially interested in these
counts, because leucocytosis if constant in appendicitis
would be a diagnostic factor of some value. In every
case except two where pus was found at operation,
leucocytosis was present, the sise of the count having,
as far as I could judge, no relation to the amount of
pus fonnd. In three cases of appendicitis proved at
operation to be catarrhal, no increase was present, as
was the case in several others whose course made the
diagnosis of catarrhal appendicitis probable, although
this waa not actually verified by operation. The
count haa seemed to me of real value in some oases
where the diagnosis was diflBcnlt, between simple
colic doe to constipation (with or without gastro-intes-
tinal symptoms) and true appendicitis. Two cases
where symptoms and signs pointed decidedly towards
appendicitis, but where no leucocytosis was present
were relieved of all these symptoms within forty-eight
hours, by clearing the bowels. The oonnt may be of
use, it seems to me, in deciding us whether an enema
ought to be given. It is sometimes desirable to give
an enema in cases simulating appendicitis to help clear
up the diagnosis, but some physicians are afraid to do
so for fear of causing a walled-off abscess to break into
the general peritoneal cavity. In such cases, if no
leucocytosis were present, we might go ahead with a
dearer conscience.

Mr. B. entered the Massachusetts General Hospital
September 20th, with a diagnosis of appendicitis. For
twenty days he bad been having paiu and tenderness
in the region of the appendix, pain being controlled by
morphia. The bowels had been loose, he said. There
was dnlness and tenderness and a distinct tumor in the
region of the appendix, with slight pyrexia. The
blood-count showed only 8,000 leucocytes. He was
given a compound cathartic pill, had a large movement
of the bowels, and all symptoms aud signs disappeared.
V. Limbeck, Rieder, Pick and Koblauck >* all state
unconditionally that leucocytosis is present in general
septic peritonitis with fever. But in three cases of
general peritonitis, two of them with appendix pus
present, no increase of white cells has been present.
I do not know how to explain these cases. It is possi-
ble that they may be explained in the same way as the

x> KobUook : InBagana DiMsrtatioB. Berlin, I88S1.

Digitized by

Google

You GXXX, No. 12.3 BOSTOJS MBDIGAL ASTD SUBGWAL JOUBSAL.

281

abMnoe of leacocytosu in some fatal oasee of pneumo-
nia. All these three cases of peritonitis died within
twenty-foar hours. It may be that the lack of leu-
cocytes is a point in prognosis, pointing to a feeble
aystemic reaction. It is interesting also that in none
of these three cases was there any pain, while in every
one of those cases where I found leuoocytosis, pain
was a marked feature. This would suggest that pus
onder tension is more likely to cause leucocycosis than
where free. The same thing is suggested by counts
that I have made in felons and small abscesses in the
Oat-Patient Department. In three felons, one of
which contained less than half a drachm of pus, I found
well-marked leuoocytosis. In a paronychia with great
pain, but -without pus, no increase was present.

Put-TtAe. — In 15 cases of pus-tube or pelvic ab-
icess I have never once failed to find leuoocytosis.
This fact may serve to help in the diagnosis between
pns-tobe and pelvic abscess, on the one band, and those
pelvic pains with uo anatomical basis, and other non-
aapporative and non-malignant pelvic affections, such
as extraputerine pregnancy, pelvic hssmatoma, and
small ovarian cyst, on the other. In two cases of
extra-uterine pregnancy I have found a normal blood-
count. I may mention here two interesting cases of
severe inflammation under the scalp, following scalp
wounds. In one of these I found normal blood-count ;
and at operation no pus was found, only boggy, water-
soaked tissue. In the other I found leuoocytosis, and
plenty of pus appeared on making a cut.

Siptie £f<mdt, etc. — I have counted three septic
bands and one septic foot, and always found leucocy-
tosis. The same is true of three buboes and two small
abscesses of the neck. One case of mumps showed
normal count.

Otteomyditu. — Two cases of osteomyelitis with
deep seated suppuration (as proved by subsequent
operation) showed marked leucooytosis, while one with
•imilar symptoms, but normal blood-oount, turned out
to be rheuaiatism. Three cases of otitis media were
counted. Two of them were purulent and had leucooy-
tosis ; one was serous and had none. In one case of
housemaid's knee in which the general constitutional
symptoms were more marked than usual, so that the
presence of pus was thought of, I found large increase
in leucocytes ; and a few hours after pus was found at
operation. Two joint cases, one of the elbow and one
of the knee, where before operation the question of
pus was seriously entertained, showed normal counts,
and no pas was found in either. Besides the three
eases of general peritonitis mentioned above, where
the indication of the blood-count was wrong, there
should be mentioned a large abscess, apparently origi-
nating iu the liver, which burrowed forward and was
evacuated in the epigastrium, and which showed a
normal blood-count. I have no idea why the blood-
oount failed in this case.

ObitnietioH. — In three cases of intestinal obstruc-
tion, one of them so closely simulating appendicitis
that it was sent iu by a surgeon of the Massachusetts
General Hospital with that diagnosu, no leucooytosis
has been found.

OarbuneU. — Two oases of carbuncle showed, as
was expected, marked leuoocytosis.

Cy«(»lt's, etc. — Two oases of cystitis, and three cases
of endometritis showed normal count, as did two cases
of so-called urethral fever following operation on blad-

Healittg Wounds. — On the whole, the cases where
the blood has seemed to me of greatest importance
have been those where after the operation, the wound
having been sewed up tight, the question has arisen
whether pus was forming inside. I shall speak of
these somewhat more in detail.

Gabs I. Frank B. was a case of appendicitis op-
erated on by Dr. Richardson at the end of an attack.
A little pus was found, the appendix was excised, and
the wound nearly dosed, a small strand of gauze, how-
ever, being left in. Several days after the operation,
there being at the time no external discharge, the tem-
perature rose. The wound seemed perfectly clean.
The man was very nervous about himself, and much
stirred up at each dressing; and as the temperature
never went higher than 101°, there seemed to be con-
siderable doubt as to what the cause of the tempera-
ture was. The blood-count in this case showed 52,000
leucocytes; and on opening the wound a large amount
of broken-down blooddot was evacuated, and the tem-
perature came down to normal.

Case II. Mrs. S. was a case of pus-tube shelled
out and sewed up tight. Ten days after the operation
the temperature began to look a little like pus. Here
again the patient was exceedingly nervous ; and, as so
often happens, the question was asked and re-asked,
whether she was keeping up her own temperature by
the state of her mind. The blood-count, however,
showed marked leuoocytosis, which led to a careful
ether examination, revealing a fluctuant mass behind
the uterus, from which pus was obtained by puncture.

Cask III. Mr. B. entered the Massachusetts
General Hospital in December, under the service of Dr.
Porter, with a compound fracture of the thigh. Some
days after it had bisen put up, the temperature b^;an
to look like pus, the wound, however, remaining per.
fectly clean. I counted the blood, and found a marked
leuoocytosis. A more thorough exploration of the
wound revealed a pocket of pus, the evacuation of
which brought down the temperature. I was not sure
in this case whether the absorption of the blood-clot,
such as takes place, I suppose, after any compound
fracture would be sufficient to cause leuoocytosis. I
therefore counted several cases in which there was
fever and presumably blood-clot absorption, namely, a
bsmothorax, a pelvic hoematooele, two compound fract*
ures and a crushed foot; in none of these was any
leaoocytosis present.

Oasb IV. Mr. S. was operated on by Dr. Warren
for traumatic epilepsy. Nothing special was found,
and the wound was closed. Ten days after the opera-
tion the temperature rose to 104°, and the patient
complained of severe headache and pain in the back.
I oounted the blood, and found no leucooytosis. Next
day the temperature was down. The patient appar-
ently had the grippe.

There is no time to report more cases in detail, but
these last cases have seemed to me to be very sugges-
tive and interesting.

OONOLUSIONS.

Only in typhoid and in pneumonia does the number
of counts which I have made warrant any conclusion.
The absence of leucooytosis in typhoid and its pres-
ence in pneumonia (except iu the severest cases) seem
to me fairly well established and of some diagnostic
and prognostic importance.

The number of cases oounted among the surgical af-

Digitized by

Google

282

BOSTON MJBJDIOAL AND SUBGIOAL JOURNAL. [MiLBCH 2i, 1894.

fections it too few to warrant any oondntionB ; bat
they are Bufficient. it seems to me, to make it import-
ant tbat the subject of leaoocytosis in surgical cases
should be studied much more carefnlly, with a yiew to
its practical diagnostic value. If a felon with half a
drachm of pus in it will cause marked leacooytosis, it
certainly seems as if the diagnosis of deep-seated sap-
purations of larger sise might be helped oat by blood-
ezaminations, as apparently it was in some of the ap-
pendix and osteomyelitis cases I have quoted.

Into the interesting and possibly important subject
of the diagnostic importance of qualitative changes in
the varieties of white cells, which is being so eagerly
pushed in Germany just now, I have not undertaken
to enter. Its advocates say it is even more important
than the quantitative variations dwelt on in this paper.

TECHNIQUE.

In most of the cases reported above I have used the
Thoma-Zeiss counter with Hayem's or Gower's solu-
tion and a dilation of 1 to 200. So great a dilution is
condemned by German writers, as affording too small
a number of leucocytes for computation, and so in-
creasing the chance of error. To avoid in part this
difficulty, I measured the field of my microscope, using
always the same lensea. It happens to measure almost
exactly one-quarter of a square millimetre, so that four
fields of my microscope are just equal to the whole
four hundred ruled squares of the Thoma-Zeiss instru-
ment. By taking four fields in each of the four direc-
tions away from the sides of the ruled spaoe of the in-
strument, we have counted as many leucocytes as we
should have done by taking four additional drops from
the pipette and counting only the ruled spaoe. As the
lines extend out some distance beyond the squares on
each side, we can use them as a guide to start us in the
right direction ; and by using a movable stage, we can
be sure of not getting off the track and into fields al-
ready counted. After counting one field, the eye is
fixed on a corpuscle at the side of the field most distant
from the central ruled squares, and then by means of
the moving stage the slide is moved until tiiat corpus-
cle is on the inner edge of the field, that is, thai near-
est the ruled squares. By counting four fields in four
directions, I had with the central ruled space twenty
thousand squares as a basis of computation. In each
count 1 did the whole process over with a second drop
as well, making forty thousand squares in all. This
gives us in most cases from fifty to one hundred leuco-
cytes as a basis of computation, which makes the error
considerably smaller.

I have used also the one-third per cent, aoetio-acid
solution, which makes the red corpuscles invisible, and
can therefore be used with much less dilution than the
other solution, 1 to 20 being that generally used abroad.
I have used generally 1 to 50, and found the results
obtained by counting the same blood first with Grower's
solution (1 to 200) and then with the acetic acid to be
so nearly the same that I have fallen back onto the 1
to 200 dilution, which has the advantage (besides that
of needing less blood) that it does not deprive us of
the count of red corpuscles, whereby we may check
any mistake in our mixing by reference to the ratio of
red to white. If the red are invisible (as with the
acetic-acid method) we are deprived of this advantage.

Mikulicz, of Breslan, 'u under consideration M the
successor of Billroth at Vienna.

TWELVE CONSECUTIVE AND SUCCESSFUL
OPERATIONS FOR APPENDICITIS.

BT JOBS W. KSant, MJ)., PBOVIDaHCB, >. t.,

VUUimt Smrgtm to St. Jot^k't Botpital, Surgeim to Out-Pahaitt at
(*e Bhodt iBlaiui BotpUal.

MoBK has been written upon the etiology, patho-
logy and treatment of appendicitis during the last five
years than upon any other disease. Even the daily
press has taken np the subject, and expatiated with
more or less correctness upon the many phases of this
so-called " fashionable disease." The operative treat-
ment is, without doubt. At method of procedure in
the large majority of cases. In Bull's collection of
cases, treated without operation, there was a mortality
of 47.67 per cent.; in Noyes's collection of 100 cases,
treated by the Willard Parker operation, there wu a
mortality of 15 per cent. ; while the mortality in tbe
early operation, or during the first three days of the
disease, is only 15 per cent. It has been shown that
about it4 per cent, of those who die, do so within tbe
first five days. 1 am fnlly convinced tbat tbe early
operation by a skilful surgeon, will save the greatest
number of lives. When the disease is of several days'
duration, and the symptoms and signs continue, the
Willard Parker operation is the operation of election.
Tbe mortality is about one per cent, in oases operated
upon between the attacks in recurrent cases of appen-
dicitis.

Case I. J. W., aiale. Age nineteen years, tele-
graph-operator and switchman on the N. Y., P. and
B. R. R.

May 4, 1891, while witnessing a base-ball game, felt
a slight pain across the abdomen. The pain continu-
ing, his mother administered a dose of castor oil, which
produced a small movement.

May 5th. Remained in bed all day, and was at-
tended by a homoeopathic physician, who prescribed
some medicine to relieve pain.

May 6th. About 4 a. m. he had a very severe
paroxysm of pain, which was almost unbearable.
Tincture opii was given, and he experienced some
relief. Nausea and vomiting. I saw him for the first
time at 10 a. m. ; his temperature was 103.5°, and
pulse 120. He had pain over McBurney's point, and
tympanitic percussion over right iliac region. Evening
temperature 103.5°.

May 7th. Temperature 108°, pulse 120. Duluess
on percussion, and sense of resistance in right iliac
region. Rigidity of right abdominal muscles.

May 8tb. No marked change iu symptoms. Tem-
perature 102.2°, pulse 110.

May 9th. Temperature, morning 100.6° ; evening,
101.8°. Mass in right iliac region defined. Consulta-
tion with Dr. Noyes. Operation advised.

May 10th. Operation at 10.30 a. m. Present,
Drs. Noyes, Mitchell and Collins. A vertical incision
four inches long was made, two inches to the left of
the anterior superior spinous process of the ileum,
through the abdominal wall, which was not more thau
three-eighths of an inch in thickness, into a circum-
scribed intra-peritoneal abscess. About four ounces
of very fetid pus was evacuated. A counter-opening
was made in the loin, and a drainage-tube drawn
through both openings. Coils of aglutinated intesdne
could be felt through the opening. The cavity was
washed out with a 1 to 2,000 bichloride-of-meroury
solution, and an antisepsic dressing applied. Four

Digitized by

Google

^oi.. C3XXX, No. 12.] BOSTON MEDICAL ASD 8USOIOAL JOURNAL.

283

lilk BQtares \rere naed to partially close the anterior
ironnd.

May 11th. Patient rallied well from the eSecU of
the operation. Morning temperature 101°, evening,
102.2**. Xhe wound was irrigated daily with a 1 to
2,000 bichloride-of-mercury solution, and an antiseptic
dressing applied.

May 12bh. Morning temperature 99.5°, evening
temperature 99.8°.

May 13th. Free fsacal discbarge from wound.
Morning temperature 98.8°, eveniug 99.5°.

May 14th. Two of the sutures were removed.

Morning and eveniu^r temperature 98.8°, and pulse 96.

May 15th. Temperature and pulse normal. Only

a alight discharge of pus. Two remaining sutures

renaoved.

May 2 2d. Drainage-tube removed.
Jane 2d. Wounds entirely healed.
June 5ih. Able to sit up.

Jane 6th. Four weeks from the day of operation :
went out. of doors.

Jaly 6th to 15th. Had an attack of cholera morbus.
August 31st. Ventral hernia, about the size of a
walnut, near the centre of the anterior wound. Truss
recommended.

Decenaber 6th. Hernia scarcely perceptible.
Cask II. F. EL P., male, age twenty-eight, baker.
This man was taken with severe general abdominal
pain and vomiting, October 2, 1892. Next day pain
was present on deep pressure over McBurney's point.
Oocssional attacks of vomiting.

October 4th. Consultation with Dr. Noyes. Dul-
ness on percnsaion in right iliac region; localised
point of pain and circnmscribed sense of resistance.
General condition good. No pain on hyperextension
of right thigh. Vomiting ceased. Temperature and
pulse slightly elevated.

October 19th. Dr. Noyes in counsel. Symptoms
and physical signs have not varied a great deal dur-
ing last two weeks. Mass can still be detected in
right iliac region.

October 22d. Same symptoms and signs with
sweats. Dr. Noyes again in counsel. Operation
agreed npon.

October 23d. I operated, being assisted by Dr.

Noyes and Dr. McCusker. An incision three inches

long was made, the centre of which was over the most

prominent point of the mass in the right iliac region,

parallel with the enter border of the rectus muscle.

When the transversalis fascia was reached an aspirator

needle was introduced twice, without entering the ah-

sceu cavity ; a third time by causing the needle to

enter obliquely and just to the left of the median line

pus was found. An incision was made with the needle

for a guide and five ounces (estimated) of fetid pus

evacuated. Two silk sutures closed the aogles of the

wound. Coils of intestine could be fell in the cavity

bat not the appendix. The wound was irrigated with

1 to 2,000 sublimate solution and a double draiuage-

tnbe inserted and an antiseptic dressing applied.

December 1st. Patient made an uneventful re-
covery. Wound entirely healed, August, 1893.

Case IIL W. R. P., male, aged thirty-five,
married. ■* •

I saw this case in consnitation with Drs. P. H.
Keefe and Wheeler, of Worcester, and McCusker, of
Providence, on December 7, 1892. This patient gave
s history of having had an attack of appendicitis one

year previously, by which he was confined to the room
ten days. He has had slight pain in the right iliac
region occasionally since then.

November 30th. During the night he was taken
with slight general abdominal pain and vomiting. He
had been working during the day and went to bed
feeling as well as usual.

December 1st. Temperature 102°, pulse 120.
Gleneral abdominal pain.

December 2d. Besting comfortably. Temperature
100°, pulse 110.

December 5th. Pain, dulness and rigidity of muscle
in right iliac region. Pain most intense over McBur-
ney's point. Temperature 99.4°, pulse 100.

December 6th. Conditions same as previous days.
Bowels regular every day.

December 7th. Pain over McBurney's point, sense
of resistance and dulness on percussion over an area
four inches in diameter, just to the left of the right
anterior superior spine of the ileum. No pain on
moving right thigh. No chUls or sweats and no fluct-
uation could be detected. Temperature 99°, pnlse
84. Operation recommended. Assisted by Drs. Keefe,
Wheeler and McCusker, I made an incision three
inches long over the centre of the area of dulness and
parallel with the median line. The skin, fat, external
oblique, internal oblique and transversalis muscles,
with the transversalis fascia were divided. An aspira-
tor needle was then introduced and pns withdrawn.
The peritoneum was now incised and three ounces of
fetid pus evacuated. Appendix not found. The cavity
was irrigated with 1 to 2,000 corrosive sublimate solu-
tion, a rubber drainage-tube introduced and an anti-
septic dressing applied.

January 12, 1893. The wound was entirely healed.

August 26th. The patient works every day and
has had no hernia or trouble since January last.

Case IV. J. H. S., male, aged nineteen.

I saw this young man December 19, 1892, at the
request of Dr. O'Keefe, his attending physician. The
patient was in good health until ten days ago, when
he was taken with pain in the " pit of the stomach "
while at work. The pain continued and two days later
was localised in the right iliac region. The third day
a mass could be detected in the same region. The
treatment consisted of warm poultices, anodynes and
laxatives. On examination, pain was present od press-
ure over McBurney's point, an area of dulness about
three inches in diameter with the above point as a
centre and a feeling of resistance over the same area.
Fluctuation could not be detected. Temperature and
pnlse slightly elevated. Operation advised.

December 20tb. Patient etherized by Dr. O'Neil.
Assisted by Dr. O'Keefe, 1 operated by making an
incision three inches long, parallel with the outer
border of the rectus muscle, and over the most promi-
nent poiut of the mass. The skin, abdominal muscles
and peritoneum were divided and five ounces of pns
(estimated) removed from a cavity which presented.
The intestines forming the inner wall of the abscess
cavity could readily be felt, but a careful search failed
to reveal the appendix. The cavity was irrigated with
a 1 to 2,000 corrosive-sublimate solution. A rubber
drainage-tube introduced, two silk sutnres to close the
angles of the wound and an iodoform and corrosive-
sublimate gauze dressing applied. The wound was
irrigated daily for a time and dressed as before men-
tioned. The patient made an uninterrupted recovery.

Digitized by

Google

284

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Habcb 82, 1894.

September 6, 1898. Patient hu bad no reearrence
of tbe diaeaae.

Cabs V. A. F., female, age eigbteen, domestic.

March S, 1898. Patient was aeiaed with severe
pain, localised in the right iliac region. In a few
hoars she Tomited a greenish fluid. A few hoars
afterwards she had a chill. She was confined to her
bed until March Ilth. She then rode b the steam
and horse cars about six miles to her home, where she
again went to bed suffering severe pain in tbe right
iliac region.

March 14th. She was admitted to St. Joseph's
Hospital. Examination shows greatest point of pain
over McBnmey's point; circumscribed area of dnlness
two inches in diameter. Sense of resistance on palpa-
tion over same area. Temperature 100.8°, pulse 1 12.

March I5tb. Operation. Present, Drt. Collins,
Noyes, Mitchell, Chesboro and O'Meil. Biohloride-
of-mercury poultice over abdomen during the night.
Field of operation rendered aseptic. Patient ether-
ized. An in<usion about three inches long was made
over tumor, parallel with the median line, down to the
peritoneum. Fluctuation could be detected at the
bottom of the wound, and tbe finger was passed
through into an abscess cavity. About two ounces of
fetid pus was removed, and the abscess cavity irrigated
with boiled water. Appendix was not found. A
counter-opening was made in the loin, and a robber
drainage-tube passed through the wounds. A glass
drainage-tube was also passed into the primary wonnd.
Irrigation again with boiled water, and two sutures of
silkworm-gut at angles of primary incision. Iodoform
and sterilised ganse, cotton and a bandage applied.
Patient rallied well from operation. A warm-milk
diet.

March 16th. Patient restless during night, and
slight pain during tbe day.

March I7th. Dressing removed. Wound irrigated
with corrosive-sublimate solution (1 to 2,000). Anti-
septic dressing applied. Temperature, a. m., 99.9°;
p. M., 99.6°. Pulse, A. M., 88 ; p. m., 96.

March 19th. Dressed. No pain.

March 22d. Dressed. Bubber drainage-tube re-
moved. Glass tube allowed to remain. Temperature
and pnlse normal.

March 25tb. Dressed. Slight ftmoant of fluid
ftaces escaped through wonnd.

March ttlsL Dressed. Drainage-tube removed.
Gounter^opening entirely healed.

April 8d. Dressed. Enemas for constipation.

April 18th. Wound entirely healed.

May 4th. Patient allowed to sit up.

May 10th. Patient discharged cured.

Cask VI. H. F. R., male, East Providence, R. I.
Age fifty, gardener.

This man I first saw at noon, Jnne 27, 1898, in con-
sultation with Dr. Mahoney. He bad been at work
the previous day, but had to leave his work in the
afternoon on account of pain in the abdomen, most
severe in the right iliac region. He had more or less
abdominal pain for the last week. Temperature 100°,
pulse 96. Sweats. Pain on pressure over McBur-
ney's point. Dnlness on percussion over an area three
inches in diameter in right iliac region. Circumscribed
sense of resistance. Could not feel a distinct tumor or
fluctuation. Operation advised.

At 5 p. M., Dr. Mitchell concurred in the diagnosis,
and advised operation. Assisted by Drs. Mahoney

and Mitchell, I made a four-inch incision, parallel with
the median line, over the area of resistance and throagh
the abdominal wall. When the peritoneum was
reached, by the aid of an aspirator, some pus was with-
drawn, and with the needle as a guide, the abscess
cavity was opened. The cavity was only abont one
inch in diameter, and contained abont two drachms of
pus. The appendix was not found. Intestine formed
the inner wall of the abscess. A rubber drainage-tDbe
was introduced to the bottom of the wonnd, and two
silkworm-gut sutures to partially close the iDcision.
Irrigation with corrosive-sublimate solution (1 to
2,000) and an antiseptic dressing. Elecovery unevent-
fal.

August 28, 1898. Scar firm. No evidence of
hernia. Patient walks about, and is in good condidon.

KTo bteoiMiiMtd.)

Clinicai Depairtment.

A CASK OF CONCEALED ACCIDENTAL HEM-
ORRHAGE DURING THE FIRST STAGE OF
LABOR, WITH RECOVERY OF MOTHER
UNDER CONSERVATIVE TREATMENT.

BT IDWAXD BXTHULDS. II.I>.

Or the 81st of last December I was asked by Dr.
F. C. Murphy to see with him a primipara of thirty-
jsight, who had been subject to asthma and in poor
health for some time, but had been in unusually good
condition throughout her pregnancy. Labor began in
the evening of December 29ih ; a few hours later Dr.
Murphy was called, and found the cervix extremely long
and rigid, the external os patulous, and the internal os
about the sise of a ten-cent piece ; a little later in tbe
evening the pulse rose suddenly to 160, and the patient
felt faint, but as she gradually rallied somewhat, no
treatment was adopted. During the night of the 89th
and the day and night of the SOth moderate labor con-
tinued, and the pulse decreased gradually in rapidity.
During the day-time of December SOtb tbe patient
became jaundiced, and began to look highly cachectic.

When I saw her at 10 a. m., December Slst, the
pulse was 110, the skin was extremely sallow, the con-
junctivae slightly yellow. The patient was feeble and
apathetic ; the cachexia was marked, and her appear-
ance resembled that of advanced malignant disease.
The appearance of the abdomen was very peculiar.
The uterus was rather small and extremely prominent,
the epigastrium sinking rapidly away behind the fun-
dus. On palpation, the fundns was tonically firm and
rounded, suggesting the presence of unbroken mem-
branes. The head presented. There was a tonic coo-
traction of considerable intensity, accompanied by
feeble exacerbations. On vaginal examination, the
external os was soft and thin, about half dilated, sod
hanging away from the head ; while the internal ox,
slightly larger, was hard and rigid, and pressed firmly
against tbe head. The foetus was moderately mscer-
ated, and a portion of its »calp, filled with fluid, occu-
pied the cervical canal. Under ether. Dr. Murphy
easily extracted a six-pound child by forceps. With
the first'attempt at expression the placenta was forcibly
expelled, and was followed by about a quart of dark,
old-looking dot.

The patient rallied well from the ether, and sabse-
quently made a rapid oonvalescenoe.

Digitized by

Google

Vol. CXXX. No. 12.] BOSTON MEDIOAL AND SUROWAL JOURNAL.

286

Though forceps are not strictly applicable to much
macerated heads, they were nsed here, on the ground
of my belief that the extraction would be easy, and
that the head was sufficiently firm to offer a secure
grasp, a belief which was justified by the result. I
think it probable that the blood was extravasated
behind the placenta on the evening of the 29 th, at the
time of the sudden rise of pulse. The foetal heart had
not been listened for at that time, and it is impossible,
of course, to state that the death of the child was due
to the haemorrhage and the consequent detachment of
the placenta; but as the mother had felt active move-
ments shortly before that time, and as some previous
experiences lead me to believe that maceration may be-
come well advanced in a period of forty-eight hours in
atero after the death of the child, I am inclined to
believe that the hiumorrhage was the cause of the
festal death in this case. It is an interesting question
whether the apparent jaundice could be haematopoietic
and due to the haemorrhage. The case is, at all events,
well worthy of record from its extreme rarity.

INTESTINAL ANASTOMOSIS (WITH SENN'S
PLATES) FOB CANCEROUS OBSTRUCTION.

BT J. W. BUJOT, If Jk.

Thk patient was a feeble man, sixty years old. In
August he had an attack of vomiting and diarrhcea.
In September he began to lose his strength and to
have attacks of dizziness. He also had a serious stop-
page of the bowels, with pain on the right side, which
was relieved by castor oil. He soon found that solid
food gave him colic, he therefore took only liquids. In
October be had more pain on the right side of the abdo-
men, and the movements became more diflScult. Then
the abdomen began to swell.

In November all his troubles became worse; he eat
leas, and had more pain. He then entered the Massa-
chnsetta General Hospital. There he vomited for
four days, eat nothing, and was kept alive by nutri-
tive enemata. He improved somewhat in his general
condition, but had absolutely no movements of the
bowels. No tumor could be felt.

Operation. — On December 15th the abdomen was
opened, and the bowel was found to be oompletely ob-
structed by a cancerous mass in the ceecum. An anas-
tomosis was then made, with Senn's plates, between
the colon and the ileum. The operation did not take
more than fifteen or twenty minutes; the patient,
feeble as he was, had little or no shock. He made a
rapid recovery. His bowels moved in twenty-four
boors, and he took solid food on the fourth day.

It is now nearly three months since the operation.
He has free and natural movements of the bowels,
and has gained twenty-two pounds. He has no pain,
and feels perfectly well. The growth has increased in
size, and can be plainly felt in the abdomen. I should
advise its removal if be were a stronger man.

I consider intestinal anastomosis one of the greatest
advances in surgery ; and it is diflScult to understand
why this very valuable operation has not yet been
taken np in Boston, Dr. Homans's case being the only
one on record. The operation is very quickly %nd
easfly done ; and Dr. Seun deserves great credit for
perfecting the technique. The advantages to the pa-
tient of an intestinal anastomosis over an artificial
anas are enormous.

O^ctncai l^ofrre^^.

RECENT PROGRESS IN THORACIC DISEASE.

BT QBORSB O. BBABS, K.D.

TUBERCULOSIS AS A CAUSE OF PLEURITIC ADHE-
SIONS.*

ScBLEUBEB gives the results obtained from 106 au-
topsies, but 21 of which showed no pleural adhesions.
Among the remaining 85 the adhesions could be attrib-
uted in a number of cases to affections of the lungs
other than tuberculosis, or to cardiac disease. Leav-
ing these cases out of consideration, there remained
57, in 33, or 57.9 per cent., of which the adhesions,
from the macroscopic examination, could be referred in
all probability to a tuberculous cause. Scbleuber is of
the opinion that these figures would have been increased
rather than diminished by the use of the microscope.

PECULIAR ODOR OF THE BBBATH OF TUBBROULODB

PATIENTS.*

Rosenbach calls attention to a peculiarity of the
breath of tuberculous patients, slightly resembling that
of mild cases of putrid bronchitis, but differing fram it
in having a disagreeably sweet quality. It may become
apparent in the neighborhood of the patient even in
the absence of expectoration. It adheres to expecto-
rated matter but feebly, being probably dependent on
some volatile substances. It is only present in the ex-
haled air, and thus becomes most evident when the pa-
tient coughs or breaths with open mouth. It is a sign
of unfavorable prognostic significance, even though
the other manifestations in the case appear favorable.
It is often present when the destructive process is not
marked, and is most noticeable when the physical signs
are unobtrusive. It is almost always an associated
manifestation of disseminated broncho-pneumonic oon-
solidation. It is wanting in oases of extensive infiltra-
tion, when cavities have formed and also when the
sputum is copious. In a large number of cases in
which this symptom was observed btemoptysis occurred.
Night-sweats, anorexia and febrile exacerbations were
also frequently noted. The phenomenon is of diagnos-
tic significance as it early indicates the occurrence of a
morbid process in the lungs, and should therefore be
sought for iu all doubtful cases. To insure against a
possible source of error the mouth and teeth of the pa-
tient should be first thoroughly cleansed.

THE DISINFECTION OF TUBERCULOUSLT-INFECTED
HOUSES.*

Delepine and Bansome give the result of their ef-
forts to disinfect rooms in which a phthisical patient
has lived by chlorine, or more correctly euchlorine.
Pieces of paper were carefully sterilized in glass cap-
sules, and then infected with tuberculous materiid,
either sputum or pure cultivations of the bacillus
(human in most cases, avian in a few). The capsules
were sealed, the sputum or cultivation being allowed
to dry on the paper, and were not opened until just
before the acid was poured on the chlorate of potash,
and were again sealed when the room was reopened.
Rabbits and guinea-pigs were then inoculated with
small pieces of infect^ paper or superficial scrapings

< Aroh. f. path. Anst., Ma., Bd. IM. Heft i.

• Wien. Med. ProM, IMS, No. 28; Ameriosn Joarnal Madlml Sol-
enocs, Oetobar, 1SS8.
> British Medleal Jonmsl, Novamber 4, 1818.

Digitized by

Google

286

BOSTOS MBDICAL ASD SUBGICAL JOVBAJL

[Mabcb 22, 1894.

mixed with sterilised bonillon. In nine experiments
made with three different liiuds of spatom the results
were nnsatisfactory ; in some cases complete disinfec-
tion seems to have been obtained, bat the control ex-
periments showed that some sputa were not as virulent
as others. In six experiments made with pure cuit-
nres of the bacilli of human taberculosis distinct evi-
dences of the disease were observed within three or
four weeks after inoculation. They therefore con-
clude that this method of disinfection, as well as that
with sulphurous acid, which tbej have also investigated,
is ineffectual. From some laboratory experiments
with an old method of disinfection (not given) they
hope before long to give practical means of effectually
disinfecting places that have been contaminated with
tuberculous products.

CONSUMPTION HOSPITALS AND TDBBBOULOOS DUST.

The Bnti$k MtdiealJoumal (September 16, 1898)
says that " the steady drift of opinion, especially among
the yonnger of our physicians, in favor of the infections
nature of tuberculous phthisis has led us to make some
inquiry at the hospitals especially devoted to the treat-
ment of consumption as to the nature and extent of
the preoantioDs which they have thought well to take,
or the warnings which they have thought it desirable
to give to their patients, with the object of preventing
or limiting the spread of the disease." The methods
adopted by the various hospitals are severally reported,
but are too long for reproduction here. They anite in
stating that the chief way in which the infections ma-
terial enters is with the inspired air in the form of
dust, and are strenuous in their efforts to keep the
sputum wet nntil it is removed, some antiseptic, usu-
ally carbolic acid or occasionally a solution of caustic
soda if the expectoration is very adhesive, being nsed
in the cups. The stools are also quite generally disin-
fected. They are much less united in their treatment
of the handkerchiefs, which by some authorities are
prohibited altogether, while by others they are allowed,
even though the danger caused by them is admitted.
No precautions are generally taken regarding the
soiled clothes ; though in one care ia taken that the
dirty linen nsed by the oflSoers, nurses, etc., is not sent
to the same laundry as that of the patients, " an ar-
rangement probably more satisfactory to the officers
than to the general public." They are equally illogical
in their dealings with the general dust of the institu-
tions, which is removed by dry cloths and brooms, reli-
ance being chiefly placed in an abundance of fresh air
for rendering it innocuous. The journal mentions with
approval the position taken by some.of the provincial
authorities, the Lancashire people, for example, not
being content with the expression of a pious opinion on
the subject, but print and distribute warnings, and in
some places receive an informal notification of cases
of tuberculosis, and even go to the expense of free
disinfection of houses where consumptives dwell.

TDBKRCULOSIS OF THE BKONCHIAL QLAND8 AND ITS
RELATION TO THE TCBERCDLOaiS OP CHILDHOOD.*

Nenmann sums up an interesting paper on this sub-
ject as follows :

Tuberculous infection in children is usually at first
localised in the bronchial lymph glands. It is very
common in the first years of life, and results from in-
halation of the infectious material. This method of
< Deat. Mad. Wooh.. INK, Mo*. S-IT.

infection may be prevented by proper hygienic regnla-
tions, which, though at times difficult to obtain in
private practice, should be demanded in all public in-
stitutions. From the bronchial glands infection either
rapidly spreads through well-known anatomical paths
or it remains latent for an indefinite period, until
its activity is finally excited by some condition (catarrh
or inflammation of the respiratory tract) in which the
glands are secondarily affected. At times, however, it
may remain permanently latent or cure result from
calcification. Diagnosis is only possible in advanced
cases, and only then when the condition of the gland
is not masked by affections of other organs. So long
as they are simply tuberculous, but not enlarged or
adherent to neighboring organs, they give rise to no
signs or symptoms, while, on the other hand, the
process which started from them may have prodaoed
such marked pathological changes in their neighbor-
hood as to conceal the original trouble. Even when
an autopsy has shown that diagnosis was possible, it
has not always been made ; nevertheless, cases compar-
atively frequently appear where a consideration of the
possibility of an earlier infection (heredity, mewles,
etc.), combined with the rational and physical signs,
makes their presence mor« or less probable. Especial
weight is to be laid on the presence of a peculiar ooogh
resembling pertussis in its paroxysmal character, and
the presence of a very loud, indeterminate, though
usually bronchial, respiratory murmur in the neighbor-
hood of the upper thoracic vertebrsa. The difficulty
in diagnosis is well illustrated by a case reported by
Stoll,* occurring in a girl ten years old, in which the
symptoms were so obscure that it was impossible to
determine the seat of the disease until the autopsy,
which showed a perforation of the trachea on a level
with its bifurcation, through which a gland about the
sise of a walnut emptied itself. Beneath this large one
were several others with softened centres. The trachea
itself was obstmcted by a plug of pus, situated above
the perforation, which filled up the whole lumen and
was probably the immediate caase of death.

OUBB OF ■MPTBHA.*

Anfrecbt describes his progress throagh the various
methods which have been devised for the treatment of
empyema. After an experience with four cases be
discarded aspiration as a means of cure, and practised
incision and drainage, but has now reached the conclu-
sion that resection of a rib is by far the most satisfac-
tory proceeding, as it obviates the danger of hasmor-
rhage, allows free exit for masses of fibrin and prevents
the too rapid closure of the opening, which by the
simpler method could sometimes be kept open only by
a silver tube. He selects a rib near the angle of the
scapula, unless contraindicated by pleural adhesions or
by the very weak condition of the patient. In the
latter case be chooses the axillary line, as there is mach
less chance of death during the operation if the dorsal
position be maintained. Reside the preliminary punct-
ure to ascertain the presence of pus, he is accustomed
to make a second after resection through the free
pleura. He recommends at first daily irrigation. Cure
results from the fact that with each inspiration the
lung collapsed by the operation must dilate if the size
of the opening in the chest-wall is smaller than that of
the primary bronchus leading to the part. In addidon,

• CentnUbUt t. kiln. Med., ISM, No. S.

• Dent. Atoh. (. kiln. M«d., Bd. 111. Haft I and 2.

Digitized by

Google

Vol. CXXX No. 12.J SOSTON H^DIOJl AND SUttGlOAl JOtmNM.

287

however, it is neoeasary that the pleura itself should
be io a oonditioD to allow adheaious to form between
ita two Burfaoes. The slow aabsidence of the pleural
inflammation in aome caaea to the point where thia ia
poaaibla, ezplaina their occasional protracted convalea-
cenoe.

LBUOOCTTOSIS IN OBODPOU8 PMKVMONIA.^

Laehr reporta aixteen very carefully atudied oases
of pneumonia in reference to the relationahip of the
leaoocytosia present in them to the temperature, amount
of infiltration and the severity of the infection, aa well
as in ita aignificance in diagnosis, prognosis and treat-
menL The cases showed a marked correspondence
between the height of the fever and that of the lenoo-
cytoaia, in that they rose and fell together, but the
correspondence did not go so far aa to show that the
greatest number of leucocytes was always associated
with the highest temperatures. A certain parallelism
was also observed between the former and the amount
of iuflltratioD, bat that other factors were present is
ihowB by two eases, both powerfully built men, in one
of whom the whole right laug was afiFected and yet the
leocoeytes numbered only 10,000 to 14,000, while iu
the other, though but one lower lobe was attacked,
91,000 were counted. This dissimilarity Laehr ac-
oouDts for by the individual peculiarity of the patient
and the force of the infection. Regarding diagnosis,
a blood-count may prove of great value in distiDgnisb-
ing early cases of pneumonia from typhoid, meningitis,
iniuensa and probably miliary tuberculosis, in which
litde or no increaae of the white elements has been
found. In prognoaia it may with probable safety be
•aid that if the number of leucocytes does not diminish
with the bll of temperature that the process has not
oome to an end, or if it sinks with the temperature to
normal, but risea by several thousand later, a recrudes-
cence of fever, or the appearance of some complication,
uwy be confidently looked for. In the most severe
eases his experience is in accord with that of Hailer,
Rieder and von Jaksch, in that either no leucocytosis
was observed or else a very slight increase.

Whether these observations will prove of value in
indicating a method of treatment, such as the admin-
istration of drugs like jaborandi, antipyrin, anti-
febrin or nuclein, which are said to increase the number
of white corpuscles, aa recommended by von Jakach, ia
yet to be proved, aa it is not yet known how far an
inflammatory leucocytosis is protective against disease
germs, mnch less then an artificially produced one. The
nsefulneas of cold baths in pneumonia receives support
in this respect from Winternitc, who claims that they
too increase their number.

OIOISION AND DBAINAGB IN PZOPBBICABDIUlf.'

Sievera gives the histories of the eleven cases of
purulent pericarditis treated by incision and drainage,
which have been previously reported, and adds one of
his own occurring in a woman twenty-two years old,
who died thirteen days after operation.

He draws the following conclusions :

(1) That the operation is a proper one, that it pro-
dnees no disturbance of the heart's action and offers
the only chance of cure.

(S) That in many cases it may lead to full recovery
(five cases out of twelve), and that in complicated

' Bnl. Uln. Woeh.. ISSS. No*. 3S ami ST.

• ZeitMhif. Uln. Had., USS, Bd. xzUl, p. M.

pymmic conditions it may at least better the condition
of the patient or prolong his life.

(3) That the incision is best made in the fourth or
fifth interspace, a few centimetres to left of sternum,
and drainage introduced, but irrigation should be
omitted.

0T8TIG DBOENBBATION OF THE MU8CULAB FIBBB8
OP TBB BEABT.*

Meigs describes a form of myocardial degeneration
in which " the destructive process, in its most extreme
form of development, removes the whole of the muscu-
lar substance from the centre of the fibre, no part of
which, when examined by the microscope, will preaent
the uaual appearance of muscular tissue except the
thin outer walls, and even these may show only in
places the cross-markings characteristic of heart
muscle." The muscle nuclei often lie loosely in the
cavities without attachment to the remaining tissue.
The hollowing-out, when most extreme, is apt to be
near the ends of the fibres toward their point of origin
or insertion, but will be unmistakable iu all parts of
the heart. " The fact that the muscular fibres of the
heart are penetrated by capillaries and are not, there-
fore, truly solid bodies, together with the appearance
of these spaces, leads to the almost inevitable conclusion
that the process is one of cystic degeneration," a
capillary becoming blocked in two places, the portion
between them dilating and thus forming a cyst. The
assumption that they are minute aueurisma ia negatived
by the nature of the material lying within the cavitiea,
which ia amorphoua and granular or conaiating of
yellowiah pigment in irregularly-shaped flakes. It is
impossible at present to predict from clinical mani-
festations which cases will present this curious change,
as it was absent in oases of brain syphilis, sarcoma, gen-
eral miliary tuberculosis, Bright's disease, pulmonary
phthisis, typhoid fever, pneumonia, dysentery, epith^
lioma of the bowel and aneurism, and present in what
was clinically recognized as organic heart disease,
Bright's disease, typhoid fever, ulcerative endocarditis
and in young infants that died of wasting.

BBADYOABDIA DDBINO OONYALESCBNCB.**

In speaking of the slow pulse (60 or less) which is
sometimes met during convalescence from acute
diseases Dehio says that we have little positive
knowledge of the cause of its appearance or the ana-
tomical changes which accompany it. With the estab-
liahment of convalescence the pulse falls with the
temperature, but the fall continues below the normal
rate until its beats number only sixty a minute or even
decidedly less. This condition in mild cases lasts but
a few days to a week, and, with this exception, the pa-
tient presents no noteworthy symptoms. The heart
seems normal though the apex beat is weak, the pulse
is easily compressed and often dicrotic, at times, also,
slightly irregular. In the severe forms, however, the
patient shows signs of great prostration, the lateral
area of the heart's 'dulness is increased, its action is
irregular and intermittent, and a systolic murmur is
heard over the left ventricle. In order to determine
whether this resulted from some change in the heart
itself or was of oeutral origin, Dehio injected hypo-
dermically one-sixtieth to one-thirtieth of a grain of
atropine, which has the power <rf paralysing the cardiae

> TnnuotlOD* Oollase of PbnloUos, Philadelphia, 3 s., ToL ziv.
» Deut. Anh. t. kiln. Had., Bd. Ul, Heft 1 and i.

Digitized by

Google

288

BOSTON MEDICAL ASD SVBGWAL JOORBAL. [Misoh 22, 1894

terminatioiiB of the ragna nerve. In a mild case he
found that the number of beat* was increated to the
same degree as under normal circumstances, while in
the more severe forms this iocrease was much leas
marked. He, therefore, concludes that the cause ia to
be found in the heart itself and not in some change in
the nervous mechanism, such as an increased irritabil-
ity of the vagus or an atonic condition of the medullary
centre of the accelerator sympathetic fibres, and is,
therefore, an evidence of cardiac weakness, and of the
same import as other symptoms (intercurrent attacks
of rapid pulse, irregularity, palpitation) of this condi-
tion, many of which were present in his cases. The
occurrence of this symptom is comparatively rare as
he only met with eight cases in his hospital clinic dur-
ing the past semester. He suggests the probability of
its being due to the toxic action of some specific ma-
terial produced in the organism during the course of
an infectious disease which causes no anatomical
change in the heart, but considers it probable that an
individual predisposition also exists, otherwise it would
be difiicult to explain Why it was not present in all
convalescent patients and why it was not more com-
mon after severe infectious cases than after mild ones.

THB 80HOTT MSTBOD OF TRBATINO OBBOMIO BRA&T
DIBBA8E."

Babcock, who has had a personal experience as a
patient, gives a brief aoooant of the so-called Schott
Method. In theory, it is the same as that of Oertel,
the production of cardiac hypertrophy through increase
of its physiological function, but can be much more
generally applied, as it is contraindicated only in aneu-
rism of the heart or large vessels, or in advanced
arterio-sclerosis. Nevertheless, as the powerful stimula-
tion produced by the baths is capable of doing great
harm, care and experience are necessary in its em-
ployment.

The method consists in the administration of warm
baths, either simple saline, or containing a large per-
centage of carbonic-acid gas, the amount of the saline
constituents and the carbonic acid being gradually in-
creased as the patient becomes aocostomed to them.
The temperature varies between 92° and 86° F., and
the duration from five to twenty-five minutes, being
short at first, and gradually lengthened. The baths
are occasionally omitted for a day. The patient ia
under general hygienic and dietetic restraints, and, in
connection with the baths, gymnastic exercises, .con-
sisting of resisted movements of the extremities and
body, are given by, preferably, a trained assistant A
single movement should not be immediately repeated,
and each one should be followed by a short period of
repose, and should not be made in such a way as to
cause acceleration of the pulse or respirations.

As a result of the baths there is a slowing of the
pulse and an increase in volume and strength, while
its irregularity lessens, or even disappears. The in-
creased vigor of the cardiac contraction permits a posi-
tive diminution in the siee of a dilated heart, which
can be demonstrated by accurate percussion practised
before and after a bath. Among other effects is a
sense of well-being, particularly of ease and lightness
in the chest, relief of dyspnoea and increased diuresis.
The effect of the gymnastics is similar to that of the
baths on the pulse and heart, but the favorable effects
are less lasting.
It joniDftl Ameriean Medieal AnoeistiOD, MoremlMr II, 1893.

Fonctional as well as organic disorders, are strik-
ingly benefited, Schott claiming highly satis&ctory
results in cases of exophthalmic goitre. Althoagh
Schott's results are obtained by the natural waters of
Bad Nauheim, there seems no reason why artificially-
prepared waters should not prove eflScacioua.

FUNCTIONAL INBCFFIOIItNOr OF THB VALVES OF TH8
LEFT HEART.**

Dombrowski, in commenting on the usual expUnation
given for inorganic insuificiencv of the mitral valve,
that it results from distention of the orifice, the flaps
being unable to completely close it, says that such
dilatation is by no means invariably found, and, be-
aidea, the orifice is surrounded by a tendinous ring
whose resistance is not easy to overcome, aa be
has proved by several experiments. He removed
the heart from the cadaver, ligatured the aorta, and
then, through an opening made at the apex, forced in
water under strong pressure, in spite of which the
valve allowed no leakage. Only when the cardiac
dilatation became very considerable did the valve prove
insuificient, and even then the orifice preserveid its
normal dimenaions. Moreover, Wnlf has shown that
the surface of the fiaps greatly exceeds the size of die
orifice, while Kirschner and Grarcin claim that the
aortic half alone suffices to cover it, even when consid-
erably dilated. Clinical experience is also opposed to
the view usually held ; for the transitory character of
the insufficiency — as shown by the behavior of the
murmur, which disappears, and then, perhaps, reap-
pears after a certain time — does not accord with a
distention of the orifice. The cause of the insufficiency
must, therefore, be sought in the muscular dilatation
producing a separation of the insertions of the papil-
lary muscles, which in systole cannot approach each
other near enough to allow the valves to close, the con-
traction of the papillary muscles only increasing the
difficulty. He would, therefore, prefer the term " func-
tional " to that of " relative insufficiency."

The aortic valve is no exception to the general rule
that all the valves of the heart may become insufficient,
but it seems to be a rare event, as he has been able to
find but a few cases reported in literature. He adds two
others proved by autopsy from his own experience.

In contrast to the functional insufficiency of the
mitral valves, that of the aortic is always relative, and
depends on a dilatation of the aorta, resulting from
increased blood-pressure followed by atheromatous
changes in the artery. It is a terminal symptom,
the precursor of death, and its recognition clinically is,
consequently, of considerable importance. It is not
always possible to distinguish it from a true aortic
lesion but in the differential diagnosis stress should
be laid on the age of the patient (it never occurs
under fifty), the signs of general atheromatous changes,
its slow and insidious development with probably a
long history of symptoms of increased blood-pressure,
oppresaion, palpitation and vertigo, to which should
be added the signs characteristic of dilatation of the
aorta, pulsation in the neck, dulness under the ,
manubrium, and the metallic quality of the second car-
diac sound.

A Stbono Mam, on exhibition in London, lifts two
horses with their riders at the same time, the total
weight being about four thousand pounds.

u B«T. d* MM., Beptemlwr 10, 1888.

Digitized by

Google

Voi„ CXXX, No. 12.] BOSTON MBDIOAL ASD 8UBOIOAL JOVBSAL.

289

lUpoct^ of ^ocietiej^.

THE OBSTETRICAL SOCIETY OF BOSTON.

CBABLBB W. TOWHaniD, II.D., ■BOUTABT.

TaiRTT THIRD ANNUAL MxETiNO, January 13,
1894, the President, Dr. Chaslks M. Grkbn, in the
chair. *'

Ds. W. L. BuRRAOB read by invitation a paper on

TBRKE tears' KXPKRIKNCB WITH KLKOTBICAL
TREATMENT OP PIBROID TUMORS OF THE UTERUS,
WITH A REPORT OP POBTY-POUK OASES,

of which the followiag is an abstract :

In the three years from October 18, 1890, to Octo-
ber 18, 1893, be had seen, in hospital and private
practice, 98 cases of libroids; 44. of these had been
treated with electricity after the method of Apostoli,
and had received at least six treatments each. Apostoli
bad been followed rigidly, and the cases had been kept
onder personal observation for as long a time as possi-
ble, iu order to arrive at accurate oonclosions as to
permanent results. The records of the 44 cases were
presented to the Society in tabular form. All eases
of doubtful diagnosis had been excluded from the
tables, and a majority of the whole number had been
subjected to an ether examination. For details of
treatment the members were referred to a previous
paper on technique by Dr. Barrage, published in the
Boston Medical and Surgical Jaumol for November
26, 1891. Most careful measurements of abdominal
girth and uterine depth were taken with the same steel
tape in every case.

It is impossible to take absolute measurements of
the sise of fibroids, owing to the varying condition of
emptiness or fulness of the intestines, bladder and
rectum, the changing thickness of the fat of the parietal
walls and omentum, and the changing shape of the
tumor. Fibroids vary in size even from day to day,
owing to temporary engorgement or depletion. It is
a well-known fact that they are smaller just after the
catameoia and larger before and during. The relative
sise must be determined by tactile sense and by re-
peated examinations (an ansesthetic is an advantage)
under as nearly similar conditions as possible.

Tonics and other forms of treatment were studiously
avoided, so that the results might be fairly attributed
to electricity.

Thirty-five of the cases are analyzed with re-
ference to anatomical results. Each had at least six
treatments with galvanism, either intra-nterine or by
puncture, and with intensities rising fifty milliamp^res,
and, in addition, had been under observation for at
least four months from the beginning of electrical treat-
ment, a majority from one and one-half to two years.
The entire 44 cases are later analysed as to sympto-
matic results.

First, as to anatomical results, the effect of electric-
ity on the size of fibroids :

Of 85 cases, 9 (25.7 per cent.) showed a decrease in
size at the end of periods varying from one to eight
months from the beginning of treatment ; but in six
of these nine, at the end of periods of time varying
from one to two and one-half years, the tumor was as
large as at the beginning or larger. The other three
were lost sight of, one in four and the other two in
eight months. The tables famished no positive evi-
dence that any of the tumors were permanently lessened

in size as a result of electrical treatment. Seven cases
out of 86 (20 per cent.) were somewhat larger at the
end of one and one-half to two and one-half years.
Deducting from 85 these 7 cases, and the 3 in which
the tumor was smaller when the patient was lost sight
of, and we have 25 as the number of cases in which
the tumor remained of the same size, or 71 per cent.
The writer had failed to observe rapid disappearance
of fibroids, but had noticed marked decrease in the size
of separate nodules following puncture. Electricity
clears up pelvic inflammation ; a fibroid previously
fixed becomes movable ; a mass made up of exudate
and ovary and tube disappears under treatment. The
fat in the abdominal wall is increased in thickness.
Measnrements of uterine depth are not materially af-
fected. Intra-nterine applications of galvanism have
a temporary carative effect on the endometritis of
fibroids, but not a permanent effect, the endometritis
returning after several months, just as it does in most
oases after curetting.

A case illustrative of the above was that of a patient
treated with intra-uterine galvanism for three months,
eleven treatments, 40°-70°. On doing a hysterectomy,
a year later, the uterine cavity was found lined with
soft, velvety tissue easily scraped off a glistening white
base.

Cervical stenosis following high intensities occurred
in a certain proportion of the cases. It is to be guarded
against by beginning treatment with the tip of the
electrode, as near the fundus uteri as possible. Steno-
sis prevents subsequent treatment with larger electrodes.
It has not caused dysmenorrboea.

Second, the symptomatic results. The thirty-five
cases are classified under four heads :

1. Those that were relieved of pain permanently.

IL Those that were relieved of flowing permanently.

III. Those in whom there was permanent improve-
ment of general strength and ability to work.

IV. Those that experienced no permanent benefit.
Of I, there were 11 cases out of 19, in which pain

was a prominent symptom, or 60 per cent.; of II,
there were 7 cases out of 23 cases, in which flowing
was a prominent symptom, or 30 per cent. ; of III,
there were 21 cases out of 25, where relief was possi-
ble, or 84 per cent. ; of IV, there were 8 cases, or 23
per cent. Adding together I, II and III, and sub-
tracting 12 for the cases inserted jnore than once, and
the result is 27, the number of cases that received
permanent symptomatic benefit, or 77 per cent. An
analysis of the entire 44 cases with reference to tem-
porary symptomatic relief g^ves 84 per cent, as ben-
efited by electrical treatment. The figures make a
very satisfactory showing when it is taken into accoant
that the cases were treated for the most part in an out-
patient clinic ; that many of them, preferably treated
at their houses, were obliged to travel long distances
and wait their turn for treatment, and then go home
often after a tedious ride in the cars and in inclement
weather.

As to particular symptoms, electricity had no effect
on a watery lencorrhoea in two cases. In two patients,
it cured the uterine cough spoken of by French writers.

Summing up, we may say, that, on the whole, the
anatomical results were unsatisfactory. Assuming
that fibroids, if untreated, have a tendency to increase
in size, we are justified in the conclusion that galvan-
ism has an inhibitory effect on a majority of these
tamon ; 71 per cent, of the tabulated oases remained

Digitized by

Google

290

BOSTON MEDICAL AND SCEGICAL JOURNAL.

[Mabok 22, 1894.

Btatiooarj. Until we know more of the oopditions
thkt favor increase or diminution in their me, the
laws of their pathological growth, we cannot say more.
The symptomatic results, on the other hand, present a
highly satisfactory showing, 77 per cent, being perma>
nently oared. The low percentage of cures of hssmor-
rhage is to be attributed to the distorted shape of many
of the tumors, making thorough intra^uterine treat'
ment impossible, and to the fact that endometritis, the
source of the hemorrhage, will return if the cause is
still present, whether the treatment has been by caus-
tics, carbolic acid, etc., by cnrettement, or by positive
intra-uterine galvanism. Intra-uterine galvaniam for
haemorrhage has the advantage over cnrettement and
the application of caustics, that it does not necessitate
the administration of an anesthetic with its attendant
discomforts and risks, and is followed by no reaction.
It is preferable to ergot and bydrastis, as it has a tonie
instead of a depressing influence on the digestion, and
its eSect is more durable. Gralvanism often sacoeeds
where ergot and hydrastis have failed.

As regards the alleged danger of electrical treatment,
it must be conclnded that, if properly applied, it is
without danger. It is oontraindioated in pr^nancy
and acute inflammation, and that is all. An illustra-
tive case of acute salpingitis confirmed by coeliotomy is
<Ated. That galvanism causes abscesses and adhesions
the writer believes to be false. Cases of pus-tabes
treated for months with galvanism, with no change in
symptoms and verified by subsequent abdominal sec-
tion, are referred to ; also cases treated with galvan-
ism, intra-uterine, vaginal and by abdominal puncture,
in whom, on opening the abdomen, no adhesions were
found. Sensitiveness to galvanism has not been an
indication of the presence of pus, although considered
so by Apostoli.

a!b to puncture, the writer advocates vaginal punct-
ure, bat thinks this in many instanoes contraindicated,
beoause of the likelihood of wounding the ureters,
bladder aad rectum. Intra-uterine treatment is to be
preferred. AH treatment should be begun gradually
and with vaginal application, because intra-uterine and
puncture treatments are more or less painful, and our
women are not as phlegmatic and insensitive as the
women who attend the foreign clinics. Faradism from
the coil of fine wire is of great service in relieving the
pain caused by high intensities of galvanism.

The results obtained in the cases included in the
third classification — those permanently improved in
general health and rendered better able to work — are
extremely satisfactory, and alone justify the time and
labor necessary for the proper application of electricity.
The results are oat of all proportion to those obtained
from general electrization, and besides, it is more ra-
tional to apply the electricity as near the seat of dis-
ease M possible. The writer believes that fibroid
tumors are not the harmless tumors they have been
thought to be ; although they seldom kill quickly, they
wear out slowly, and many a woman leads a life of
misery and suffering because the profession has be-
lieved and advised that nothing but hysterectomy could
relieve.

As we learn more and more about these tumors, and
appreciate better the symptoms to which they give rise,
their laws of growth, the danger to the economy from
long-continued pressure, and, as the technique of hy-
sterectomy is improved, the speed in operating increased,
and the mortality lowered, it is the writer's opinion

that total removal will be practised of tener and oftener
and earlier and earlier in the life-history of fibroids.
When such a radical measure is ineicpedient, and it
always will be in a certain proportion of cases, our
duty is plain, we must relieve suffering. Electricity,
on account of its safety, on account of its proved ability
to relieve hnmorrhage and pain, and on account of its
surety to improve the general health and strength, is
the best means at our oommand with which to treat
this distressing condition.

Conelution*. — (1) Hysterectomy is contraindicated
in a majority of oases of fibroids, because of the high
rate of mortality, and because it uusexes the patient,
an important consideration in younger women.

(i) Electricity is the best therapeutic means at onr
disposal to combat pain, haemorrhage, and impaired
health and strength.,

(3) Intra-uterine galvanism is most useful.

(4) We must not look for a permanent reduction in
the size of the tumor.

(5) Galvanism, vaginal, intra-uterine, or by punct-
ure, does not cause alMcesses or adhesions.

(6) Galvanism is of no use as a means of diagnosing
the presence of pus.

(7) Treatment by electricity, after the Apostoli
method, is absolutely safe.

(8) Every case of fibroid tumor of the uterus should
be under competent medical observation, beoause of the
danger of malignant degeneration, kidney disease from
pressure, complications daring pregnancy, and the lia-
bility of the occurrence of pain and hasmorrbage and
functional nervous disorders, especially during a de-
layed and protracted menopause.

Dk. G. H. Washbdrn said he had watched a num-
ber of the cases reported by Dr. Barrage, and had him-
self treated a number of other cases. He recalled one
case where a rapidly growing fibroid diminished rapidly
after the second treatment by electricity. The first
application had no effect except to make the patient
more comfortable. After the second application there
was a diminution in size, of one-third or one-half. This
was the only case where he saw such marked diminu-
tion. In another case there was some dinaination in
size after six months' treatment. The results in other
respecu were most satisfactory. He would agree most
thoroughly with Dr. Burrage's oonclnsions, that as oar
ability to operate on these cases increases so would
the number of operations; and the careful statistics
of Dr. Burrage shows us the scope of electricity, and
that it is of great value within certain limits.

Db. M. H. Hichabdson said that he had had no
personal experience in the electrical treatment of fibroid
tumors, for this was a branch of medicine in which he
preferred to send his cases to the medical electrician.
Patients had frequently come to him in whom the
symptoms were so severe that the tumor could be re-
moved only with the greatest danger. In such casM
tiM patient's strength is so reduMd by hnmorrhage
and long suffering that the formidable manipulations
of a hysterectomy are almost surely fatal. To leave
the tumor untouched, however, means gradually increas<-
ing weakness, suffering and death. When the brilliant
results of (he electrical treatment of fibroids were firat
published, a safe middle course seemed at hand, by
which the strength of the patient might be increased
enough to enable her to undergo with comparative
safety the radical operation, — even if we made allow-
ances foiT the usual exaggerations of the merits ef new

Digitized by

Google

»x.. GXXX, No. 12.] BOSTON MBDIOAL AND 8UB6J0AL JOURNAL.

291

afchoda of treatment. While the brilliant results
|>RK this method of treatment which were at first pub-
. ?^ bave not been fully realized, yet the nse of elec-
*<n.t;jr in naany advanced cases has so diminished both
>o psiin and the bsemorrhage that the patients have
»eKk enabled to undergo successfully total extirpation.
r«>iai the standpoint of the operating surgeon a hy-
^^rectomy for fibroids carries a considerable mortality.
^^tha are due, first, to the weakened condition of
^^ p&tient ; and, secondly, to peritonitis from noavoid-
t>le contamination during the operation. With the
MAient in good condition, the results of the operation
'fc^ the present time are very satisfactory indeed. Dr.
Ucbardson's mortality is constantly decreasing, and
rcit he does not expect ever to be able to avoid fatal
"eactlts in this class of cases.

Puncture of the tumor for the application of elec-
irioity the speaker regards as dangerous, because he
haa Been at times excessive haemorrhage from small
perforations of the enormous veins which sometimes
ramify in the capsule of the tumor. He is now more
inclined to advocate the early removal of these tumors
than he was formerly, chiefly beoanse of the vast in-
crease in the dangers which attend advanced cases.
On the other hand, he believes that one may easily go
to the other extreme and become dangerously meddle-
■ome in his efforts. Total extirpation of the uterus
for a fibroid of small dimensions which u causing no
trouble is unjustifiable except in the rarest instances.
£vea if the tumor is of considerable size, so long as it
produces no symptoms except those of weight — so
long as there is no excessive haemorrhage, no pain or
diacomfort, and no evidence of pressure upon the ure-
ters — the operation is unjustifiable, even with the
present excellence of technique. Yet there is one
consideration which mast be borne in mind in advising
agMoat operation in these cases, and that is the possi-
bility of malignant degeneration. This danger is
always present, and is the only good reason for
interference in the class of cases which is r^erred to.
Dr. Richardson has rarely seen a malignant tumor of
the uterus which has resulted from the degeneration
of a fibroid. Certainly there have not been as many
cases of hopeless malignancy as there have been vA. un-
necessary death — if among unnecessary deaths are
included those cases of fibroid which died after an
operation that was not imperative. In his experience
there have been two deaths after the removal of fibroids
in which the symptoms were not distressing. In both,
the operation was undertaken at the urgent solicitation
of the patient for the relief of pain and disability ; in
both, life — endurable though not enjoyable — might
have been prolonged for many years by palliative treat-
ment.

As far as the speaker's observations have gone in
his own practice and in that of his colleagues, the re-
moval of a fibroid tumor of the uterus by hysterectomy
is one of the most formidable of procedures. Even
with the greatest skill and experience in operating, the
mortality is considerable. He would welcome, there-
fore, any method by which either the operation might
be rendered unnecessary, or the patient could be so
improved as to enable her to undergo more safely the
inherent risks of the radical operation.

Db. K J. FosTBB spoke of a case he had seen in
coosnitation, where there were two fibroid tumors of
the uterus, one subperitoneal and one snbmucoid.
These were treated by eleotcic puncture. The sub-

peritoneal tumor disappeared, the other tumor sloughed.
The patient has since become pregnant.

Dr. £dwa.rd Rbtnolds said that his experience
with electricity in other gynsBcoIogical affections ac-
cords with Dr. Barrage, that it is of great value and
as safe as any method of treatment. Its use tends to
a surprising degree to relieve reflex nerve troubles.

Dr. J. W. Elliot believes in very early operation
on fibroids in those cases of rapid growth, with fre-
quent haemorrhage, and debarring the patient from
earning a living. Early operations give a very low
mortality from fibroids. As the passing of a uterine
sound may in careless or unskilled hands cause septi-
caemia, so may and has the application of the electrode.
In specialist's hands, as with Dr. Burrage, this can be
done safely.

Dr. 6. Haven would agree with Dr. Burrage that
an exudate wa^ absorbed by means of the electricity.

Dr. F. H. D&tbmport said that the use of electric-
ity in these oases needs, of course, special apparatus
and much time; and it is a question whether this
method should supersede the other methods we are in
the habit of using. He had for two or three years
been treating fibroids with electricity, and although
he has had good results, he is not sure but that as
good results might be obtained by other methods.
Two series of cases treated in the two ways would be
of great interest.

Dr. Bcrbaob: I should like to ask Dr. Elliot if
the case of peritonitu he has referred to was following
puncture through the vagina or through the abdommal
walls? As I said in my paper, I consider that the
latter procedure involves too much danger to recom-
mend it.

With reference to the danger of sepsis following
intra-uterine treatment, I regard it as trivial. I have
bad no trouble with my cases, nor do I have constitu-
tional disturbances after passing the sound. I attribute
this to painstaking and constant care in cleansing my
electrodes and sounds each time before introducing
them, and also to the fact that it is my habit to either
douche or wipe out the vagina with a strong antiseptic
(corrosive, 1 to 2,000 ; creolin, 1 to 500 ; lysol, one
per cent.) previous to any intra-uterine instrumenta-
tion, whether electrical or otherwise. To this fact,
more than to great gentleness in passing the instru-
ment, I attribute my immunity from septic trouble.
Although the micro-organisms in the vagina are not all
destroyed by the antiseptic, their number is lessened
and their activity diminbhed, and fewer are carried
into the uterine cavity. The antiseptic action of the
positive pole is also a factor in guarding against sepsis.
Apostoli has proved this.

Dr. Davenport has spoken of the good results he
has obtained by the use of methods other than electric-
ity. It seems to me that the profession is in need of
facts and figures liearing on this matter. I, for one,
wish tliat some one, having in view the object of re-
porting results, would follow up for a reasonable length
of time a series of cases treated by these methods, and
also cases not treated at all. The data so gained
would be of the greatest value. Personally, I plac<!
reliance on electricity.

As Dr. Richardson has said, if electricity can be
used in getting patients who are worn out by years of
suffering in proper condition for operation — patients,
who, if operated on at once, are almost sure to die —
it has great value. 1 can assure him that electricity

Digitized by

Google

292

BOSTOS MBDIOAL ASD SVMGJVAL JOVBBAL. [Uabcb 22, 1894

has been many timea so used. It is a means of lower-
ing the mortality of hysterectomy. Maoy patients are
so mach improved after a conrse of electrical treatmeut
that they do not need hysterectomy, whereas others do
not receive permanent benefit. Electricity does no
harm and may do great good.

In treating fibroid tumors, we have to face a com-
plicated and difScnlt problem. It is seldom that we
can say, the first time we see a patient, hysterectomy
or nothing. We must do the best we can to relieve
suffering. Because too much has been claimed for
electricity ia no reason why we should refuse to avail
ourselves of the good that it surely can do.

Db. Eowabd Rktnolds reported

A CA8B OF CONCBALBD ACOIDBNTAL HiBHORKHAOE
DDRINO KIB8T STAGE OF LABOR, WITH BKCOVEBT
or MOTHEB UNDBB CON8EBTATITB TBBATMENT.'

Db. a. Wobcksteb wished to ask whether the
reporter considered the mother's jaundice due to the
absorption of the coloring matter in the blood-clot in
the uterus. He did not see how that was possible.

Db. C. W. Townsend said that in regard to the
rapidity of maceration after the death of the child, he
iukd seen a case of transverse presentation where the
child was alive and where the mother refused to have
any operation done. He saw the case twenty-four
hours later when she was brought to the Lying-in
Hospital. Here, the child was delivered by version
and was not only dead, but the skin was slightly macer-
ated. The speedy maceration here might be doe to
the fact that the membranes had ruptured early.

Db. a. Wobcestbb said be could go even further
than this, for he had once delivered a child whose skin
was macerated that lived.

MASSACHUSETTS MEDICAL SOIETY.
SUFFOLK DISTRICT.
SECTION FOR CLINICAL MEDICINE, PATHOL-
OGY AND HYGIENE.

BBHBT JA.0K8OH, 1I.I>., SBOBBVABT.

Rbodlab Meeting, Wednesday, January 17, 1894,
Db. F. C. Shattdck in the chair.

Db. R. C. Cabot presented a paper on

THE diagnostic AMD PBOGNOSTIC VALCB OF LBCCO-
CIT0S18.*

Db. M. H. Biohardson : I should like to say a
word in regard to the application of this method to
surgical diseases. Dr. Cabot examined the blood in
many of my cases this past summer, and his conclusions
were almost invariably correct. Several of the cases
which he has quoted were in my wards. With one
exception we found pus every time the blood-count
indicated it. Of coarse, in many instances we can tell
well enough whether there is pas present or not with-
out any such investigation ; in other cases we cannot
be sure, especially in the secondary abscesses which
sometimes follow the drainage of appendicitis, in
which one is very unwilling to stir up the abdomen
without good reason. In one case referred to by Dr.
Cabot, in which an appendix was removed at the end
of the attack, there was a small amount of pus. Dr.
Cabot is mistaken in regarding this case as aseptic.
> 8m |M(a 277 of the Journal.

> 8m pag* 284 of the JonnuL

The patient, a young man, had developed very serious
symptoms some time after the appendix had been re-
moved. There was nausea and vomiting, with pain
and tenderness. The pnlse and temperature were
elevated. Yet beyond the probability of pus deeply
seated somewhere, we could form no definite opioion.
Dr. Cabot examined the blood, and found a leooocytosis
that indicated pus. We therefore felt justified in ex-
ploring the wound — an operation which should be
undertaken only when clearly indicated. Dr. Conant
operated for me twice, and the boy recovered. The
amount of pus was very large; it was deeply seated
and gave no physical evidence of its situation. The
only instance in which we were mistaken was a case
of general peritonitis following appendicitis. My diag-
nosis the first day was appendicitis, and I advised
immediate laparotomy. The others thoagbt it was
some acute condition not demanding interference;
moreover. Dr. Cabot found no leucocy tosis. Inasmuch
as he had been invariably correct in previous oases, I
decided not to operate. On the following day, for
other reasons, we opened the abdomen. Dr. Shattack
on that day made the correct diagnosis of appendicitis
with general peritonitb ; I, meantime, changed my
opinion. The patient's abdomen was distended with a
very septic fluid ; there was a gangrenous and pe^
forated appendix, with a general purulent peritonitis.
He died in the course of twenty-four hours.

From the surgical standpoint this subject is a very
promising one. There is a very intimate connection
between a leucocy tosis and the presence of pathogenic
micro-organisms. From the valuable work that Dr.
Cabot has done, the treatment of patients has already
been very materially improved. Farther researches
will undoubtedly give this method of investigation a
still greater value in its practical application.

A question that arises frequently is, whether or not
there is pus in the abdomen or in some of the closed
cavities Iwyond reach. Now. if by sach an examina-
tion as this we can be sure that, for instance, there it
a perforation of the appendix or pus deeply seated in
the abdomen, the vexed question of interference is
decided at once. Moreover, if an expert examination
of the blood is able clearly to demonstrate a condition
of septic absorption ; if, in connection with other
symptoms, it can show unmistakably that there is a
deep-seated focus of pus in the abdomen, in the thorax,
in the head, or in a joint, it seems to me that we have
added to our resources in diagnosis one of the most
important and valuable aids of recent years.

Personally, I feel much indebted to Dr. Cabot for
the work which he has done. .

Dr. F. C. Shattook : I cannot forbear adding a
word in expression of my appreciation of and interest
ill this paper. As I have watched Dr. Cabot's work
in my ward and among my patients, I have learned to
attach much value to this study which seems to me to
promise great things for us in the future when thor-
oughly worked up.

1)k. Mason : The very great interest of this subject
is certainly apparent, and I have listened with great
pleasure to the paper. There are one or two questions
I should like to ask. In speaking of purulent menin-
gitis, I suppose that would include the epidemic cerebro-
spinal form ?

Dr. Cabot : Only two counts were made.

Db. Mason : In that affection thtm is a good deal
of purulent secretion within the head and spinal canal.

Digitized by

Google

7oL. CXXX, No. 12.1 BOSTON MEDICAL AND SURGICAL JOXJBNAL.

293

Cues sre rare with ds now ; eometimes there is diffi-
coltj in determining the diagnosie with accuracy. I
ihould think that blood examination would be very
Taloable. In ooe other affection I lately have been
interested in having the blood counted ; that was in a
case of Graves's disease ; and I should like to ask Dr.
Cabot if, in his researches, he came across any state-
meDt with regard to that affection. Of course, it is
pretty well known that internal abscesses give rise, as
a general thing, to a greater or less degree of leuoocy-
tosis. In one case last year, or the year before, a liver
abscess was explored for two or three times, and
finally found, the blood-count having shown a high
degree of lencocytosis. In the one case of Graves's
disease I have observed there was no increase in the
white elements.

Dk. Cabot: I have counted only one case of
Graves's disease, and in that the blood was normal.
In those about which I have read the blood has been
normal as far as the qoaotitative changes of the red to
white were concerned.

lEtecent Etteratuce.

Handrbooi of Jksanity. For Practitioners and Stu-
dents. By Db. Theodore Kirchhoff, Physician
to the Schlerwig Insane Asylum and privatrdocent at
the University of Kiel. New York: Wm. Wood
& Co. 1893.

Text-books on insanity are often abstruse through
the use of new or unfamiliar terms, technical expres-
sions and complicated classifications, which make them
heavy reading for the student and general practitioner.
When one appears, therefore, that is practical, simple
and concise in statement, well arranged, accurate and
complete in the consideration of the various aspects of
mental disorder likely to interest the general physi-
cian, we have the model book for instruction. Such
is the hand-book before us — a scientific work by an
alienist of ability and experience and powers of obser-
vation and insight of a high order. It is ap-to-date,
clear in style, brief and correct. At the same time,
its 368 pages are more complete in the number of sub-
jects and points considered than any work we call to
mind that is not an elaborate treatise on the disease.
It is also a decided advantage that the space devoted
to each subject is for the most part in direct propor-
tion to its importance. The fact that it contains no
allusion to the jurisprudence of insanity may be ac-
counted for by the class of readers for whom the work
is designed. The author's classification of the forms
of insanity is a brief clinical one, which, if possibly too
umple, has no more flaws than are common to all
attempts to bend partially understood pathological
conditions of the nervous system to a natural system
of nosology.

The numerous illustrations are well executed and
more than usually characteristic of the different forms.
As a rale, there is more than one picture of the same
patient in different aspects or stages of the disorder.
These, with the explanations given in detail of the
caase and import of the expressions and attitudes de-
picted, greatly enhance the value of the text.

To condense from the original so extensively, and
at the same time to preserve and perhaps improve
vpon its simplicity and clearness, slfows no ordinary

skill in translating and book-making. It is indeed
surprising that under the circumstances so few obscuri-
ties have crept in. It is unfortunate that a poor index
should mar, as it does, such a serviceable book.

The publishers contribute generous pages, good
paper and clear type.

Supplemtnt to th« Reftrtnct Hand-book of the Medical
Scieneet. By various writers. Illustrated by
Chromo-Iithographs and fine Wood - engravings.
Edited by Albert H. Book, M.O. Vol. IX.
New York: William Wood & Co. 1898.
The original eight volumes constituting the " Refer-
ence Hand-book " were published between 1885 and
1889. In some departments of medical knowledge —
notably in Pathology, Materia Medica and Therapeu-
tics— there have been very considerable changes in
and additions to our knowledge since then. The pres-
ent supplement was undertaken in order to bring the
hand-book as far as possible np to date without super-
seding the original work. In addition to a revision of
previous articles, some articles on entirely new sub-
jects, not previously discussed, have been incorporated.
This volume contains 1,100 pages. There are 122
contributors. Many of the illustrations are very good.
As a rule, the standard attained in the original vol-
umes has been well maintained. The editor's work
has been done with judgment and discretion.

2%e Theory and Praetiet of Medicine. Prepared for
Students and Practitioners. By Jakes T. Whit-
TAKKR, M.D., LL.D., etc., with a Chromo-litho-
graphic Plate and three hundred Engravings. New
York: William Wood & Co. 1893.
The author of this book is the professor of the sub-
ject about which he writes, in the Medical College
of Ohio. The volume is an octavo of eight hun-
dred pages. The first part is devoted to general dis-
eases, takes up nearly half of the book, and is the
most thorough. The second part is devoted to diseases
of organs. Diseases of the nervous system occupy
three chapters ; and this is perhaps the least satisfac-
tory part of the volume. The illustrations are numer-
ous and of varying merit. The letter-press and paper
are very good. A number of the chapters are oon-
densed or adapted from the anther's previous contribu-
tions to hand-books, systems or text-books of medicine.

Di$eate* of Childhood {Medical). By H. Brtan Don-
kin, M.A., M.D.Oxon., F.R.C.P., East London
Hospital for Children, at Shadwell ; Physician and
Joint Lecturer on Medicine and Clinical Medicine,
Westminster Hospital. New York : William Wood
& Co. 1893.

In his new work on the medical diseases of children
Dr. Doukin has made a most valuable contribution to
our literature. It is in no way a compilation, but is
the result of the author's own clinical observations,
well put together and carefully analyzed. He has in-
deed adhered to his personal experience so closely as
to omit any account of variola and the general subject
of cutaneous affections, with which be says he has had
but little to do. He has, however, in an appendix
given us a summary of the conclusions from the latest
report of the Clinical Society of Loudon, and the in-
cubation and contagious periods of the commoner
infectious diseases, which is an admirable addition.

The fine press-work of this neat volume renders it
all the more attractive.

Digitized by

Google

294

608 f OS MSmOAL ASD SVSmOAL JOCSSAl.

[IfABOH 22, 1894.

THE BOSTON

jiaeDical anD ^utfifcal SouttmL

Thursday, March 22, 1894.

A Jomntal o/MeMeiiu, Surgerr, amd AUied Saiemou,pnbUth«d at
Boibm, tcttklf, &y (Ae tmdenigned.

SUBMRiPTiOK TiBna : 16.00 per gecur, iit advance, pottage paid,
f&rtht UwUtdatalm, Canada and Mexieo; tiMperymrfarmUfar-
fi^ comtitiet telongittf to tlte PoetcU Union,

All communieationM far the Kdttor,a»td all booke for review, ekonid
be addreieedtothe KdUort^the Boelon Medical amd SmrgioalJommal,
283 Watkimgion Street, Botbm.

All lettere eontaininff buiineee eommemiaaUoini, or reftrrlmg to ttte
piMieation, nAteription, or advertieimg dqiartmtent of <Me Jbamai,
tWould be addreeted to tin wndenifnoi.

Bemittameet ekould be made bg montf order, drmfl or rogMorod
letter.pagable to

DAMRKI.T. * UPHAM,
1S8 WAMaaoTOx 8tu>t. Boarov, Mamb.

PROPOSED REDUCTION OF THE ARMY MEDI-
CAL DEPARTMENT.

Thx following are extract* from the draft of »
proposed Army Appropriation Bill for the fiscal year
beginning Jnly 1, 1894, as submitted to the full Com-
mittee on Military Affairs by the Snb-Committee :

" Provided, That hereafter no appointment shall be made
to the office of assistant surgeon-general with the rank of
colonel until the number of such assistant surgeons-general
shall be reduced below four, and thereafter the number of
officers in that grade in the Medical Department shall be
fixed at four ; and no appointments shall be made to the
office of assistant surgeon-general with the rank of lienten-
antpcolonel until the number of such assistant surgeons-gen-
eral shall be reduced below six, and thereafter the number
of officers in that grade in the Medical Department shall be
fixed at six; and no appointments shall be made to the
office of surgeon with rank of major until the number of
such surgeons shall be reduced below thirty, and thereafter
the number of officers in that grade in the Medical Depart-
ment shall be fixed at thirty ; and no appointments shall be
made to the office of assistant surgeon until the number of
assistant surgeons shall be redoced below ninety, and there-
after the number of officers in that grade in the Medical
Department shall be fixed at ninety."

Fortunately the House Military Committee baa lis-
tened to reason, and admitted the weight of argument
against thu proposal, and has abandoned the idea of re-
ducing the number in the upper ranks of the medical
corps ; but it still proposes to cut oS thirty-five assistant
surgeons, bringing these down to ninety. This is by
no means so bad (at least in its immediate action) as
the original bill submitted by Mr. Onthwaite, of Ohio,
Chairman of the Committee, from which we have quoted
above. That bill, had it become law would have
reduced the medical department two colonels, four
lieutenant-colonels, twenty majors, and thirty-five junior
officers; wonld have stopped all promotions and ap-
pointments in the corps for about eight years; and
would have greatly injured the department. The
present modified proposition, however, is bad enough,
and is, from an economical point of view, unwise.

There are now barely enough medical officers to sap
ply Posts, and it is forbidden to employ acting assist-
ant surgeons. Moreover, when a competent physician
has served in the army thirty-two or thirty-three years,
as the ten senior army snrgeona ranking as majors have
done, he ought not only to have the chance to be paid
a lieutenant-colonel's salary, but he also ought to feel
secure in his position.

It is very desirable to have first-rata men in the
army medical corps, men who may be detailed for
important and delicate services ; but to such the corps
is already none too attractive. It now has six vacan-
cies. Under such circumstances that is poor economy
which threatens to lower the standard.

The idea of the promoter of this measure (for we
credit him with some other purpose than simply posing
aa a watch-dog of the treasury) seems to be to retain
merely a skeleton of an army medical corps in times
of peace, and to supplement its deficiencies in time of
war by surgeons drawn from civil life. This would
be very poor eoonomy. The civil surgeon may be
available when wanted; he may know how to ampu-
tate a leg, drees a wound, or extract a bullet as well
as the army surgeon, but he does not know the
routine (call it red tape if you will) of the army ser-
vice and of government bureaus. He does not know
and cannot be expected immediately to know, how
to provide and care for those under him. He is sum-
moned when the emergency is great and immediate
action is required. The hopeless and costly confusion
existing in some of the government pension rolls to-day
is partly due to this very thing. It has cost our tax-
payera millions of dollars, which wonld have paid the
salaries of many medical lieutenant-colonels, majors,
etc., and still left much over to be appropriated in
those forms of gross extravagance, such as river and
harbor bills or sugar bounties, which are less vexing
to the pious souls of Congressmen. There are two
members of Congress from New England upon the
House Military Committee, Mr. Gillett from Spring-
field, Massachnsetts, and Mr. Lapham, from Rhode
Island. We hope they may hear from their constitu-
ents in regard to this proposal. This is a matter in
which the medical profession at large ought to interest
itself.

RECENT INVESTIGATIONS OF THE BRITISH
GOVERNMENT UPON THE INFLUENCE OF
CERTAIN TRADES OR OCCUPATIONS UPON
HEALTH.

DcRiNO the past year special committees have re-
ported to Parliament upon different industries of a
dangerous character in which legislation seemed to be
necessary for the protection of persons employed in
them. The industries which were the subjects of
report were the lead indnstries, lucifer-match works,
potteries, chemical works and stone quarries.

Lead Lidtutriet. — This committee was directed to
inquire (1) into the conditions under which lead smelt-
ing, the working t>f blue lead, and the production of

Digitized by

Google

ToL. CXXX, Mo. 12.1 BOSTON MBDIOAL ASD SUBQIOAL JOUBBAL.

296

vhite lead, red lead and yellow litharge are conduoted,
with the object of diminiahing any prored ill-effecta
npoD the health of the work-people engaged therein ;
(2) whether the special roles which already exist with
regard to the manofaotare of white lead are sufficient ;
and (3) to suggest any precautions necessary to the
indastries specified for the protection of life or health.
The committee was also charged with conducting
farther special inquires, including an investigation of
the canse of death of a yonng woman engaged in lead-
works.

In summing up the recommendations, which are very
Bomerons and minute, the committee calls attention to
the fact that the works in which the largest number
of cases of lead-poisoning has occurred are those in
which there has been the least expenditure of money
sod care in precautionary measures for the health of
the operatives.

The greatest change which is recommended is the
eielosion of females from all direct contact with white
lead. The committee also records, as the result of its
experience, the fact that lead, and all its compounds are
in a greater or less degree poisonous, and that the
handling or use of each or all of them is attended with
danger.

PoUmrieM (China and Barthenwan.) — This com-
mittee condndes that the potter's trade is attended
with injnrjr to health and life. The ill-effects are due
to two causes: dust, and the poison of lead. The
former is of wider action, since it pervades all the oper^
stions or processes wherein potter's clay and flint
powders are in use. The latter prevails in the depart-
mraits of work concerned in the glaaing and coloring
of the ware, after it leaves the hands of the potter.
A third but less potent canse exists in the operations
necessary to the completion of the ware by firing.

The oommittee presents statistics in support of their
coooIusionB, showing that the inhaling of the noxious
dost of day and flint is a fruitful cause of diseases of the
respiratory organs. The mortality returns of Stoke-
apou-Trent for 1890 show that, of the males over four,
teen years of age who were potters, 42 per cent, died
of bronchitu, 8 per cent, of pneumonia and pleurisy,
sod 21 per cent, of phthisis. In a general way it was
slto shown that only 4.5 per cent, of potters died of
woile decay, and 12.5 per cent, of persons who were
not potters, a fact which shows that potters generally
die yonng.

The committee found that much of the mortality
from lead-poisoning was avoidable, although no code
of regulations coald entirely obviate the effects of the
poison to which the workers were exposed.

The following modes were indicated by which the
poison gains access to the body : (1) by eating food
with unwashed hands, or partaking of it in the rooms
where lead is dealt with ; (2) by neglect of cleanli-
ness of clothing ; (8) allowing glaze and colors to drop
•boot, become dry, and so form dust which is inhaled ;
(4) holding the pencil used in painting, in the mouth,
u is done by women employed in majolica painting ;

(5) robbing the eyes with dirty hands ; (6) near-eight-
ness, causing the workers to be too close to their
work ; (7) constitutional idiosyncrasy, producing exces-
sive Bnsceptibility to lead-poisoning.

The oommittee formulated a code of regulations
which, if established and enforced in every pottery,
would greatly diminish the injurious effects of the dif-
ferent processes of manufacture. These rules had
reference mainly to personal cleanliness, and the cleanli-
ness and ventilation of the work-rooms, the employ-
ment of females and children under fourteen, and the
eating of food upon the premises.

Luciftr- Match Works. — The special danger to
which persons engaged in the manipulation of phos*
phorns are exposed, is necrosis. The committee ap-
pointed to consider this trade recommended several
rules. These provided for the isolation of certain
processes from other parts of the factory, with thorough
ventilation in apartments where such processes were
conducted ; that hot and cold water, soap, nail-brushes
and towels should be furnished, and the operatives
required to use them; that all workers should be
examined, at least once a month by a surgeon, who
should have power to order temporary suspension or
total change of work for any one showing symptoms
of incipient necrosis; that all persons complaining of
toothache or swelling of the jaws should be examined
at once ; that no person should be permitted to work
in the processes of mixing, dipping, drying or boxing,
after the extraction of a tooth, without the certificate
of a duly qualified medical practitioner, that the jaw
is healed. Penalties were recommended for neglect
to comply with these rules.

Ohemieal Worb. — The committee upon these in-
dustries was charged with duty of inquiring " into the
dangers to life, limb and health attending employment
in chemical works," with a view to discover " (I) how
far the manufactures, as at present carried on, injuri-
ously affect the health of the work-people, and how far
the injurious effects depend on the age and sex of the
operatives ; (2) what means can be adopted to abate
the injurious effects of the manufacture; (8) what
special regulations should be adopted to protect vats
and other dangerous places and utensils used in the
manufacture."

The manufacture of bleaching-powder is by far the
most harmful to the operatives, of any department of
chemical work. Lime is treated in chambers with
chlorine gas, which is absorbed by the lime. At the
end of four days the doors are opened, and men enter
the chambers to pack the lime. In disturbing the
powder free chlorine gas is let loose. The packers
are obliged to wear respirators or muzzles of thirty
folds of damp flannel, tightly tied over the mouth, the
nose being free ; the men inhale through the muzzle
and exhale through the nose. If they happen to re-
verse the process they became '* gassed." The exer-
tion of breathing through the thick folds of flannel
shows itself in the red and puffed state of the men's
faces and profuse perspiration in coming out of the

Digitized by

Google

296

BOSTON MEDICAL ASD SVBGICAL JOCBBAL. [Mabch 22, 1894.

chambers, which they are obliged to do at interval*.
The lime-du8t also injures the eyes. None bat robust
men could endure this work. The sufferings of these
operatives are vividly portrayed in the "minutes of
evidence."

Question 22,615. What you suffer from is the escape of
chlorine gas, I suppose?

Tes, that is what we suffer from. When we go into the
chamber, sometimes we are not able to stop there five min-
utes, sometimes a quarter of an hour, sometimes half an
hour, sometimes you cannot stop two minutes.

Qaettion 22,566. Have yon anything further yon would
like to say to the Commission ?

I have got the muzzle with me. (Witness puts on the
muzzle.)

Question 22,557. Whenever you are packing in a hot
chamber you are obliged to use that?

Yes.

Question 22,668. And no man could enter the chamber
without it ?

1^0 I they could not put their noses inside. .

Question 22,569. It is nothing but ordinary flannel ?

Yes.

Question 82,560. Several folds of ordinary flannel 7

Yes ; it must be the best flannel It has to be renewed ;
it gets eaten away with the gas.

In another inquiry of the same character, made by
an English trade-journal, a workman said : " Every
man is liable to a visit of the gas right through the
muzzle." Grassing is such a common matter that the
men readily describe its symptoms. " Is it ever fatal ? "
— " Yes, sometimes."

A workman's clothes-bill for a fortnight amounted
to fifteen shillings. The shirt was torn, and in several
parts hung in strips. It was hardened by acid or
powder, and tore freely. This shirt had seen two
days' work, and was now good for nothing.

'* If a premium of £100 were to be offered by the
alkali magnates, there would be clothing (diving-suits)
put together in no time, with proper air-pumps, and
an anti-corrosive coating which would resist the rasp-
ing and tearing of the dust and gas. The directors
might do worse than keep the photographs of the
powder^packer's head, which appeared last week, on
their breakfast-tables and in their board-room, just as
a reminder."

In the salt-cake (sulphate of soda) department, the
danger is from the escape of hydrochloric-acid gas.
Many workmen have had their teeth entirely destroyed
by its effects.

In the manufacture of caustic soda, the danger results
from the splashing of the liquor, and frequent injury
to the eyes.

In the manufacture of chlorates, the chief danger is
from explosions, and the saturation of the clothing
with the dust and its taking fire.

In making bichromate of potash and soda, the com-
mittee found that almost all the men working where
dust was prevalent had either perforation of the septum
of the nose, or had lost the septum altogether. These
results often cause partial or complete loss of the sense
of smell, with irritation and ulceration of the throat,

trachea and bronchial tubes. Many of those employed
suffer from what are called "chrome holes" in their
hands and arms, caused by dust or liquor acting on the
broken skin, or by handling the crystals.

The medical officers of the commission suggested the
following as means of lessening the evils of working
in the bleaching-chambers :

(1) Free and thorough ventilation in and about the
bleaching-chambers.

(2) Oiling or greasing the exposed parts of the body
before beginning work, the wearing of " goggles," and
the introduction at intervals of a few drops of oil into
the eyes for their protection.

(8) Let the respirators be moistened from time to
time with a solution of sulphide of soda. If this sug-
gestion were carried out, the " muzzles " might be
made much thinner than at preseut, and the men
could breathe with greater freedom and safety.

To obviate the evils caused by the inhalations of
the dust of chrome compounds, the following is ad-
vised : Let the sponge or other absorbent material of
the respirator be moistened with a solution of bismuth
(Liquor bismuthi, B. P.). The chrome dust coming
in contact with this is decomposed. The same result
might be attMned by plugging the nostrils with cotton-
wool, moistened in the same solution. Frequent
washing of exposed parts of the body is desirable, and
protection of the hands with water-proof gloves.

StoM Quarries. — The committee upon this subject
was required to report upon the dangers to life, limb
and health, attending employment in open quarries.
The field of inquiry included operations conducted in
nearly every county of the kingdom, the number of
persons thus employed in 1891 being 121,637; but
the sessions of the committee of which the minutes of
evidence are published, were mostly held in the quarry-
regions of Wales.

Dr. Ogle, of the Registrar Greneral's Office, who
appeared before the committee, stated that the mortal-
ity of quarrymen from phthisis and respiratory dis-
eases was very high (three times as high as that of
fishermen), and that, in his opinion, this excessive
mortality was due to the inhalation of stone-dust

MEDICAL NOTES.

Thb Mbdical Depastmknt op the Univkrsitt
OF Pknnstlvamia. — There are 801 active studenu
in the Medical Department of the University of Penn-
sylvania this term, 45 less than last year, which was
the largest number yet registered.

Thb Dbatb of Mbb. Chablbs L. Dana. — Dr.
Charles L. Dana, of New York, will have the sym-
pathy of his personal and professional friends in his
recent bereavement in the loss of his wife, who died in
Bermuda on March 8th, from injuries received in a
carriage accident.

Thb P088IBILITIB8 OF Chbhioal Nombnclat.
CBB. — The possibility for a chemist to tell all that is

Digitized by

Google

70L. CXXX, No. 12.] B08T0S MEDICAL AHL SVBGICAL JOVBXAL.

297

m a snbstanoe by its name, is well illn«trated by one
of the new synthetic remedies, which has the simple
cognomen of monosodic metbylamido brommethyl pro-
pylamine-benzol.

Choleba in Tripoli. — Cholera is o£ScialIy re-
ported to have broken ont at Tripoli. Several cases
of the disease have occurred in the military hospital out-
tide the town.

Influenza, at Genoa. — During the past month
die influenza has been violently epidemic at Genoa.
Over twenty thousand cases have been reported to the
health authorities, and the daily mortality of the city
tias risen from twelve to fifty.

Shall-Pox on a United States Wabbhip. —
Information has been received from China that the
United States warship Monoeay reached Woe Sung
from Chin Eiang on the llth of February with sev-
eral cases of small-pox on board. Six of her crew
were taken to the general hospital at Shanghai.

The Cbioaoo Corbino Doctor. — A " Doctor "
McFadden died recently in Chicago, who had not a
Kttle reputation as a cursing doctor. His sole method
of treatment was by laying on of hands and swearing
at the evil spirit or disease until it left the patient.
His cursing was not a simple exorcism, but was genuine
Billingsgate, unpurged and unrefined. He had a large
and rather lucrative practice.

The Diaonosib of Appendioitib in a Tioer. —
A tiger in a Wisconsin circus was recently operated
upon for " appendicitis." According to the newspaper
account, "He clawed his abdomen so that it was
guessed he had the disease. He was securely chained
and muzzled, and a doctor cut into him. In the in-
flamed sac was found the rim of a pair of spectacles.
The tiger foamed with rage while the operation was
in progress."

Choleba Insurance fob Rdsslan Phtbicianb.
— In the Bnssian province of Wiatka, a resolution
was recently adopted at a general meeting of the citi-
zens for insuring the lives of medical and surgical prac-
titioDers against cholera. From the funds of the
province on deposit in the imperial bank, the family of
a physician practising within the province will receive
opoD his death by cholera the interest on 5,000 roubles,
or on 8,000 if he has practised within the province ten
years. A surgeon's family will receive the interest on
1,000 roubles.

Canned Ykobtablbb containing Poison. — In
the course of investigations made last year by the
Chemical Division of the Department of Agriculture
80 samples of canned and bottled peas were examined,
43 of American and 37 of foreign origin. All of the
foreign brands, except two, contained copper ; one con-
tained zinc. Fourteen of the 43 American samples
contained copper ; 29 did not. Salicylic acid was pres-
ent in five French and 10 American samples. Tin
was present in 50 samples, lead in 50, and zinc in 15.
Id all, 248 samples of all sorts of vegetables were
examined, and in no less than 121 was salicylic acid

detected. Zinc was found in 40, copper in 88, and
lead in 182.

The New Yobk Pastedr Institute. — The sta-
tistics for the preventive treatment i^aiust hydropho-
bia of the New York Pasteur Institute for 1893 show
that there were 26 patients who were bitten by animals
in which hydrophobia was evidenced by experimenta-
tion or by the death of some other person or animal
bitten by them ; 11 patients who were wounded by
animals recognized as rabid by clinical or veterinary
examination ; and 43 bitten by animals in which rabies
was suspected, bat who were killed or lost sight of be-
fore any proof was obtained. No deaths occurred in
any of the patients. Forty-five of them had had the
wounds cauterized before entrance, but in all cases in
an iDsuflScient and non-efficacious manner. The 104
patients treated in 1892 have all remained free from
disease up to the present time.

Another Dangerous Fastiub. — Another good
out-door sport has been added to the list of dangerous
games, fortunately before it has become so deeply
rooted in the affections of our youth that they cannot
be kept from its harm. Golf-playing is the cause of
severe gluteal strain, with possible rupture of fibres in
the anterior portion of the muscle which is made over-
tense in the position of " driving strokes." Two such
cases have been reported already in the Lancet.

BOSTON AND NEW ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon, March 21, 1894, there
were reported to the Board of Health of Boston, the
following numbers of cases of acute infectious disease :
diphtheria 31, scarlet fever 33, measles 26, typhoid
fever 13, smaU-pox 6 (2 deaths). There are now
15 patients in the Canterbury Street Small-pox Hos-
pital. During the week 9 cases of small-pox were re-
ported to the State Board of Health from Holyoke.

A Scbolabship in Mekort of Dr. Charleb
Pratt Stbono. — A number of friends of the late
Dr. Charles P. Strong, of Boston, have given to Har-
vard University the sum of $3,750 to found a memorial
scholarship in the Medical School. For the present,
all income from this sum over one hundred dollars is
to be added to the principal until that reaches five
thousand dollars.

The Medical Registration Bill before the
Massachusetts Legislature. — A majority of the
Committee on Public Health have reported to the
Legislature a bill to control (?) the practice of medicine
in this Slate. A minority, among whom is Senator
Harvey, of Worcester County, have offered an adverse
report.

Measles, Judgment and Discretion. — A sub-
urban board of health offers the following piece of
wisdom, as advice to the people whom it is called upon
to protect : " The Board is of the opinion that it is not
wise to try and stop the spread of measles among chil-
dren, for it is one of the diseases that a large majority
of the people are liable to have during their lives, and

Digitized by

Google

298

BOSTON MEDICAL AND SUROWAL JOURS AL. [Maboh 22, 1894

it is a well-BetUed fact that it is more dangerons and
tronbleBome with older people than with the yonng."
And furthermore the Bame board saya: "It is very
important that men of experience, judgment and disere-
Hon should be selected," as members of boards of health.
How does the foregoing statement appear in the
light of the following facts, taken from the State Regis-
tration Report for the year 1890 (page 821) ? Num-
ber of deaths from measles in Massachusetts, for the
twenty-eight years ending with 1890, 5,649 ; of this
number 5,073, or 89.8 per cent., were children under
ten years of age ; and 4,581, or 81 per cent., were
children under five years of age.

Bequests to Medical Charities. — The will of
the late Rufus S. Frost bequeaths the sum of one thou-
sand dollars to the Chelsea Day Nursery, and five
thousand dollars to the R. S. Frost General Hospital
for the establishment of a free bed.

A Gkmkrous Bequest to Yalb Umivbbbitt. —
The will of Mr. Richard S. Ely of New York, after
leaving many bequests to charitable instttations, creates
of the remainder of his estate a trnst for Yale Univei^
sity, the income to be used to found professorships in
the medical, law and academic departments. The es-
timated value of this trnst is between fifty and one
hundred thousand dollars.

NEW TOBK.

Two Dbaobms or Magbkdib'b Solution Gitbn
BT Mistake. — At the New York Hospiul one of
the female nurses recently gave a patient two drachms
of Magendie's solution of morphia by mistake, in con-
sequence of which he died. The man, whose name
was Conway, was suffering from fracture of the skull
and other injuries, the result of a fall from tbe ele-
vated railroad, on which he was employed as a track-
walker. It is believed, however, that the injuries
would have proved fatal had the morphia not been
given. At the inquest the nurse stated that at about
8.80 p. M., one of the house-staff of surgeons adminis-
tered a hypodermic injection of Magendie's solution to
a patient in the bed next to Conway's, after which the
bottle was handed to her to place in a medicine cabi-
net. A few minutes later she administered to Con-
way two teaspoonfuls of what she supposed to be the
old U. S. P. morphia solution of the strength of a
grain to the ounce. When be had swallowed it she
discovered that she had given him Magendie's solution
instead, and notified the doctor. The stomach pump
was employed and other appropriate measures taken,
but during the night the man died. Dr. Donlin, the
coroner's physician who made tbe autopsy in the case,
expressed tbe opinion that Conway could not possibly
have survived his injuries, and stated that he found
that the base of the skull was badly fractured and the
tissue of the brain severely lacerated ; in addition to
which the clavicle and four of the ribs were broken.

A Bill to Establish a State Coi.ont fob
Epilbptiob. — There was a hearing March 7th on the
bill now before the legislature, to establish a State

colony for epileptics. The scheme as perfected in the
pending bill has the strong endorsement of the State
Board of Charities, the State Charities Aid Associa-
tion, the State Commission in liunney, and the Con-
vention of Superintendents of the Poor.

An Outbbbak or Ttphoid Fbteb at Buffalo.—
A serious outbreak of typhoid fever has occurred at
Buffalo. Up to March 15th there were reported 236
cases and 20 deaths. There seems to be no doubt that
the disease is due to the impurity of the water supplied
to tbe city, and on March 18th the Mayor called an
emergency meeting of the Board of Health to take
measures to suppress the epidemic. It seems that three
weeks before the cases of typhoid commenced to de-
velop, the Water Department, in filling a new reser-
voir, took water from what is known as Bird Island
inlet, a source of supply which is contaminated by city
sewage, and which was last autumn condemned on this
account by Health-Commissioner Wende.

A Bequest to St. Luke'b Hospital. — By the
will of the late Richard S. Ely, the sum of $90,000 is
left to various charitable objects. The largest single
bequest is that to St. Luke's Hospital, amounting to
$20,000.

THE DERMATOLOGY OF TO-DAY.

In his presidential address delivered before tbe Hsr-
veian Society of London,^ Mr. Malcolm Morris, re-
viewing tbe progress recently made in dermatology,
said:

" The change, not merely in details, but in fands-
mental principles of treatment, is the result of the new
light which experimental pathology has thrown on the
nature of disease-processes and on the factors concerned
in their production in the skin as in other organs. . . .
We now recognize the precise microbic agents which
produce lupus, scrofuloderma, impetigo, leprosy or
glanders. It is not only as primary causes, however,
that the importance of the part played by microorgan-
isms in the genesis of skin diseases has come to he
acknowledged, the effects of their activity as secondary
causes are now seen to be still more far-reaching. . . .
In the domain of practice the teachings of bacteri-
ology have borne fruit in the extensive use of para-
siticide agents. There is hardly a case of skin disease
in which at some period or another of its, course
antiseptic and antiparasitic remedies are not indicated.
The ideal antiseptic still remains to be discovered.
I have so often found the latest products of the
chemical laboratory fail to come up to the expecta-
tions that I had been led to form of them, that I
can only conclude that tbe power of a substance to
destroy or check the growth of micro-organisms in
a test-tube is no measure of its therapeutic potency
when applied'to the human skin.

" It is not so much in the discovery of new reme-
dies as in the improvement in the means and manner
of applying those already known that progress has
chiefly been made in recent years. . . . 'The intro-

> BrlUih Hediosl Jonmsl, JsDiisrr irtii.

Digitized by

Google

Vol. CXXX, No. 12.] BOSTOJS MEDICAL ASt> SVttOtOAL JOVJtSAL.

299

daction of superfatted soaps, and cleanly pastes and
jellies has been of the greatest value. These methods
of applying medicaments to the skin are as superior to
those used by our predecessors of not many years ago,
u the Henry Martini's and magazine guns of the pres-
ent day are to the muskets with which Wellington's
battles were won. I do not say that we are better
men than those who have gone before us, but assuredly
we are better armed.

" All this has led to a truer understanding of the
iDsufficiency and folly of dietetic treatment of skin
diseases and to a more intelligent control of the gen-
eral medication. In the application of local treatment,
for which we have better vehicles and better remedies,
there are two essential conditions of success : first, the
strength of the remedy must be carefully tempered to
the disease ; and, secondly, the application must be
not only thorough but continuous."
Of massage, be says :

" Wherever there is effusion that cannot find an
exit on the surface ; wherever there is pain from
pressure of imprisoned fluid or thickened tissues on
the nerve ends ; wherever there is stagnation of the
Uood stream, there massage is likely to be useful by
its mechanical action on the parts to which it is ap-
plied. That, however, is the limit of its therapeutic
virtue. . . .

" Almost the only distinct evidence of progress apart
from local treatment to which I can point, is the fuller
recognition which has been arrived at of the influence
of the nervous system in the production of skin aSec-
Uons. . . . The knowledge of the intimate patholog-
ical connection between the nervous system and the
skin gives the key to the successful treatment of many
cases which defy all local measures."

AN ECCENTRIC RUSSIAN PHYSICIAN.

Professor Zakhabin, of Moscow, one of the phy-
sicians in attendance on the Emperor of Russia, and
since the death of Dr. Botkin, the leading consultant
in Russia, is renowned for his eccentricities as well as
for his skill.*

On entering a house he requires all the doors to be
left wide open, all the clocks stopped, and dogs to be
securely fastened away from his presence. He re-
moves his over-garments gradually and never all in
one place, his furs in one room, his over-shoes in the
next, his gloves in a third, and so on. He insists on
absolute silence on the part of the patient and the
family, and will have no question answered save by
" Yes," or " No." His dread of over-influence is al-
most a monomania ; and his attention to detail is such
that even in the simple cases he investigates the whole
family history and social relations before directing
treatment- His examination of the patient is some-
times three hours long — even in ordinary conditione.

One of bis favorite theories is that of an idiopathic
hypertrophy of the heart, upon which he has based a
rule of living : " It is necessary to rest htfort getting
tired." Accordingly he has the habit of sitting down
every seven or eight steps.

Zakharin is now sixty-five years old, has been pro-
fessor of clinical medicine at Moscow for thirty-five
years, and is reported to have acquired over a million
dollars.

1 lA BUdseliie ModwM, Ho 16, US4.

OFFICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFnOEBS SERTINO IN THE MEDICAL
DEPARTMENT, U. 8. ARMY, FROM MARCH 10, 1891, TO
MARCH 16. 18M.

Leave of absence for six months, to take effect on or about
May 1, 1891, with permission to go beyond the sea, is granted
Captain Waltkk W. R. Fishbb, assistant surgeon, U. S. A.

By direction of the President, the retirement from active
serrice, March 13, 1891, by operation of law, of Majob John H.
Baktholt, sargeon, U. 8. A., nnder the provisions of the act
of Congress, approved Jane 30, 1882, is annonnced.

FiBST-LiauT. Paul F. Stkaub, assistant sargeon, U. 8. A.,
is relieved from duty at Fort Riley, Kansas, and ordered to re-
port in person to the commanding ofBcer, San Carlos, Arizona,
for daty at that post, relieving Fibst-Lixut. Hablan E. Mc-
Vat, assistant surgeon, U. 8. A.

FiBST-LiBUT. McVat, on being relieved by Fibsi-Licut.
Stbaub, will report in person to the commanding officer,
Whipple Barracks, A. T., for duty at that post.

A board of officers to consist of Libut.-Coi.. Cbablbs R.
GBBiNLBAr, deputy surgeon-general; Libut.-Col. Albbbt
UABTSurr, deputy sorgeon-general, U. S. A. ; Majob Bbnjamim
F. Pope, surgeon, is appointed to meet at the call of the presi-
dent thereof at San Francisco, Cal., for the examination of
Captain William R. Ball, assistant surgeon, with a view of
determining his fitnera for promotion, as contemplated by the
acts of Congress approved October 1, 1890, and July 27, 1892.

Captain Hall will report in person to the president of the
board for examination at such time as he may designate.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. S. NAVY FOR THE WEEK ENDING MARCH
17, 1891.

L. W. Spsatliho, sargeon, ordered to the U. S. 8. " Alsrt."

E. J. Dbbb, surgeon, ordered to the U. 8. 8. " Raleigh."

E. M. Sbipp, assistant surgeon, ordered to the U. S. 8.

" Raleigh."
W. C. Bbaisted, passed assistant sargeon, ordered to hold

himself in readiness for U. 8. 8. "Colombia."
U. E. H. Habmon, surgeon, from the U. 8. S. " Yorktown "

and three months' leave.
G. P. Lcmsdbn. passed assistant surgeon, ordered to the U.

S. S. "Yorktown.''

APPOINTMENTS.

At the last regular meeting of the Board of Managers of the
Massachusetts Charitable Eye' and Ear Infirmary, Db. Hxnby
L. 8baw was elected as consulting surgeon ; Db. Fbxdbbick
E. Chbnbt was elected as ophthalmic surgeon ; Ds. Alezanobb
Qcackbnbobs was elected as assistant ophthalmic surgeon and
Db. Alkon G. Mobsi as ophthalmic house officer.

Db. Pacl Tbobndikb has been appointed sargeon to out-
patients at the Boston City Hospital.

HARVARD MEDICAL SCHOOL.

Evkninq Lbctubks.

The next lecture will be given on Wednesday evening, Ifarch
28th, at 8 o'clock, by Dr. J. 3. Putnam. Subject, " The Present
Status of the Therapeutics of Nervous Diseases." Physicians
are cordially invited.

SOCIETY NOTICES.

Boston SociiTT roB Mbdical Impbovxmbnt.- A regular

meeting of the Society will be held at the Medical Library, No.
19 Boylston Place, on Monday, March 26, 1894, at 8 o'clock,

p. K.

Dr. E. H. Bradford : " Sprains and Disabled Joints." Dis-
cussion opened by Drs. W. M. Conant and R. W. Lovett.

Dr. A. Coolidge, Jr.: ''Deviations of the Cartilaginous
Septum." Discassion opened by Dr. J. W. Farlow.

John T. Bowbn, M.D., S<cre(ary.

NoBroLK Distbict Mrdical Socibty. — The Brookline
Fellows of the Norfolk District Medical Society cordially invite
the Society to a Meeting for Scientific Improvement, to be held
at the Town Hall, Brookline, on Tuesday, March 27, 1891, at
7.16 p. M.

Subject for discassion, Tubbbculosis. "The Natural His-
tory of the Tubercle Bacillus," 8. A. Houghton, M.D. '• Tu-
berculosis in Cattle, its Detection, Prevalence, etc.," F. H.
Osgood, M.R.C. V.S. " The Treatment of Laryngeal Phthisis/'
S. W. Langmaid, M J>. " Tuberculosis in Mental Disease," W.

Digitized by

Google

soo

BOSTON MEDICAL AND SURGICAL JOURNAL. [Haboh 22. 1894

ChanniDx, H.D. " Home Treatment of Pbthisii," G. K. Sabine,
H.D. "The Application of Climatic Tberapeatics to Polroonaiy
Tnbercnlosii," £. O. Otia, H.D. Dr. F. C. Shattock will open
the diacoaalon.
LoDcb at 9.46 P. if .

J. C. D. PiOBOM, M.D., Secretary.

RECENT DEATHS.

Db. GmssppiDAONAiEmeritas Dean of the Medical Facalty
of the University of Pavia, died February 3d.

SUROKON-COLONKL AbCHIBALD HAMILTON H1I.8OX, H.D.,

C. I. E., late iDspector-general of Civil Hospital!, Bengal, and
one of the heroes of the Sepoy Revolt of 1867, died January itb,
aged fifty-nine years.

BOOKS AND PAMPHLETS REGEIVBD.

Dartmontb Medical College Catalogue, 1893-M.

MaMachnsetts Institute of Technology, Boston, Annual Cata-
logue, 1803-91.

Massachusetts Institute of Technology, Annual Report of the
Prei>ident and Treasurer, December 13, 1893.

Society of the Lying-in Hospital of the City of New York,
Midwifery Dispensary Medical Report. 1893.

Enterorrbaphy ; Its History, Technique and Present Status.
ByN. Senn, M.b., Ph.D., LLD. Reprint. 1893.

The Discovery of Annstbesia. By Whom Was It Made? A
Brief Statement of FacU. By Dr. Laird W. Nevlns.

Treatment of Depressions ip the Skull of the New-bom. By
David D. Jennings, M.D., New York. Reprint. 189t.

Cleft of the Hard and Soft Palates. Naso- or Betro-Pharyn-
geal Growths. By J. Ewing Mears, M.D., Philadelphia. Re-
prints. 1893.

Transactions of the Medical Society of the State of North
Carolina, Fortieth Annual Meeting held at Raleigh, N. C, Hay
9, 10 and 11, 1893.

Longevity, with a IJst of Persons Known to have Lived One
Hundnd Years or More. By Archer Atkinson, M.D., of Balti-
more, Hd. Reprint.

The Year-Book of Treatment for 1894; A Critical Review for
Practitioners of Medicine and Surgery. Philadelphia: Lea
Brothers & Co. 1894.

Transactions of the American Pediatric Society, Fifth Session.
Edited by Floyd M. Crandall, M.D. Volnme V. Printed by
Bailey ftFairchild. 1893.

Studies from the Department of Pathology of the College of
Physicians and Surgeons, Columbia College, N. Y. Vol. IH.
For the Collegiate Year, 1892-93. ReprinU.

Gmndriss der Histolo^e fiir Studierende nod Aerzte. Von
Dr. Bemhard Rawitz, Privatdozenten an der Universit&t, Berlin.
Mit 204 Abbildungen. Berlin: S. Karger. 1894.

Studier ofver Transitorisk Albumlnuri Hos Till Utseendet
Friska Personer. Af Tborbjorn Hwass, Med. Dr., Decent,
Stockholm. Stockholm : P. A. Norsteat & Soner. 1893.

Die Infections-Krankheiten, ibre Entsteknog, ihr Wesen and
ihre Bekampfnng. Fiir Aerzte und Verwaltbungs-Beamte von
Dr. W. Plange, Kgl. Kreisphysikns. Berlin : 8. Karger. 1894.

Cases to Illustrate the Relationship which Exists between
Wryneck and Congenital Hematoma of the Bterno-Mastoid
Muscle. By U'Arcy Power, M.A., M.B., Ozon., F.R.C.S., Eng.
Reprint. 1894.

Report of a Case of Cerebral Tumor, Diagnosed by Focal
Symptoms, with Operation, Successful Removal of Tumor and
ExhiDition of Specimen. By D. A. K. Steele, M.D., Chicago.
Reprint. 1891.

A Manual of Therapeutics. By A. A. Stevens, A.M., M.D.,
Lecturer on Terminology snd Instructor in Physical Diaxnosis
in the University of Pennsylvania, etc. Philadelphia: W. B.
Saunders. 1894.

The Relation of Peripheral Irritation to Disease ; Considered
from a Therapeutic Standpoint. Therapeutic BeJBections; A
Plea for Physiological Remedies. By Simon Baroch, M.D.
Reprints. 1890-93

Pain, Pleasure and JSsthetics, An Essa^ Concerning the Psy-
chology of Pain and Pleasure, with Special Reference to
.Esthetics. By Henry Rnigers Marshall, M.A. London and
New York: Macmillao & Co. 1894.

Congenital Affections of the Heart. By George Carpenter,
M D., Lond., Uember of the Royal College of Physicians ; Senior
Physician to Out-patients at the Evelina Hospital for Sick Chil-
dren, London. London : John Bale & Sons.

Tables and Notes on Human Osteology, for the Use of
Students of Msdicine. By Sebastian J. Wimmer, M.A., M.D.,
with a preface by Prof. William F. Wangh, A.M., M.D. Phihi-
delphia: The Medical Pnblishing Co. ivai.

Scarlatina and Scarlatinal Sore Throat; A Record of Milk In-
fection. Bv Arch. K. Chalmers, M.D., Ph.D., P.H. (Csmb.),
one of the Medical Officers of Health for the County of the City
of Glasgow. Glasgow: Robert Anderson. 1894.

Excision of the Hip-Joint in Tntiercular Disease. Circoiar-
Saw Injury. The Early Removal of Tubercular Foci of the
Bone. Primary Syphilis and Gonorrhoea in Children. By B.
Merrill BJcketta,M.D., Cincinnati, O. Reprints. 1898.

Pigmentation of the Whole Surface of the Body, OoonnlDg
Suddenly during the Treatment of a Case of Psoriasis; Warty
Growths npon the Palms and Soles following the Internal Use
of Aiaenic. By Albert E. Carrier, M.D., of Detroit. Reprint.
1894.

Modem Homoeopathy; Its Absurdities and Inconsistencies.
By William W. Browning, A.B., LL.B., M.D., Brooklyn, N. Y.,
Lecturer Upon and Demonstrator of Anatomy, Long Island
College Hospital, etc. Philadelphia: Press of Wm. F Fell ft
Co. 1894.

Tumors, Innocent and Maliniant, Their Clinical Features and
Appropriate Treatment. By J. Bland dutton. Assistant Surgeon
to the Middlesex Hospital, London. With two hundred and
fifty engravings and nine plates. Philadelphia: Lea Brothers
& Co. 1803.

Hospital Dispensaries and Nursing : Papers and Discusdons
in the International Congress of Charities, Correction and
Philanthropy, Section HI, Chicago, June 12 to 17, 1893. Edited
by John S. Billings, M.D., Henry Hurd, M.D. Baltimore: The
Johns Hopkins Press. 1894.

Syllabus of the Obstetrical Lectures in the Medical Depart-
ment of the University of Pennsylvania. By Richard C. Norris,
A.M., M.D., Demonstrator of Obstetrics, University of Penn-
sylvania: Assistant Obstetrician, University Maternity, etc.
Third edition. Philadelphia: W. B. Saunders. 1894.

A Practical Treatise on Medical Diagnosis for Students and
Physicians. By John H. Mnsser, M.D., Assistant Professor of
Clinical Medicine in the University of Pennsylvania, etc. Illns-
trated with one hundred and sixty-two wood-cuts and two
colored plates. Philadelphia: Lea Brothers & Co. 1891.

Suicide and Insanity ; A Physiological and Sociological Study.
By S. A. K. Strahan, M.D., Barrister-at-Law ; Fellow of the
Royal Statistical Society; Member of the Medico-Psychological
Association of Great Britain and Ireland ; Member of the Medico-
Legal Society of New York, etc. London : Swan, Sormenschein
& Co. 1893.

Essentials of Physics, Arranged in the Form of Questions and
Answers, Prepared especially for Students of Medicine. By
Fred J. Brockway, M.D., Assistant Demonstrator of Anatomy
at the Collep;e of rhysicians and Surgeons, New York. Second
edition, revised, with one hundred and filty-five illostratioos.
Philadelphia: W. B. Sannders. 1894.

Medical Jurisprudence, Forensic Medicine and Toxicology.
By R. A. Whitthana, A.M., M.D., Profeasor of Chemistrv,
Physics and Hy^ene in the Universi^ of the City of New York,
etc., and Tracy C. Becker, A.B., LL.B., Counsellor-at-Law, Pro-
fessor of Criminal Law and Medical Jurisprudence in the Uni-
versity of Buffalo. Vol. L New York: William Wood & Go.
1894.

ToUl Extirpation of the Uterus ; Cases Illustrating Various
Indications for and Different Metbcids of Performing ^e Opera-
tion ; Remarks npon Removal of the Uterus in Diseases of the
Appendages. The Technique of Total Extirpation of the Fibro-
matons Uterus. The Operative Treatment of Complete Pro-
lapsus Uteri et Vagina. By George M. Edebohls, A.M., H.D.
Reprints. 1892-93.

Folitzer's Text-Book of the Diseases of the Ear and Adjacent
Organs, for Students and Practitioners. Translated by Oscar
Doidd, M.D., Assistant Surgeon at the Illinois Charitable ^e
and Ear Infirmary, etc. Edited by Sir William Dalby, F.R.C.8.,
M.B., Cantab., Consulting Aural Surgeon to the St. George's
Hospital. With three hundred and thirty original illustrations.
Philadelphia: Lea Brothers & Co. London: Baillifere, Tindall
ft Cox. 1894.

Syphilis in the Innocent (Syphilis Insontinm), Clinically and
Historically Considered with a Plan for the Legal Control of the
Disease. By L. Duncan Bulkley, A.M., H.D , Physician to the
New York Skin and Cancer Hospital ; Consulting Physician to
the New York Hospital, etc. The essay to which the College of
Physicians of Philadelphia in 1891 awarded the Alvarenga
Prue for the best Memoir on any medical subject. New York:
Bailey ft Fairchild. 1894.

An American Text-book of the Diseases of Children, Inelnding
Special Chapters on Essential Surgical Subjects; Diseases ol
the Eye, Ear, Nose and Throat ; Diseases of the Skin ; and on
the Diet, Hygiene and General Management of Children. By
American Teachers Edited by Louis Starr, M.D., Physician
to the Children's Hospital and Consulting Podiatrist to the
Maternity Hospital, Philadelphia, etc , assisted by Thompson 8.
Westcott, H.D., Attending Physician to the Diapensary for Dis-
eases of Children, Hospital of the University of Pennsylvania,
etc Philadelphia: W. B. Saandeis. 1894.

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MEDICAL AND SURGICAL JOVENAL.

301

Anginal %itit\tfi.

THE OPERATIVE TREATMENT OF UTERINE
FIBROIDS.»

BY E. W. cnSHIHO, H.D., B08T02(, MASS.

Of all the advances io surgery achieved during the
Ust few years none has been more surprising or more
gratifying than the improvement in the methods and
in the results of the operative treatment of fibro-myo-
aata of the uterus ; while at the same time the more
accurate knowledge of the clinical history and morbid
degenerations of the neoplasms, which has recently
been obtained, has introduced entirely new views as to
the indications which call for operation and as to the
dangers which are incurred by neglecting such growths
until the life of the patient is actually endangered by
their presence.

It is not very many years since, on the one hand, a
uterine fibroid was regarded as a wholly benign growth
almost sure to cease increasing, or to diminish, at the
menopause ; while, on the other hand, the results in
the few cases subjected to operation were so unsatis-
factory that there was but little encouragement for
surgeons to persevere in attempting to remove these
growths. Thus Mathews Duncan could say, " Who-
ever heard of any one dying of a fibroid tumor?"
while physicians everywhere sharing his views created
a body of professional sentiment which has come down
to the present day, regarding such growth as compara-
tively innocuous, and strongly discouraging all opera-
dre interference, even in extraordinarily severe cases,
until the life of the patient was in imminent danger.
Od the other hand, as good operators as Sir Spenser
Wells, a man already distinguished in abdominal sur-
gery and experienced in the removal of ovarian tumors,
would entirely refuse to interfere with uterine fibroids ;
sod if by chance one was disclosed on opening the ab-
domen for the removal of an ovarian tumor, far from
proceeding with the removal of the growth, they would
close the abdomen and in confusion lament the error
of their diagnosis.

As the natural consequence of these views and con-
ditions, hysterectomy was only performed as a last and
desperate resort in patients who were sinking from
hemorrhage, or from exhaustion incident to the growth
or degeneration of the tumor. And it is little wonder
that the mortality was high. The pioneer work in
this operation was done in Massachusetts by those
determined operators, Buruham and Kimball, of
Lowell. Burnham's first operation was performed
June 26, 1855, the patient being still alive in 1884.
It is conceded that this was the first removal by ab-
dominal section of the uterus and appendages for
fibroid disease. Burnham operated 15 times with 12
deaths, a mortality of 80 per cent. ; while his mortality
in 338 cases of abdominal section of all kinds, includ-
ing the hysterectomies, was 25 per cent, that from 288
complete ovariotomies being 20 per cent.*

By improvement of technique, and by the growth
of institutions where a large number of cases could be
operated upon under improved conditions by trained
surgeons, the mortality from hysterectomy was grad-
ually reduced from 80 per cent, to 60 and 50 per cent.

> Scad before the Obitetrleal SeotiOD of the Suffolk Diatrlot Medi-
al Society. Korember M, ISSS.

' A fall rmort of Burnbam'a 838 oaaei wu published b; Us grand-
(00, Or. H. P. Perkins, Jr., In the Annals of GrnaooloK7, May, 1888,
TO). I. page 339.

and finally to about 86 per cent., where it stood some
ten years ago at the beginning of the era of advances
in abdominal surgery. Since then the reduction of
mortality has gone on progressively ; but it is of the
utmost importance to remember that the improved
results are not all due to the improvement of surgery,
but are due to the fact that the operation is now per-
formed before the patients are so reduced as to have
thrown away most of their chances of recovery.

Nevertheless, grim and lamentable cases still occur
too often, where, either from timidity on the part of
the patient, or oftener from bad advice and mistaken
ideas on the part of her medical adviser, the time for
favorable operation has passed by. The chances of
recovery have been cruelly thrown away by miserable
delay and worse than useless treatment, until the pa-
tient is delivered to the surgeon sinking under her
burden, a subject for a hazardous and gruesome opera-
tion, and likely then to die, leaving grief to the friends,
blame to the surgeon and discredit to the profession.

We are passing through the same change in theory
and practice in regard to fibroid tumors which has al-
ready been accomplished in regard to ovarian growths.
With the gradual enlightenment of the profession and
of the public, it is now rare to find the formidable
'cases of huge neglected ovarian tumors which were
formally so frequently brought to surgeons for opera-
tion. No one will now maintain, as was formerly
done, that an ovarian cyst should not be removed until
its presence actually threatens the life of the patient.
Instead of throwing away the chances of the patient
by delay, by treatment, by repeated tappings, all com-
petent physicians now recommend removal of an
ovarian cyst as soon as its presence is detected, with
the result that the operation in these early cases has
become practically free from mortality ; it is approached
with confidence ; it is accomplished with facility ; it is
a grateful interlude between the serious acts of impor-
tant abdominal surgery.

Now, in regard to uterine fibroids a similar course
of reasoning will apply, mutatit mutandit; like ovarian
tumors, they are apt to grow, and when of large size
they are very likely to degenerate and to cause the
death of the patient ; unlike ovarian tumors, they are
peculiarly apt to injure the health and exhaust the
vitality of the patient by repeated and protracted
hsemorrhage, and they are liable to slough and to
suppurate. In a considerable proportion of cases the
myomatous uterus becomes affected with malignant
disease. The tumor is liable to cause dangerous
symptoms or fatal consequences by pressure on the
ureters or on the intestine. If, therefore, there were
any such certainty or probability of the continued
growth of fibroid tumors that there is of the increase
of ovarian tumors, the rules which are applicable to
the latter class would at once govern our practice in
regard to the former ; the immediate removal of uterine
fibroids as soon as discovered would be the rule. But
here is precisely the difference between the two classes
of tumors. Many women have fibroids which are
small, which do not grow, and which cause no symp-
toms. In many others the tumor slowly increases
during the years of functional activity of the uterus,
but ceases to grow (or even diminishes) after the
menopause. It is, therefore, obviously not necessary
to operate on every tumor of this kind ; and the estab-
lishment of the indications for surgical interference
becomes in the highest a matter of individual judgment

Digitized by

Google

302

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Mabcb 29, 1894

and experience, to be determined by the natare of
each separate case. Wherever there is a chance for
difference of opinion, it is safe to aBsame that doctoro,
like other people, will disagree ; but the more opinion
can be founded on sonnd pathological knowledge and
on the records of wide observation, and the more ques-
tions in dispute are illnminated by experience and
elucidated by discussion, the nearer shall we approach
to a consensus of opinion and to the establishment of
definite rules of practice. In nothing is this more
evident than in the treatment of fibroid tumors, and
in no department of surgery is professional opinion
crystallizing more rapidly into definite rules of pro-
cedure, based on accurate knowledge.

The latest aspects of this question are not as yet
presented in the text-books, but are earnestly discussed
in medical societies and medical journals in this and in
other countries. Particularly, at the last two meet-
ings of the American Gynecological Society and at
the Pan-American Congress a great deal of attention
was devoted to the subject of uterine fibroids; and
while there are numerous individual differences of
opinions, yet it is plain that those mont interested in
the subject, and whose opinion is based on the widest
experience, have modified their views greatly within
the last few years and are now approaching unanimity
of opinion.

In the first place, it is practically conceded that
electricity is powerless to prevent the growth of fibroid
tumors ; and it has been abandoned by many very
competent men who, a few years ago, were adopting
the new treatment with enthusiasm. It will, in many
cases, arrest and control haemorrhage ; in many others
it will allay pain and nervous symptoms ; in not a few,
however, it will set up very serious suppuration, or
cause peritonitis of various grades, leaving adhesions
which afterwards seriously complicate any operation
which may become necessary.

It is substantially agreed that tumors, even of mod-
erate size, require operation if they are growing, if
they cause haemorrhage, if they occasion pain or press-
ure symptoms, or if they are complicated by salpingi-
tis. There is some difference of opinion as to the size
which a tumor should have obtained to warrant re-
moval. One would operate on growths as large as the
fist, another on nothing smaller than a cocoannt, but
none would countenance waiting until the tumor was
larger than the adult head as was so frequently done
only a few years ago, and as is still advised by some
conservative, but ill-informed practitioners. It is
agreed that the dangers of operation increase in direct
proportion to the size of the tumor, the age of the
patient, the reduction of vitality caused by repeated
hemorrhage and disturbance of the nutrition ; that the
fatal cases are usually the neglected ones; that the
difiiiculties of operation and consequent dangers are
enormously increased by the presence of adhesions, by
the complications of salpingitis, of pyo-salpinx, or of
cystic or purulent degeneration of the ovaries ; that
incarcerated tumors may press on the ureters and
bladder, while large ones drag these organs out of
place, often leading to serious and fatal disease of the
kidneys ; that a very large proportion of tumors com-
mence to grow or continue to grow after the meno-
pause ; that even a larger proportion of those which,
having arrived at large size at the time of the meno-
pause, then cease to grow, do not diminish but degen-
erate, becoming soft and decomposed, and by slough-

ing or septic absorption lead to the death of the patient
or to an operation t» txUxtmit. It is agreed that an
operation for removal of an ordinary fibroid of the
uterus by a competent surgeon upon a healthy patient
is not much more dangerous, if at all, than is the re-
moval of an ovarian cyst, and that all improvements
of technique tend to reduce the danger of operative
interference in uterine tumors to such an extent that
they are more and more coming under the rules which
are applied to ovarian tumors.

Another consideration is worthy of mention here,
namely, that the diagnosis of pelvic growths is fre-
quently so obscure ; and the examinations on which it
is based are even more frequently so insufiicient that
growths are often called fibroids which really belong
to other and more dangerous categories. I have seen
not a few cases where supposed fibroids of the ntenu
were really cases of cancer of the ovary, cancer of the
uterus, solid ovarian tumor, pyo-salpiuz with indura-
tion of the pelvic roof, impacted dermoid cysts, etc.
Other surgeons have had similar experiences. The
chances of operation have been lost or the result* of
surgical interference unduly jeopardized in these cases
by well-meant delay based on the supposition that the
growth was a fibroid of the uterus and therefore re-
quired no operation.

Having now noticed at some length the indications
for operation in fibroids of the uterus, we may con-
sider the different operations proposed for their relief
or their removal. Those which have received any
extended trial are:

(1) Removal of the uterine appendages (Hegar,
Tait).

(2) Tying uterine arteries from vagina (Franklin
Martin).

(3) Myomectomy or removal of the tumor, leaving
the uterus intact.

(4) Removal of snbmuooas fibroids through the os
uteri and vagina.

(5) Vaginal hysterectomy.

(6) Supra-vaginal hysterectomy : a, stump fixed in
abdominal wound ; h, stump fixed just below abdomi-
nal wound, but outside of abdominal cavity (Kelly) ;
e, stump turned forward into vagina (Byford) ; i,
stump intra-peritoneal (Schroeder); «, moditied by Mar-
tin, Zweifel, etc. ; /, stump extra-intra-peritoneal, the
arteries being tied in broad ligament and the stump
covered by peritoneum (Eastman, Chrobak, Dudley,
Goffe, Baer).

(7) Total extirpation : a combined operation, tumor
from above and cervix from below, with clamps below
(M. D. Jones) ; with ligatures (A. Martin, Boldt).
Total abdominal extirpation (A. Martin, L. Stimson,
Krug, Polk and others).

The time at our disposal this evening will not suf-
fice for the discussion of the technique of these various
forms of operation ; and probably such a treatment of
the subject w.ould not be of general interest. As may
naturally be supposed, opinions are somewhat divided
as to the choice of methods and as to certain details of
operation and procedures which on the whole are es-
sentially similar. Nevertheless, 1 believe it will be of
interest to point out the indications which would gov-
ern me in selecting one method or another, omitting
here historical details and questions to priority or in-
vention.

(1) As to the removal of uterine appendages. This
operation, introduced by Hegar and Tait, and resting

Digitized by

Google

\

Vol. CXXX, No. 18.] BOSTON MEDICAL AND SUROIOAL JOURNAL.

303

very largely on the authority of these names, aod espe-
cially on the strong recommendation of Tait, gives
excellent results in the case of small tumors where the
principal difficulty is monthly haemorrhage. Few op-
erators, however, at present are willing to trust to it
where the tumors are large and rapidly growing. It
is hard to see how the artificial induction of the meno-
pause will do more than (he natural change of life ;
and this, as stated above, notoriously does not control
the continual growth of tumors which are large and
show a tendency to increase rapidly. Even Tait does
Doi claim that it is of any use in cases of solitary soft
myoma or in fibro-cystic tumors.

Id the light of facts recently placed in evidence con-
cerning Tait, his statistics have far less weight with
the surgical world than was the case a year or two
ago. The chief objections to this method, wheu the
tumor is large, are, first, the possibility of degenera-
tion of the growth, and, secondly, the difficulty of
employing drainage. My own experience with this
method has been very satisfactory. I have used it a
good many times for small tumors, but only once for
one larger than a cocoanut, which was firmly bound in
the pelvis. This case died ; and I have always been
sorry that I did not perform a hysterectomy, inasmuch
as I could not use drainage when the tumor was in the
pelvu. In all the other cases menstruation ceased
entirely, and the growth diminished or gave no further
troable. Other surgeons, however, report cases where
the tamers continue to grow in spite of this operation,
necessitating subsequent hysterectomy. The chief in-
dication for the choice of this operation is the fact that
the tumor is growing in the fold of the broad ligament,
leaving the appendage readily accessible.

(2) As for tying the uterine arteries from the
vagina hoping thereby to check the growth of the
tomor, this is an operation recently suggested by Mar-
tin, of Chicago, but I have no personal experience of
it. As the procedure is easy and safe, it seems not
onphilosophical to try it in cases where the tnmor is
not so large that there would be danger of its degen-
erating or sloughing from the sudden cutting o& of
most of its blood-supply.

(3) Myomectomy, or removal of the tumor, leav-
ing the uterus intact, may be a very simple or a very
formidable operation, according to whether the growth
is pediculated or is imbedded in the wall of the uterus
and inclosed by a capsule consisting of uterine tissues.
In the first case it is a safe and quick operation to
constrict a pedicle and fasten it with pins in the angle
of the abdominal wound. It is not so easy to treat the
pedicle intra-peritoneally. As is the case in ovarian
tumors, if the growth is cut away, the stump of the
pedicle retracts, the vessels are hard to isolate and se-
cnre, the wound in the uterus gapes, and stitches used
to close it are apt to bleed. The best method of intra-
peritoneal treatment is to reflect the peritoneum from
the pedicle, commencing at the lower part of the
tnmor, then to sew through the pedicle the shoemaker's
stitch of catgnt before cutting it, tightening and tying
the ligature as the tnmor is cut away, and -covering
the stump with reflected peritoneum.

The removal of large myomatous nodules from the
uterus has been principally practised aad recommended
by Martin of Berlin, and is fully described in his work.
It is not often that suitable oases occur for this opera-
tion, since usually the large nodule is accompanied by
smaller ones ; and where it does not seem that the pa-

tient will be cured by the removal of the uterine ap-
pendages, surgeons perform hysterectomy rather than
to make and then close considerable cavities in tis-
sues as' retractile and vascular as are those of the
uterus. The singular celerity and dexterity of Martin
enables him to obtain results which are satisfactory,
while those less gifted would not suceed as well.

(4) I shall say little concerning the removal of sub-
mucous fibroids through the os uteri. There is little
new in this question, except that the ecraseur and the
wire loop have fallen into innocuous desuetude, being
replaced by simpler and more surgical methods of cut-
ting and tying the pedicle, if there is any. While
sublimate irrigation and packing with iodoform gauze
have diminished the dangers of sepsis from cavities
left in the uterine wall by the enucleation of sab-
mucous nodules, the difficult and hazardous operations
which were formerly performed for the removal of
large submucous growths have mostly been supplanted
by hysterectomy. My experience would lead me to
believe, however, that where a fibroid tnmor of the
uterus in the abdomen is complicated by the presence
of a sloughing fibrous polyp which has been extruded
from the uterus, it is the safest to remove the polyp
first by vaginal operation, leaving the hysterectomy to
be performed at a later date when the cavity of the
uterus is free from infection.

(5) Vaginal hysterectomy offers an easy and safe
way of treating cases where the uterus is of moderate
size and where there is much haemorrhage which is
not easily relieved by curetting. It may also become
an operation of necessity, when in attempting to re-
move a submucous growth, the uterus is perforated.
Vaginal hysterectomy may fairly be considered as a
rival of the removal of the appendages, as in suitable
cases it is just as easy, is fully as safe, and because the
uterus is of no use after the removal of the append-
ages, but may be very annoying to the patient, since
it is heavy and is apt to become retroverted.

(6) A discussion of the various methods and modi-
fications of supra-vaginal hysterectomy would alone
form a voluminous paper. Of the two great varieties
into which it is divided, the extrarperitoneal treatment
of the stump by fixing it in the angle of the abdominal
wound has been popular, and on the whole has given
the best results of any method devised. Keith, Ban-
tock, Tait, in England, and in this country Price and
his followers, use a wire loop to constrict the pedicle,
which is tightened by a small ecraseur or tvnre-naud.
The Continental operators, and some in this country,
prefer the use of an India-rubber constrictor made of
an ordinary piece of tubing; and if this is properly
used, it is in my judgment far superior to the wire loop.
The principal point to be observed is that it should
pass twice around the pedicle, above one pin and below
the other ; in this way it can be made to lie on the
skin instead of being buried in the wound. If the
pedicle is properly made, it is slender ; by exposure to
the air it becomes entirely dry, does not slough nor
smell badly, and when properly adjusted the dressings
need not be toached at all uutil about the tenth day,
when the constrictor and the stump are removed to-
gether. The other points to be observed are infinite care
in cleansing the vesico-uterine fold of the peritoneum,
the accurate coaptation of the abdominal peritoneum
around the stump and below the constrictor, and the
use of the glass drainage-tube in all complicated cases.
The tube should be separated from the stump by two

Digitized by

Google

304

BOSTOm MBDICAL AUD SVBGICAL JOVBBAL. [Mabch 29, 1894.

or three stitches, that is, by ao iDterval of aboat three-
quarters of an inch, and can be removed as usaal on
the second day without interfering at all with the
stamp. With these precautions the objections to this
treatment, which have been the priucipal cause of the
introduction of other methods, are not well founded.
There is no need of having a bulky pedicle or a slough-
ing stump or a large opening predisposing to hernia.
Contrary to the general opinion on the subject, it re-
quires a higher degree of real surgical skill, care and
perfection of technique to treat the pedicle in this way
properly than to remove the uterus entirely ; but the
saving of time, of shock, of hssmorrhage and exposure
of the intestines, which can be obtained by this method,
mutt weigh strongly in its favor as against the more
recent methods of operation which have lately oome in
fashiou and which are considered more ideal. The
method has served me well in all sorts of difficult cases
— in big tumors, in adherent tumors and in tumors
complicated by pyo-salpinx, and even where there was
perforation of the intestine ; and I know that in feel-
ing that it should not be abandoned lightly in favor of
other methods, I have the full support of Bautock, of
Price, and of many other operators, whose excellent
results entitle their opinions to the utmost considera-
tion.

In spite of the good results obtained by the extra-
peritoneal method of treating the stump, some opera-
tors have always insisted that this was not the best
procedure that could be devised, but that like the cor-
responding treatment of the pedicle in ovariotomy, it
was merely a temporary method and a haliing-place in
the march of progress towards an ideal method. First,
Schrceder, and then Martin, of Berlin, were the great
maintainors of this theory ; and their method, as is
well knowu, consisted in making the stump with an
anterior and pobierior ttitp which were brought together
by silk or catgut sutures. Unfortunately, owing to
the treacherous nature of uterine tissue, the stumps
would slough if tied too tightly, while if tied less tirmly
they would ooze or bleed ; so that the results would
not compare with less ideal but more practical methods.
Zweifel has now so modified this method by an interlock-
ing ititch of silk in the broad ligament and of catgut
across the cervix, that he has obtained admirable re-
sults ; while Martin has abandoned it in favor of total
abdominal extirpation. The iutra-peritoneal method
of Schroider has, however, also been modified in this
country in such a manner that the uterine arteries are
tied in the broad ligament outside (but near) the uterus,
when the cervix is cut away low down, and is then
either dilated, burned or drained after the method of
Eastman, which has been followed by Chrobak and
others on the Continent, or is simply left untouched
according to the method of Baer ; in either case the
peritoneum is united above the stump. The only difli-
cuiiy with this operation is that there is a tendency to
suppuration below the peritoneum ; and if much of the
stump is left, it is very apt to slough, owing to the en-
tire deprivation of nutrition of the park This not un-
naturally leads to the conclusion, that where the uterine
arteries were so securely ligated as to make the stump
liable to slough, it was best to remove it in UHo ; and
this method has been adopted with great enthusiasm by
Martin in Grermany, and by L. Stimsun, Krug, Polk,
Boldt, Edebohls and others in this country. As one
step in arriving at this operation, the body of the
uterus was removed from above and the cervix from

below, as in vaginal hysterectomy, but with the intro-
duction of the Trendelenberg posture it is so easy to
remove the whole from above, that it is now usually
done in that way. Martin attaches the vagina to the
peritoneum all around with catgut sutures, the ends of
all of which are brought out through the vagina.
Stimson and Polk use simply four sutures, one each in
front and behind and one on each side, the ends of
these are brought out from the vagina and the space
between is occupied with a packing of iodoform gauze.
Polk and Mann strongly recommend the additional
use of a glass drainage-tube in the abdominal wound.
Other operators close the vagina with catgut and unite
the peritoneum above it with a sero-serous continuous
catgut suture. Many consider a glass drainage-tube
desirable in all these cases, although not all consider it
essential.

This, then, at last would seem to be the ideal opera-
tion for the removal of fibroids, the only objections
being the time required and the resultant shock. The
abdomen is widely open for from one to two hours, ac-
cording to the dexterity of the operator and the char-
acter of the case ; this is a very serious consideration,
and without desiring to depreciate the march of prog-
ress toward the ideal, I will say that this operation is
not one for beginners, but for dexterous, experienced
and skilled surgeons.

A reiumi of my experience may prove interesting.
From January 1, 1890, to November, 1893, I per-
formed hysterectomy for fibroid tumors of the uterus
SS times at the Charity Club Hospital; and from
June 25, 1892, to November 1, 1893, 1 performed the
same operation 14 times in my private sanitarium, and
three times in private houses, making a total of 50
cases, of which I have accurate records, with 10
deaths, or 20 per cent. Of these cases there were:
extra-peritoneal stump, 29, with 4 deaths, or 13.7 per
cent. ; eztra-intra-peritoneal stump, 18, with 4 deaths,
22.2 per cent. ; abdominal total extirpation, 3, with 2
deaths, or 66.6 per cent. Besides these, I have had
one case of vaginal hysterectomy for fibroids, which
recovered ; two cases where the operation was prima-
rily to remove large, sloughing, fibroid tumors which
had been extruded through the uterus, and in which it
seemed at the time best to remove also the body of
the uterus from which the growth originated, and
which was the seat of other myomatous nodules. Both
of these cases died: one on the second day, from
uraemia caused by long pressure of the tumor on the
ureters and secondary disease of the kidneys; the
other sank on the third day after operation, without
rise of temperature, dying apparently from cardiac
failure due to repeated haemorrhages, septic absorption
before the operation, and the shock of the delivery of
the tumor, which, when I first saw the patient, was
hanging between her thighs, larger than a child's head,
and extremely ofiensive. During the same period I
have removed the uterine appendages some ten times
for small uterine fibroids, often combining the operation
with ventro-fixatiou of the uterus. All of these cases
recovered, except one who died of chronic sepiiia four
weeks after the operation. Besides these cases I have
had a number of ordinary fibroid polyps, which were
removed without difficulty ; but I have not taken the
trouble to look up the exact number.

Now, in considering the results obtained by the dif-
ferent methods of operation, it is necessary toexafflioe
the causes of death in those cases of each class which

Digitized by

Google

Vol. CXXX, No. 13.] BOSTON MEDICAL AND 8UBGJ0AL JOURNAL.

305

ended fatally, in order to discover which operation
ofiers the best chaDce of recovery, and which is best
adapted for aoy particular class of cases. And first,
as to the four deaths which occurred in 29 cases where
the stump was treated extra-peritoneally. Three of
these occurred at the Charity Club Hospital, and two
came close together, and were accompanied by three
other deaths from sepsis following particularly simple
operations. I think that all these deaths were due to the
poisoning of the house by one of the cases of sloughing
fibroid above referred to, although they occurred some
time after the death of that patient ; it seemed impossi-
ble to get good results, and I was compelled for a time
to suspend abdominal work in that place. It was on
the presentation of these facts to the management of
the Charity Club that it was decided to build a new
building adapted to the serious work which had to be
performed there. I am happy to say that the new
hospital gives such facilities as can never be obtained
in an old dwelling-house used as a hospital, and that
there ia but little danger of an occurrence of an epi-
demic of sepsis within its walls. This leaves two
deaths to be accounted for among the 29 cases where
the stunap was treated extra-peritoneally ; of these, one
occurred at the Charity Club Hospital after the re-
moval of a very large tamor from a woman consider-
ably passed the menopause. The other case was at
my sanitarium, in a patient who hud a large myoma
complicated by pregnancy, requiring a Porro opera-
tion ; in each case the death was due to obstruction of
the bowels. The occurrence of these two deaths set
me to reflecting on Keith's remarks concerning the
tension of the broad ligament which is occasioned by
the traction of the stump when treated extra-peri-
toneally, and led me to try the intra-extra-peritoueal
treatment which was so warmly advocated by East-
man, Chrobak, Baer and others.

Eighteen cases treated by the latter method gave four
deaths, «r a mortality of 22.2 percent. ; these deaths
all came near together, and were particularly painful to
me because three of them occurred in patients where
there were no particular complications, where the
tumors were not inordinately large, and where the
operation could have beeu performed by the extra-
peritoneal method with excellent prospects of success.

These four deaths occurred after a series of 13 con-
secutive recoveries by the intra-extra-peritoueal method,
and just when I was flattering myself that I could re-
move fibroids without fatal results. Besides the cases
that died, one other bad a considerable discharge of
pug from the vagina, no doubt coming from the cervix
uteri. The study of these cases revealed one impor-
tant point in all of the first ten, that is, in nearly all of
those who recovered, so much of the uterus was re-
moved that very little of the cervix was left ; this was
widely dilated, the canal thoroughly burned with the
thermo-cautery, and occupied by a twist of iodoform
gauze providing free drainage for the space left below
the peritoneum and leaving very little of the cervical
tissue to be nourished indirectly by anastomosis. In
all of the cases that died the dilating and burning of
the cervix was omitted ; and although gauze was drawn
through the vndilated cervix from above downward, it
is probable that drainage was not sufiBcient. Probably,
too mach cervical tissue was left to be properly nour-
ished after the ligation of the uterine arteries. We are
thaa met with &e same difficulty as in Schroeder's
openUion where a cervical stump is left ; if the blood-

supply is entirely checked, it sloughs, otherwise it
bleeds. One of these cases was of a nature that prob-
ably could not have been saved as the tumor had de-
generated ; the patient was some fifty-four years old,
and she had suffered from a series of very severe
chills, fever and profuse sweats at intervals of two
or three days for three months before she came into
my bauds. Her physician, Dr. Thurlow, had^ recog-
nized the nature of the trouble and insisted on the
necessity of operation, but the patient obstinately
maintained that she had chills and fever, and would
not consent to surgical interference until she was
evidently failing. The tumor was removed without
accident, but the patient showed symptoms of shock
while on the table, and did badly from the first. She
had a severe chill and sweat the day after the oper-
ation, had almost complete suppression of the urine,
and died ou the fourth day. The tumor weighed over
seventeen pounds, and contained over a quart of pus
and much broken-down tissue. At the autopsy there
was a little purulent-looking fluid on the stump ; no
signs of general peritonitis. There was multiple ab-
scess in one of the kidneys. Neither of the ureters
bad been included by the ligatures. Leaving this case
out of consideration, I have ten cases of the Eastman-
Chrobak operation where the cervical stump was short
and was dilated, burned and drained ; all of these re-
covered. There were six cases which were meant to be
done by Baer's method, without dilating or burning
the stump ; and three of these died, besides the hope-
less case above reported.

The results of the latter cases, which occurred last
summer, lead me to try total abdominal extirpation, in
order to get rid of the stump entirely, as advised by
so many advanced operators of the day ; although I
have tried this three times, and lost two cases, yet here
again the studies of the causes of the deaths show
how misleading are percentages which give only the
mortality, without describing the cases.

The first patient had cardiac disease, with compen-
satory hypertrophy of the heart. She had a large
fibroid, which was growing rapidly in a young woman
under thirty years of age, and occasioned very profuse
and exhausting hseinorrhages, leaving the patient in a
deplorable state. She entered the Charity Club Hospi-
tal last summer, and insisted on operation in such a
way that I could not refuse it, although the extra risk
was pointed out to her. The tumor rose high in the
abdomen and was freely movable, and it seemed prob-
able that it could be removed in a few minutes with
extra-peritoneal treatment of the stump. On opening
the abdomen, however, it was found that the tumor
had lifted up the broad ligament on each side, and that
to make a stump it must be widely separated from its
investment of peritoneum. Wheu this was done, the
stump was so small that it was a very little matter to
remove it entirely. The patient, however, did not
react well. She suffered no pain whatever, but was
ominously quiet, with a slightly subnormal temperature,
and died on ihe third night, her temperature rising that
very evening.

The next case was an ordinary one and recovered
without any trouble whatever.

The last case was in a middle-aged woman who had
carried a small fibroid tumor for several years, and
until past the menopause ; during the seven months
preceding operation, it had begun to grow very rapidly,
so that the specimen, which I showed at the last meet-

Digitized by

Google

306

BOSTON MEDICAL AND SURGIOAL JOURNAL,

[Mahcu 29, 1894.

ing of the Suffolk District Society, weighed some
twenty-five pounds. The tumor was firmly adherent
to the abdominal wall and to the omentum, obtaining
nourishment chiefly from the latter through a multitude
of vessels of which the veins were dilated and looked
like bunches of earth-worms. The ovaries were cystic,
and with the tubes were firmly bound down to the
pelvis. ■ From the rapid growth I feared that the tumor
was sarcomatous, and thought the safest way was to
remove all. The patient never rallied well from the
long operation, never got fairly warm in her hands
and feet, although everything possible was done for
her ; and she died septic on the third day.

The conclusions of my own experience briefly sum-
med up are as follows :

(1) That electricity is useless and dangerous, and
has no place in the armamentarium of the surgeon.

(2) That no method will compare with that of ex-
tra-peritoneal treatment of the stump in favorable
cases, that is, where the abdominal walls are not too
thick and the tumor can be lifted out so that a cou-
strictor can be applied around the whole pedicle, in-
cluding the uterine appendages ; that the advantages
of this method lie in its rapidity, in the short time
during which the abdomen is open, in the entire protec-
tion of the intestines from exposure and from handling,
and in absence of shock ; that with proper care there
need be no sloughiug of the stump, and little or no
suppuration of the wound. I show here two stumps,
each removed on the tenth day, with the ligature still
in position ; they are perfectly dry, hard and inoffen-
sive. This, then, for me is the operation of election
for the present, especially in private practice and in
all cases where patient is not strong and is ill prepared
to withstand the shock of the longer operation required
by other methods of treatment of the stump.

(3) For the intra-extra-peritoneal treatment, I should
always in future leave as little of the cervix as possi-
ble, dilate it, burn it and drain it. This method is
applicable to cases in which it is difiicult to apply the
former one, owing to thickness of the abdominal walls
or the rigidity of the pelvic floor, or the presence of
dense adhesions requiring drainage. I see little ad-
vantage to be gained from leaving any cervix. To
avoid the great danger of sloughing of the stump, it
must be amputated well below the level of the internal
08, after separation of the bladder from the cervix and
ligation of the uterine arteries. When all this has
been done, there is no difiSculty or loss of time in re-
moving all the uterine tissues. Drainage should us-
ually be employed, both through the vagina by gauze
aud by a glass tube at the bottom of the pelvis, as
there is pretty sure to be free oozing.

The fact remains, however, and must never be
forgotten, that for either of these methods of operation,
by intra-extra-peritoneal treatment or by total abdomi-
nal extirpation, the operation is prolonged from half
an hour to an hour. During this time the pelvis is
exposed to the air aud to much handling ; considerable
blood may be lost, which runs in among the intestines ;
there is an added shock from the large amount of ether
consumed ; and the whole burden of proof is, in my
judgment, still on those who would use these oper-
ations in cases in which the extra-peritoneal treatment
can easily and quickly be performed.

AccOKDiNO to Dr. Squibb, American chloroform is
on the whole purer than that used in Europe.

TWELVE CONSECUTIVE AND SUCCESSFUL
OPERATIONS FOR APPENDICITIS.

BT JOHN W. KEBFB, H.D., PBOTIDBNCE, K. I.,

KMMny Swrgton to St. Jo*eph't HotpUal, SurgtoH to Out-PatieaU at
tht Mode Maud HotpUal.

(GoDOluded from Mo. 12, page 284.)

Case VII. M. O'G., male. Age thirty, weaver.
First case operated upon in Rhode Island between the
attacks.

Admitted to St. Joseph's Hospital May 7, 1893.
Family history good. No evidence of transmitted dis-
ease ; good moral habits. He has since infancy been
delicate, although he has had no serious illness until
August, when be was taken with pain while at work;
pains at first general abdominal, later becoming local-
ized in the right iliac region. He has had attacks
since, on an average, every two weeks. Some attacks
lasted ten days, while others but one or two days. He
was obliged to remain from work so often that he
finally had to give up his position in the factory. He
had a cyanosed and anxious expression of countenance,
weak pulse and poor general appearance. There was
pain on deep pressure over McBurney's point.

May 9th. Patient's abdomeu mad,e aseptic previous
night, and bowels evacuated. Ether breakfast.

Operation. Patient etherized. Present, Drs. Col-
lins, Day, Mitchell, Noyes, Black, Mahoney, Barry
and O'Neil. Abdomen scrubbed again with soap and
water, ether and corrosive-sublimate solution. Steril-
ized towels about the field of operation. Instruments
sterilized by steam. An incision three inches long
was made, a little to the right of and parallel with the
border of the rectus muscle, through the abdominal
wall. After considerable search the appendix was
found, very much enlarged and bound down by firm
adhesions to the inner and posterior aspect of the
csecum. Following the longitudinal muscular fibres
of the csecum materially aided in finding the base of
the appendix. The adhesions were so firm that I re-
moved three-quarters of an inch of the appendix,
thinking that was all there was left of it ; but with the
flnger I was able to break up the adhesions between
the appendix and caecum, disclosing one and one-half
inches of appendix still remaining. A catgut ligature
was tied around the base of the appendix, aud allowed
to remain ; the appendix was severed with scissors,
and a Paqueliu cautery used to sear the end of the
stump. While searching for the appendix several
mesenteric glands were noticed having the appearance
of tubercular infiltration. All of the coats of the ap-
pendix were thickened. The abdominal cavity was
flushed with boiled water and sponged dry. A catgut
continuous suture was used to approximate the perito-
neum, and four silver-wire sutures through the entire
abdominal wall. Silkworm-gut sutures through skin
completed the operation. An iodoform dressing was
applied. Patient made a good recovery from the
operation. Patient rested well during the night.
Treatment consisted in giving a drachm of hot water
every fifteen minutes.

May lOih. Temperature, morning, 101°, pulse
103; evening, 102.5°, pulse 104. No nausea. Pa-
tient of a nervous temperament, discontented, and
worries a great deal. He has a cough, with slight ex-
pectoration.

May llth. Temperature, a. m., 101°; p. ic., 102".
Peptonized milk, one drachm every fifteen minutes.
Pulse strong.

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MBDIOAL ASD 8UR010AL JOURNAL.

807

May 13th. Patient slept bat little, exceedingly I
DervoQS and fretful.

May I5tli. Bowels evacuated by rectal injection of
a few drachms of warm glycerine.

May 17th. Temperature normal at nooo. Coughs
a great deal, and expectorates considerable thick
mocns.

May 18th. Dressings removed for first time since
the operation. Union perfect. No tympanites or pain
on pressure, as before operation. The four silver-wire
sutures were removed. Another aseptic dressing ap-
plied. Diarrhoea in afternoon, controlled by bismuth
and opium.

May 23d. Silkworm-gut sutures removed. Firm
union present. Flexible collodion painted on wound,
and an abdominal binder applied. Forcible pressure
in the right iliac region now gives no pain, and all
symptoms which he complained of before the operation
hsVe disappeared.

May 25th. Temperature, p. K., 103°. Delirious
at night. Greneral weakness.

May 28tb. Examination of chest shows dulness at
both apices and increase in vocal resonance. Sputum
examined, and found to contain tubercle bacilli.

May Slst Diarrbcea. Temperature 103.5°, pulse
130. Patient takes considerable nourishment.

June 5tb. Still weak, cough and expectoration.
Appetite improving.

June 6th. Discharged at own request.

September 6th. Patient has improved a great deal.
Is able to go about out-of-doors, but still has a cough,
and expectorates a thick, yellowish mucus. Has had
DO trouble, since the operation, in the right iliac region.

Case VIII. £. M., male. Age seven and one-
half years.

This boy I saw in consultation with Dr. Payan on
the ninth day of last August. He gave a history
of having injured his right side while playing with
another boy some weeks previously. Dr. Payan
saw him for the first time August 2d, when his tem-
perature was 103°, pulse 120. Pain referred to right
knee.

August Sd. Pain in right lumbar region.

August 8th. Temperature and pulse elevated.
Slight nausea last few days. No vomiting at any
time. IBowela regular. Chills and sweats for last
four days. Dulness over right lumbar region, and
sense of resistance. Dr. Payan introduced a needle,
but did not detect pus. Poultices locally and ano-
dynes.

August lOtb. At 10 A. u., the boy was restless
and hypersensitive. Temperature 100°, pulse 110.
Anxious expressioD. Right thigh flexed. On inspeo-
UoD of abdomen, a fulness was seen in right loin.
Sense of resistance. Fain and dulness on percussion
over tbu prominence. Pressure over McHuruey's
point produced pain, which was referred to right loin.
Operation advised.

At 4.30 p. M. an operation was performed. Dr.
Payan etherized the patient, and I made an incision, one
inch above and parallel with the crest of the ileum, two
inches long, cutting through the skin, muscles, fascia
and peritoneum, into an abscess cavity which extended
from the region of the right kidney to the iliac fossa.
Intestines formed the inner wall of the abscess cavity.
The appendix was not found. About six ounces of
very fetid pas escaped. A second opening was made
in the right iliac region by cutting down upon a

finger introduced into the abscess cavity through the
original wound, and a rubber drainage-tube passed
through both openings. The cavity was sponged out
with a solution of corrosive sublimate (1 to 2,000),
and an antiseptic dressing applied. The patient's re-
covery has been uneventful ; the wounds are entirely
healed.

September 6th. Boy attends school ; no trouble
from wound.

Cask IX. W. S., male. Age forty-two, grocer.

Admitted to St. Joseph's Hospital August 13, 1893.
Father died of phthisis; he, however, was the only
one of his family to have the disease. Mother's
family noted for longevity. Until within two years
patient was an exceptionally healthy man, weighing
200 pounds. He has gradually failed, until at the
present time his weight is only 130 pounds. Last
January patient had a severe intestinal haemorrhage,
the cause of which was diagnosed by his attending
physician as duodenal ulcer. He then gained in
health and strength until two weeks ago, when he was
seized with severe pain in the right iliac region. Four
days later he could feel a swelling in same location.
Pain on walking or stooping or pressing over swell-
ing. A surgeon was called, who accompanied him to
Boston, where an eminent surgeon of that city was
consulted. A second consultation of surgeons from
Providence and Boston was held at patient's home on
August 11th, and an unfavorable prognosis given the
patient's family. No operation advised.

August 14th. I saw patient for the first time.
Temperature 100°, pulse weak; sweats; anxious
countenance. Inspection showed slight prominence in
right iliac region. Circumscribed area of dulness,
with sense of resistance about five inches in diameter
just below and to the right of the umbilicus. No
fluctuation could be detected. Diagnosis, appendicitis
with circumscribed intra-peritoneal abscess. Opera-
tion advised.

August 15th. Operation. Present, Drs. Collins,
McCusker, O'Neil and Barry. Patient etherized.
Field of operation rendered aseptic. An incision
about three inches in length was made over the most
prominent portion of the tumor, and parallel with the
median line, through the abdominal wall, and iuto an
abscess cavity walled o£P by firm adhesions to the
parietal peritoneum. About six ounces of greenish
pus was evacuated. The abscess was irrigated with a
corrosive-sublimate solution (1 to 10,000), and two
silkworm-gut sutures introduced to close the angles of
the wound. A rubber drainage-tube was passed iuto
the abscess cavity, and an iodoform dressing applied.
Patient rallied well from the operation. Warm pep-
tonized milk and whiskey given in small doses. At
night patient complained of abdominal pain, unrelieved
by morphia. An enema of soap-suds and turpentine
produced a discharge of fsecal matter and a large quan-
tity of gas with great relief.

August 16th. More abdominal pain, relieved by
enema. Wound dressed, considerable discharge. Even-
ing temperature 100°, pulse 120.

August I7th. Patient's general condition improved.
Drainage-tube removed. Temperature normal.

August 19th. Patient sleeps and takes nourishment
well. Diet: milk, egg-nog and beef-tea. Wound
looking well. Slight discharge.

August 24th. Wound dressed every second day.
Sutures removed.

Digitized by

Google

808

BOSTON MEDICAL AND SUBGICAL JOURNAL.

[Makcb 29, 1894.

Aognst 27th. Edges of wouad broogbt in apposi-
tion with strips of adhesive plaster.

Angnst 29th. NotwithstandiDg the patient has strict
orders not to leave bis bed, he went out twice to the
closet.

September 2d. Two silkworm-gnt sntares were
introduced to bring granolaiing edges of the wound in
apposition, and antiseptic dressing applied.

Septeml)er 4th. Wound nearly healed. Area of
dniness has disappeared, with the eiception of a slight
amount of dulness in close proximity to the incision.
Patient eats, sleeps and looks well. Says he feels as
well as he ever did in his life.

October Ist. Patient has gained in weight. No
pain in right iliac region.

Case X. D. C, male. Age fourteen years, mes-
senger boy.

Patient has been strong and robust until the present
illness. He is an exceptionally well-developed boy.
On August 13, 1893, after playing base-ball, he was
seized with pain in the right side of the abdomen. On
the following day the pain increased, and he was
obliged to remain in bed. The family physician was
called. Diagnosed the disease as appendicitis, and
ordered anodynes and ice applied locally. He ob-
tained considerable relief, and the case looked like one
that would terminate by resolution. I saw the patient
for the first time August 21st. His temperature was
100°, pulse ISO. Abdomen distended and tympanitic
on percussion, except just above the crest of the right
ilenm where there was an area of dulness three inches
in diameter, and tenderness on pressure. Deep press-
are over McBurney's point produced pain in area of
dulness. The boy's general appearance was poor, and
his anxions expression denoted serious trouble.

August 22d. Boy admitted to St. Joseph's Hos-
pital. No marked change iu symptoms.

Angnst 23d. Tympanites has disappeared. Tem-
perature 100°, pulse 98. Area of dulness, and pain
on pressure above crest of right ileum. No sense of
resistance. No fluctuation ; mass could be detected
on palpation. Assisted by Drs. Day, O'^eil and
Barry, I operated by making an incision three inches
long iu the right lumbar region, commencing just
above highest point of the crest of the right ileum and
continuing toward the ribs ; the incision being parallel
with the median line. The several layers of the ab-
dominal wall, namely, integument, superficial and deep
fascia, the external and internal oblique muscles, trans-
versalis muscle and transversalis fascia, subserous are-
olar tissue and peritoneum, were all readily recognized
and divided with the knife. There was no cedematons
condition of these tissues, such as is commonly found in
this disease. Owing to the thickness of the abdominal
wall, fluctuation could not be detected, even when the
peritoneum was reached. About five ounces of green-
ish and fetid pus was evacuated. Coils of intestine
could readily be felt forming the inner wall of the ab-
scess cavity. Appendix was not found. The cavity
extended from the lower border of the right kidney to
the cfficnm. The abscess cavity was irrigated with
boiled water, a rubber drainage-tube inserted, and an
iodoform dressing applied.

August 24th. Patient slept well last night. Warm
peptonized milk in small doses. Wound dressed. Con-
siderable discharge in dressing.

August 25th. Dressed. Tube cleansed, reinserted.
Enema produced copious evacuation from bowels.

August 27th. Diet, milk and grael. Wonnd dressed
every day. Discbarge is decreasing and cavity becom-
ing smaller.

August 31st. Tube removed. Wonnd looks well.

September 6th. Patient eats and sleeps well. Gen-
eral appearance good. Wound gradually closing.

October 1st. Wound entirely healed.

January 1, 1894. Patient in good health. No re-
turn of disease.

Case XI. A. C, male. Twenty years of age,
single, carpenter.

Admitted to St. Joseph's Hospital September 9,
1893. Good family history. Three years ago patient
bad an attack of diarrhoea and vomiting, with severe
abdominal pain, most intense in the right iliac region.
He recovered in a few days, and has had two attacks
since, the last occurring last snmmer. His tempera-
ture then ranged from 100° to 102°. Pain severe,
localized in right iliac region. Vomiting and consti-
pation were also accompanying symptoms. His tem-
perature on admission to the hospital was 99°, and be
complained of pain on firm pressure over McBurney's
point. No mass or sense of resistance could be felt.
Removal of appendix advised.

September 18th. Operation, under ether. Asepsis
aimed at in preparations. An incision three inches in
length was- made, parallel with the median line, the
centre of the incision being over McBurney's point.
The abdominal cavity was opened, and the appendix
was found bound down by slight adhesions behind and
to the left of the caecum. It was three-quarters of an
inch thick and two and one-half inches in length. Coats
thickened. The appendix was excised about three-six-
teenths of an inch from the csecum. The mucous and
muscular layers of the stump were drawn outwards, and
a ligature of fine sterilized silk placed about them. The
peritoneal coat of the appendix was now drawn over
the ligatured mucous and muscular coats, and united
by three fine silk, Lembert sutures. Four silver-wire
sutures through abdominal walls, and several silk-
worm-gut sutures through skin and superficial musdes
closed the abdominal wound. No drainage. An asep-
tic dressing applied. Patient bad a comfortable night.
Scarcely any pain. He took only drachm doses of hot
water every fifteen minutes daring the first twenty-
four hours.

September 14th. Drachm doses of peptonized milk,
alternated with hot water. No nausea at any time.

September 18th. Bowels moved for the first time
since the operation by an enema.

September 22d. Silver- wire sutures removed. Pri-
mary union.

September 26th. Silkworm-got sntares removed.
Discharged from the hospital cured.

December 20th. Patient in good health.

Case XII. E. H., male. Aged twenty-seven
years, horse-car driver.

Admitted to St. Joseph's Hospital October 16, 1898.
Patient's family history is good. Until one year ago
he was in good health ; then he was seized with severe
abdominal pain, more intense on the right side, accom-
panied by fever. In a few days he was better, but
occasionally had pain in the right iliac region, bat not
severe enough to prevent him from attending to his
work. Last March he had a similar attack to the first
seizure. Ten days ago he had more severe pain than
in previous attacks, with pain localized in right iliac
region. Vomiting and rise in temperature. He was

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MEDICAL AND 8UROI0AL JOURNAL.

309

treated by ice locallj and opium internally, nntil these
symptoms subsided so that be was able to walk aboat
for past few days. He has pain on complete exten-
sion of thigh, and greatest tenderness on pressure just
below and to the right of McBorney's point. There
is a small area of dulness and a sense of resistance
over the same region.

October 17th. Operation, under ether, with strict
asepsis. An incision three inches long, parallel with
the median line, was made over the area of daloess.
The various abdominal layers were incised until the
peritoneum was reached, when it was found that the
cscum was adherent to the abdominal wall below the
site of the incision. The wound was enlarged upwards
until the abdominal cavity could be opened above the
point of adhesion of caecum to thu abdominal parietes.
By careful manipulation the adhesions, which were on
all sides of the caecum, were severed by the fingers,
and the appendix was found by following the longi-
tudinal fibres of the caecum. The appendix was bound
to the caecum throughout its entire length. Its coats
were thickened, and near the junction of the appendix
and caecum its cavity was obliterated and its walls
gangrenous. A silk ligature was passed around the
Slump of the appendix and tied. Owing to the inflam-
matory process which had occurred, the peritoneal coat
of the appendix could not be united over the remain-
ing stump ; neither could a fold of the adjacent perito-
neum covering the caecum be employed to cover the
stump of the appendix, as the coating of lymph so
thickened the peritoneum that it was not readily pli-
able. The abdominal wound was closed with thirteen
silkworm-gut sutures, and an aseptic dressing applied.
A drachm of hot water was given every fifteen min-
utes during the next twenty-four hours.

October 18th. Pain relieved by sulphate of mor-
phia (gr. ^), hypodermatically given. No nausea.
One drachm of peptonized milk every half-hour. Pa-
tient feeling well.

October 24th. Bowels moved by enema. Temper-
ature normal. Sleeps well. Takes plenty of milk.

October 27th. Seven of the sutures removed.

October 30th. Six other sutures removed. High-
eat temperature since operation 99.5°, which was on
the third day. Wound has healed by primary union.

December 15th. Patient in good health.

None of the cases reported have had recurrence of
the disease. Two cases developed small hernia at the
seat of the cicatrix. My observations lead me to say
that while some of the cases require a very simple op-
eration, others call into action all the skill and inge-
nuity of an expert. I am convinced that the aspirator
may be very harmful, and should never be used in
cases of appendicitis. Early operation, that is, within
the first forty-eight hours, by a skilful surgeon, will
•ave the greatest number of lives.

Alcmindm fob Sdboical Instkdmknts. — A phy-
aidan who got rid of some of his steel instruments and
boDght others made of aluminum, says that he is
sorry that he changed. The aluminum probes, sounds,
tongne^epressors, and that sort of thing do not oxi-
dize, to be sure, but he finds that they are deficient in
elasticity and stay bent after pressure. He declares,
moreover, that he likes to feel that he has a hold on
something when he uses an instrument, and aluminum
is so light that he can put no (rtt8( ii| it.

PATHOLOGY OF DIABETES MELLITUS.*

Br ELLIOTT P. J08LIM A.B., PH.B.

Diabetes mellitus is now considered by many au-
thors to be a disease of more than one type and in this
paper the classification of Lancereaux * will be adopted.
He divides the disease into three forms, (1) constita-
tional, (2) nervous and (3) pancreatic. The symptoma-
tology, pathology and experimental work which has
been lately done on these varieties of diabetes will be
here discussed, and an account of Chauveau's recent
work given.

(1) The constitutional or fatty diabetes is the common
form of this disease, and is well known to you all. It
is most apt to occur in middle life, and frequently
comes on in successive generations of a family, and
cases are on record where it has been traced through
four generations. Schmidtz ' has traced heredity in
248 out of 600 cases of diabetes, and probably they
were mostly of this variety. Obesity and gout are
often precursors ; and headache, epistaxis, haemorrhoids
and neuralgia are frequently prodromal symptoms.
The disease begins insidiously, slowly advances, and
often is accidentally discovered or brought to light by
some of its characteristic complications. When dis-
covered it rapidly yields to dietetic treatment, and
after a residence at some resort like Carlsbad, the sugar
may wholly disappear from the urine. It will re-
turn, however, in time, and the treatment must con-
stantly be kept up. In these persons, the urine seldom
rises above three or four litres per day, and the amount
of sugar varies between 90 g. and 300 g. for the
greater part of the time. This form of diabetes may
have a long duration, and not greatly interfere with a
man's business. Cases have lasted thirty and forty
years.^ Death comes either from an intercurrent
disease or from the complications.

Unfortunately the pathology of this disease is not
understood, and later investigations may destroy this
classification.

Experimental work has added little to our knowl-
edge of this type of diabetes. Considerable work,
however, has been done on the so-called alimentary,
toxic and phloridzine glycosurias, which will now be
described.

Normal urine contains a small quantity of dextrose.^
Experiments have been made on men and dogs to
whom large amounts of sugar have been given. When
250 g. of cane-sugar were given to a man * who had
been previously kept on a nitrogenous diet, 0.7 per
cent, of the amount appeared in the urine. In dogs *
the ingestion of such an enormous quantity as 500 g.
caused 3 per cent, of the amount to appear. Eleven
individuals * underwent a rather agreeable experiment
in which they partook of a supper of sweets, ices and
champagne. Two to four hours later the urine of five
of the party contained from 0.1 per cent, to 0.25 per
cent, of sugar. Two hours later the sugar had disap-
peared. Another writer* has found that animals
which had been starved for a few days, when given
small amounts of sugar experienced a transitory glycos-
uria. A similar lack of assimilation of sugar may
explain light forms of diabetes. This is known as
alimentary glycosuria.

Toxic glycosuria is due to the ingestion of various
poisons, notably curare. A host of investigators have

• Ke«d before the Boylston Medleal Society of (he Uanrard Medi-
cal School, NoTember 17, 1883.

Digitized by

Google

310

BOSTON MEDICAL AND SURGICAL JOVBNAL

[llABCB 29, 1894.

found SDgar in the urine after injections of curare ; but
an equally large number have affirmed that glycosuria
was absent, providing artificial respiration was main-
tained. Halliburton^ says that the glycosuria is not^
present in these cases, but that the sugar reaction is
due to glycuronic acid. He furthermore adds that
this explains the supposed glycosuria which sometimes
follows the use of morphia and chloroform. Strychnia,
nitrate of uranium and many other drugs are claimed
to have the power of bringing about a temporary
glycosuria.

Phloridzine glycosuria has excited much interest.
When phloridzine is given to an animal in the food, or
snbcutaneously, a glycosuria is produced. It com-
mences about three hours after the ingestion of the
glucoside, attains a maximum in twenty hours, and
ceases within a day and a half. The glycosuria varies
with the amount of food ingested. Various explana-
tions of this phenomenon have been offered, but a re-
cent series of experiments by Minkowski and von Mer-
ing throw much light on the subject. In birds glycos-
uria does not follow extirpation of the pancreas, but
von Mering ' found on giving phloridzine that sugar
appeared in their urine. Dogs, rendered diabetic,
passed an additional amount of sugar when they were
given the drug. This led Minkowski to make the fol-
lowing experiment.' He removed the kidneys, both
from a healthy dog and from a dog suffering with dia-
betes produced by pancreatic extirpation. To the
healthy dog he gave phloridzine. After a time the
blood of both animals was examined. The diabetic
animal's blood contained O.S per cent, to 0.5 per cent,
of sugar, which is from two to three times the normal
quantity, while the phloridzine animal showed an ab-
normally small amount of sugar in the blood. He
argues that if sugar is being formed in the organism,
removal of the kidneys, thus preventing its excretion,
will cause a storing up of it in the blood. The experi-
ment shows that in the diabetic animal this was done,
while in the phloridzine animal the sugar, far from
being increased, was diminished. He, therefore, con-
cludes that the glycosuria produced by phloridzine is
due to its direct action on the kidneys.

In considering this constitutional type of diabetes,
with regard to which we know so little, it is well to
remember that an excessive amount of carbohydrates
and some poisons may cause a temporary glycosuria,
and that the kidneys under certain circumstances may
allow the passage of sugar.

(2) The nervous or traumatic ' variety of diabetes is
the mildest of the three forms. It comes on after shock
to the nervous system caused either by trauma or some
severe mental strain, for example, worry, anxiety and
tlie like, and runs a variable course. Polyphagia is
absent, and the patient is seldom troubled with poly-
dipsia. The urine is perhaps twice the normal amount,
and though sugar is present, it is not in large quantities.
There is little loss of weight. Subjected to treatment,
hygienic and dietetic, the individual rapidly recovers,
and the transitory glycosuria is over. Complications
are rare. There is a sure tendency to recovery, and
death almost never occurs unless there are extensive
lesions of the central nervous system.

Pathology. — The pathology of the nervous form of
diabetes has been earnestly studied and with good rea-
son, for clinically mental .disturbance appears to play
a great role in its etiology. Packard * says many rail-
road engineers are victims to this disease. Paige '"

lays great stress on mental emotions. Madigan " has
observed glycosuria alternating with insanity in a pa-
tient. Savage " has found diabetes and insanity alter-
nating in families. Nagel " has observed two cases of
persistent glycosuria following an apoplectic attack.
Dr. R. H. Fitz '* referred to the presence of glycosuria
in epilepsy. Windle '* has tabulated the records of
184 brain examinations in the post-mortems of diabe-
tic persons. In 91 instances, the brain was normal;
and of the remaining 93, 23 were connected with the
fourth ventricle. These lesions were of the most vary-
ing type; cerebral hsemorrhage, meningitis, tumors
and congestion of the blood-vessels were all noted.

The whole subject was looked into by a committee
of the London'* Pathological Society in 1882, who
reported that they failed to find in the brain " an;
change which could be regarded as exclusively or cod-
stantly associated with diabetes."

In .58 cases of diabetes in which an examination
of the spinal cord was made, 37 were found normal ;
and in the remainder there was no characteristic
lesion.'*

Experimental Work. — The experimental work of
Claude Bernard, on the production of glycosuria by
the puncture of the fourth ventricle, was one of hie
most brilliant achievements. This has been repeated
many times with success. If the medulla be punctured
in the region of the vaso-motor centre of a well-fed
animal, sugar will appear in the urine in considerable
quantity. After a few hours the sugar will have
reached a maximum, and in a day or two, or even less,
the sugar will be absent from the urine. If the ani-
mal has been starved previous to the experiment, little
or no sugar appears. It would thus seem likely that
the lesion to the fourth ventricle in some way acted
on the liver so that the change of glycogen into sugar
was accelerated, and the blooid thus loaded with sugar
emptied its excess into the urine.

The pneumogastric nerves " run to the liver, via
the solar and hepatic plexuses. Section of these
uerves does not give rise to glycosuria, nor does stimu-
lation of the peripheral end of the section. This shows
that the impulse from the diabetic centre in the medulla
does not travel along these nerves. On the other
hand, electrical stimulation of the central eud of the
section produced a glycosuria analogous to that brought
about by puncture of the medulla. Furthermore, it
is claimed that in some cases an irritation of the
branches of the tenth pair of cranial nerves in the ab-
domen, liver, lungs, heart, stomach and intestines may
in some cases bring about a temporary appearance of
sugar in the urine. This would imply that the pneu-
mogastric exercises an inhibitory influence upon the
diabetic centre of the medulla.

The liver receives another nerve-supply through the
splanchnics. When these nerves are cut, no sugar
appears in the urine ; and if then the diabetic puncture
is made, it fails. Evidently, the action of the diabetic
centre on the liver is by means of the splanchnic
uerves. These have been traced to the spinal cord,
with more or leas probability, through the gangliated
cord of the sympathetic, the first dorsal ganglion, the
annulus of Vieussens and the lower cervical ganglion.
Probably they do not leave the cord always at the
same level.

Lustig obtained a transitory glycosuria by making
lesions of the solar plexus, and Lepine has produced
diabetes by electrization of the nerves of the pancreas.

Digitized by

Google

Vol. CXXX, No. 18.) BOSTON MEDICAL AND SURGICAL JOURNAL.

311

"Section and lubseqaent Btimulation of the central
end of the sciatic nerve causes diabetes." ''

With regard to these experiments on the nervous
Bystem, I should like to call your attention to the
following coDsiderations : (I) the glycosaria has been
transitory in every case ; (2) the experiments are
severe, and might of themselves produce such a con-
stitutional derangement that glycosuria would result,
even if there was no injury to the nerves ; (3) as for
an injury of the solar plexus producing glycosuria,
Minkowski has shown this view to be erroneous.
The work of Chauvean on nerve lesions is so recent
that it will be deferred to the end of the paper.

(8) The pancreatic or thin type of diabetes is the
most severe form of diabetes mellitus. In one class of
cases, an individual who has been in perfect health is
plunged into the midst of a severe diabetes. In other
cases the symptoms come on gradually ; and belching
of wind, nausea, a sense of fulness and weight iu the
epigastrium are often the first indications of trouble.
Diarrhoea is often present. In still other cases, what
is supposed to be a fatty diabetes develops into the
thin variety." When the disease is established the
polyphagia, polydipsia and polyuria are extreme. The
skin is harsh, dry and leathery to the touch. Emacia-
tion qnickly comes on, and there is great fatigue on
exertion. The knee-reflex is usually abolished. Often
the hair is lost, and the patient's teeth decay or fall
out. The mental character is changed, and the un-
happy individual is often in a state of mental depres-
sion. Hectic fever has been observed. The evolution
of the case u characterized by its rapidity, and in the
coarse of a period from a few months to three or four
years, the patient usually snccumbs to phthisis or dia-
betic coma. The urinary symptoms are much more
severe than in either the fatty or the nervous forms.
The quantity ranges between three and ten litres, and
is generally between five and seven. The urea is
decidedly increased and the sugar excreted per day is
from 300 g. to 500 g.

Pathology. — Thomas Cowley,* iu 1788, was the
first to record a lesion of the pancreas in connection
with diabetes mellitus. He observed an atrophy of
the gland, with the presence of calculi, and suggest^id
that it might be the cause of the disease. During in-
tervals of forty years, more or less, Chopart * and
Recklinghausen ^ made similar observations. But it
was not until 1877 and the few following years, that
the matter received much attention. Laucereaux *
then published his two cases. In one of these the
pancreas was atrophied, and much of the glandular
stractare was lost ; in the other it was only with diffi-
calty that the gland was found at all ; but when found,
calculi were discovered in the canal. Lancereaux's
memoir led pathologists to study the pancreas more
carefully ; and, as a result, in quite a number of in-
stances of diabetes, pancreatic lesions have been found.
There would undoubtedly today be more recorded
cases of changes in the pancreas in diabetes, were it
not for the fact that the gland may look perfectly nor-
mal to the naked eye and yet on microscopical exami-
nation show marked alterations.^** Until this be-
comes more generally known, a diseased pancreas will
be often overlooked.

What is the character of these changes ? They are
most varied, but the predominating characteristic is an
increase in the amount of interstitial tissue. William-
ion ** has collected 100 oases from the literature upon

the subject ; 47 showed an atrophy more or less
marked, and of this number the gland was almost
absent iu three ; in two others it was not recognized
by the naked eye, and in two there was a cystic dilata-
tion of the duct. Seventeen out of 100 were in a
condition of marked fatty degeneration ; and in some
instances an increase of the connective-tissue, the
presence of calculi or atrophy were coexistent with
the main lesion. In another group of 13, the gland
was transformed into a firm mass of fibrous tissue ; in
three of this number the lesion is stated as a marked
cirrhosis. Of the remaining cases eight were cancer,
six were cysts and three abscesses. There were two
cases of " pancreatitis and pancreatitis hsemorrhagica,"
and one each of calcified, cirrhotic and cystic pancreas,
while in the remaining case the occurrence of calculi
was alone stated. Rokitansky " found the pancreas
affected iu 13 out of 30 cases. Saundby ^* gives seven
cases in which the pancreas was atrophied and four
where it was abnormally firm and fibroid. Windle ''
collected post-mortem records on the pancreas in 139
cases. In 65 of the number, the gland was normal.
Lest some of his cases and those of Williamson may
be identical, I will pass them by, simply stating that
atrophy and fatty degeneration were the most common
affections.

Are these changes iu the pancreas which are found
in diabetes accidental? Are they the result of the
disease ? Do they furnish the cause of one form of
this malady ?

The first question can be answered in the negative
with a good deal of assurance. Pancreatic changes
have been found too often in connection with diabetes
to be accidental. It does not seem likely either, that
they are the result of the disease. They are too di-
versified to have a common origin. That they are
concerned intimately with the production of diabetes,
their frequency and the experimental work done on the
pancreas makes highly probable.
(2V> baeonHmud.)

REFERENCES.

Lancereaoz: Bull. Acad, de M^d., Paris, 1877, 2d sc'rie, ri,

1215-1240; Bull. Acad, de M£d., 1888, No. 19, p. 588.
Scbmidtz: Laucet, i, 1883, qaoted, Roberts's Urioary and

Renal Diseases, p. 215.
Worm-Muellec: Pfliiger'g Archlv., tome zzzir, qaoted in

Arohtr. de Med., Ezper. No. 1, January, 1892, by Lepine

in an article entitled Revue Analytique et Critique des

Travaux R^cents Relatif il la Pathoggnie de la Olycosurie

et du Diabfete.
Seegan: Pfliiger'g Archiv., tome xzzvi, qaoted in Lepine's

article.
Moritz: Munch. Med. Woch., 1891, p. 6, qaoted in Lepine's

article.
Hofmeister: Quoted in Lepine's article.
Halliburton : Chemical Physiology and Pathology, p. 789.
Minkowslii: Diabetes Mellitus nach Ezstirpation des Fan-

kreaa, 1S93.
Packard : in Hare, vol. i, pp. 1009-1036.
Paige: Mew York Polyclinic, vol. i, pp. 10-44.
Madigan: Medical Standard, 1893, vol. xiii, p. 33.
Savage: Medical Standard, 18H3, vol. xiii, p. 33, qaoted.
Nagel : See Lepine's article under note 3.
Fitz : Lecture xi, 1893.
Windle: Dublin Journal o{ Medical Sciences, 1883, vol.

Uxvi, p. 112.
Qaoted by Pardy: London Pathological Society, Diabetes,
1890.
Lauder-Brunton: British Medical Journal, 1871, pp. 1, 39,

221.
Landois and Sterling : Human Physiology, p. 310.
Vaughn-Harley : British Medical Joarnal, Jannary 2, 1892,

p. 9.
Rendu: Semaine M^d., 1891, zl, 109.

Also see the following on Pancreatic Diabetes.
Williamson: Medical Chronicle, March, 1892; Rokitansky

Is also qaoted.

Digitized by

Google

312

BOSTON MEDICAL AND SVRGIOAL JOURNAL. [March 29, 1894.

Deplerre: Hedical News, xzzix, p. 334: Original Article In

Joar. de M^d. et de Chlr. Pratiqnes, Deceiiib<>r, 1880.
VaaKhn-Harley: British Hedical Joarnal, viii, 27, 1893.
Nichols: New York Medical Joarnal, 1888.
Boatard : Thise de Paris, 1890.

20. Lemoine and Lannois: Arcbiv. de HM., Exper., Jannary,

1891.

21. Sanndby: Qnoted in Osier, ander Diabetes Heliitas.

SI. Leplne: Lyon M^. Jonr., January 26, 1891 ; Semaine M£d.,
1881, pp. 24, 111, 179, 388, 467, fitS; Also see note 3.

Clinical SDqiatrtment.

THROMBOSIS OF THE CENTRAL ARTERY OF
THE RETINA, WITH UNUSUAL FEATURES.*

BT BDWIR B. JACK, H.D.,

OpMha'mic Surf/eon to Out-fatiaUt, Botlon CUy HotpUai; Auit-
iant Ophthalmic Surgeon, MauaehuulU ChmritatU Rye and gar
Infirmary,

The patient was a small and rather thin woman,
forty- three years of age, who had always had fair
health, and had never had any previous trouble with
the eyes. On July 2.5, 1893, she was seized with sud-
den and severe pain through the left eye. The pain
was confined to the eye, and was sharp and cutting in
character. On the night of the 28th, the pain, still of
the same kind and sitoation, became excessively severe,
and the sight of the eye was suddenly lost. Coinci-
dent with this the coojuuctiva became injected and the
eye " looked swollen " — this increasing in the next
few days. For about six weeks previous to this time
the patient had had attacks of sadden blindness in the
left eye, possibly three a week, coming on at irregular
intervals and lasting from ten minutes to two hours.

I first saw her July SOth, and at that time the was
much exhausted by the terrible pain and the entire
loss of sleep for three nights. The condition of the
eye was as follows. Conjunctiva injected and quite
(edematous, raised in a mound partly around the cornea.
y=0. Media clear. Whole fundus, except at periph-
ery, an almost milky white, more intense around the
macula. Macular region, for a space about one-third
the size of disc, a pale red approaching a slaty color
and sharply defined. Nerve head white except at
porus, where it was pinkish ; outlines obliterated. On
lower temporal side a fair-sized beemorrhage, near this
other very small haemorrhages. All vessels small.
Some began at porus without blood-contents, but as they
approached the periphery were partially filled with a
granular-looking blood-column, giving the vessel an
uneven appearance of local contractions and dilatations.
Other vessels began at the porus with blood-contents
of the same granular appearance, and as they ap-
proached the periphery lost their contents and appeared
as white cords. These cords, however, were inter-
rupted in places with small cylinders of blood — this
happening mostly at the junction of branches. At
every heart-beat there was a to-and-fro movement of
the broken blood-column in both arteries and veins —
toward the periphery in the arteries and toward the
disc in the veins ; but no progress was made, the blood
returning to its original position. Some of the vessels
with blood-contents had white borders ; and two small
vessels branching from the disc toward the macula
were visible only as white, thread-like lines.

The appearance of the fundus August 2d was about
the same, except that the macular region was a slaty-

> Bead before the New England Ophthalmologlcal Soelet;, Febru-

brown color and no movement of the blood-column
was visible. There was less injection and oedema of
the conjunctiva. On August 4th there had been bi^
little pain since the last visit. The region around the
eye, especially the brow and nose, was tender. No
oedema of the conjunctiva and very little injection.
FunduB-nerve very pale, but outlines very little ob-
scured. Some oedema of retina remaining, but general
color of eye-ground pink. Macular region, for a space
rather larger than the disc, mottled much as in chorio-
retinitis.

The last observation was on January 25th of this
year, just six months after the attack. Externally
nothing abnormal. Fundus in general of normal color.
Disc atrophic. Vessels about the same as previously
described, but with more signs of perivasculitis.
Macular region mottled, and around it spots, mostly
small, of a pale-yellow color. Toward the periphery,
especially between the vessel branches, there were ap-
pearances very like those seen in retinitis proliferans,
bat with no elevation, these patches merging into
others having the characteristic appearance of disturbed
retinal pigment. The eye was still absolutely blind.

Fourteen months ago the patient gave birth to a
child after an easy labor. Seventeen years before
this her only other child was born. About ten days
after her last confinement she complained of a prick,
ling and sleepy sensation in the right arm, which
under bathing and massage disappeared. Three months
later she began to have trouble in using the arm and
hand, and soon they were practically useless. At
present she can raise the elbow but little ; the arm is
fixed in a partially flexed position; the fingers alto
are partially flexed and have but little movement.

The present health of the woman is good. Within
a year she has felt hardly as well as usual, but there
have been no definite symptoms except dyspepsia.
There have never been any signs pointing to cardiac
or renal disturbance, and she has never bad rheuma-
tism. There is no history, and there are no sigus of
syphilis or of vascular degeneration. An examination
of the urine at her last visit showed — color pale, specific
gravity 1,012, no albumen, no sngar. The heart hat
been examined recently by her physician, Ur. E. S.
Jack of Melrose, and is wholly normal.

There are in this case, it seems to me, several un-
usual and interesting features. The excessive pain
and the conjunctival oedema are certainly unique and
bard to explain. As far as the attacks of blindness
and the fundus appearances are concerned there are
several possibilities. These are embolism and throm-
bosis of the central artery and thrombosis of the cen-
tral vein.

The case certainly has the typical appearance of
embolism, with more than usual cedema. This suppo-
sition, however, does not well explain the many at-
tacks of transitory blindness. The aura which occa-
sionally precedes embolism, taking place in about one-
fourth of the recorded cases, is, I think, rarely so
frequent or complete. Schuabel and Sachs have ex-
plained these attacks by the theory that partial emboli
shift their position at times, eventually becoming per-
manently fixed and entirely blocking the blood-car-
rent. Another explanation is that a partial embolus
may cause a spasm of the vessels, thus shutting off the
blood-current, this passing ofiF and allowing the blood
to circulate again.

Thrombosis of the central vein was first noted by

Digitized by

Google

Vol. CXXX, No. 13.] BOSTON MEDICAL AND SURGICAL JOVRHAL.

313

Loriog, and corroborated later, anatomically, bj An-
gelucci. Its dUtingaisbiDg feature in all grades is a
great distention of the veins, and there is usually no
diminution in the size of the arteries, lu the severe
cases there is a strong resemblance to haemorrhagic
retinitis, with large and tortuous veins. In our pres-
ent case there were a few small hsemorrhages, but they
certainly occur to a limited extent in embolism. There
was no venous distention — an important negative
point. With this exception the case resembles one of
Loring's examples of venous thrombosis, especially as
regards the extensive oedema of the retina. In his
patient, who had aortic obstruction, he considered that
the attacks of transient blindness which had come on at
intervals for many years, were the effect of tempora-
rily weakened heart-action on an eye with abnormal
vessels. The absence of physical or other signs of
heart-trouble in the present instance does not eliminate
the possibility of an embolus starting from that source ;
but it does, it seems to me, destroy the application of
such a theory in accounting for the repeated attacks.

Finally, there is arterial thrombosis, a condition
which, according to Loring, Priestly Smith and others,
is probably more frequent than supposed. Indeed,
they consider that many of the specimens called em-
boli are really thrombL The fundus changes are the
same as in embolus. Previous attacks of transient
blindness in the affected eye and even in the fellow
eye, from probable spasm of the vessels, are given as a
distinguishing feature of this condition. This corre-
sponds more easily to the facts in the present instance
than either of the other alternatives. The presence of
the moving blood-columns, showing in all probability
an incomplete shutting off of the current, does not aid
iu establishing this diagnosis, as the same phenomenon
undoubtedly occurs in embolism. Unfortunately, too,
the existence of perivasculitis of the retinal vessels so
early cannot be taken as a sign of any analogous pro-
cess further back, for the same thing can come on in
the very earliest stages of embolism, where there is
not any question of vascular trouble in the central
artery.

It is interesting to look at the matter from another
point of view — the possible connection in etiology
between the monoplegia and the process in the eye.
The monoplegia, judging from the nature of the paral-
ysis, was cerebral, and it would seem most probable
that it was of thrombotic origin. The existence of
signs of vestol degeneration would throw much light
OD the question of a common pathology ; their absence
leaves room for doubt. Whether the blood state soon
after the confinement may have had any influence in
cansing the monoplegia and in creating a condition of
the heart or large vessels from which later an embolus
eoold have come, is a question of importance. I will
go DO further than to say that, if we admit any con-
nection at all, such a sequence seems probable.

From this standpoint, then, we come to no conclu-
lion more definite than before. Clinically the case
resembles one of thrombosis of the artery more than
anything else. This diagnosis, too, explains best a
pathological connection between the menoplegia and
the blindness. For these reasons, and because there
seems to be a growing opinion that thrombosis rather
than embolism is the more usual process, I have re-
tained that title. The conjunctival oedema may have
oome from an involvement of other vessels. I know
of no explanation for the pain.

Q^eDical |^ro0reierie(.

RECENT PROGRESS IN LEGAL MEDICINE.

BY F. W. DBAPBB, H.D.

MEDICAL EXPERT TESTIMONY.

Medical expert testimony has inexhaustible in-
terest as a reform topic The uses and abuses of this
kind of proof continue to engage the earnest attention
of medico-legal writers. As iu the case of some of
those chronic ailments of the human race so familiar
to medical practitioners as clinical opprobria, the num-
ber of remedies suggested attests the difficulty of the
treatment; so iu the present instance, every year calls
out a new panacea for a disorder about the diagnosis
of which there is substantial unanimity among physi-
cians. One of the latest suggestions relative to the
employment of experts comes from Dr. L. C. Gray, of
New York, and evidently had its source in a very ex-
tensive personal experience in court proceedings.*
Dr. Gray's remedy takes a dou'ble form : (I) the selec-
tion of medical men by the presiding judge to sit on
the bench with him in an advisory capacity in trials
which do not need juries; and (2) a conference of all
the medical men in cases tried by a jury. The former
plan has its analogy in the use of assessors in the
English admiralty courts. The latter method, in the
author's opinion, would bring about substantial agree-
ment among the medical witnesses with reference to
facts and objective conditions, although conclusions
therefrom, diagnostic and prognostic, might differ. To
the objection that the system of medical assessors and
medical conferences here urged is opposed to the prin-
ciples of our law. Dr. Gray courageously answers that if
that be so, " the principles of our law are radically
faulty " ; and again, " a law that ceases to be the em-
bodiment of common-sense has outlived its usefulness
and ought to be superseded."

WODND8 WITHOUT INJDKT TO OTBRLTINO CLOTH-
ING.

Examples of the improbable serve to check the
medico-legal sin of dogmatism. The following are
illustrations of what must be considered an unusual
combination of conditions.

Dr. Spokes, of London,' reports the case of a man
who, while leading a horse, stumbled and fell ; the
animal trod on him iu such a way as to make a wound
of the scrotum out of which the right testicle was ex-
truded so that it lay outside its normal covering. The
man's explanation of the wound was that the horse's
hoof forced against the scrotum the metal edge of a
purse which was carried in the pocket in such a posi-
tion that it lay close to the genitals. The clothing,
including the fabric of the pocket, was entirely intact.
The edges of the wound were clean-cut.

Dr. Wagner, of St. Louis,' found in the foregoing
a reminder of an experience of his own having similar
features. While on a hunting trip through thick woods,
Dr. Wagner carried a small hatchet in his belt for the
purpose of cutting away a passage through the under-
brush. In following game down a rather steep hill,
he tripped and fell quite heavily, driving the blade of
the hatchet against his thigh. He felt some pain, but
as his clothing showed no external sign of a cut or

> New 7ork Medloal Joomal, May 20, 1883.
' Lancet, Februarj 6, 1SS3.

> New York Medieal Jonmal, Haroh 11, 1893.

Digitized by

Google

314

BOSTON MEDICAL AND SURGICAL JOVBNAL.

[March 29, 1894.

tear, he attribated his sensation to a simple bruise,
until he felt the blood within his underclothing and ou
undressing found a cut three-quarters of an inch long
in the front of his thigh. The cut was somewhat ir-
regular and left a scar as broad as it was long. The
clothing showed no sign of injury whatever.

THE DIAPHANOUS TEST AS A PBOOF OF DEATH.

The term "diaphanous test" has been applied to an
observatiou which consists in raising the hand of a sup-
posed dead person, placing it before a strong artificial
light, with the fingers extended and just touching each
other and looking through the narrow spaces between
the apposed fingers to see if a scarlet line or edge per
sists ; the theory being that the presence of such a tint
indicates that circulation of the blood contioaes and
that there is evidence of life. This test received the
approval of the French Academy of Medicine.

Edwin Haward presents a case which shows that the
test should not be relied on alone as a conclusive one ;
the case also demonstrates the difficulty occasionally
encountered in distinguishing real from apparent death,
and the need, in such cases, of applying all the reliable
methods for the prevention of deplorable haste, awut-
iug if need be the advent of decomposition if other ap-
pearances and conditions are in the least equivocal.*
A woman of seventy-three, a subject of chronic bron-
chitis, was found early one morning in bed, insensible
and apparently dead ; but she looked so like-life, al-
though not breathing, that her family had great doubt
if death had actually occurred and Dr. Haward was
summoned to solve the doubt. He found on his arri-
val, half an hour later, entire absence of respiration, of
pulse and of heart-beat; the hands, slightly flexed,
were rather rigid. These signs afforded a strong pre-
sumption that the woman was dead ; but her counte-
nance looked like that of a living person. This fact
and the fact that once previously she had passed into
a death-like state, with similar symptoms, even to the
rigidity of the arms and hands, from which state she
had recovered, caused the medical attendant to apply
all known reliable tests and to call in expert help for
the purpose. Sir Benjamin Ward Bicbanlson was the
consultant and his observations on the body of the wo-
man were made with unusual care. Ten tests were
applied, of which eight gave affirmative results in
conformity with death ; but there were two which were
equivocal. Blood drawn from a vein in the arm was
very dark, but flowed out in a fluid state and did not
coagulate when exposed to the air. But the diapha-
nous test was the more striking ; when the hand, with
the fingers brought near together, was held before a
strong light, there was a distinct red line of coloration
between the fingers, as is seen in the healthy living
hand. The body was allowed to remain in a warm
room until the final proof, that of decomposition, re-
moved every possible doubt. Dr. Richardson observes '
that the lesson to be learned from this case is that the
diaphanous test is of itself "positively worthless."
He has seen an ordinary case of simple syncope in
which there was entire absence of the rosy tint between
the fingers, although the patient quickly recovered
consciousness.

HEDICO-LKOAL RELATIONS OF CRANIAL INJURIES.

The head is, of all regions of the body, a part whose
lesions present the greatest gravity, and are the most

< Lan(s«t, Jnns 10, 1893.
• Aioleplad, vol. x, Ko. 38.

often fatal ; it is particularly exposed to contusion in-
juries which represent weapons of the most primitive
kind, and which offer the most frequent examples of
homicidal violence. Maissiat,* of Lyons, has made a
comprehensive study of these injuries of the skalj.
He calls attention first to the difficulties met in de-
termining the kind of weapon with which a given
scalp-wound has been made; a blow with a blunt in-
strument may make a wound upon the head resembling
an incised or punctured wound. In these cases the
nse of a lens is a valuable aid ; it discovers irregulari-
ties of the edges and deeper parts not apparent other-
wise. Scalp-wounds tend to take ou a rectilinear ap-
pearance in consequence of the retraction of both the
pericranium and the outer tissues of the scalp where
the parts are divided ; this tendency is more marked
in the scalp than in any other part. Another impor-
tant medico-legal point is brought out by the author:
there may be fracture of the skull without any lesion
of the external soft parts or any external suggestion
of traumatism.

For medico-legal purposes, cranial fractures are
studied by Maissiat according to the method of their
production : (1) by puncture ; (2) by a cutting weapon ;
(8) by contusion; (4) by a fall from a height. In
fractures of the first group, the lesions are limited to
the point struck ; if the weapon is of medium size,
there are no radiating fissures in the bone, and even if
the weapon is of considerable size, the stellate radia-
tions are not extensive. Fractures by a cutting
weapon (sabre, hatchet) show most often a clean sec-
tion of the bone, with fissures extended in the axis of
the principal lesion, with few fragments, and with
only an exceptional extension of the break into the
base of the cranium. Blows with a club cause a more
or less comminuted fracture, with radiations extending
from the chief lesion, and offering no uniform rule of
extension; if the weapon used has a broad striking
surface, the bony lesion which results is more apt to
penetrate to the base of the skull, thus resembling the
effects of a fall. In these latter cases, unless the fall
is very considerable, the comminution is not exten-
sive ; in any case, it is very common to find the fissure
or fissures projected from the vertex to the base, espe-
cially into the anterior fossse. Experiments by Per-
rin have shown that these indirect lesions of the base
of the skull are rarely the result of any injury other
than a fall ; that they do not readily follow a blow
with a club, however heavy the blow may be.

PHEMOUENA AFTER DECAPITATION.

Laborde has reported some instructive observations
upon the head and body of a man executed by decapi-
tation.' In two-and-a-half minutes after the axe of
the guillotine fell the oculo-palpebral reflex failed to
respond. The patellar reflex continued to the end of the
third minute. The persistence of the reflexes through
even this short interval proves, at least, that decapita-
tion does not cause immediate and absolute inhibition.
The cardiac impulse continued eleven and a half
minutes. The cadaver presented the penis in a state
of erection, without a discharge of any kind. The
right frontal lobe of the brain was uncovered by tre-
phining, the operation being begun twelve minutes
after the decapitation ; after exposing the motor con-
volutions, an electric current was passed for stimnlar

" Maraellle-mMlcal. July, 18S3.
' Le Bulletin MM., June 21, 18«8.

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MEDICAL AND SUROIOAL JOURNAL.

316

tion of the graj matter. Very clearly defined move-
mentB of the right facial mascles resulted. Laborde's
explanation of the appearance of the muscnlar con-
tractions on the right side, rather than on the left, is
that the electric onrrent was diffused.

DEATH BT HANOINO.

In the course of some investigations into the pathol-
ogy of subserous hsemorrhages in asphyxia, Corin in-
stituted a series of experiments on the blood-pressure
and the nervous phenomena in death by hanging.'
Repeating with some modifications the observations of
Predericq, Konow and Steenbech, he established the
important part which compression of the carotids and
poeumogastric nerves has in the course of death by
baoging, and demonstrated the secondary or negative
importance of occlusion of the jugular veins. With
regard to the pneumogastrics, Corin found that press-
ure on those nerves, whether they were isolated or
not, resulted in a slowing of the respiration and a co-
incident quickening of the heart-beats. There is no
qaestioning of the truth of Coutagne's theory that
compression of the vagi abridges the duration of the
asphyxia in hanging.

With regard to compression of the carotids, experi-
ments by injection prove the complete occlusion of
those arteries when the body is suspended by the
neck, and such being the case, there must necessarily
he a marked degree of cerebral anaemia to aid in the
fatal issue, for the vertebrals are too small and tortu-
ous to maintain the supply of arterial blood.

DEATH BT STBAN6ULATION.

Strangulation as a method of suicide is so rare that
the following instance is of interest.* This case was
the subject of an inqnest at Hastings, England, the
deceased being a middle-aged female servant. Her
dead body was found in a room whose windows and
doors were locked on the inside ; it was lying on the
floor, face down, with the hands beneath the chest.
There was no appearance of struggling. Blood oozed
from the mouth, and the tip of the tongue protruded.
Around the neck were two yards of list, and, over
this, three "yards of tape; neither of the ligatures was
knotted, but was simply wound about the throat,
below the cricoid, evenly, layer on layer. The only
clothing was a night-dress, and alongside the body, on
the floor, was a blanket. A little blood was found on
the pillow of the bed in the woman's bedroom, and
the surgeon who made the autopsy testified that, in his
belief, the strangling was begun in this room, and was
completed in the room where the body was found.
The woman was a strong, muscular person ; her
motive for self-murder was not determined, although
there was some evidence that she had been a subject
of religious mania. The post-mortem appearances
were those of asphyxia.

The Dowmimo Pkofbssor of Medicine. — The
Downing Professorship of Medicine in the University
of Cambridge, England, which was left vacant by the
retirement of Dr. Latham after a service of twenty
years, has been filled by the election of Dr. J. Buck-
ley Bradbury of Cambridge.

' BalletiD de I'Aoad. rojale de Med. de Belglqua, Maroh its, IS93.
' Brlttob Medical JootdiU, July 16, 1893.

OBSTETRICAL SECTION OF THE SUFFOLK
DISTRICT MEDICAL SOCIETY.

O. a. WA8HBUBH, M.D., SKCBETART.

Meeting of November 24, 189-3.
Dr. E. W. CnsHma read a paper on

THE OPBRATIVB TREATMENT OP UTERINE FIBROIDS.'

Dr. John Homans : I am glad to hear this full and
honest report from Dr. Cushing, giving the results in
all his cases, whether good or bad. This is the only
way we can arrive at any conclusions as to the advis-
ability of operations or methods of operating.

In these cases of fibroid tumors wisdom is shown in
choosing the cases that ought to be operated on, and
in letting alone those that will do well unmeddled with.
I have seen about GOO cases, and have operated upon
about eighty. I presume that some of the 520 I ought
to have operated on, and that in some of them my
diagnosis was wrong ; but I have tried to choose
wisely. I always ask women on whom I do not oper-
ate to come and see me again in six months, or sooner,
so that I may keep track of the tunoor. I have watched
a number of women, and have seen tumors diminish
and disappear, and others increase in size ; and I have
operated on a tumor whose growth 1 had watched for
thirteen years. I must say that I operate more fre-
quently now than I did five years ago. I have oper-
ated nineteen times during these past ten months.
Sometimes the shock of the operation in removing a
large tumor full of blood is severe. I have had one
lately where the tumor was not simply red in color, it
was scarlet; and the removal of the tumor with other
haemorrhage caused a fatal result from shock twelve
hoars after operation. Very much blood was taken
away with the tumor.

Fibroid uteri occasionally become cancerous. I have
seen this happen in an old calcified fibroid which I saw
at an ovariotomy in a woman of seventy. She died
of cancer of the uterus four years after ovariotomy.
This would be an argument in favor of operating on
fibroids. Sometimes the blood-supply of fibroids will
be cut off without apparent cause, and they will slough.
I removed one about a month ago which filled the
uterine wall symmetrically and was about nine inches
by six inches in size. It was brown, and would have
caused the patient's death in a few weeks or months.
I did not suspect the condition before operating. Al-
though the pedicle was treated intra-peritoneally, the
patient left the hospital at the end of three weeks,
having bad no rise of temperature.

Fibroids may become filled with dilated lymph-
spaces, and these spaces may become the seats of haem-
orrhages of quite an extensive character. Both of
these last two conditions would warrant removal.
Adhesions in fibroids are y^rj rare, but sometimes one
meets with quite serious posterior ones, causing much
hiemorrhage if they are attached to the mesentery, as
I have once seen them. Some tumors grow very large
slowly, and some diminish in size without apparent
cause. If you only see these cases once you cannot
tell which will grow and which will remain stationary
or retrograde ; but if you can watch them, you may
be able to decide wisely.

I have had to operate once daring pregnancy. I

> See page 301 of tbe Journal.

Digitized by

Google

316

BOSTON MEDICAL AND SOBGICAL JOURNAL. [Masob 29, 1894.

had advised against marriage on accoant of the fibroid ;
bat my advice was not heeded, and pregnancy followed.
A practitioner who was called tbonght the case was
one of ovarian tumor ; and as there seemed some
doubt about the character of the tumor, I got Dr. Mix-
ter to draw oat a little disk of the growth. This little
operation caused intense pain, so that at least a grain
of morphia was injected in the coarse of about an hour,
I think. The next day the patient was insane, and
became more and more violent ; the temperature rose ;
and I operated to save her life. I was able to remove
the tumor without opening the uterine cavity, or re-
moving the ovaries. The stump was treated extra-
peritoneally. About tea days afterwards abortion took
place, and sanity gradually returned. A little blood
comes out of the scar at the menstrual periods.

I have removed some very large tumors and some
very small ones. The largest was fifty-two pounds in
weight, and the smallest a few ounces. Electricity a
la Apostoli is useful in relieving pain and in checking
haemorrhage ; but it does not diminish the size of the
tumor, as a rule, unless the menopause occurs daring
or soon after the treatment.

In regard to the treatment by removing the ovaries,
I operated by this method several years ago. One tu-
mor as large as a large orange disappeared in four
weeks, and none has ever grown since, during a period
of ten years. In another case the uterine hsemorrhage
continued ; and two years after removal of the ovaries,
I removed a large pedicalated fibroid through the
vagina, so that the loss of the ovaries was unneces-
sary. Two other cases were unaffected when I last
heard from them.

The method of operating that I most aSect at pres-
ent is the intra-peritoneal one. I tie off the ovaries
and broad ligament, and then amputate the uterus, as
I would the thigh in a circular amputation, tying the
uterine arteries just before I sever the neck of the
uterus and burning out the uterine cavity thoroughly
with the cautery. I do not think there has been much
difference in the mortality following the two methods
in my experience.

Dr. M. U. Riohabdson: The mortality in hyster-
ectomies for fibroids is still so large that the question
of interference should not be hastily decided ; uor
should the woman be advised to run so great a risk
unless the indications are clear. In uncomplicated
cases, in which the patient's strength is good, the mor-
tality is small. Yet, in spite of all precautions, deaths
do occur from causes beyond human control as well
as from accident that may be avoided. Among the
former are thromboses aud embolisms ; the latter in-
clude chiefly errors in technique aud accidental con-
tamination of the peritoneum from the uterine cauul.
The danger from avoidable errors is steadily diminish-
ing, and we can predict with some confidence the
result in a given case. Yet the risk is still consider-
able.

There are two indications for this procedure which
may be pressing : the one a debilitating haemorrhage,
and the other an exhausting pain. Both indications
not infrequently exist in the same patient. A third
indication common to all large abdominal tumors is
the existence of pressure symptoms. This last may
be more important than all others. Among the less
serious complications should be included the malignant
degeueratiou that occasionally develops in the tumor.
This, however, in my experience, is extremely rare —

so rare that it may be practically disregarded as an
influencing factor in prognosis.

The most important indication for interference, per-
haps, is great rapidity of growth. This symptom
combined with heemorrhage, or with discomfort, or
with both, renders an operation Imperative. Haemor-
rhage itself, if it is causing serious debility and does
not yield to palliative treatment, demands surgical in-
terference. Long-continued pain or a discomfort that
makes life unbearable, while not demanding operation,
justifies it. Whatever the symptoms may be, we are
not warranted in letting them continue until the
strength is so reduced that the dangers from operation
are materially increased.

The method of operation to be chosen depends upon
the case, the length of the pedicle, the accessibility of
the tumor, the necessity for speed. If the patient's
strength justifies the more prolonged method of total
extirpation, this is much to be preferred to the extra-
peritoneal treatment of the stump. If the patient is
so reduced that there is danger in prolonged manipula-
tions we cannot use the intra-peritoneal method.

The Trendelenberg posture has made abdominal
hysterectomy ope of the most beautiful operations of
modern surgery. In this position the dissection of
the cervix can be carried out with perfect accuracy ;
the ureters can be isolated and protected, the blood-
vessels seen and tied. In closing the wound the pelvic
floor can be covered in with peritoneum, perfectly ad-
justed and sutured. General peritoneal infection can
,be avoided in this operation by means of sterile gaaze
barriers. In case of suspected infection vaginal
drainage can be used suocessfnlly through the pos-
terior cul-de-sac, either by means of rubber tubing,
gauze wick, or by both. By this method even the
more septic diseases of the uterus, like cancer, can be
removed with small mortality. In one case I removed
successfully the whole uterus containing a sloughing
fibroid of the foulest description. There was no in-
fection of the peritoneum whatever.

In the extra-peritoneal method the disasters that
have occurred in my experience have been caused by
an infection from the uterine canal. The dauger
from this source is also present in the total' intra-peri-
toneal extirpation, but it may be materially lessened
by preliminary irrigation and packing. In the extra-
peritoneal treatment the infection is apt to take place
at the time of amputating the tumor.

On the whole, hysterectomy is one of the most
gratifying in the list of abdominal operations. The
signs of the times point towards earlier and more fre-
quent interference, with a corresponding increase in
favorable results.

Dr. a. T. Cabot said that he regarded the extra-
peritoneal method as safest when a stump could be ob-
tained and easily brought to the surface. He said that
he had had a considerable number of operations for
uterine fibromata, and perhaps he could show the dan-
gers that he had met with best by reporting briefly
the cases of death that he had had.

The first one was in a patient with a very large
tumor, so large that many years before she had been
advised never to have it operated upon, aud bad only
been driven to this course by the excessive discomfort
and almost helplessness that its size had entailed.
The tumor grew down so into the vagina, that it could
not be wholly lifted up aud the pedicle had to be made
through a portiou about four inches in diameter before

Digitized by

Google

.- CXXX, No. 13.] BOSTON MEDICAL AND SURGICAL JOURNAL.

317

C«^,

l^ressioD, and cettainly as much as three inches
" it had been compressed by the wire. The teosion
«o great upon this pedicle, that there was some
*J^^»^hing bothf of the bladder and of the rectal wall.
*^^^'^* fistulse, discharging fseces and urine, healed up
^*-*-^si' a time, and everything seemed to be going well ;
^■^■^i-l she suddenly, about four months after the opera-
^**«»-, developed arasmic symptoms, which were evi-
■-*-'^*itly due to the compression of the ureters, owing to
^ <^ODtraction of the scar tissue in the pelvis. Of this
^*»^ died.

"-I'he second case was one in which a woman with a

^^ «> tighing fibroid on the top of the uterus became preg-

^^Mt. Dr. Cabot saw her at the hospital, after the

^^^^roid bad set up considerable peritonitis. She was

*^«Aite sick when she first entered, but became somewhat

^^^tter, and it was deemed wise to remove the tumor.

"_-*-" be fibroid was found adherent over a considerably

'x.Kkflatned area of the peritoneum. It was easily separated

^nd the uterus was removed with the fibroid. She

lived only about forty-eight hoars ; and at the autopsy

xt; was found that the peritonitis had started from that

portion of the peritoneum that had been in contact

^itb the sloughing tumor.

The only other case of death after the removal of
the uterus that he had had, was in a healthy woman
with a fibroid of considerable size. The stump was
treated intra-peritoneally.

The amputation was made through the cervix, and
the stump, which was cut in a cup-shaped manner,
was carefully drawn together by interrupted sutures.
The closure seemed perfect. This patient did excep-
tionally well for two days. Then, without any special
abdominal pain, she began to vomit, and died of a
mild, septic peritonitis, starting about the stump of the
nterus.

Iq addition to these cases of complete removal of
the uterus for fibroid, Dr. Cabot said he had a number
of times shelled out smalt fibroids by simply splitting
the peritoneal covering and turning them out of their
capsule. These cases have all done well and in some
of them very great relief of symptoms has followed.
A small fibroid, wedged down in the pelvis, close to
the neck of the uterus, may cause more pain aud.dis-
comfort than a much larger one which rises rato the
abdominal cavity.

Ou one or two occasions, when the removal of the
fibroid uterus appeared to present more than usual
difficulty on account of the depth within the pelvis at
which the uterus lay, he said he had contented him-
self with removing the ovaries. This was done, both
wi^b the object ot checking the growth of the tumor,
and also of checking the htemorrhage, which in oue
case, at least, was a very troublesome symptom.

Hitherto these cases have done well ; and although
the want of success reported by other operators would
lead him to think that he had been fortunate in not
having after trouble, yet be was still inclined to resort
to oophorectomy iu ilitBcult cases, where the risks of
the removal of the uierus appeared greater than the
ditiiculties which the patient suffered from, would war-
rauu

L>R. £. W. CusHiNO, in closing the discussion,
debcribed the method by which iu all cases the stump
cuulil be diminished by enucleating any masses of
fibroid tissue which have grown near the cervix, so
tbat finally nothing is left but the uterine tissue proper.
In this way the stump should never be thicker than

the size of two thumbs. In thus enucleating and
forming the stump, it is of the greatest advantage to
use a rubber constrictor, for by its elasticity it allows
nodules of fibro-tissue to be extracted from under it.
After the stump is formed, a wire constrictor can be
used if the operator prefer, although it is hard to see
what advantage this offers over the rubber tubing.

In regard to selecting cases for operation. Dr.
Cushing repeated that he would only operate where
there was htemorrhage, rapid growth or considerable
pain, or where the tumor acted injuriously by com-
pressing the rectum or ureter.

THE NEW YORK NEUROLOGICAL SOCIETY.

Stated Meeting, held at the New York Academy
of Medicine, Tuesday evening, February 6, 1894, Dr.
M. Allkn Starr, President, in the chair.

ELECTRICAL REACTIONS AMD THEIR VALCE IN DIAG-
K08I8 AND PROGNOSIS.

The President said that he has seen statements from
various sources, some very dogmatic and others scepti-
cal, in regard to the value of electrical tests as an aid
to diagnosis and prognosis in various forms of nervous
diseases. A careful review of the literature of ner-
vous diseases will reveal to any one that most men who
have written books on this subject have gone right
back to the original article of £rb, published in 1872,
in the first edition of Ziemssen's Cyclopedia, and have
recopied Erb's diagrams and statements. Individuals
who have had many opportunities of making electrical
tests have noticed from time to time that their results
did not correspond with the statements laid down by
Erb. Their results, however, were not made public,
or else they tried to explain them away, as if there
was something wrong with them. A discussion on
this subject, therefore, is Very timely.

Dr. C. L. Dana opened the discussion, and spoke
of the value of electrical reactions in spinal lesions.
In connection with this subject he has lately studied a
certain number of cases iu which he was able to test
the reactions many times in the course of the disease.
The tests were made in cases of anterior polio-myelitis,
progressive muscular atrophy and bulbar palsy ; also
iu oue or two cases of facial palsy and locomotor ataxia.

It was absolutely necessary, Dr. Dana said, in mak-
ing any comparative statements about our results, that
we should understand how the reactions were taken
by each observer, aud what he means by reaction of
degeneration. The reactions were subject to such
variability, and it was so easy to deceive oue's self, that
the operation required an extremely judicial state i)f
mind and great care. In the tests made by himself he
employed an indifferent electrode, about the size de-
scribed by Erb; this was to be tied down, not held by
the band, so that there were no variations in the amount
of pressure. For the active electrode he employed a
small, pointed electrode, the surface of which measures
one square centimetre each way. By means of this
you cau get the muscular irritability at different parts
of the muscle, you can see whether the contractions
are sluggish or otherwise, and you also learn the dif-
fusibility of the contraction, which is a form of reac-
tion which has not been sufficiently noted. If an elec-
trode with a large surface is employed, the diffusible
reaction is not brought out with any certainty. The

Digitized by

Google —

318

BOSTON MEDICAL AND SURGICAL JOURNAL.

[March 29, 1894.

tmall, pointed electrode can also be shifted to the
motor point of the nerve, and thus the nerve reaction
be obtained. In some cases the strength of the current
required is 80 great that the point electrode gives rise
to too much pain ; in such a case he employs the or-
dinary-sized electrode. The electrode is first placed
on the body of the muscle, and reaction obtained with
a gradually increasing current; and then the same re-
action with a gradually decreasing current. These
reactions are compared with those on the opposite side
and the operation repeated two or three times with a
proper interval between, in order to allow the muscle
to rest.

The three points that be has particularly investigated
in connection with spinal lesions are: First, the rela-
tive irritability of the two poles ; second, the character
of the reactions, that is, whether they are sharp or
sluggish, or sluggish and diffuse ; and third, the coarse
of the variations of the reactions in the different stages
of the disease.

With regard to the relative irritability of the posi-
tive and negative poles, many of the recorded cases
merely showed that the cathode exceeded the anode in
irritability, without giving the exact number of milli-
amperes required to produce contractions. Dr. Dana
said he considered this an inaccurate method of mak-
ing the measurements. In all reports it should be
carefully put down how many milliamperes are neces-
sary to produce a positive pole contraction, and then
a negative pole contraction, or viceverta. In this way,
by following the coarse of the disease, we should find
that each pole bad a definite course of increased and
decreased irritability, in accordance with the progress
of the disease. The speaker exhibited a number of
diagrams which he had prepared, showing the course
of the polar irritability in several cases of progressive
muscular atrophy, in two cases of anterior polio-myeli-
tis and in one case of double facial palsy ; in the latter
case he was able to make daily examinations of both
sides of the face for a number of weeks. His obser-
vations go to show that there is a difference between
the course of the polar irritability in neuritis and that
in progressive muscular atrophy and polio-myelitis.
In neuritis there is a pronounced steady rise in the
polar irritability, while in the spinal lesions it is very
slight or absent. So far as his observations go, there
is a true degenerative reaction in progressive muscular
atrophy, as there is in polio-myelitis, but we only get
it in certain stages of the disease. In all the descrip-
tions of electrical degenerative reactions, the fact is
spoken of that in normal muscles and in partly degen-
erated muscles the reactions are sharp and quick, but
that when the muscles become degenerated the reac-
tions are sluggish or vermicular. Further (ban this,
with the point electrode there is a diffuse contraction
of the muscle ; that is, the whole belly of the muscle
and even the adjacent muscles will contract. This
diffusibility of the contraction, Ur. Dana said, he con-
sidered equally important with the sluggishness, al-
though it does not always take place. It was better
seen with the anodal contraction.

In conclusion. Dr. Dana thought we ought to revise
many of onr views of the reaction of degeneration ;
but it was too soon to formulate new views.

Dr. W. M. Lesztnskt continued the discussion,
contining his remarks more particularly to the value of
electrical reactions in cases of traumatic neuritis. His
method of making the examination, be stated, was v.ery

similar to that outlined by Dr. Dana. The conclu-
sions drawn by him were as follows :

(1) That the value of electricity as an accessory
method in diagnosis and prognosis of disease of the
peripheral nerves is not as universally recognized as
its importance demands.

(2) That the result of this procedure often furnishes
corroborative and conclusive evidence, where only a
provisional diagnosis has been made.

(3) That the necessary technical skill in successfully
pursuing such investigations and correctly interpreting
the result can only be acquired through special study
and practice.

(4) That the use of the faradic current alone is quite
sufficient for diagnostic purposes.

(5) That, as a rule, the galvanic current is supple-
mental to the faradic, and in the absence of faradic
irritability in nerve and muscle it is of the greatest
service in prognosis.

(6) That the discovery of the reaction of degenera-
tion is not an essential feature in the differential diag-
nosis as to the location of the lesion.

(7) That the peripheral nerve fibres possess an in-
herent power of regeneration which seems almost un-
limited, the length of time required for the completion
of the regenerative process varying from a few weeks
to seven years or more. Therefore, in severe forms of
injury, the cause, degree and character of damage to
the nerves are often of greater importance in prognosis
than the demonstration of the reaction of degeneration.

(8) That the presence of reaction degeneration, or
partial reaction degeneration, is not incompatible with
the preservation of motility iu the same area. This
paradoxical condition has been found in cases of lead-
poisoning and a few others ; but thus far the cause has
been inexplicable.

(9) That strong currents are only rarely necessary.
The weakest current that will produce a distinctly
perceptible reaction is all that is requisite.

(10) That a decrease or disappearance of faradic
irritability in nerve and muscle simply denotes an in-
terference with the nutrition in the course of the motor
tract between the multipolar cells in the anterior horn
and the peripheral nerve distribution. It does not en-
able ns to judge of the nature of the pathological pro-
cess.

(11) That the character of the reactions does not
differ, whether the lesion be situated in the cells of the
anterior horn, the anterior nerve roots, the nerve trunks,
or in their ultimate distribution. The same rule holds
good iu reference to the various cranial motor nerves
and their nuclei, such as the facial, hypoglossal aud
spinal accessory nerves.

(12) When the farado-muscular irritability is lost,
no reaction can be obtained by a rapidly interrupted
galvanic current.

(IS) The secondary current from an induction coil
is the one generally used in testing faradic irritability.
Owing to its high electro-motive force, the resistance
encountered in the moistened skin may be disregarded.

(14) The difference in the poles of the faradic cur-
rent is only a relative one, and cannot be determined
by the usual tests as applied to the galvanic current.
The electro-motive force in the secondary coil is greater
at the " break " than at the " make." ' The electrode
that is felt to be the stronger in its sMStion is usually
considered as the negative or so-called "faradic
cathode."

Digitized by

Google

Vol. CXXX. No. 13.] BOSTON MEDICAL AND SURGICAL JO VENAL.

319

(15) In 8ome apparenCly healthy individuals the
muscalo-Bpiral nerve fails to react to strong currents
applied with the "faradic anode," while a compara-
tiyely weak current from the. "faradic cathode" calls
forth a quick response.

(16) in a case of undoubted peripheral paralysis the
faradic irritability may be preserved, but it almost in-
Tsriably requires a stronger current to produce muscu-
lar contractions than upon the healthy side (quantita-
tive decrease) ; Dr. Leszynsky said he has never seen
a oue where this could not be demonstrated within a
few days after the onset of the paralysis.

(17) The character of the muscular reaction de-
mands attention. A slow and labored contraction as-
lociated with decrease in faradic irritability denotes
degenerative changes.

(ly) The faradic irritability may return in persistent
cases of peripheral paralysis without any perceptible
improvement in motility.

(19) Electro-diagnosis is inapplicable in paralysis of
ocnlar muscles.

(20) When the farado-muscular irritability is lost
npoii skin excitation, its presence may be demonstrated
in the muscle for a longer time by means of acnpunct-
ore.

(21) If electricity is to be of any service to as in
ascertaining whether the nerve trunk has been divided
or not, as a result of traumatism, the examination must
be made as soon after the injury as possible. We can
then determine at once if special surgical interference
is necessary. Should two or three weeks elapse be-
fore such examination, it will be impossible to state
whether the absence of reaction is due to traumatic
neuritis or to complete division of the nerve. Explor-
atory incision would then be called for.

(22) The tests with the galvanic current require ade-
quate apparatus and a working knowledge of the rela-
tionship between electro-motive force, resistance and
current strength. It also requires mnch time, patience
and perseverance ; hence its unpopularity.

Dx. M. A. Stabr spoke of the value of electrical
reactious in cases of multiple neuritis. He reviewed
the conclusions of Nothnagel, Pal, Gowers and others
on this subject, and gave the histories of a number of
cases of mnltiple neuritiir coming under his observation.
The first case reported was one of general alcoholic
multiple neuritis, with total paralysis io both arms and
both legs. In this case, within two mouths after the
onset, when the paralysis was extreme and when no
voluntary movement was possible in the muscles of the
arm, forearm or hand, the electrical reactious differed
completely in these localities ; in the arm there was a
diminution of response to both currents without polar
chauges; in the forearm there was a loss of faradic
response and diminotion of galvanic response without
polar changes ; in the hand there was loss of faradic
renpoose, diminution of galvanic response with polar
cbsDges.

Id two other cases of alcoholic multiple neuritis,

very great variations were present in muscles which

Were equally paralyzed. In a case of diphtheritic

paralysis there was a total loss of contractility' to fara-

disiD, but no polar changes to the galvanic current. In

Sboiher case of diphtheritic multiple neuritis, in which

ataxia rather than paralysis was a marked symptom,

an interesting fact was noted. There appeared to be a

slight weakness in the right supinator lougus muscle.

The electrical reactions of this muscle, however, were

found to be normal, the reaction to faradism being
prompt, and the cathode closure contraction being
greater than the anode closure contraction. For pur-
poses of comparison the left supinator longus was sim-
ultaneously tested, there being no voluntary paralysis
of this muscle whatever. It was found that the reac-
tion to galvanism in this muscle showed polar changes,
the anode closure contraction being greater than the
cathode closure contraction, although there was no re-
duction in the faradic response. Here, then, was an ob-
servation which confirms the statement of Pal that
electrical changes are sometimes present in muscles
which are not paralyzed.

In closing his remarks. Dr. Starr said that every
possible change to electrical reactions may be present
in muscles affected in the course of multiple neuritis.
The conclusion is inevitable, therefore, that to the
electrical changes no very great diagnostic significance
can be assigned. In the cases cited, there was no
parallelism between voluntary power and electrical
condition. Voluntary power in all the cases seemed
to return before the electrical reactions became nor-
mal. Therefore we cannot project a reaction line
upon a chart into the future and say that at a certain
date, when the electrical reactions become normal, the
voluntary power must necessarily return. Electrical
reactions, while of some interest, are not to be taken
as of great importance in the diagnosis of multiple
neuritis.

Dk. B. SAcns discussed the value of electrical re-
actions in dystrophies. In regard to the general sub-
ject of reaction degeneration, the speaker said he has
been forced to the conclusion that there are only two
points of value. The first and most significant feature
of reaction degeneration was the loss of faradic re-
spouse. The second was the sluggishness of the cou-
iractiou. The variability between the anodal and
cathodal contraction was extremely great, and he had
long since abandoned the idea that the relationship
between the two can be utilized in all cases either for
the purpose of diagnosis or prognosis. Physiologists
have demonstrated with considerable plausibility that
the electrical excitation of nerves and muscles largely
depends upon the rapidity and succession of single
shocks, in muscles iu which the faradic contractility
seems to be absent, if you diminish the interruptions,
you will often get a contraction, whereas you will not
get it with the ordinary faraiiic machines we use. Dr.
Sachs said he believed we could state that reaction de-
generation was present in any given case if the faradic
response was absent, lie agreed with Dr. Dana's re-
marks regarding the variations in polar irritability in
different stages of anterior polio-myelitis and other
diseases. In Erb's diagrams, which have been so ex-
tensively copied, he does not differentiate between
anodal and cathodal response. He does not make any
distinction between the two poles. Dr. Sachs said he
had i'oand the greatest possible variability in the ac-
tion of the two poles. In many cases, particularly in
peripheral nerve palsies, he had found that the cathodal
excitability was increased as long as the disease lasted.
After full power had returned, the faradic excitability
might still be diminished, or last for a period of time
varying between several weeks and a year. In excep-
tional cases the faradic response remained normal from
beginning to end, but the galvanic chauges were pro-
nounced.

The speaker said it was well to divide mnscnlar

Digitized by

Google

320

BOSTON MEDICAL AND SURGICAL JOVSNAL,

[March 29, 1894.

dystrophies into two classes, namely, primary muscular
dystrophies and the so-called spinal amyotrophies.
In the pare dystrophies we rarely got a defiuite reac-
tion degeneration ; that is, there was rarely entire
absence of faradic response and marked slaggish reac-
tion, excepting in the very last stages of the disease,
when 80 little muscular fibre was left that we could
not expect to get either faradic or galvanic response.
In primary muscular dysirophy, therefore, there was
no typical reaction of degeneration. In other than
primary muscular dystrophies, we got a very strong
resemblance to the typical reaction degeneration. In
progressive muscular atrophy of spinal origin reaction
of degeneration might be present in its entirety ; but
we often found partial reaction of degeneration and
other irregular types of electrical reaction.

As regards the value of electrical reactions in diag-
nosis and prognosis, Dr. Sachs said he was fully in
accord with the statements made by the previous
speakers. He still believed that Erb's observations
were extremely well founded and held good in the
majority of cases. It was certainly true that if the
faradic response — in a case of facial paralysis, for in-
stance — was never lost, in nine cases out of ten re-
covery will be more prompt than where It was lost.
That the faradic irritability returns in some cases be-
fore the power, as claimed by Dr. Leszynsky, he
thought exceptional, to say the least. It was much
more certain that the power returned long before the
faradic response did, in the vast majority of such
cases.

As regards the value of electricity as a means of
prognosis in cases of muscular dystrophy, the speaker
thought it was very slight. The senses of sight and
touch will teach us much more than the electrical ex-
amination in such cases. By the degree of response
to the faradic and galvanic currents we can get some
idea as to the condition of each individual muscle, but
no definite conclusions can be drawn. In some cases
of typical muscular dystrophy, certain muscles unques-
tionably do recover ; others do not. In the cases which
recover, the electrical reactions do not undergo any
decided changes.

Dr. a. D. Rockweli, said he agreed with Dr.
Sachs that the main importance of electricity as an aid
to diagnosis was in connection with the absence or
presence of the faradic reaction. The importance of
this subject to the general practitioner was impressed
on his miud by a case that recently came under his
observation. The case was one of facial paralysis, and
the patient for seven weeks had been under the care
of a general practitioner, who treated him with the
faradic current without any benefit. Under the use of
galvanism the patient at once began to improve. The
following case indicates very positively the value of
electricity as a diagnostic agent. The case was one of
typical facial palsy on the right side from peripheral
causes. During the course of the patient's recovery
from this, a paralysis occurred on the left side of the
face ; this started as a peripheral paralysis, but on test-
ing the muscles with faradism, it was found that they
responded with perfect facility. Therefore, it was
evident that the paralysis on this side was central.
Shortly afterwards the patient had a second attack in-
volving the right side of the face, again peripheral.
Dr. Rockwell said that in ovarian or uterine diseases
of an inflammatory character, the faradic current pro-
duces 00 improvement, but rather aggravates the pain ;

while in non-inflammatory conditioBs the faradic cur-
rent will relieve the pain.

Dr. Gkokob W. Jacobt said that the statements
made in the text-books on this subject are too dog-
matic. The diagnostic value of electricity is limit^ to
certain peripheral affections, and even there it is not
as great as originally claimed. In prognosis, also, we
must limit its value. In a number of cases of facial
paralysis of long standing, he has found it impossible
to obtain any reaction of degeneration. In a couple
of other cases in which the paralysis had entirely dis-
appeared with the exception of a slight obliteration of
the labio-nasal fold, there was marked reaction of de-
generation. These are exceptional cases, and he could
give no explanation of them. Cases have been pub-
lished in which there was a reaction of degeneration
found in cerebral palsies ; also in cases of primary
dystrophy.

Dr. C. a. Herter referred to the electrical reac-
tions in some cases of cerebral palsies. In one case
under bis observation, a woman aged seventy years,
the patient had a series of slight apoplectic attacks,
succeeded in time by complete paralysis of the right
side of the body (face, arm and leg) and complete motor
aphasia ; at the end of one week distinct atrophy of
the muscles of the forearm was noticeable, and at the
end of one month it was very pronounced. The faradic
irritability of certain muscles of the forearm was very
much reduced. The contractions were exceedingly
sluggish, and the reaction of degeneration was oa-
doubtedly present. The galvanic irritability of these
muscles was somewhat diminished. Dr. Herter alio
referred to the rapidity with which the reaction degen-
eration makes its appearance in some cases of injary
to the spinal cord. In two instances coming under his
observation it was pronounced at the end of four days.

Dr. L. Stieolitz agreed with Dr. Sachs that the
most important feature of the reaction of degeneration
is the sluggishness of the contraction. It must be
borne in mind that muscles of coarse fibre react mach
more sluggishly than those made up of tine fibres.

Dr. G. M. Hammond said he agreed in the main
with the statements made by the previous speakers.
Like Dr. Sachs, be had noticed that muscles whicb do
not respond to a rapidly interrupted faradic current
will respond to a slowly interrupted one. The reverse
is true with the galvanic current. With a battery that
he employs be can get about 170,000 interruptions per
minute, and he has found that the greater the unmber
of interruptions, the stronger the current required.
This rule applies in both healthy and diseased condi-
tions.

Dr. Starr narrated the history of a case of facial
paralysis that came under his care. An examination
showed increased contractility to galvanism in the mus-
cles, and perfect preservation to taradism, the cathode
being greater than the anode. On the strength of tins
he gave a favorable prognosis. After six weeks' care-
ful treatment the reactions remained about the same,
but the paralysis was no better. The patient tben
went to another neurologist who made a simiUi'ly
favorable prognosis, and applied electricity with equally
unfavorable results. That is now a year and oue-h«lf
ago ; the reactions are still normal, but the face re-
mains just as much paralyzed as it ever was.

Dr. Dana exhibited a Portable Perimeter which
he has devised. It is made by Meyrowita & Co., of
Mew York.

Digitized by

Google

Vol. CXXX, No. 18.

BOSTON MEDIO AL AH J) HUJiGJCAL JOUMHAL.

321

Hecent %ittxd.tvxt.

A Treati$e on Diseaset of the Rectum, Anus and Sig-
moid Flexure. By Joseph M. Mathews, M.I)., Pro-
fessor of Surgery, and Clinical Lecturer on Diseases
of the Bectum, at the Kentucky School of Medicine,
etc. Six chromo-lithographs and numerous illustra-
tions ; 537 pages. New York : D. Appleton & Co.
This book has been written to record individual ex-
perience acquired during fifteen years' practice as a
rectal specialist. The inteDtion has been to state only
what is substantiated by fact. When this differs from
statements of other authorities, both conclusions are
given and the reader is left to decide between them.

Besides discussing the subjects usually treated in
works of this class, namely, hemorrhoids, fistulse, rec-
tal ulcers, fissure stricture, cancer, tumors and malfor-
mations, the writer has introduced chapters describing
disease of the sigmoid flexure, rectal neuralgia, hyste-
ria, rectal reflexes, rectal antisepsis, and a new opera-
tion for fistul».

The book is an attractive volume, clearly printed
and well indexed. The style is concise, and the au-
thor's statements direct. His ideas are practical, and
are interestingly presented. Dr. Mathews states defi-
nitely what he thinks and what his experience has
taught him. He makes no effort to'harmonize it with
oft-quoted ideas or theories if it does not so correspond.
If a method of treatment is eflicient, he so describes it.
If in bis practice he has found the reverse true, he
condemns it in no doubtful terms. Such a book is
easy to read and understand. It is one which contains
information of value, both to the specialist and general
practitioner. It is well illustrated.

Lettttret on Mental JHteaeet. By Hknrt Fdtnau
Stearns, A.M., M.D. Pp. 627. Philadelphia :
P. Blakiston, Son & Co. 1893.

These twenty-nine lectures form, as a whole, a use-
ful text-book. Although no new light is thrown on
the subject, ihe established facts relating to the differ-
ent features of insanity are graphically stated, and the
namerous illustrative cases will appeal strongly to the
interest of "the student and practitioner, for whom the
volume is especially designed."

The classification offered is a very satisfactory one
for its purpose. It is of a mixed setiological and symp-
tomatological variety. The term " paranoia," which
has become so general in its application, the author
looks upon as a palpable misnomer, on the ground that
it is a Greek name for insanity in general applied to a
special form, and one, moreover, which has no rela-
tious with any basis of nomenclature. He accordingly
uses the more accurate and familiar term *' primary
delasional insanity."

lu the chapter on " Insanity of the Puerperal Pe-
riod"— one of the best in the book — we find the
SQggestive statement, based on the statistics of thirty-
nine recoveries, that age was a factor of no importance
in promoting the prognosis or duration of the disease,
and that the recoveries were not particularly hastened
by early admissions.

We regret that so high an authority has not thought
it necessary to give us his views on the relations be-
tween ordinary insanity and syphilis, or to accord more
than a brief allnsion to the recognized influence of that
important agent in general paresis. The diagnosis
of the latter disorder is inadequately considered also.

not only as regards cerebral syphilis, but also ordinary
diffuse and focal lesions of the brain. Some sugges-
tions as to the method of examining the insane for
certification, would surely have been welcome to the
general physician ; and we are left in the dark as to
many of the borderland states between mental health
and disease, as well as the simulation of insanity.

These omissions, however, do not seriously detract
from the value of the book, which is sure to find favor
with those for whom it is designed, by reason of its
thoroughly practical tone. Extracts from the laws of
the different States and Territories of the United
States, which relate to the general care of the insane,
are appended.

Rest and Pain. A Course of Lectures on the Influ-
ence of Mechanical and Physiological Rest in the
Treatment of Accidents and Surgical Diseases, and
the Diagnostic Value of Pain. By the late Jobn
Hilton, F.R.S., F.B.C.S., Surgeon Extraordinary
to Her Majesty the Queen, Consulting Surgeon to
Guy's Hospital, Member of the College Council,
President of the Royal College of Surgeons of Eng-
land, Member of the Court of Examiners, and Pro-
fessor .of Anatomy and Surgery, etc. Edited bv
W. H. A. Jacobson, M.A., M.B., M.Ch.OxonI,
F.R.C.S., Assistant Surgeon to Guy's Hospital,
Surgeon to the Royal Hospital for Children and
Women. Fifth edition. Loudon and New York :
- George Bell & Sons. 1892.

There can be no doubt of the value of this book.
It is more than a monograph, and can be safely placed
in the catalogue of surgical classics. The present edi-
tion is satisfactorily edited. The printing and the
plates are passable. The book is in the form of eighteen
lectures, and na one who is interested in surgery should
neglect reading the work. There are few books in the
English language which can give the reader more food
for thought than Hilton's Lectures on Rest and Fain.

I'he Use of Antiseptics in Midwifery: Their Value
and Practical AppUeatiou. By Robert Boxall,
M.D. (Cantob.), M.R.C.P. (Lond.), Assistant Olv
stetric Physician to, and Lecturer on Practical Mid-
wifery at, the Middlesex Hospital ; formerly Physi-
cian to the General Lying-in and Samaritan Free
Hospitals, etc. London : H. K. Lewis. 1894.

This little pamphlet is of considerable interest and
value. The statistics given for the General Lying-in
Hospital certainly show most admirable results. The
entire absence uf deaths from sepsis in the wards of so
large a hospital for four years is an admirable record,
and the confinement of more than a thousand consecu-
tive out-patient cases without a single death is a result
that can be rivalled by few institutions. The conclu-
sion which the author draws from the Registrar Gen-
eral's Reports, as to the standard of asepsis among
the general profession in England, are indeed sad, and
are, we believe, even worse than that which undoubt-
e<lly exists among the less carefully trained portion of
the profession in this country. A death roll of 2,356
unnecessary deaths in England, in a single year, is
certainly sufficient justification for the publication of
this work. The language of the* pamphlet is clear,
concise, and striking: the precautions recommended
are excellent, and leave nothing to be desired, except
the use of the nail-brush and nail-cleaner, which,
strangely enough, are never mentioned.

Digitized by

Google

322

BOSTOH MEDICAL AND SVBGICAL JOVBXAL.

[Makob 29, 1894.

THE BOSTON

ineDtcal ano Surgical %mtm\*

Thursday, March 29. 1894.

A Jownal of Medicine, Surgery, and Allied SeienetM, pnbliiked at
BotUm, w<ei(y, fry the underiigned.

Sdbscbiptiom Tbrms : tB.OO per tfr, in advance, pottage paid,
for the United Slate*, Canada and Mexico i f6.Se per year for all for-
eign countries belonging to the Postal Union.

All commnnicattons for the Sdilor, and all books for review, should
be addressed to the Bdilor of the Boston Medical and Surgical Journal,
283 Wcuhington Street, Boston.

All letters containing btuinest communications, or referring to the
publication, subscription, or advertising department cf this Journal,
should be addressed to the undersigned.

Bemittances should be made by money-order, draft or registered
letter, payable to

DAMKSLL A UPHAH,
28S Waibinotos Stbut, Bobtoh, Mam.

THE REGISTRATION OF AND PREVENTIVE
MEASURES AGAINST TUBERCULOSIS.

The qaeatioD of the wisdom of the registration of
tuberculosis and the adoption of other preventive
measares against this disease — by the dissemination
of circulars, the afttxing of placards upon honses occu-
pied by the tuberculous, and the disinfection of rooms
and apartments where there has been a death from tu-
bercalosis — has occupied the attention of some local
boards of health, notably in New York and Philadel-
phia, and been pretty thoroughly discussed by some of
our medical societies this winter. The difficulty and
delicacy of the problems involved are unfortunately iu
direct ratio to the importance of the question.

The American Public Health Association, at its last
meeting, and the Pan-American Medical Congress
adopted resolutions in favor of registration. In Eng-
land, also, some of the local boards of health have
petitioned the Local Government Board for sanction
to include pulmonary tuberculosis as a disease notifi-
able under the provisions of the Infectious Diseases
Act. The whole question of tuberculosis is now under
the invesiigation iu England of a Royal Commission.

The College of Physicians of Philadelphia held a
special meeting in January to consider the proposed
action of the board of that city in reference to the reg-
istration of tuberculosis. The following amended form
of a resolution, offered by Dr. L. F. Flick, was under
discussion.

Whereas, Tuberculosis is now known to be a contagious
disease; and

Whereas, The methods by which the disease is conveyed
from the sick to the well are now clearly understood ; and

Whereas, It has been shown that the room which is
occupied by a consumptive during the infectious period of
the disease, and the furniture and the bed-clothing whiuh
have been used by him, beuome infected, and are liable to
convey the disease to others who may occupy or use them
subsequently ; and

Whereas, Tuberculosis, owing to its long duration, crip-
ples the bread^earning capacity of the family, when it
occurs among the poor, to such an extent that the want

and hardships which follow in its wake prepare the
healthy members of the family for the disease ; therefore
be it

Resolved, That we recommend to the Board of Health
of the City of Philadelphia the registration and dinnfec-
tion of honses which have been infected by tubercniosis ;

Resolved, That we recommend to the City Councils of
the City of Philadelphia the establishment of a municipal
hospital for the treatment of persons suffering from tubei^
culosis.

We regretted not having space at the time for the
publication of the full discussion, which was participated
in by a number of the promiuent members of the Col-
lege of Physiciaos, and dealt with the various sides of
the questions at issue in a broad and enlightened spirit.
At the end of the discussion, the college rejected the
amended resolution offered by Dr. Flick, and voted
the following resolutions offered by the Council of the
College :

Resolved, That the College of Physicians believes that
the attempt to register consumptives and to treat them as
the subjects of contagious disease would be adding hard-
ship to the lives of these unfortunates, stamping them as
the outcasts of society. In view of the chronic character
of the malady, it coijd not lead to any measures of real
value not otherwise attainable.

That strict attention on the part of physicians in charge
of the individual cases insisting on the disinfection of the
sputum and of the rooms, on adequate ventilation, and on
the separation of the sick from the well as far as possible,
will meet the requirements of the situation so far as they
practically can be met, and better than any rules that, for
diseases so chronic, can be carried out by a board of health.

That the College of Physicians respectfully requests
that no official action be taken in the matter by the Board
of Health, except the insisting on the disinfection of
rooms in which consumptives have lived and died in in-
stances in which such procedure is not likely to have been
adopted under the direction of the attending physician.

On the other hand, our readers will remember that
in November last Dr. H. M. Biggs, of the Bureau of
Bacteriology and Disinfection, in an elaborate re-
port to the Board of Health of the City of New York,
made a number of recommendations having in view
the more efficient limitation and prevention of pulmo-
nary tuberculosis. The Board, acting on the advice
of the Sanitary Committee, has since adopted a series
of measures designed to carry these recommendations
into practical effect.

In the first place, it is proposed to place a placard
upon the door of every apartment that has been occu-
pied by a consumptive patient, stating this fact and that
it has thus become infected. The remainder of the in-
scription reads as follows :

It must not be occupied by other persons than those now
residing here until an order of the Board of Health direct-
ing that it be cleansed and renovated has been complied
with.

Name of occupant . Floor . Street No. •

This notice must not be removed until the order of the
Board of Health has been complied with.

Secondly, a circular has been prepared, which was
to be issued to all physioiana praotising in the city,

Digitized by

Google

rox.. CXXX, No. 13.1 BOSTON MEDIOAL AND SURGICAL JOURNAL.

323

itating that the Bo^rd has resolved to adopt the fol-
Lovring prelininary precautions:

C*) The Department will hereafter register the name,
address, B«ac and age of everjr person suffering from tubei^
eolosia, so f ajr aa such information can be obtained, and re-
qaests tha.t hereafter all physicians forward such informa-
tion on the postal cards ordinarily employed for reporting
cases of contagious diseases. This information will be
solely- for the use of the Department, and in no case will
visits be made to such persons by the inspectors of the De-
partment, nor will the Department assume any sanitary
aurveUlance of such patients unless the person resides in a
tenement-house, boarding-house, or hotel, or unless the at-
tending physician requests that an inspection of the prem-
ises be made. In no case where the person resides in a
tenement-house, boarding-house, or hotd, will any action be
taken If the physician requests that no visits be made by
inspectors and he is willing himself to deliver circulars of
mformation or furnish such equivalent information as is
required to prevent the extension of the disease to others.

(2) When the Department obtains knowledge of the ex-
istence of cases of. pulmonary consumption in tenement-
houses, boarding-houses, or hotels, (unless the case has been
reported and the attending physician requests that no visits
be made,) inspectors will visit the premises, will leave cir-
culars of information, and will instruct the person suffering
from consumption and the family as to the measures which
should be taken to guard against the spread of the disease.
U it is considered necessary, the inspector will make such
recommendations for the cleaning or renovation of the
apartment as may be required to render it free from infec-
tious matter.

(3) In all cases where it comes to the knowledge of the
Department that premises which have been occupied by a
consumptive have been vacated by death or removal, an in-
spector v»ill visit the premises and direct the removal of in-
fected articles, such as carpets, rugs, bedding, etc., for dis.
infection, and will make such written recommendations to
the Board as to the cleaning and renovation of the apart-
ment as may be required. An order embodying these
recommendations will then be issued to the owner of the
premises, and compliance with this order will be enforced.
Ho other persons than those residing there at the time will
be allowed to occupy such apartments until the order of the
Board has been complied with. Infected articles will be
removed by the Department, disinfected, and returned
without charge to the owner.

(4) In the prevention and treatment of pulmonary tuber-
culosis it is of vital importance that a positive diagnosis
shoald be made at the earliest possible moment, and that
the value of bacterial examinations of the sputa for this
purpose may be at the service of physicians in all cases not
under treatment in hospitals, the Department is prepared
to make such bacteriological examinations for diagnosis, if
nmples of the sputa, freshly discharged, are furnished in
clean, wide-necked, stoppered bottles, accompanied by the
name, age, sex and address of the patient, duration of the
disease, and the name and address of the attending physi-
cian. Bottles for collecting such sputa, with blank forms
to be filled in, can be obtained at any of the drug stores
ttow used as stations for the distribution and collection of
•erom tubes for diphtheria cultures. After the sputum has
Iwn obtoined, if the bottle with the accompanying slip
filled oat is left at any one of these stations, it will be col-
Wted by the Department, examined microscopically, and
s report of the examination forwarded to the attending
physician, free of charge.

(5) The authorities of all public institutions will be re-
quired to furnish to the Department the name and last
address of any consumptive coming under observation
within seven days of such time.

This circular coucludea in the following words : " It
is the earnest wish of the Board of Health that all
practising physiciaus in this city co-operate with the
Board in an earnest and determined effort to restrict
the ravages of the most prevalent and formidable dis-
ease with which we have to deal."

In the third place, a circular has been prepared for
general distribution, especially among consumptives
and their families, which treats of the nature of the
disease, the special danger of infection from the sputa,
and the measures necessary for protection, and in-
cludes a number of general sanitary directions. While
endeavoring to impress upon the pnblic the contagious-
ness and p>erils of the disease, it is hopeful in tone and
encourages those affected with it and all coming in
contact with them, to unite in an active crusade against
it. " Consumption," it states, " can often be cured if
its nature is recognized early, and proper means are
taken for iu treatment. In a majority of cases it is
not a fatal disease. ... A person suffering from con-
sumption may often not only do his usual work with-
out giving the disease to others, but may also get
well, if the sputum is properly destroyed." The cir-
cular also urges that whenever a person without medi-
cal attendance, is thought to be suffering from con-
sumption, the name and address should be sent at once
to the Health Department iu order that an investiga-
tion of the case may be made.

A law may be good in the abstract, but it is practi-
cal only in so far as it secures the co-operation of the
community which it affects to such an extent as to
permit its enforcement without excessive annoyance
and expense ; moreover, no law is good which causes
more harm to society than it cures.- The same may
be said of the registration or notification of such a dis-
ease as tuberculosis, and of the adoption of general
preventive measures against it. Nobody would advo-
cate dealing with tuberculosis as with leprosy. Ita
chronicity is sometimes very great, and we all have
before us numerous examples of those constantly and
intimately exposed to its infectious principles with im-
punity. At what stage shall a suspected case of tuber-
culosis be reported ?

We are disposed to sympathize, in a measure, with
the position taken by Dr. Da Costa, and with Dr. J.
S. Billings's statement in a letter read at the meeting
of the College of Physicians :

I am doubtful as to what the decision of the College
should be on this point. I presume that there are about
six thousand people in Philadelphia affected with consump-
tion, and that a considerable proportion of these have con-
tracted the disease in infected bouses. If it were possible
by a systematic notification for the Board of Health to
locate a considerable number of these infected houses,
what steps would it take to purify them ? How would it
deal with those of the poorer classes who are affected with
this disease, and with their furniture, bedding and rooms ?

Digitized by

Google

324

BOSTON MEDICAL AND SVKQIVAL JOVBNAL. [Makch 29, 1894.

Until these questions are answered, I do not find it possible
to form a definite opinion as to wliether it is wordi wiiile
to put in force a compulsory system of notification.

THE ROLE OF ALCOHOL IN THE CAUSATION
OF CIRRHOSIS OF THE LIVER.

CiBRBOSis, or more properly sclerosis, of the liver,
also aDDalar cirrhosis and commoo atrophic cirrhosis
(gin-drinker's liver) has been long regarded as chiefly
of alcoholic origin. The earlier writers, as Bodd and
Frericha, speak of alcohol as the ordinary exciting
cause ; Murchison states that he had never seen a case
due to any other cause ; and Frerichs adds that while
there may be other causes, yet we are totally nnac-
quainted with them. This etiological conception,
based on clinical observations, has been found to be too
exclusive.

Chauffard, in his masterly article on " Diseases of
the Liver," in the Traiti de Midecint, sums up his eti-
ological classification under three heads : (1) toxic, (2)
infectious, (8) dystrophic agencies, and assigns to alco-
hol a chief place among the toxic causes. Even here
the causation is more complex than might be supposed,
for the alcohol of ordinary consumption is not a con-
stant and always uniform chemical compound, but a
product of very variable and often sophisticated com-
^sition.

' Letienne has taken up the subject in a recent num-
ber of La Miiteine Modeme (February 21, 1894).
While recognizing the fact that the influence of alcohol
on the liver may determine a hypertrophic form of
cirrhosis as well as an atrophic form, he proposes the
question : " Is alcohol necessary to the establishment
of atrophic cirrhosis ? Is it sufficient of itself to en-
gender this disease ? "

First of all, comes the evidence from physiological
experimentation. The first experiments on alcohol-
poisoning were made by Dablstrom in 1852, and by
Duchek in 1853. The subjects were dogs. The au-
topsy indicated no lesion of the liver. The experiments
of Ferrin, Lallemand and Duroy, in 1860, showed that
in poisoning by alcohol the different viscera retained
unequal proportions, and the liver more than any other ;
they did not, however, indicate any particular anatomi-
cal lesions in this organ. Later, Kremiansky (1868)
and Magnan (1869) obtained marked hepatic lesions ;
they noted cellular steatosis (acute fatty degeneration)
without traces of sclerosis. The results of Ruge ( 1870)
are the same. Pupier, in 1872, observed fatty accu-
mulation in the livers of fowls poisoned by alcohol.
Sabourin, in 1879, poisoned guinea-pigs with alcohol,
and obtained " central steatosis of the lobule, with
peri-sub-hepatic phlebitis." In 1884, Dujardin-Beau-
metz and Audig^ made an important series of observa-
tions on hogs. The anatomical examinations made by
Cornil did not reveal any processes of interstitial hepa-
titis. Some of these hogs were dosed for a series of
years with various kinds of alcohol.
Straus and Blocq in 1887 noted lesions more ad-

vanced and well defined. They produced in hares,
which they bad been able to keep longest under the
influence of alcohol, an embryonic infiltration of the
portal spaces (third month), which became more pro-
nounced and ended by Encircling the lobules about the
seventh month, without, however, presenting the as-
pect of a dense fibrous tissue.

Other experimenters, as Maret, Combemale and
Strassmann, noted tlie state of the liver in animals
poisoned by alcohol, and found only fatty degeneration
of the parenchyma. Laffitte, in 1892, in his graduat-
ing thesis compares the lesions produced as a result of
experimental alcohol-poisoning with those of Leennec's
cirrhosis. In the hare, he says, the prolonged inges-
tion of alcoholic liquids produces lesions which have
no relation with common cirrhosis. The hepatic cell
is almost always damaged, the connective-tissue is never
irritated. Per contra, in studying chronic experimental
lead-poisoning, be has been able to reproduce an atro-
phic sclerous hepatitis which has the greatest similarity
to Lsennec's cirrhosis.

Some experiments by Richter (1892) differ some-
what from the foregoing, and confirm those of Straus
and Blocq. He obtained pathological processes strik-
ingly like those of annular cirrhosis. There are, how-
ever, differences in the systematiEation of the sclerous
processes, according to the animal under experimen-
tation. The cirrhosis is peri-portal in the hare, peri-
hepatic in the dog.

The writer in LaMidecine Mod*me thinks it demon-
strated as a result of all this experimentation that atro-
phic cirrhosis is not a simple affection, due solely to
the effects of the poison ingested upon the walls of the
blood-vessels which this traverses in the hepatic paren-
chyma. When we make section of a cirrhotic liver,
the lesions which we see under the microscope are not
simply an expression of the action of alcohol on ele-
ments of the tissue : they are the effect of complex
causes. The alcohol has a certain part, but infection
or toxic-infection also impresses its stamp on the organ.
The liver undergoes, from the fact of its slow impreg-
nation with alcohol, a profound depreciation ; it toler-
ates badly even the common infections which assault it.
There comes a time when it can no longer react
against them, and it suffers degeneration. The nobler
tissues as they perish, are replaced by a connective-
tissue proliferation.

It has been remarked that the anatomical schemes
which serve to classify the cirrhoses have not in natore
the rigorous exactitude represented in the didactic
treatises. Recent writings (as those of Letienne and
Hanot) tend to relegate to a second rank the rOle of
the peri-vascular connective-tissue, and to substitute
for it that of the hepatic cell. There is no hepatic
sclerosis without previous cellular alteration. At the
ultimate and most characteristic periods of atrophic
cirrhosis, there exists a veritable consumption of the
liver. It has lost the faculty of making those efforts
of struggle and of regeneration, which are observed in
normal conditions. The liver becomes inactive, almost

Digitized by

Google

Vol, CXXX, No. 13.] BOSTON MSDIOAL ADD SURGICAL JOVBDAL.

325

without a physiological rdle, secreting insufficient bile
without colored quality, lesviog in the blood the prin-
ciples it should eliminate. The normal deglobnlization
DO longer takes place in its cells. The corpuscular
dibrit appears in the urine, in the liquid of ascites ;
and the blood, which is charged with these waste ele-
ments, gives to the tissues a nrabilinic, icteroid tint.

These considerations have lately been presented by
Hanot in an interesting study on alcoholic cirrhoses.
Neither this writer nor the author of the article before
referred to deny the sclerogenous power of alcohol ;
they only point out that this toxic agent is but one
factor, and they emphasize the rule of other toxic
agents in the production of the same sclerotic phe-
nomena. There is a cirrhosis caused by lead-poison-
ing, of a very typical kind, and of which we are begin-
ning to learn much. There is a tuberculous cirrhosis,
and there are certain acute infections cirrhoses, distinct
from every form of grave icterus, and which end in
the same atrophic degeneration as alcohol. Atrophic
cirrhosis of the liver may be the result of divers influ-
ences, certain of which are now known. It offers a
uniform type of reaction of the hepatic tissue towards
very varied irritant causes, and illustrates this principle
of general pathology that the tissues have but limited
means of reacting against agents of different species
and indefinite number.

MEDICAL NOTES.
Reduction in tbe Armt Library Appropria-
tion.— The House Military Committee has again cut
down the appropriation for the Army Medical Library
from $10,000 to $7,000.

Illness of Sir Fbanois Lakino. — Sir Francis
Laking, private physician to the Prince of Wales and
surgeon-apothecary to the Queen, is reported to be
dangerously ill in London.

The Hambdro Cholera Inspector. — Surgeon
Woodward who acted so efficiently as cholera inspector
at Hamburg last summer has been ordered to the same
port for the coming season.

Cbolbba in Russia. — On the first of March all
tbe governments of the Russian Empire, with tbe ex-
ception of Volhynia, Eovno, Flock and TchernigofiF,
were officially declared free from cholera.

Adjunct Pbofbssob of PiBoiATRios. — W. T.
Northrup, M.D., of New York, has been recently
elected Adjunct Professor of the Diseases of Children
io the Bellevue Hospital Medical College, as the asso-
ciate of Dr. J. Lewis Smith who has held tbe full pro-
fessorship for over thirty years.

Examinations for the United States Army
Medical Cobps. — In view of the possibility of the
redaction of the Medical Corps from one hundred and
twenty-five to ninety assistant surgeons, by action of
Congress at its present session, and to save possible
Ion of time and expense to candidates if such action be
taken, the examinations appointed for March and

April, 1894, will, by order of the Secretary of War,
not be held until further notice. It is probable, that,
if the Corps should not be reduced, the Examining
Board will be convened In the fall of 1 894. Of this,
notice as early as possible will be given.

Small-Pox Epidemic in Brooklyn, N. Y, — The
Brooklyn Board of Health has declared small-pox to
be epidemic in that city. There are at present over
one hundred cases under care, ninety-one being in the
hospital which can accommodate but one hundred and
twenty. A requisition has been made upon the State
for tents, three having already been set up in the hos-
pital grounds. An appropriation of $18,000 has been
granted from the Emergency fund for special sanitary
work, and a general vaccinition has been ordered.
The spread of the disease is now thought to have been
caused by a ball given January 31st by some organiza-
tion known to but not named by the authorities.

Prizes of the Spanish Academy of Medi-
cine. — The Spanish Royal Academy of Medicine
offers its annual prize for the best essay on the follow-
ing subject, "Clinical and Therapeutical Study of
Chronic Affections of tbe Intestine." The A. E. 6.
Cano Prize will be awarded for the best essay on " In-
fectious Endocarditis." Essays may be written in
Spanish, Portuguese, French, Italian, German, or Eng-
lish, and must be sent to the Secretary of the Academy,
22 Montera, Madrid, before September 15, 1894.

An Indian Medical Congress. — A proposal
laid before the Calcutta Medical Society to have a
general Medical Congress in India has met with much
favor ; and the First Indian Medical Congress will be
held in Calcutta in the beginning of January, 1895.
Physicians practising in every part of the world are
invited to take part, especially those in India and tbe
East. The Congress will comprise the following sec-
tions: (1) Medicine, including Pathology; (2) Sur-
gery ; (S) Obstetrics and Diseases of Women and Chil-
dren ; (4) Public Health ; (5) Medico-legal Medicine
and allied subjects.

boston and new ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon, March 28, 1894, there
were reported to the Board of Health of Boston, the
following numbers of cases of acute infections disease :
diphtheria 46, scarlet fever 48, measles 10, typhoid
fever 6, small-pox 5 and 1 death. During the week
one case of small-pox was reported to the State Board
of Health from Melrose.

A New Public Bath in Boston. — A new pub-
lic bath-house has been opened at the South Cove dis-
trict in Boston where bathing facilities can be had for
a nominal sum, both summer and winter. It is a pri-
vate concern backed by persons interested in hygienic
charity, and will help to fill the need which is so
marked in Boston of a large, well-appointed bathing-
place daring the cold months when the summer baths
are unavailable.

Digitized by

Google

326

BOSTON MEDICAL AND SUSOIOAL JOURNAL.

[March 29, 1894.

The Couuittbb on Public Hsalth. — The Com-

mittee on Public Health of the Massachusetts Legisla-
tare has reported adversely on a proposed bill to re-
quire patent medicine bottles to have on them a label
stating the percentage of alcohol in the medici ne, and
also adversely on a bill reqairing cans and receptacles
used by milk-dealers to be kept free from impurities.

The Massachusetts Hospital for Dipsokani-
Acs. — The Committee on Public Charitable Institu-
tions has rejected a bill introduced to provide further
luxuries for the Hospital for Dipsomaniacs and Ine-
briates in Foxboro. It was proposed to erect a gymna-
sium and a swimming-tank for the patients.

A Bequest paid to the Springfield Hospital.

— The Springfield Hospital has received during the
week the bequest of thirty thousand dollars, under the
will of the late Mr. Horace Smith. Among other
charitable institutions which received at the same time
the payment of the bequests to them were the Home
for Friendless Women and Children (thirty thousand
dollars), and the Springfield Home for Aged Women
(fifteen thousand dollars).

SuALL-Pox IN Portsmouth, N. H. — A case of
small-poz was discovered in Portsmouth on March
25th in a farmhouse just outside the city.-

NBW YORK.

Hospital Saturday and Sunday Association.

— The distributing committee ot the Hospital Satur-
day and Sunday Association met in the Mayor's o£Bce
OD March 20th and divided $48,000 received from the
annual collection among thirty-three institutions rep-
resented in the Association. Mount Sinai Hospital
received the largest amount, $5,290, and St. Luke's
the next largest, $5,153. The total sum collected this
year was $58,300. Of this about $7,000 was specially
designated for certain hospitals, and the expenses of
the Association amounted to some $3,000.

A Raid on Abortionists. — On March 23d the
police arrested sixteen advertising abortionists simul-
taneously in different parts of the city. The arrests
were made at the request of the New York Society
for the Enforcement of Criminal Law, which, through
a skilful male and female detective, had secured evi-
dence for the prosecution of the offenders. Some of
the accused succeeded in securing bail, the bonds iu
each case being fixed at $2,500.

PuBi ic Health. — The unprecedentedly mild and
pleasant weather that has prevailed during the month
of March has had a marked effect upon the public
health and reduced the death-rate of the city to a very
gratifying extent. During the week ending March
17tb the number of deaths reported was only 787,
while in the corresponding week of last year, when the
estimated population was at least 65,000 smaller than
at present, the deaths amounted to 1,110. This mor-
tality is also 175 lower than the average for the cor-
responding weeks of the past five years. Measles
continues to be the most prevalent of the contagious

diseases. During the week ending March 17tb there
were reported 309 cases, with 25 deaths, and daring
the week ending March 24th, 375 cases, with 29
deaths. Diphtheria increased from 187 cases and 40
deaths to 220 cases and 53 deaths. Small-pox and
scarlet fever do not show any material change ; but
there was some decrease in the mortality from poeo-
monia, and the deaths from influensa decreased from
12 to 4. There are very few cases of typhoid fever
reported, and during the week ending March 17th
there were but 2 deaths from this disease.

Death of Dr. Stanabd. — Dr. Alfred Gush-
man Staoard, one of the most promising young phy-
sicians in the city, died at the New York Hospital on
March 20th of peritonitis resulting from appendicitis.
On the 16th he was operated upon, and at first it was
hoped that the procedure would be successful in saving
his life, but an extension of the peritonitis soon fol-
lowed. Dr. Stanard was born iu New York and was
twenty-nine years old at the time of his death. He
was graduated from the Medical Department of Har-
vard University in 1889, and afterwards served as an
interne at the New York Hospital. Later he was ap-
pointed one of the attending physicians to that instita-
tiou.

AUTOPSY ON THE GEEENWICH ANARCHIST.

The autopsy recently made on the body of the mao
killed in Greenwich, England, by the explosion of a
bomb held in his hand, is of considerable interest as
showing the variety of lesions possible in such an acci-
dent.

The report shows ^ that the man held the bomb in
his left hand about on the level of the abdomen. It is
remarkable how little damage was produced by the
bomb. The left hand and wrist were blown away and
the tendons left hanging. A circular opening over an
inch in diameter, wiih a charred margin, was found a
little to the right and above the umbilicus. Posteriorly
there was an almost linear wound of exit beluw the
last rib on the right side. On the left thigh and leg
there were several charred wounds of varying extent
and depth, while on the right thigh there were two
deep wounds extending nearly to the femur, one iu
front and one -on the outer side over the trochanters,
which must have been very nearly on the opposite side
of the body from the bomb. In this latter wound a
piece of metal was found. As a rule, no pieces of
metal were found in the wounds, but many biu of
clothing.

On opening the abdomen some intra-peritoneal hem-
orrhage was at once seen. This was due to great con-
tusion and laceration of the right lobes of the liver, es-
pecially of the quadrate lobe and the adjacent part of
the right lobe from the velocity of the air surrounding
the bomb rather than to the metal itself. The gall-
bladder had escaped injury. None of the intestines at
this stage appeared to have been damaged, but on the
removal of the peritoneum it was at once found that
there was a large amount of retro-peritoneal haemor-

VLsucel. Febriuir; 24, 18S4.

Digitized by

Google

Vol. CXXX, No. IJJ.J BOSTOH MEDICAL AND SVBGIOAL JOVBSAL.

327

rhage. Careful eiamination showed that the second
part of the duodenuni had been raptured on the right
side for rather more than an inch, and that the ante-
rior surface of the right kidney was extensively lacer-
ated. All the 01 her abdominal viscera, including the
stomach, which contained food, and the other portions
of the intestine, were uninjured. The thoracic viscera
and brain were quite normal.

THE FOREIGN QUAEANTINE OF IMMIGRANTS.

In an editorial upon the request of the United States
delegates to the International Sanitary Conference,
that proper means be taken by European governments
to prevent cholera and other infectious diseases from
being brought to this country, the Lancet says :

"Precautions should be enforced, if not on the
American side, then at the point of departure. The
latter is the solution of the difficulty which the Ameri-
can Government desires to submit to the European
Powers. In the name of humanity and of good neigh-
borly feelings, care should be taken not to ship over to
America infected clothing or persons likely to convey
infections or contagious diseases; but, if this principle
does not suffice, then, even from selfish motives, the
European Governments should act in the manner de-
sired. A great deal has been said about the pilgrim-
ages to Mecca, and it has been urged that, in English
ships alone, as many as 20,000 pilgrims have been
taken to Mecca in one single season ; but this is noth-
ing when compared to the 400,000, or so, immigrants
who yearly go over to America. This great current
of humanity travelling through Europe on its way to
the New World exposes Europe itself to considerable
danger, and it would be to the latter's interest if these
immigrants were forced to observe laws imposing clean-
liness, etc., from the moment that they commence their
joarney. Then, when finally the immigrant reaches his
ship, he is stowed away in an over-crowded steerage,
where the most unsanitary conditions prevail. The
pilgrims to Mecca are not worse oR than the steerage
passengers to America; and the sanitary regulations
of the pilgrim ships will be better in themselves and
better applied than are those governing the steerage
passengers to America. If considerable improvement
in this respect is not enforced, the European Powers
will be the losers, because quarantine will be imposed
00 ships arriving in America, and this will not only in-
jare the passenger traffic but also the exportation of
merchandise to the United States."

IN MEMORIAM.— JOEL SEAVERNS, M.D.

At a meeting of the Roxbury Society for Medical
Improvement March 2'i, 1894, the following resolutions
in regard to the late Dr. Joel Seaverns were passed :

WhereM, Through the wisdom of our Heavenly Father,
oar friend and associate, Dr. Joel Seaverns, has been called
to a higher sphere of duty,

Resolved, That in the death of Dr. Seaverns this Society
has lost one of its most valuable and honored members, and
one whom we shall sadly miss at our meetings for medical
improvement and social converse.

Raolved, That the Roxbury Society for Medical Im-
provement tender to Mrs. Seaverns and family, their cordial
sympathy in the sad bereavement and loss of the dear and
loving husband and kind and affectionate father.

Resolved, That a copy of these resolutions be forwarded
to Mrs. Seaverns, by our Secretary, and that the same be
inscribed on the records of the Society, and that a copy
be published in the Boston Medical and Surgical Journal.

A. B. Coffin, Secretary.

€ottt0pont>tnte,

AMERICAN MEDICAL ASSOCIATION.
San Francisco Meeting.

San Francisco, March 14, 1894.

Mr. Editor : — San Francisco is a comparatively new
city, hut it is not lacking iu places of interest to the visitor.
About a half-mile to the northward of the city limits, nest-
ling in a little valley and surrounded by evergreen trees,
is the Presidio, the United States Army Station. A short
distance l>eyond is old Fort Point, upon the water's very
edge ; the waves of the bay, dashing upon its cement abut-
ments are broken into spray and lost upon its walls. Mc-
Dowell Avenue leads from near the fort, around the top of
the cliffs, overlooking the Golden Gate and the broad ex-
panse of the Pacific Ocean. Vessels of all nations and de-
scriptions can be seen in the offing or quietly gliding through
the waters of the gate.

The Cliff House — a famous resort — is situated upon a
promontory directly overlooking the ocean. In the distance,
on a clear day, the Farallone Islands — twenty-five miles
away — are seen rising abruptly from the water ; while less
thao one hundred yards from where one stands, the Seal
Rocks jut up from the waves and the loud barking of the
seals and sea-lions upon them tells why they are so named.

Sutro Heights are just above the Cliff House. Here
nature and art have so blended their works that the visitor
is truly astonished and delighted with what he sees. The
committee of arrangements are planning an entertainment
at this place for the wives and daughters of visiting mem-
bers of the Association. All San Francisco is justly proud
of Golden Gate Park. What was once dreary sand dunes,
has been transformed into a very garden, flowers bloom
throughout the year, and the grasses are always green.
Broad avenues wind in and out past the conservatory, the
deer paddock, around the base of Strawberry Hill and on
to the ocean beach.

The California Mid- Winter Fair is being held in the
Park, at the base of Strawberry Hill, and occupies a space
many acres in extent. This fair has an individuality pecu-
liarly its own, and offers much of interest to every visitor.
R. H. Plummbr, M.D.
Chairman Committee of Arrangements.

OKFICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM MARCH 18, 1891, TO
MARCH 23. 1894.

So much of Par. 8, S. O. No. 60, March 12, 1891, from A. Q. O.
as relates to Fiasr-Lixin'. Harlan E. McVay, assistant sur-
geon, is amended to direct him, od being relieved from duty at
Han Carlos, Arizona, by Fibst-Libut. Straub, assistant sur-

feon, to report in person to the commauding officer, Fort
luachuca, instead of Whipple Barraclis, Arizona Territory.
Major Hbnry M. Cronehitb, surgeon, U. S. A., is relieved
from duty at Fort Clark, Texas, and ordered to report in person
to the commanding officer, Fort Reno, Oklahoma Territory, for
duty at that post, relieving Captain Wm. C. Qobgas, assistant
surgeon.

Caftain Goroas, on being thus relieved, will report to the
commaodioK officer, Fort Barrancas, Florida, for duty at that
post, relieving Fibst-Libut. Robbrt S. Woodson, assistant
surgeon.

FiBST-LisuT. RoBBBT S. WooDsoN, assistant surgeon, on be-
ing relieved by Captain Gobqas, wilt report iu person to the
commauding officer Fort Mcintosh, Texas, for duty at that post
and for field duty in the Department of Texas, relieving First-
LiBUT. Benjamin L. Tbn Etck, assistant snrgeon.

FiBST-LiBUT. Tbn Etck, on being thus relieved, will report
to the commanding officer. Fort Clark, Texas, for tempoiary
duty at that post.

Digitized by

Google

328

BOSTON MEDIO AL AHI) SUBGIVAL JOURNAL.

[Habcb 29, 1894.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. S. NAVY FOR THE WEEK ENDING MARCH

2(, 1894.

B. 8. Mackib, sargeoo, ordered to the U. S. ReceiviDg-ibip
"Frsnklin."

W. G. Bkaistbd, passed assistant surgeon, from Naval Hospi-
tal, New York, and to tbe U. 8. 8. " Colnmbia."

S. 6. Evans, passed assistant surgeon, from the Naval Hoa-
pital, Philadelphia, and to tbe Naval Hospital, New York.

W. G. Fakwbli., surgeon, ordered to the U. 8. S. " Colom-
bia."

OFFICIAL LIST OF CHANGES OF STATIONS AND DUTIES
OF MEDICAL OFFICERS OF THE UNITED STATES
MARINE-HOSPITAL SERVICE FOR THE FOUR WEEKS
ENDING MARCH 17. 1894.

Fbssendbn, C. S. D., surgeon. Detailed as chairman, Board
for physical examination of Assistant Surgeon L. E. Gofer.
March 6, 1894.

PcaviANCB, Geobob, surgeon. Detailed as chairman. Board
to inspect Reedy Island Quarantine. February 20, 1891. To
report at Bureau for temporary duty. March 2, 1894.

Button, W. H. H., surgeon. Detailed chairman. Board for
physical examination of Inspector of Hulls. March 9, 1894.

Gassawat, J. M., surgeon. Detailed as recorder, Board for
physical examination of Assistant Surgeon L. E. Cofer. March
6, 1894.

GoDi-BBY, John, surgeon. Detailed as chairman. Board for
physical examination of candidates, Revenue Marine Service.
March 6, 1894.

Ibwin, Faibfax, surgeon. To proceed to Paris, France, for
special duty. February 24, 1894.

Mbao, F. W., surgeon. Detailed as chairman. Board for
physical examination of candidates. Revenue Marine Service.
March 10, 1894.

Cabtbb, H. R., surgeon. To report at Bureau for special
duty. March 14, 1894.

Banks, C. E., passed assistant sniveon. To proceed to Ports-
mouth, N. H., as inspector. March u, 1894.

Kallocb, p. C, passed assistant surgeon. Granted leave of
absence for thirty days. March 12, 1894.

Glbnnak, a. H., passed assistant surgeon. Detailed as mem-
ber. Board to inspect Reedy Island Quarantine. February 20,
1894.

Wasdin, Euobnb, passed assistant surgeon. Granted leave
of absence for sixteen days March 3, 1894.

KiNTOUN, J. J., passed assistant surgeon. To report to chair-
man, Committee ou Ventilation and Acoustics, House of Repre-
sentatives, for special duty. February 21, 1894.

WooDWABD, R. M., passed assistant surgeon. To report at
Bureau for special duty. March 14, 1894.

GuiTERAS, G. M., passed assistant surgeon. Granted leave
of absence for twenty days. February 19, 1894.

Stimfson, W. G , assistant surgeon. Granted leave of ab-
sence for twenty-five days. March 6, 1894. Detailed as re-
corder, Board for physical examination of Inspector of Hulls.
March 9, 1894.

HoooBTOK, E. R. , assistant surgeon. Ordered to examination
for promotion. March 3, 1894.

RosBMAU, M. J., assistant surgeon. Ordered to examination
for promotion. March 6, 1894.

CoFBB, L. E., assistant surgeon. To report to Board for phy-
sical examination. March 6, 1894. Placed on " waiting orders."
March 16, 1894.

Gaudnbr, C. H , assistant surgeon. Detailed as recorder,
Board for physical examination of candidates. Revenue Marine
Service. March 10, 1894.

Stbwabt, W. J. S., assistant surgeon. Detailed as recorder,
Board for physical examination of candidates, Revenne Marine
Service. March 10, 1891.

SOCIETY NOTICES.

Boston Socibtt fob Ubdicai. Obsbbvation.— Tbe annual
meeting will be held at 19 Boylston Place, on Monday, April 2,
1894, at 8 o'clock.

Readers: Dr. C. H. Hare: " An Ovarian Dermoid Discharging
through Bladder for Three Years before Operation and Cure.
Discussion by Dr. W. H. Baker and Dr. W. F. Whitney.

Dr. Charles Harrington: "Massachusetts Laws Relating to
the Sale of Foods; their Enforcement."

Election of officers for ensuing year.

Election of honorary and associate members.

Report of auditing committee.

JuBN C. HuNKO, H.D., Secretary.

Thb Suffolk Oistbict Mbdicai. Socibtt, Subqicai. Sic-
xioN. - The Surgical !:?ection of the Suffolk District Medical
Society will hold its regular monthly meeting at 19 Boylston
Place on Wednesday evening, April 4, 1894.

Dr. E. W. Cushing will present a paper upon " Abdomin&l
Drainage." Dr. M. H. Richardson and others will take part in
tbe discussion.

Dr. F. Q. Balch will report " Cases of Compound Fracture of
the Ankle."

CHABl.Ba L. Scusdbb, M.D., Secretary, 1 Marlborough St.

Thb Association or Ambbican Mbdicai. Coi.LBai8.-The
fifth annual meeting of the Association of American Bledical
Colleges will convene at Maple Hall, Grand Pacific Hotel, San
Francisco, Cal., at 3 o'clock p. K., Wednesday, June 6, 1894.
Action will be taken at this meeting upon several proposed
amendments.

N. S. Dayis, M.D., LL.D., Pre*ident.

Pbhbt H. Millard, M.D., ^Secretary.

Mbdical Association of GKOKOtA.— The forty-fifth annual
session of the Medical Association of Georgia will meet in
Atlanta, Ga .on April 18th, 19cfa, 20th.

W. H. Elliott, M.D., President, Savannah, 6a.

Dak H. Howell, M.D., Secretary, Atlanta, Ga.

HARVARD MEDICAL SCHOOL.
Evening Lbctubbs.

The next lecture will be given on Wednesday evening, April
4th, at 8 o'clock, by Dr. P. C. Knapp. Sublect, "Traumatic
Nervous Affections." Physicians are cordially invited.

RECENT DEATHS.

John H. Radcb, M.D., of Chicago, died suddenly in Lebanon,
Penn., March 24th. He was a well-known authority on sanita-
tion and medical education. He organized the Board of Health
of Chicago, and was President and Secretary of the Illinois
State Board of Health from its organization to 1^. He was a
delegate to the International Medical Association at Berlin in
1890, and to the Pan-American Medical Congress in tbe City of
Mexico. During tbe war be was brigade surgeon under General
Augur, assistant medical director of the Army of the Potomac,
and medical director of the Gulf Department of the Nineteenth
Army Corps.

Ebnbst Hbnbt Jacob, M.D., Professor of Pathology in
Yorkshire College, died of acute arachnitis in Leeds, England,
on February 28th, aged forty-four years.

AuousTE Ollivier, M.D., died recently in Paris, aged sixty-
one years. He was a member of the Academy of Medicine and
physician to the Vicfaey and St. Louis Hospitals, and to tbe
Enfante Malades. His various writings have been of consider-
able value, especially his "Le9ons Cliniqnes sui les Maladi^
des Enfants."

BOOKS AND PAMPHLETS RECEIVBD.

Verbrecben nnd Walmsinn helm Weibe, Statistische, Klin-
ische und anthropologisch-biologlsche Untersnchungen. Von
Dr. P. Nacke-Uubertnsburg. AMruck.

A Text-book of tbe Diseases of Women. By Henry J.
Garriques, A.M., M.D., Professor of Obstetrics in the New York
Post-Graduate Medical School and Hospital, etc. Containing
three hundred and ten engravings and colored plates. Philadel-
phia : W. B. Saunders. 1894.

Clinical Lectures on Pediatrics, delivered in the Vanderbilt
Clinic during the Session of 1892-93. By A. Jacobi, M.D., Clini-
cal Professor of the Diseases of Children in the College of Phy-
sicians and Surgeons of New York, etc. Stenographic reports.
Reprint. 1893. New York : Bailey ft Fairchild. 1893.

An Illustrated Bncyclopffidic Medical Dictionary, being a
Dictionary of the Technical Terms Used by Writers on Medicine
and the Collateral Sciences in the Latin, Englifih, French and
German Languages. By Frank P. Foster, M.D. Vol. IV, with
illustrations. New York : D. Appleton & Co. 1894.

A Text-Book on Diseases of the Eye. By Henry D. Noyes,
A.M., M.D., Professor of Ophthalmology and Otology in Bellevoe
Medical College, etc. Second and revised edition, illustrated by
five chromo-lithograph plates, ten plates in black and colors,
and 2t)9 wood-engravings. New York: William Wood & Co.
1894.

First Aid in Illness and Injury, Comprised in a Series of
Chapters on the Human Machine; Its Stractnie; Its Imple-
ments of Repair and the Accidents and Emergencies to Which
it is Liable By James E. Pilcher, M.D., Ph.D., Captain in the
Medical Department of the United States Army. Revised edi-
tion with 170 illustrations. New York: Charles Scribner's
Sons. 1891.

Digitized by

Google

Vol. CXXX, No. 14.J BOSTON MEDICAL AND SUBQIOAL JOURNAL.

329

£XERCISE IN THE TREATMENT OF LATERAL
CURVATURE.'

BT a. e. BRACKBTT, II.D., BOtTOX.

The use of ezerciBe is ooe of the meaoB to be em-
ployed ID the thorough treatment of lateral cnrvatare,
and ▼aries in its object with the case, and character and
d^ree of carve. It mutt be remembered that- all de-
grees of aeverity are found, from those light postural
cases ID which there is no actual distortion, but in
which the condition is one of malposition only and self-
correction can be easily assumed, to those severe forms
of fixed and rigid curves in which there is marked
stractural change both in the bone and in the softer
parts, and in which no degree of force which can be
borne by the patient is able to immediately bring about
the full correction of the deformity. The treatment
in the different cases will differ in the methods and the
means employed ; but the object of the treatment in
all cases is essentially to increase the flexibility of the
spine and the trunk, to hold the patient in a corrected
position, and to improve the general muscular condi-
tion. The employment of exercise, in its object and
in the method of its application, will vary necessarily
according to the object of the treatment and the stage
in which it is used. In most of the severer forms of
lateral curvature, the most important element in the
treatment is to increase the flexibility of the spine, to
make a better attitude on the part of the patient possi-
ble. To attain this, obviously something more than
exercise on the part of the patient is required, such as
the mechanical correction, and in this stage of the
treatment the use of exercise is an accessory part to
this one of mechanical force. In the later treatment of
lateral curvature the object of exercise is to improve
the muscular condition, and to enable the patient to
hold himself in a correct attitude. In those lighter
forms in which the forcible correction is not necessary,
the employment of exercise has a more prominent
part.

The question of mechanical correction is not here
considered. The employment of gymnastics will re-
ceive separate consideration, as to whether it is used as
an aid to mechanical correction to increase the flezi-
Inlity of the spine, or as a means of muscular training
and development.

With reference to the character of the exercises,
they may be classed as active and passive ; the former
including those in which treatment is performed purely
by the aid of muscular exertion, aided only by the
gravity of the body, and the second those in which this
is either supplemented or substituted by additional
force, used either by mechanical means or by an assis-
Unt.

The passive are included under the head of mechan-
ical correction, and are, therefore, not considered here.
The active may be further classified with reference
to the object for which they are used, whether for the
increase of flexibility of the spinal column, or for the
improvement of general muscular condition, and they
will be considered under those heads.

hencue of FlexibiUty. — Exercises of this character
have the same object as the passive mechanical correc-
tion, that is, the stretching of contracted structures in

> Bead before the Botton Soolety for M«dl«al ImproTemant, Jsnn-
»rj22, ISM.

such a way as to lessen the obstacles to correction of
the deformity. These, in the main, consist of forcible
bending and twisting of the spine in such ways that
the force will be exerted against the distortion. Pre-
caution is needed in this exercise that no such move-
ments are employed which in any way tend to increase
the flexibility of the spine in the direction of the con-
cavity, and second, that all such motions are avoided
which tend by themselves to the crowding together of
the already distorted vertebral bodies, forcing them
still further from the vertical line, and thus increas>
ing the rotation which accompanies the lateral devia-
tion. As the plane of the bodies of the vertebrse are
carried farther away from the vertical line than is the
axis of rotation, during flexion of the spinal column
they are crowded together and are forced still farther
away from the median line, thus increasing the rota-
tion. This fact is made use of frequently in the exam-
ination, as when the patient is told to bend forward,
which exaggerates the amount of rotation at first ap-
parent. The opposite of this is equally true as seen
in the diminution in the degree of rotary curve during
suspension and during recumbency. In the same way
that the pushing together of the vertebrae increases the
rotation, the forcible stretching tends to pull them into
the median line, and if this motion is carried still fur-
ther by a backward bending, the force toward the cor-
rection of the rotation is still greater. For this reason
all exercises which allow a forward bending of the
spine are to be avoided, and those which tend to in-
crease the backward flexibility should be encouraged.

Care is also necessary in those cases of double curve,
that exercises directed toward the increase of the flexi-
bility in one part of the spine shall not result in bend
ing of the concavity in the other. Such particularly
being the case with those asymmetrical movements in
which the trunk is carried to one side, either in the
standing position or by leaning over the side of a table
or a roller. As the spine bends much more freely in
the region of the concavity than of the convexity, unless
great care is used when the effort is made, or when press-
ure is brought to bear upon the convexity of the curve,
in all those motions where the whole trunk is involved
the spine invariably moves more in the concavity than
in the convexity. If this is allowed to happen, it obvi-
ously counteracts all the good that may come from the
pressure or the force which may be used upon the con-
vex portion.

This class of exercises is intended either to increase
the backward flexibility of the spine and thus indirectly
to improve the rotation, or is directed to the rotation
itself. The first, or those for backward flexibility of
the spine, are performed both when the patient is re-
cumbent, and when the influence of the superincumbent
weight is removed, and we have the force of muscular
action only ; and, second, those in which the patient is
suspended, but in which we have not only a partial re-
moval of superincumbent weight but also the force of
direct traction ; and, third, those in which the patient is
standing, but in which either additional force or simply
the weight of the body is used as a means to increase
the amount of backward bending. The first of these
are employed while the patient is lying prone, and
the effort is made to forcibly raise the head and shoul-
ders from the couch by muscular action alone. These
are varied and made more forcible by bending back-
ward over a padded surface, which is placed at the
point where the greatest increase of amount of motion

Digitized by

Google

830

BOSTON MBDIOAL AND SUBOIOAL JOURNAL.

[April 5, 1894

U required while the patient is lying on the back, and
allows the head and shonlders to fall downwards over
the end of the couch. These are either done alone, or
at first with the aid of an assistant in case the patient's
strength ii not sufficient.

In the second series of these exercises, in which the
patient is suspended or partially suspended, the weight
should be equally divided between the head and the
arms, that is, the rope from the head-sling should pass
over a single pulley and return to the handle which the
patient grasps. If a compound pnlley is used, then
the amount of force used upon the head is relatively
increased in proportion to the number of pulleys, and
too great force upon the head and neck may be used.
The object of the suspension is to exert a stretching
force on the spinal column, and the suspension should
be so performed that the force shall be expended as
directly as possible on the contracted structures.

The third series consists of body movements, com-
prising bending and torsion of the trunk, and which
bring the strain from the body weight and muscular
action on the convexity of the distortion. These are
taken in part alone, and in part with such assistance as
will enable them to exert increased muscular action,
as from straps and bars properly arranged for the
direction of the pull, or by the hands of an assistant.

Eocercitei for the Improvement of the General Mmew-
lar Condition. — The object of exercise used with this
purpose is to train the patient to maintain a more nor-
mal attitude, and by this training to make this posi-
tion habitual. This is practicable only for those curves
which have, by the other means, been made flexible
and thus a corrected position possible, and in the light
postural cases in which correction has always beien
possible. In the large majority of non-paralytic cases,
the amount of asymmetry in strength is not great, at
least not appreciable to practical tests ; and for this
reason special exercises for weak muscles do not play
a prominent part. The matter of unequal use of mus-
cles is one of greater importance ; and such exercise
is rather to the training of such use of the muscles,
that the patient at first with effort can, and later will,
maintain this corrected attitude without effort and an-
conscionsly. The matter of aids to this by apparatus
to prevent the patient from assuming injurious attitudes,
both in standing and sitting, is important, but will not
here be considered.

These exercises may be placed under three groups :
(1) for correction of round shoulders; (2) for self-
correction ; (3) exercises in the corrected position. No
attempt is made to enumerate the individual exercises
used for these purposes, as this would open a subject
of itself too large for the scope of this paper, but rather
to consider the object of the various forms, and the
conditions under which they may be used.

In the large majority of these cases of spinal distor-
tion, there is found the condition of round shonlders,
frequently associated with a pushing forward of the
neck and head ; and the early correction of this is im-
portant in thorough treatment. Like exercises that
tend to increase a forward bending of the spine, the
position of round shoulders exerts a force which is
detrimental to the improvement of the rotation.
When the curve and the rotation of the spine are in
the upper part of the trunk, the forward movement of
the shoulders tends to push backward the spine in such
a way that the rotation of the vertebrse are increased.
As the chest becomes more fully developed, and the

shonlders are carried and forced backward, the result is
the same as in those exercises which tend to increase
the backward flexibility of the spine. Many of these
cases present a condition of decided rigidity, in which
instance the treatment must be directed towards in-
creasing the flexibility of the spine in this region,
until correction becomes easy.

By exercise for self-correction is meant those move-
ments in which the attempt is made by the patient's
voluntary effort alone to assume a corrected position.
In this, the patient may either stand erect, or be aided
by such a position of the arms as will allow greater ease
and more perfect correction, as, for instance, by the
effort of the sense of raising and pushing with the
shoulders or head, with the hands on the hips or clasped
behind the neck ; but no general rule can be laid
down, as each case must be studied with reference to
this by itself. In this effort, a marked improvement
in the position is possible, while its value is manifest
by the greater ease in assuming and maintaining this
position, and, after practice, in the nearer approach to
the complete correction. As an exercise this position
is held for an increasing length of time during the
regular hours of gymnastic work, and the effort made
at all times during the day.

An additional force that can often be employed
with very excellent results is gymnastic work in the
corrected attitude. Bernard IU>th has insisted on the
value of maintaining this, which he has called the
key-note position ; and its value lies in its training one
to perform body movements while the spine is held aa
far as possible in the corrected position. The key-note
position may be one which has been found best tbrongh
the effort of self-correction, or by the varied positions
of the arms and the plane of the pelvis ; or the ex-
ercises may be taken with the patient recumbent, and
a more complete position of correction obtained by the
addition of mechanical force pressure. The advantage
of muscular work in the corrected position, maintained
in any way, is obvious. After it has become easily
possible to assume an attitude of self-correction, it is
difficult to maintain the correction when any movement
is attempted. By holding this position during gymnas-
tic exercise, this same self-correction is maintained with
greater ease during the day, and becomes more nearly
habitual.

PATHOLOGY OF DIABETES MELLITDS."

BT BUUOTT P. J08LI1C, A.B., PH.B.

(Conoloded from No. IS, page Sia.)

Experimental Work, — The experimental work of
Herr von Mering and Herr Minkowski,* on the pro-
duction of diabetes by pancreatic extirpation, forms
one of the foremost chapters in all experimental path-
ology. It is about two hundred years since Wirsnng
gave his name to the pancreatic duct. The pancreas
must have excited a good deal of interest at that time,
as we find Regnier de Graaf " and Conrad Brunner "
trying to extirpate it. They thought that their attempt
was successful, and published two articles, in which
the medical fraternity was informed in Latin that the
removal of the pancreas was provocative of no results.
Their word was accepted — or forgotten ; and I find
no further mention of the subject until Claude Bernard
attempted to produce a diabetes by plugging the daot

• Bead btfor^ths BoyUton Madloal Soolstr of tbo Harrard Hedl-

oal School, Koraiaber IT, IKSS.

Digitized by

Google

7oi.. CXXX, No. 14.] BOSTON MEDIOAL AND 8UBGI0AL JOURNAL.

331

of Wiraang, and failed. In 1889 von Mering and
Minkowski began their work on the aabject, to which
they have added from time to time ever since. Many
investigators have confirmed their work, bat none have
essentially added to it.

The technique of the removal of the pancreas is no
mean piece of surgery. The gland is difflcalt to get
at, the blood-sapply is free, and it has an intimate
connection with the sarroanding parts. The total re-
moval is essential for the success of the experiment,
and it is in this particular that so many have failed.
So carefally has Minkowski conducted his operations
that in not a single instance did he leave even a small
part of the^pancreas in the abdomen. Peritonitis is
one of the greatest bugbears to the operation. After
foil extirpation, first intention is seldom obtained,
though this was obtained in partial removal of the
gland. The experiments have been conducted on dogs.
Cats are difficult to experiment upon, and the pancreas
of rabbits cannot be successfully removed. Good re-
sults come from the extirpation in swine, but in birds
and frogs the returns are not so satisfactory.

When a healthy dog is deprived of the pancreas he
is attacked invariably within twenty-four hours with
glycosuria, which continues for some weeks without
interruption up to the death of the animal. On the
first day after the operation the urine contains one per
cent., or less, of sugar ; on the following day the per-
centage has risen to four or six ; and on the third day
it has reached eight, ten, or even more. If no food
is taken, the sugar begins to diminish ; but after seven
days of starvation it does not fully disappear. The
amount of sugar decreases when the animal becomes
very weak, and at some time before death may wholly
disappear from the urine. In two of Minkowski's
cases this occurred. " The diminution in the amount
of sugar excreted in no way corresponds to an improve-
ment, but rather to a worse state of the conditions of
nutrition." Peritonitis and septic processes may lead
to a disappearance of the sugar. If carbohydrates are
taken, the amount of sugar rises rapidly, and the sugar
ingested is practically wholly excreted. The urea
stands to the sugar in the ratio of two to three, when
the dog is on a pure flesh diet ; and this ratio is main-
tained with very slight variations through all the vicis-
situdes of the experiment. Thirst, polyphagia and
polyuria are constant accompaniments of the glycoa-
nria ; and the emaciation, feebleness and the slow heal-
ing of the wound all show that the animal is suffering
from a severe diabetes mellitus.

Von Mering and Minkowski have further reported
that after a partial extirpation of the pancreas a dia-
betes was not produced. To this fact they attach much
importance. They think this explains the non-appear-
ance of glycosuria in man in some pancreatic lesions.
A part of the gland can perform the function of the
whole. Furthermore, this answers the objection which
has been raised that the diabetes was due to nerve
lesions caused in the operation. In the removal of a
large portion of the gland, for example, four-fifths,
the same nerve lesions would be committed as ia the
removal of the whole gland. Just how much of the
gland must be left in the abdomen to prevent diabetes
cannot definitely be stated. The nutrition of the part
left behind here enters into the problem. In some of
the instances where a portion of the gland is removed,
a diabetes of light grade is produced. This is present
only when the animal is on a carbohydrate diet ; and

it is supposed that slight glycosurias in man might be
attributable to some moderate disturbance of the pan-
creatic function.

The abdominal grafts of the pancreas are by far the
most striking part of Minkowski's and von Mering's
work. This was suggested by Schiffs work on the
thyroid. The art of the experimenter is here given
full range. The pancreas is a fragile organ and quickly
dies. Moreover, an animal which has submitted to an
operation on the gland is in great danger of peritonitis.
Both obstacles were overcome in the following manner.
The pancreas was carefully dissected from its attach-
ments in the abdominal cavity, turned on its axis and
stitched to the abdominal wall. The blood-supply
was disturbed as little as possible. The wound was
allowed to heal, and gradually the pancreas became
engrafted on its new surroundings. When this was
firmly established the dog was submitted to another
operation, in which the internal part of the gland was
removed. On the recovery of the animal no diabetes
resulted. After an interval of some time, the engrafted
pancreas was removed ; and when this was done, dia-
betes in all its forms appeared. What more striking
proof could be asked for the action of the pancreas in
producing diabetes ?

The removal of the graft with its sequence of diabetes
throws aside completely the theory that in these cases
nerve lesions are the cause of the disease. The blood-
supply of the graft, in some cases from the abdominal
parietes, in others from the aorta alone, excludes any
theory which ascribes the prevention of the diabetes
to the different blood-supply the gland might receive.

No connection exists between the intestinal secre-
tion of the gland and its functions in the prevention of
glycosuria. Minkowski has observed the absence of
the ordinary secretion and yet no diabetes, while
Thiroloix *^ has seen a diabetes come on when the se-
cretion was active.

Is this function whose disturbance leads to the pro-
duction of diabetes a specific property of the pancreas ?

Minkowski concludes that it is, else why should
diabetes appear on its extirpation ? Various authors
have thought differently. Renzi and Beale** found
sugar in the urine after the removal of the salivary
glands. Minkowski has carefully gone over their work
in his own laboratory and finds (1) that the glycosuria
was usually slight in intensity, (2) that it was transi-
tory, and (3) that it was not even a constant result of
such extirpation. And as for the work of the same
authors on duodenal extirpation, much the same con-
clusions were reached which Weintrand^ has further
confirmed. .

Falkeuberg, after removal of the thyroid, obtained
a glycosuria in 13 out of 20 cases. Gley ^ and Min-
kowski agree in thinking this glycosuria due to trau-
matism.

It may be well to definitely state that the removal
of the gland so that all intestinal secretion is cut off
brings on no diabetes. A transitory glycosuria may
result from the abdominal operation.

Minkowski's experiments of total extirpation, partial
extirpation and grafts of the pancreas have been con-
firmed by Hedon," Thiroloix" and Abelman." Le-
piue" in 100 pancreatic extirpations, and Sand-
meyer "* in 29, have come to the same result.

How does removal of the pancreas cause diabetes
mellitus ?

Minkowski does not say, but simply states the two

Digitized by

Google

382

B08T0S MEDICAL ASD SVRGIOAL JOVBJSAL.

[Afbil 5, 1894.

theories which are advanced, and point* out that there
are further channels for experimental work which
when traversed will enable us to have a clearer insight
into the question.

The first of the two theories at present most advo-
cated is that there is a ferment in the blood which
destroys the sugar. This ferment is furnished bj the
pancreas, disease or removal of which causes a heap-
ing up of the sugar in the blood, due to the non-as-
similation of the sugar by the tissues. The other
theory implies a poison in the blood, which in the nor-
mal person is destroyed or rendered inactive by the
pancreas ; removal of this gland allows an accumulation
of the poison and grave nutritional disturbances.

Lepine *' was a fellow-worker with Dr. H. P. Bow-
ditch, who has spoken highly of him to me as a
scientist. He discovered that the normal pancreas
when treated with a little water made alkaline was
able to destroy a small quantity of sugar. The blood
of an animal deprived of its pancreas lost less sugar
than the blood of a sound animal ; and hence Lepine
concluded that the pancreas yielded to the blood a
ferment which contributed powerfully to the destruc-
tion of the blood sugar. This ferment he called the
glycolytic ferment. He found that the blood of the
portal vein was richer in this fermeut than that of any
other part of the body, and after an elaborate series of
experiments proved that this ferment was contained
in the white blood-corpuscles. This fermeut is dimin-
ished, he has shown, in the blood of diabetic persons
to the number of seven ; and, in fact, in all cases in
which there is an increased amount of sugar in the
blood the ferment is present in less than the normal
quantity.

Writers on diabetes speak favorably of Lepiue's
theory, but most of the experimenters have not yet
accepted it. This theory of Lepine's necessitates the
view that glycosuria results from the lack of the power
of assimilation of the sugar by the body. Hedon"
and Seegan "^ also consider that the lack of assimilation
of the sugar is the cause of diabetes.

RECENT WORK OF CHADVBAU."

Chauveau was a fellow experimenter with Claude-
Bernard. He has done much eminent work in time
past, and the field of experimental diabetes is well
known to him. Two articles which he has recently
published connect the work of Claude- Bernard and that
of Minkowski. In his first memoir be proves that dia-
betes is due to an increased production of sugar by the
liver. In a normal animal the blood in the hepatic
veins contains the most sugar of any. blood in the
body. The sugar in the arterial blood always is
greater iu amount than that in the venous. Claude-
Bernard has shown the formation of this sugar to be
the property of the liver, aud Chauveau has made clear
that the destruction of the sugar takes place in the tis-
sues. Somewhere in the capillaries between the red
arterial and dark venous blood the sugar is lost. If
this sugar continues to be lost in an animal rendered
diabetic, we can feel sure that the cause of the diabetes
rests on the overproduction of sugar and not on its
lack or destruction.

So Chauveau produced diabetes in animals by trau-
matism, by puncture of the fourth ventricle, by section
of the cord just below the medulla and by removal of
the pancreas. In each instauce the analysis of the ar-
terial and venous blood showed the normal excess of

sugar in the former. It is well known that a section
of the spinal cord from the last few cervical to the
sixth dorsal vertebra produces a diminished amoant of
sugar in the blood ; but when this section was made,
the arterial remained richer in sugar than the venous
blood. His experiments confirmed his theory that
diabetes is due to an increased production of sugar.
This work was preliminary to his next article.

We know that sugar is formed in the liver. Is it
formed anywhere else? The muscles remove the
sugar from the blood, which they use dehydrated in
the form of glycogen. There is no reason why these,
like the liver, should not convert this glycogen back
into sugar, but no proof of this has eve* been given.
Furthermore, if the muscles did do this, we should ex-
pect to find more sugar in the venous blood than in
the arterial, bat Chauveau's previous work has shown
that this is not so. The liver, then, is the source of
the increased sugar in the blood — hypoglycemic —
in diabetes ; and if we can explain the mechanism by
which the liver brings this about, we can explain the
disease.

For a long time it has been known that puncture of
the fourth ventricle would produce a passing glycosuria,
and lately von Mering and Minkowski have shown
that removal of the pancreas will cause the same result.
Various clinical facts also go to show that the pancreai
is connected with the production of diabetes. And
this leads us to consider the pancreas in a new light as
a moderator of the glycsemic function of the liver.
Now in diabetes there is besides the glycsemia a de-
struction of the tissues going on throughout the entire
body. The losses of the body surpass its gains. Kata-
bolism is the ruling feature, and from the products re-
sulting from the katabolism part of the sugar is formed
in the liver. This we know because diabetic animals
which are starved still continue to secrete sugar. But
how does the pancreas act to prevent this destruction
of tissue and subsequent formation of sugar in the nor-
mal state ? As the veins of the pancreas empty into
the vena porta, it is natural to explain this infiuence of
the pancreas upon the fornuttion of sugar in the liver
by supposing an internal secretion of the gland which
empties into the blood, by which it is carried to the
liver and participates in its functions. However, as
yet experiment has given no proof of the direct action
of this pancreatic secretion on the liver. The facts al-
ready known, with what Chauveau adds later, tend to
show that this action is through the agency of the ner-
vous system.

The functions exercised by these two glands depend
without doubt upon their inherent properties, but the
nervous system cannot fail to regulate their action.
Glands have been shown to have excito-secretory
nerves — compare the submaxillary gland and the
chorda tympani — and there is no reason to suppose
that the pancreas and the liver are exceptions. In
fact the teachings of physiology would impose upon us
the consideration of the existence of excito-secretory
and inhibito-secretory nerves Qf the liver. Indeed,
study of nervous action on the liver has been made;
but CJiauveau combines the former experiments with
pancreatic extirpation.

When a section of the spinal cord at its junction
with the medulla was made on starving dogs, hypo-
glycemie resulted as after the extirpation of the pan-
creas aud this hypoglyc^mie was attended with gly-
cosuria. These common symptoms lead us to draw a

Digitized by

Google

Vol. CXXX, No. 14.] BOSTON MEDICAL AND SURGICAL JOURNAL.

333

connection between the resalt obtained on bulbar sec-
tion and pancreatic extirpation, and to conclude that
in both instances the animal is subjected to the same
ioflnence ; in one, pancreatic secretion is rendered im-
possible by removal of the pancreas ; in the other, it
is made quite as impossible by paralysis of the gland/
From the effects thus produced by bulbar section we
can conclude that the pancreas is thereby isolated from
its escito-secretory centre, whence suppression of the
internal secretion and subsequent hypoglycemie. But
this section did not injure the ezcito secretory centre
of the liver; on the contrary, it became more active,
which would imply that it was not antagonized. The
following deductions then can be drawn from bulbar
section : (1) the action of the pancreas on the glucose-
forming function of the liver appears to be under the
control of a centre which excites the internal secretion
of the pancreas; (2) this centre is situated at some
point above the junction of the cord and medulla ; (3)
the sugar-forming function of the liver is controlled
by an excito-secretory centre which is situated in some
region of the spinal cord ; (4) the action of the pancreas
upKJa the liver is exercised upon the excito-secretory
centre of the liver and not on the liver itself.

Puncture of the fourth ventricle causes much the
same train of phenomena as does the section of the
cord at its junction with the medulla. In bulbar sec-
tion the animal of course dies because his life is de-
pendent on-artificial respiration. In medullary punct-
ure respiration is not disturbed. The identity of the
results leads us to consider that in sugar-puncture of
the fourth ventricle the excito-secretory function of
the pancreas is for the time deranged. This leads up
to the conclusion that this centre is no higher up in
the nervous system than the medulla, and the section
between the spinal cord and medulla has shown that
it is no lower.

This production of glycosuria by bulbar section can
also be explained on the hypothesis that there is an
inhibito-secretory centre of the liver in the medulla,
which by the operation is shut off from its influence on
the liver. The internal secretion of the pancreas then
would stimulate the inhibito-secretory centre and moder-
ate the excito-secretory, while its absence would pro-
duce just the opposite results and hypoglycemic would
appear. The lighter glycosuria which appears on bul-
bar section could then be explained by the pancreas
acting to a slight extent, though removed from its
excito-secretory centre. Having thus set forth the
theory, Chauveau proceeds to the more original part
of his work.

When a section of the cord is made between the
fourth cervical and sixth dorsal pairs of nerves, a
hypoglycemic is produced. Evidently this is due
either to increased action of the inhibitory centre or
paralysis of the excitatory. The second alternative
conforms more easily to the facts. Now as this paraly-
tic effect ceases when we go above the fourth cervical
pair, and we then get hypoglycemie, it is evident that
the excito-secretory centre of the liver is in the neigh-
borhood of the fourth cervical pair. The section be-
tween the fourth pair cervical and sixth pair dorsal is
then explained by this section severing the communica-
tion of the excito-secretory centre with the liver. It
can furthermore be deduwd that the inhibitory fibres
of the liver pass out of the cord above the fourth, or
else the hypoglycemic would not result from section
below that point.

When a section between the fouHh cervical and
sixth dorsal is followed by removal of the pancreas,
instead of getting a hypoglycemie with the symptoms
of diabetes which are ordinarily obtained on removal
of the pancreas, Chauveau found a condition of hypo-
glycemic, and following the theory as detailed above,
the explanation is easy. The connection between the
liver and its excito-secretory centre having been severed,
the removal of the pancreas could not produce its or-
dinary effects.

When suppression of the pancreas is followed by
section of the cord between the fourth cervical and
sixth dorsal, from the previous work we should expect
that the symptoms of diabetes would cease when the
latter part af the operation was performed ; but no
such result awaits the experimenter. The hypogly-
cemie continues. The reason can be found in the
sympathetic ganglia which lie in the track of the
nerves. These act as relays to the central nervous
system; and from these nervous impulses are sent
forth, only these are dependent in character upon the
primary impulse which is received from the higher
source. They continue to act in the same way even
though separated from their centres in the central ner-
vous system. So when the cord was cut between the
fourth cervical and sixth dorsal, the ganglia were left
under the control of the inhibitory centre, and sub-
sequent removal of the pancreas had no effect.

These experiments are further varied by substitut-
ing the bulbar section for removal of the pancreas,
and the same results are obtained. Thus, section of
the cord between the fourth cervical and sixth dorsal,
followed by section at juncture of medulla and cord,
produces no hypoglycemie. The hypoglycemie is
produced and not diminished, however, when the sec-
tion below the medulla is followed by section of the
cord between the fourth cervical and sixth dorsal.
Thus, in these experiments the isolation of the excito-
secretory centre of the pancreas (or what we can con-
sider as connected with it, the inhibito-secretory centre
of the liver) acts in the same way as does removal of
the gland itself. A section just below the medulla,
combined with removal of the pancreas, makes no
greater hypoglycemie than does simple removal of the
gland.

To recapitulate Chauveau's theory : Diabetes is due
to an excessive production of sugar by the liver. This
production is regulated by the internal secretion of the
pancreas, which acu upon the liver through its excito-
secretory and inhibito-secretory nerves. The excito-
secretory centre is in the cord near the origin of the
fourth cervical pair. The inhibito-secretory centre is
in the medulla. The internal secretion of the pancreas
acts on these so as to stimulate the inhibito-secretory
centre and moderate the excito-secretory centre. Re-
moval of the pancreas does the reverse, and brings on
hypoglycemie. Section just below the medulla cuts
off the action of the inhibitory centre, and hypogly-
cemic results. Section of the cord between the fourth
cervical and sixth dorsal allows the inhibito-secretory
but not the excito-secretory centre to act — whence
hypoglycemic. These centres act through ganglia,
which, once excited, keep on originating impulses of a
similar nature unless they receive an excitation of an
opposite character. The removal of the pancreas has
the same action on these ganglia as does the section at
the junction of the cord and medulla. "The close
connection between the effects of depaucreutization and

Digitized by

Google

334

BOSTON MBDIOAL AND SUROIOAL JOURNAL.

[Apbil 5, 1894

thoee of bnlbar Boction serve to eBtablish the identity
of the direct mechanism which presideg over the mani-
festation of these effects. The pancreas plays the rdle
of an inhibitor of the liver by means of its central ner-
vous regulators."

This theory of Chaoveau's, which I have not stated
quite as fully as the author gives it, calls our attention
to the unity of diabetes. It is complicated. It is based
on analyses of the blood and experiments on the ner-
vous system, both of which methods of experimentation
give opportunity for error. Nevertheless, it furnishes
a better explanation of all forms of diabetes than any-
thing yet advanced and will be useful in suggesting
further work.

REFERENCES.

8. Minkowski: Diabetes Mellitus nach Exstirpation des Pan-
kreas, 1S93.

22. AbelmaD : Ueber die Ausantzang der NahroogsstoSe nach

Pankreas-exstirpation mit besooderer Beriicbsicbtigung
der Ijelire von der Fettreaorption.

23. Renzi and Reale : Quoted from Minkowski, see note 8.

24. Tbiroloiz: Archiv. de Physiol., 1892, p. 716.

28. Weintrand : Quoted from Minkowski, see note 8.

26. E. Gley : De la Glycosurie cliez lea cbiens thyroidectomises,
Arch, de Physiol., p. 240, No. 2, 1893.

2T. Hedon: Arch, de Med., Gxper. 1, p. 44, 1891: Arch.de Mdd.,
Ezper. 6, p. 696, 1893; Arch, de Physiol., Ezper. 1, p. 166,
1893; Arch, de Physiol , Exper. October, p. 617. 189^.

28. Tbiroloiz: Arch, de Pbysiol., Ezper. 6, s. iv, pp. 716-720,

1892.

29. Quoted trom Sandmeyer, see note 30.

30. Sandmeyer: Zeitschrift fiir Biologie, zziz, p. 86.

31. Lepine: Lyon M^. Jour., January 25, 1891; Semaine M^d.,

1891, pp. 24, 111, 179, 388, 467, 5()9; Also see note 3.

32. Seegan : Quoted by Lepine, see note 3.

33. Cbauveau and Kaufmann: Soc. de Biol., February and

March, 1893.

RELAXATION AS A CURATIVE AGENT.

BV AKNIB PAT80H CALL, BOBTOX.

Mant diseases are either caused by or accompanied
with unnecessary tension, and in addition it might be
said that many diseases cause tension. This tension,
which is involuntary but can be voluntarily dropped,
disturbs the natural equilibrium of the forces of the
body, and will not allow Nature to do her perfect work.
The antidote is relaxation; and this being the case,
certainly relaxation is not given the place that should
be accorded to it among the natural curatives. Neither
is it yet recognized to be as effectual an aid to the bet-
ter working of medicine, as exercise, fresh air, nourish-
ment, and so-called rest, which is often very far from
relaxation. These four are accepted natural curatives ;
but their good effects may be greatly enhanced by
systematic relaxation, which renders the body more
susceptible to their influence.

Take the simple instance of severe pain, which of
itself directly excites contraction. A very slight effort
of the will to relax the sufferiiTg part often brings al-
most immediate relief. It is because of their relaxing
power that warm applications are made. If these in
return were assisted by the natural voluntary relaxing
of the patient, each might help the other greatly and
save much unnecessary suffering. With severe pain
contraction is so abnormally instinctive that it seems
at times to relieve it, but after such relief there is
always a reaction which means increased suffering.

Many forms of indigestion result from contraction,
and nothing else, and it is marvellous that medicine
should have any effect in such cases, when it is steadily
thwarted by an extreme tension on the part of the pa-
tient, a tension which might be dropped voluntarily.

Of course indigestion of this sort can become chronic,
when the tension is continued long enough to get be-
yond medicine or natural cures.

The semi-invalids who come week after week for
more medicine and expect it to do its work and cure
while they are steadily resisting it, are familiar ooca-
pants of a physician's office. But it does not, appar-
ently, occur either to the patient or the physician that
the patient can be taught not to resut, by as normal a
process as a child is taught tbe use of its fingers on the
violin — or the voice is given its natural freedom, that
it may express itself in song.

It is an almost equally familiar fact that there are
invalids, so-called, in whom the original disease has en-
tirely disappeared, but the brain impression is almost,
if not quite as strong as during the disease, and the
patient is ignorant of the fact that he has recovered.
Tbe disease habits here often take some form of teo-
sion, the dropping of which helps the patient to reach a
normal state, although there must be at the same time
some mental effort.

Nervous tension is often so immediately connected
with some mental impression that in order to relieve it
the greatest tact is required. For instance, yon can-
not say to a man, " My dear sir, you are quite well if
yon will only behave as if you were." That would
throw him back more decidedly upon the sick-list;
but you can lead him little by little until he sees the
state of his own case, believing this to be entirely his
own discovery, and so takes pleasure in removing all
abnormal habits and curing himself.

So it is with many cases of nerve trouble which
arise from an over-worked, over-excited, or over-
anxious brain. One form after another of mental
strain the patient must removt himself before he can
really begin to get rid of the tension that is keep-
ing him ill. The triviality of these nervous anxieties
is most remarkable, but of course they should be
looked upon as mere forms of tension and dropped, just
as one might study a muscle that is unnecessarily con-
tracted and train it to a natural freedom. On the other
hand, their triviality can never be truly impressed upon
the patient unless he is led to discover it himself. A
blunt effort at persuasion merely increases the teosioo,
and. this same tension, of course, retards the recovery.

A nervous invalid of this sort should be trained al-
ways objectively, as far as possible. Without such
training, a man, or more especially, a woman, may be
kept ill unnecessarily long, through the action and re-
action of an anxious mind and tired nerves. The
anxiety seems real and so works upon the tired nerves.
The tired nerves are a physical reality and not only in-
crease the anxiety but, in nine cases out of ten, cause
it. The tension is continued and the patient is kept
ill, and neither fresh air, exercise, nourishment, sleep,
nor medicine can help a man, to any extent, where bis
own will persists in permitting his abnormally anxious
brain and tired nerves to play back and forth one upon
tbe other. This condition is more common with women
than with men. Some women seem to take pleasure
in overloading and emphasizing their anxious brains,
in lacerating their tired nerves and then takiug a daily,
almost hourly, unhealthy observation of both. This,
of course, is due to the more sensitive nervous temper-
ament of the woman. But it is like rubbing a wound
and then expecting it to heal, or perhaps in this case
there is even a grim enjoyment of tbe non-healing pro-
cess. And all so unnecessary if one would learn to

Digitized by

Google

▼oi. CXXX, No. 14.J BOSTON MEDICAL AJSD SURGICAL JOURSAL.

336

look the other way, while nourishmeut, fregh air, exer-
cise, sleep, and a normal relaxation are doing their
own work with the assistance of whatever medicine
may be needed.

Beside this nervous fatigue, there are many forms of
nervous contraction from apparently no immediate or-
ganic cause, which might be greatly helped by gainbg
the power to relax normally. As an instance may be
given a case of a woman who had suffered for years
from an inability to articulate clearly and a want of
power to direct her muscles. She could not make her-
self anderstood by any ope, and at times would fall
fall length upon the floor, so uncertain was her bal-
ance. Physicians had told her that there was no cure,
and after thirty years of this unfortunate state, she has
now learned not only to balance herself on both feet,
bat to stand and rest easily upon one, and has gained
the power of communicating with others with a perfect
articalaUon.

The fact of the possibility of dropping unnecessary
tension seems to be little recognized by many physi-
cians. A short time since a very prominent doctor in
one of our large cities, informed a man who applied
to him for help in a spasmodic contraction of the throat,
that be could not help him in any way : but added,
" Nothing worse will happen than that you will faint
away, and yon will be all right then, for yoar throat
will relax." It never occurred to him that the man,
who had an excitable, nervous temperament, somewhat
over-strained, might learn to relax his own throat, and
save the inconvenient relief of fainting at times for the
purpose of regaining his breath.

Unnecessary contraction, while more immediately
recognized in such cases as the above, may be found,
although by no means to so great an extent, in many
diseases that have not a directly nervous cause. Vari-
ous forms of congestion are accompanied with contrac-
tion. Fever may be increased by an excitement which
causes contraction, and decreased by quietly giving up
to it and letting it have its way. And so one form of
disease after another could be named, which is in-
creased by the accompanying contraction and would
be correspondingly abated by its removal.

With unnecessary contraction, nourishment has not
its fall effect, the digestion is labored, so that nervous
force is used in the process of digestion which wooJd
otherwise be kept for new life. Fresh air has not its
fall reviving effect, for the circulation is impeded, and
the blood cannot carry the oxygen so freely through the
body. Vigorous exercise is not taken as easily when
the muscles are not normally directed, neither is it as
beneficial in its results. First, because of the waste
of force in motion ; second, because as a result of this
waste, there is often more or less tension when resting,
which does not allow the quickened circulation all the
freedom required for its best result. With unnecessary
tension, sleep is not so restful as it should be, for when
one does not give way to a perfectly natural sleep, the
waste cannot be supplied so rapidly. Where it should
be all a building up, there is at the same time a using
np of force, all the more trying because it is abnormal.
Fresh air, exercise, nonrishment and sleep are Na-
ture's curatives. To lead the patient to a greater free-
dom is only to open the way that these may have a
more immediate effect. The freer the body, the quicker
Nature can bring it to a state of health, whatever may
have been wrong in the beginning, and this, of course,
applies equally to the action of medicine.

A man takes ether not only to get relief from pain,
bat to be kept in a passive state which will enable the
surgeon to do his work, unhampered by the contrac-
tions that would inevitably come from fear or pain.

There is no ether that will keep a sick man in a
state of freedom and allow the disease to run its course
and be over with, but there is a natural freedom which
might come without ether if the patient had a little
knowledge of how to gain it.

A disease has a natural course, even though it is a
disease, so truly does order reign in spite of man's dis-
order, and to give it its freedom with the guide of the
curatives, would lessen the possibility of ^ter effects
which are often worse than the disease, or of death it-
self.

It is, of course, impossible to train a very sick man
to keep quiet and free and let the disease be taken care
of by Nature and medicine, but it is quite possible to
train one who is not very ill, so that he may be saved
much unnecessary suffering. £ven a very sick man,
if he is in his right mind, may be helped by gentle and
constant suggestion.

Of coarse, as a preventive, a training to natural free-
dom could be used illimitably, but the object of this
article is only to call attention to its curative power.
A sense of weight may be given to the whole body,
through getting the impression of weight from the slow
lilting of an arm — either by another's moving it gently
so that it must gradually be passive, or by the patient's
being taught to lift it himself from the shoulder — even
an inch from the bed, and then dropping it. As this
is repeated over and over, the impression grows and a
greater sense of weight is spread over the whole body,
which relieves the tension and gives a certain degree
of freedom. In addition to this, is the quiet effect
upon the brain, which comes from fixing the mind upon
something so simple. The result of the idea of weight
tends to spread the freedom over the entire body, un-
consciously to the patient.

Great care must be taken that the sense of weight is
weight alone and not pressure.

This same result sometimes comes more quickly by
a very slow lifting of the head by the two bauds of an-
other. The extremely slow motion of head, legs, or
arms always has a directly quieting influence and so
leads to greater freedom.

The immediate effect upon the brain of breathing is
very well known, and various forms of quiet, long, and
short breaths, can be made most useful, especially if
the patient is well enough for the simple concentration
of counting, — for instance, inhale counting seven, ex-
hale counting seven — rest (breathing naturally) count-
ing seven — and repeat this seven times keeping his
own count. This may be increased to nine, twelve,
fifteen, twenty-four, and the resting periods may be
doubly as long as the breathing.

This simple concentration is often difScult even for
those who call themselves well, and is most useful in
focussing the mind with many who have, or have had,
nervous prostration. A return, after a long nervous
illness, to a natural ase of the mind in talking, in read-
ing, or in the various daily affairs of life, is often diffi-
cult, when otherwise one might be perfectly well, and
is made easier by this simple form of concentration in
breathing, because through it the brain gets a better
balance. Added to these, are other exercises in con-
centration, by which, through keeping the mind steadily
for a very short time on various forms and motions of

Digitized by

Google

n6

BOSTON MEDICAL AND SVBGIOAL JO USUAL.

[Apbil 5, 1894.

natare, a etrong brain impresiioD ii made and a healthier
state of nerre brought about. These must be chosen
with care and with special reference to iodividual needs,
and are meant, of course, for help in nervous cases.
Thejr are successful often where the interest needs to
be roused, and help comes as much from the way the
exercise is given as from the exercise itself.

Having given an idea of weight and the deep breath-
ing exercise according to the state of the patient, more
or less can always be done in helping the power of di-
rection, 80 that only the muscles needed will be used,
even in turuing over in bed or moving an arm or leg.
Very great help is given through conveying an idea
of what it is to free one's self from unnecessary men-
tal tension.

Take a case, for instance, in which the patient is
resisting constantly in his mind the fact of being ill.
This resistance produces a tension of the brain, the
effect of which is felt upon the entire body. Now if
he can be shown, quite simply, that he must be per-
fectly willing to be ill, for that will help Attn moit to
get welt, there is a counteracting effect at once and
Nature and the doctor are given a better chance.

To be sure there are often instances where the pa-
tient instead of resisting the illness gives up to it too
willingly. In that case he is resisting recovery and
must uo more be permitted to do so than to resist the
illness. Relaxation ii neeeuaty otdg in to far at it
traint the body to a nortnal frteiom <md to enabUt it to
find and hold itt own equilibrium.

It may be thought to be impossible to change a
man's mental state to such a degree, but that depends
upon how it is approached. As has been said before,
all the tact of a diplomatist mast be used in such train-
ing, as indeed in all training for a natural freedom.

The same is true of the resistance to various annoy-
ances, great and small. Indeed irritability is one of
the most fruitful causes of prolonging disease. The
unwillingness in each case has the same effect upon the
brain, and its counteraction brings immediate relief and
so opens the way for a more rapid cure.

The process of relaxation as a curative may be briefly
summed up thus : a greater freedom of the body to
be gained through obtaining a sense of weight, quiet
and deep breathing, and a power of natural direction
and simple concentration.

It results in a freeing of the body, which will more
certainly and rapidly permit a wholesome effect from
fresh air, exercise, nourishment, sleep, medicine, and
other curative processes.

Clttiical IDepartmettt.

TWO CASES OF PULMONARY CONGESTION
AND (EDEMA OCCURRING DURING PREG
NANCY.'

or rsAKCiB w. ooss, m.d., koxboby, mass.

Case I. Acute pulmonary congestion and oedema
in patient six and one-half months pregnant Death.

At 2 A. M., March 27, 1889, I was called to see
Mrs. D., six and one-half months advanced in her first
pregnancy. She had recently moved to Boxbury from
a distant part of the city. Her pregnancy had been
uneventful till the present illness.

> Road before the Boaton Soolety for Kedioal ImproTement, Jiuta-
arj 22, 1894.

Daring the afternoon preceding my summons she
bad been to see her physician, three or four miles away,
because of a slight cough, and some difficulty of breath-
ing, which had troubled her for a day or two. She
retired as usual, slept for several hours, and then woke
suffering from great dyspncea and distressing cough.
When I reached her she was sitting in a chair, in ex-
treme distress, with alarming dyspnoea, rapid breathiDg,
coughing and expectorating quantities of bloody serum.
Her face was dusky, skin cold, and bathed with dammy
perspiration. Her pulse was very rapid and feeble;
the lungs filled with moist r&les, and her condition be-
tokened impending death. She lived but a short time,
— not more than half an hour after my arrival.

Her physician informed me that there was nothing
apparently serious in her condition when she called
upon him the previous afternoon, and he was much
surprised at her sudden decease.

Case II. Sudden pulmonary congestion and oedema
in patient six and one-half months pregnant. Induced
labor. Recovery.

Mrs. M., six and one-half months advanced in her
seventh pregnancy summoned me at 11 p. m., October
26, 1893, on account of severe dyspnoea.

She had been seen nine days before by Dr. G. W.
Clement in a similar attack, when her husband came
for him saying that he believed his wife was " choking
to death." Dr. Clement informs me that he found her
sitting in a chair, bent forward, coughing bard and
raising bloody, frothy sputa. The chest was filled
with moist r&les, the pulse was quick and feeble, and
her condition critical. He was with her some three
hours before she was sufficiently relieved for him to
feel that it was safe to leave her. She rallied under
the use of stimulants and of pilocarpin nci cute. On
subsequent examination he found a mitral systolic
murmur of the heart, and albuminuria.

Being obliged to leave the city for several days Dr.
Clement directed that I should be sent for during his
absence, if there was need.

When first seen by me the patient was suffering from
alarming dyspnoea and orthopnoea, frequent cough and
expectoration of bloody sputa. Pulse 1 20, respiration
48. In about two hours, under the use of aromatic
spirits of ammonia, nitro-glycerine, etc., she became
easier, and I left her for the night.

October 27th. She was much more comfortable,
and had slept somewhat. She reported an attack of
acute rheumatism several years ago, and another last
winter.

Examination of the heart showed marked mitral
systolic souffle; not much enlargement of the organ.
Some oedema of extremities. Urine abundant under
the use of diuretics prescribed by Dr. Clement. Alba-
men, one-third bulk. Epithelial and granular casts.

The ptatient said that she had not felt any foetal
movements since the attack of dyspnoea ten days ago.
No foetal heart heard on anscultation. She has had
two premature births of dead children at about seven
months, since birth of last living child four and one-
half years ago.

October 29th. Has had some return of the parox-
ysms of dyspnoea. In view of the recurrence of Uie
attacks and the continued tendency thereto, and the
cardiac and renal disease, it seemed to me that the pa-
tient's condition was critical so long as the foetus
remained in atero. Accordingly, under anUseptio pre-
caaUons, I introduced a catheter through the cervix

Digitized by

Google

Fot. CXXX, No. 14.] BOSTON MEDIO AL AND SURGICAL JOURNAL.

337

ateri, trith the view of bringing on premature labor.
Pains came on dnring the evening and at 12.20 A., m.
October 30tb she was delivered of a foetot apparently
of aboot six and one>half months' development which
bad evidently been dead for several days.

With the exception of some rise of temperature on
the gecond day, for which an antiseptic intra-uterine
douche was given with immediate improvement, the
patient made a satisfactory recovery.

November 30th. The patient is about and doing
hoa8e-work. Feels fairly strong ; no return of dyspnoea
since labor. Urine abundant; specific gravity 1,025 ;
albumen small in amount; and but one granular cast
foDod in examination of two slides.

Judging by what I can learn from- the text-books,
and from conversations with physicians, such cases as
those here reported are fortunately rare. When they
occur, and medicinal treatment does not relieve, it
seems to me the only hope for the patient may be
speedy delivery, if it can be effected. In the first case
there was no opportunity for the procedure. In the
second, the patient's life was in jeopardy as shown by
the recurrence of the alarming attack, notwithstanding
she was under the influence of digitalis, diuretics,
cathartics, etc, prescribed by Dr. Clement.

Whether such conditions appearing in pregnant
women are always accompanied by cardiac or renal
disease, or by both, I do not know. These troubles
were present in the second case. In the first the point
was not determined.

TOXIC EFFECTS AFTER USE OF OIL MALE
FERN (ETHEREAL) FOR TAPEWORM.

BT JOHN H. OSAKT, M.D,, FOBT POBTKB, BUFVALO,
Botpital Sttmard, U. S. AtTny.

t;

C. H., aged thirty-five, was a soldier in the Grarza
campaign on the lower Rio Grande in Texas during
the winter of 1890-91, at which time he was often
obliged to subsist in part on insufficiently cooked goat
meat. As a result, he became the possessor of a tsnia
saginata. Outside of the few large towns in this part
of Texas, defecation by the inhabitants (principally so-
called greatert) is universally carried on in the open-
air and readily accounts for the manner in which our
patient became infected.

In 1892, an army surgeon treated him by the admin-
istration of oil of turpentine, which produced violent
strangury and the passage of about sixteen feet of the
worm.

Id November last he was again treated with drachm
doses of oil male fern (ethereal) (of an old stock some
time on hand) ; but two doses were retained, aborting
about eighteen feet of the entosoa.

March 1st the man requested further treatment ;
•nd a fresh supply of the male fern having been re-
ceived (W. H. Schiefflin & Co., New York), an emul-
sion with acacia was prepared, each fluid ounce con-
taining one and one-third drachms of the oil. The day
previous the patient abstained from solid food, a saline
cathartic being administered at sunset. The morning
following, at 6.30 one ounce of the mixture was
given, and at 8.30 a like quantity ; at noon a dose of
sal rochelle was taken, resulting in the expulsion of
about eighteen feet of the parasite. About 4 o'clock
the patient, on leaving the water-closet, fell to the floor
and had to be carried to his bed. The writer being

then called, fcand the patient in a most pitiable condi-
tion — almost pulseless, skin cold, eyeballs protruding
and staring, &:.flu8ed with tears, the lids puffed and of
a dark-brown color. Deafness was nearly complete in
both ears, but the sight was not at this time affected.
Patient was husky, suffered from a vise-like constric-
tion of the chest, gMping for breath, and with a ghastly
expression of despair. He appeared to be in extremis.
As soon as possible whiskey (one ounce) was adminis-
tered, and a sinapism applied over the sternum. In
about flve minutes the pulse could be felt. The other
symptoms gradually disappeared, so much so, that in
a half hour the case was considered safe. The feeling
of chest constriction and of burning within the stomach
lasted for a few hours ; but a few ounces of milk and
whiskey and particles of ice freely dissolved in the
mouth, soon gave relief. The patient had dimness of
vision and was very weak and nervous the day follow-
ing, keeping his beid for two days.

There were two interesting points about this case.
The first was the extreme depressant action of the male
fern in what might be considered not a large dose.'
It will be noticed that it was nearly eight hours after
the second and last dose in this case before any alarm-
ing symptoms presented, and not until after the bowels
had been moved several times. The second point was
the thrice-repeated failure to bring away the head.
Diligent search in the present instance failed to discover
any traces, although a portion of the voided parasite
was very narrow. Possibly the head is very securely
imbedded beneath a fold of the valwlte conniventei
and protected from the direct action of the drug. The
peristaltic action of castor oil might have secured the
head, but owing to the disgust excited by it in the pa-
tient on previous attempts, an -alkaline cathartic was
prescribed instead.

RECENT PROGRESS IN PUBLIC HYGIENE AND
PREVENTIVE MEDICINE.

BT SAHDEL W. ABBOTT, M.D.
INFECTIOUS DISEASES, AND THEIR PREVENTION.

Diphtheria. — Dr. Thome Thorne, chief medical
officer of the Local Groverument Board of England, in
a recent lecture upon Diphtheria, said :

" Bad sanitary conditions might have an influence,
but they are overwhelmed by other conditions which
cause the disease. . . . Diphtheria chiefly attacks chil-
dren of school age, from five to fifteen and it is clearly
proved that the disease is influenced by school attend-
ance. Dr. Power has shown conclusively that, by an
aggregation of children at school, you can deliberately
manufacture a potency of diphtheria. The reasons for
this are chiefly the special infection from the breath of
those who are congregated together for any length of
time, and the limited space set apart for the scholars.
There is also the danger, at young ages, of children
passing confectionery from mouth to mouth, of drink-
ing from the same unwashed cups, the absence of venti-
lation, and other conditions."

He laid special stress upon infection through the
medium of milk, and advised every one to leave off
drinking raw milk. He also named the lower ani-

' Pepper, TOl. ii, p. Ml ; Hand-beok of Medloal Solenees, toI. Ill,
p. 6S, and vol. Til, p. TM.

Digitized by

Google

338

BOSTON MEDICAL AND SURGICAL JOVBNAL

[April 5, 1894.

mals and especially the domestic cat, as carriers of in-
fection.

Isolation was recommended as absolutely essential.
In hospitals there should be much more attention to
the amount of lineal space per bed, which he deemed
of more importance than cubic air-space or high rooms.
No child should go to school from a house where there
is a sore-throat. The system of keeping up " average
attendance " by insisting that all scholars should go to
school had done much harm. Everything that touched
the mouth or lips of a patient should be burned.
Houses should be selected which are not damp, and
dense foliage sbould not grow near them.

THE DI88B1IINATION OK BMALL-POX BT THA1IP8.

Special prominence has been given to this subject
by the medical officers of health of England, daring the
past year ; and valuable papers have been published
by Dr. Armstrong, of Newcastle-on-Tyne, and others.
Dr. Armstrong says : " Of 63 towns invaded in 1892-
98, the medical officers of health of which have given
me the particulars, 37 or 59 percent., had the infection
primarily from vagrants. The disease was brought
secondarily by vagrants into 36 towns, including some
into which first cases had also been brought by the
same class of {>er8ons. Such secondary infections oo-
curred as often as nine times in Carlisle, Southampton
and Sunderland, twelve times in Warrington, fifteen
times in Keighley, eighteen times in Blackborn, and
no less than twenty-five times in Nottingham. In nine-
teen times only out of the 63 towns reporting, was small-
pox infection stated to have been brought otherwise
than by vagrants ; and in seven of these it was sub-
sequently reintroduced by vagrants no less than twenty-
five times. As a result of his inquiries Dr. Armstrong
presented the following resolutions : *

That the Incorporated Society of Medical Officers of
Health consider it desirable :

(1) That vagrants should be restrained in their powers
of carrying infection about the country, especially in epi-
demic times.

(2) That they should be made to report their movements.

(S) That they should, when considered requisite, be sub-
ject to disinfection and detention for such time as the sani-
tary authority of the district in which they are may think
necessary for the protection of the public health.

(4) That in epidemic times all persons frequenting casual
wuds or common lodging-houses sbould be medically ex-
amined on admission.

(5) That sanitary authorities and the police should have
power to detain for medical examination any vagrant found
in any public place.

UILK-INFBCTIOM.

Prof. W. T. Sedgwick has contributed valuable
papers upon different phases of this subject to the Bog-
ton Medical and Surgical Journal and to the Twenty-
fourth Report of the State Board of Health of Massa-
chusetts. Other investigations confirm the conclusions
presented in these papers, first, as to the presence of
bacteria in large numbers in milk as drawn from the
cow, and, second, as to the question of milk as a me-
dium for the transmission of the infection of typhoid
fever.

Konig,* in his recent volume, says : " Cow's milk,
although it may leave the udder free from bacteria,
will be found to contain them immediately after milk-
ing. These bacteria enter the milk by means of hair,

1 Chemi* der Menschllohen Nahrungs and QeauMmlttel, Third
Edition, ISM.

and particles of dirt floating in the air of the stable,
and increase with extraordinary rapidity.

Cropf and Escherioh * found in milk, two or three
hours after milking, by means of Koch's method of
cultivation, from 60 to 10,000 colonies, and io five to
six hours after milking 200,000 to 6,000,000 colonies
per cubic centimetre.

E. von Freudenreich * demonstrated the rapid de-
velopment of bacteria in milk as follows ; at different
temperatures :

NDMBBB of COLOBIBS or BAOraaiA PBB COBIC CBNTtKETBE.

1B»0. CSO°F.) 28° C. (77« p.) JB° 0.(96°?.)

8 honis af termlllcing . . 10,000 18,000 SO.OOO

S boars aftermlllcltic . . 2S,000 172,000 12,000,000

t houn after mlllciDg. . 46,fi00 1,000,000 3S,»0,0M

14 boon after milking. . S.700,000 077,000,000 tO,000,COO

Miquel * also testifies to the rapid development of
bacteria in milk, and to the fact that the rapidity of
development depends upon the temperature of the
milk. Although the bacteria may be harmless, their
presence must be borne in mind, especially in the use
of cows' milk as food for infants. In addition to the
harmless bacteria, those which are pathogenic may
also gain access to the milk, and thus cause disease.

In Luzerne, Switzerland,* several epidemics of ty-
phoid fever hare been traced to buttermilk, which
was returned from the creameries to milk-dealers after
the cream had been removed for making butter.

A similar typhoid epidemic * is detailed in the
Danish " Wochenschrift ftir Aerzte," which occurred
in the fall of 1886 in the three districts of Ore,
Haarsley and Skowby, in the island of Fttnen. The
cause was traced to a common establishment belong-
ing to these three parishes, from which buttermilk
was re-sold to customers. Typhoid fever was found to
exist at this establishment, and the sick patients' had
partaken of the returned buttermilk.

Another epidemic traced to buttermilk is reported
from two districts in Hanover.*

In Groningen, Holland,* another typhoid epidemic
was reported in 1886, the cause of which happened to
be the infection, in the dairies, of vessels washed with
water which had been polluted by the excreta of ty-
phoid fever patients.

Almquist' reports an epidemic of the same disease
which occurred near Gdteborg, Sweden, in 1889, in
which the cause was determined to be the infection of
skim-milk which had been returned from a dairy to
the consumers.

Kitasato" reports cases of cholera which were
caused by the use of infected milk in Calcutta. The
investigations of Koch and Kitasato show that cholera
bacteria will multiply in milk. Their length of life
depends on the reaction of the milk. The sooner it
sours the sooner they die.

THB HTOIENE OF OOCnPATIONS.

The well-known observations of Dr. Farr upon the
mortality of persons engaged in certain occupations,
as deduced from the Registration Reports of England,
have been supplemented by valuable papers on the
same subject by his successor. Dr. Ogle.

> Chem. CentrslbUtt, Bd. li,pp. S83. 884.
< Klsina MilohMitaiis, 1890, No. 2.
4 Cliem. Centralblatt, 1880, i, p. 1004.

• Hilobxeitong, IStO, p. 2Se.

• Ibid., 1888, p. 834.
' Ibid., 1890, p. 248.

• Ibid., 1888, p. 8TS.

• Zeltaohrift (Ur UTgieue, 1890, 8, 137.
» Ibtd., 188», 8, 491.

Digitized by

Google

Vol. CXXX, No. 14.] BOSTON MSDICAL AND SVJKGlCAl JOURNAL.

339

The following is selected from geveral tables pre
seated by Dr. Ogle at the last session of the Interna'
tional Congress of Hygiene at London.

COXPAKATIVK MOKTALITY FKOM PHTHISIS AND KlgPIBATOKY
DlSKASES, OF HBlf FBOM TWBHTT-PlVK TO SiXTT-FlTB TBABS
OF AOE, EHOAOBO VS VaBIODS DCST-lBHALIIfa OCCUPATIONS.

Lbi12

Phtblsls. DlMSMS. Total.

TIahermen <u itandwd) . . . . U 4S 100

Cwpentera, join«n .... 103 65 ITO

Bakers lOT 94 201

Wool-worken 130 104 234

Cotton-workers 137 137 274

Ontlera, nlasor-makera .... 187 198 383

Flle-raakers S19 177 896

Muoiu, brlek-Uyers .... 127 102 229

Stone- and (late-quarry men . . . IM 138 294

Fottary-maken 239 326 666

Condah miners 348 231 679

Coal miners 64 lOS 186

The point most worthy of note in the foregoing
table is the remarkable immunity of coal-miners from
phthisis, as compared with the high mortality of the
metal miners of Cornwall.

OH THE QDALITT OF THE BEBLIN 8KBVI0B-WATBB.''

Dr. Proskauer furnishes additional facts upon the
effect of filtration of water through sand, as investi-
gated by Piefke and Frankel.

The volume of water furnished to Berlin is daily on
the increase, and this increase is not due alone to the
growth of papulation, but also to a larger consumption
per head. Respecting the composition of the unfil-
tered water of the Spree, and of Lake Tegel, which
furnish the city water-supply, the author points out
that the experiments carried out during the last few
years, with reference to the power of the sand-filters
to arrest micro-organisms, have shown that it is im-
perfttive that the source of water should be, as far as
possible, protected from pollution by human excreta,
so as to furnish a raw material of the utmost degree
of purity.

In this respect, the water of Lake Tegel is greatly
preferable to that of the river as drawn at the Stralau
works. The river water is, as a rule, strongly yellow
in color, almost always turbid, and has a muddy taste
and smell. When allowed to stand, it has at times a
considerable deposit, consisting mainly of organic de-
tritus and bacteria. The water of the lake is, as a
rale, clear, but occasionally slightly turbid ; in color it
is pale yellow, and the taste and smell rarely dead and
earthy. This, in fact, occurs only when the snow
melts in the spring, and there is at certain periods
a slight deposit. The bacteriological examinations
ahowed that the river water was usually very rich in
germs, and that the number is on the increase. Out
of sixty analyses in the period of two-and-a-half years,
the number of colonies of bacteria in one cubic centi-
metre of water was,

In 16 cases or 28.6% of the tests over . 100,000

In 23 oases or 38.3% of the tests between 10,000 and 100,000
In 20 oases or 33.3% of tbe teats between 1,000 and 10,000
Only one sample eontalned less than 1,000 germs.

Contrasting the totals per cubic centimetre in the
present peri(^ with those in former years, it appears
that in

USl-86 there were from
1886-86 there were from
1886-87 there were from
1887-88 there were from
188a-S9 there were from
18S&-91 there were from

69 to 8,316 germs
191 to 110,740 germs
7S0to 17,000 germs
1,400 to 186,000 germs
220 to 190,000 germs
•40 to 860,000 germs

The author believes that the water of the Spree is
becoming so polluted that its use must either be
shortly discontinued on sanitary grounds, or the filtra-
tion must only be permitted to be carried out under
the most stringent precautions.

There were only three occasions, however, when
the number of germs per cubic centimetre in the
water of the Tegel exceeded one thousand.

With reference to the filtered water, the author says
the number of bacteria capable of development after
filtration were as follows :

During 1889-90 from
During 1890-81 from
During 1891 (last half)

12 to 110 per onUo oentlmetre
9 to 310 per oublo oentlmetre
3 to 60 per onbie oenUmetra

Only three times during the whole period did the
number of germs in the filtered Tegel water rise above
one hundred per cubic centimetre.

On twenty-three occasions the filtered water of the
Spree cootainecl more than 150 germs, the nnmbers
ranging from 810 to 13,000 per cubic centimetre. In
certain cases these high ratios of germs were attrib-
uted to the freezing over of the filter-beds. The
beds at the Tegal works are covered in and cannot be-
come frozen in winter.

After reviewing the chemical and bacteriological
analyses of the water, the author points out that only
the latter tests furnish an accurate and liable indica-
tion of the working of the filter-beds. The quality of
tbe service-water was tested in the mains at various
parts of Berlin, and copious tables are given of the
analyses of the water, made at stated intervals daring
the whole period.

LBAD-POISONINO FEOH A PUBLIC WATBB-SUPPLT.

Several cases of poisoning in the town of Calau **
induced the government to make an inquiry as to the
cause. The water was of extreme purity, as indicated
by chemical analysis, and contained only five germs
per cubic centimetre. It was brought to the town in
cast-iron pipes coated with asphalt composition, but
the houses were supplied by means of lead-pipes of
considerable length. Two mouths after the water
was introduced there, some cases of lead-poisoning
were reported among inhabitants where the water re-
mained undisturbed in the pipes during the night.
An inquiry conducted under the direction of Dr.
Koch revealed the presence of lead, varying in amount
from a mere trace to thirteen milligrammes per litre.

The reason for this rapid absorption of the lead was
shown to be the richness of the water in free and par-
tially combined carbonic acid, the low percentage of
carbonates, and its extreme softness. The tendency
to dissolve lead was further increased by the large
volume of air contained in the water, which was taken
up during its flow through the mains, for at the source
it contained no air whatever.

THE WATBB-SDPPLT OF PABI8.

The new water-supply of Paris," now being intro-
duced, will yield a supplementary supply of 25,000,-
000 gallons per day, at a cost of about $7,000,000.
The sources are two streams, tbe Breuil and the Vigne,
whence it is to be brought to the reservoirs at Montre-
bon, a distance of about 68 miles, of which 38^ miles
are open cutting, 18^ miles are underground conduits,

" Zeitsohrlf t f Ur Hygiene, toI. sir, 1883, p. 2G0.

i> Ibid., TOl. ziT, 1893, p. 295.

» Le Genie OiTll, vol. zzU, 1891, p. 181.

Digitized by

Google

340

BOSTON MSDIOAL AND SVB6WAL JOVSNAL.

[Afbil 5, 1894.

8 miles elevated conduit, and 4^ miles are siphons.
The diameter of the open cutting varies from 5 feet 10
inches to 6 feet 2 inches. The reservoirs are designed
for a capacity of 10,600,000 cubic feet, aud are divided
into three compartments.

A MEW DISINFKOTWO APPABiiTUB.

This apparatus was designed by Mr. O. Krell and
Dr. Baptschefsky, at the direction of the inspector of
the medical department of the Russiau army. In the
first instance all existing forms of apparatus were pro-
cured, and were submitted to a searching trial. The
conditions laid down for the new apparatus were:

(1) That it should destroy entirely, not only the
germs of all kuown pathogenic organisms, bat even
those bacilli found to be the most difficult of extermi-
nation (the garden-mould bacillus).

(2) That the disinfection should be accomplished in
the shortest space of time.

(3) That the apparatus should be as simple as pos-
sible, both in construction and in manipulation.

The various systems tested were: (1) hot air; (2)
superheated steam ; (3) saturated-steam jets ; (4) satu-
rated steam at rest, with means for creating high
pressure during disinfection; (5) saturated steam at
rest at about atmospheric pressure, with means for
producing a vacuum by condensation ; (6) saturated-
steam jets at high pressure, with superheating.

The operations of these various classes of disinfect-
ing apparatus were discussed in detail ; and the experi-
ments led to the conclusion that the new apparatus
must work by means of saturated steam at a high
pressure, with provision for the ventilation of the dis-
infecting chamber, aud with special air-inlets also at
the floor level, without special heating apparatus
within the chamber, but furnished with heat-accumu-
lators. The apparatus is made of steel, is cylindrical
in form (3 feet in diameter and 5 feet long). The
cylinder is placed horizontally, and has doors at each
end, fastened to bronze rings with six screw-bolts to
each. The chamber is tested to a pressure of ten at-
mospheres at the works, but the safety-valve is
weighted to lift at three-quarters atmosphere above
normal.

The total weight of the apparatus is about one ton.
It is distinguished from all others by its rapidity of
working. The previous heating up of the chamber
from the cold state takes two minutes ; and in fifteen
minutes more a temperature of 100° C. (212° F.) is
reached, even through a thickness of thirty-two blan-
kets, while, in five minutes more, the temperature
rises to 112° C. (234° F.). The disinfection, there-
fore, even of the most difficult objects, can be com-
pleted in twenty-two minutes. The working speed is
contrasted by the author with that of other forms of
apparatus now in use, and the advantage of saturated
steam at 100° C. over heated air, even at 150° C, as
determined by Koch,^* is insisted upon.

BBCKNT APPABATUS FOB CBBMATION.

Dr. T. Weyl,^ of Berlin, gives a brief historical
account of the practice in all past ages (introduced by
the Aryan race), and traces the revival of the practice
to the close of the eighteenth century, although from
that time till the first cremation in Europe at Milan,
January 27, 1876, a period of nearly eighty years

>< GMnndheits Insentoar, Angnat SI, 1882, p. S2I.
"Ibid., 1892, p. «7.

elapsed. Since that date the practice has extended in
Italy, till there are now 27 crematories in operation in
that country alone.

In Germany, the first crematory was built at Gotha
in 1878. No others were introduced till that at Ham-
burg in 1891, but very soon after others were erected
in Heidelberg, Berlin and 0£Fenbach. The number of
cremations at Paris reaches a total of 400 annually,
and the system is in use to some extent in Switzer-
land, Denmark, Sweden and the United States. The
author classifies the existing establishments under two
heads, those without regenerative furnaces and those
which adopt this plan. To the former class belong the
crematories of Milan, on the system of Gorini, and
that of Yeuini, which is a modification of the former.
In the latter class are included the crematory at
Gotha, in which, during the period ending November,
1891, DO less than 976 bodies had been disposed of.
The process here lasts two hours-and-a-half, and the
cost is about eighty marks ($18.50). The system of
Bourry at Zurich, the furnace of Toiseul and Fradet
at Pere-la-Chaise, in Paris, and others at Stockholm
and Gothenburg are founded on the regenerative fur-
nace of Siemens. The furnace of Guichard differs
from those mentioned by the use of coal-gas and com-
pressed air ; it has, therefore, no gas-producer furnace.
In an experimental trial of this furnace at Paris, the
process lasted forty-six minutes, and involved the use
of 190 cubic metres (about 6,700 cubic feet) of gas
and 500 cubic metres of compressed air. A table is
appended, giving the cost of cremation with each
system, together with the time employed in the ante-
cedent heating, and also in the cremation itself.

INFECTIOCS DI8KASEB. — PEBIODS OF INCUBATION,
QUABANTINE AND INFECTION, AMD BODBCE» OF
INFECTION.

The following summary is condensed from Dr. L.
F. Parkes's recent " Handbook of Infectious Diseases,"
and will be found very useful to boards of health and
sanitary officials for reference, as well as to general
practitioners of medicine.

SIPHTBBKU..

•

Ineabation Period : least, nnkoown ; average, 2 days ; greatest,
7 days.

Qoarantine Period : 7 dnys from last exposure to infection.

Infective Period: from the l>eginiiing of symptoms, for the
wbole period of illness.

Sources of Infection : 1. From a previoos case, acnte or odd-
valescent. 2. From a case of apparently simple tonsillitis. 3.
From a case of apparently simple nasal ulceration or ozana. i.
From domestic animals (cats, pigeons or fowls) suffering from
a throat affection of a. dipbtheriiil natnre. fi. From cows' milk,
by human infection of the milk in the cow-sbeds and dairies, etc.
6. From fomites, that is, infected bedding, clothes, carpets, oor-
tains, Irooks, toys, cops, spoons, forks, etc. 7. From a person who
has l>een in contact with a diphtheria patient, bat who has not
himself contracted the disease. 8. From deteotive sanitary con-
ditions ; these are probably merely predisposing causes engender-
ing morbid conditions of the tonsils favorable to the growth of
diphtheria contagion when implanted thereon.

SCABLET FEVKB.

Incubation Period: less than 24 hoars; average, 1 to 3 days;
greatest, 7 days.

Quarantine Period : 7 days from last exposure.

Infective Period : from earliest appearance of symptoms, till
all desquamation has ceased.

Sources of Infection : 1. From a previous case of scarlet fever,
acute or convalescent. 2. From a case of sore throat without
discernable rash, but merely a mild form of the disease. 3.
From cows' milk, either by .human infection of the milk in
cow-sheds and dairies, or during the milking, or from a diseased
condition of the cows. 1. From fomites. Infection may be
carried by persons who are not themselres sufferers, if they
have been in contact with patients.

Digitized by

Google

CXXX, No. 14] BOSTON MSDWAL AND SVMGIOAL JOVttNAL.

841

MKA8I.B8.

Incabation period: from ezpoeare to infection to onset of ill-
less: least, 1 days; average, 9 to 10 days; greatest, U days.
?*Tom ezpoenre to infection to appearance of rash: least, 7
l^TB i average, 14 days ; greatest, 18 days.

QiuarantiDe Period : IS days from last exposure to infection.

Infective Period: from earliest appearance of symptoms till
son-v&leaoence is well established. The catarrhal stage preced-
uag Vkaa eraption is very infectioos.

Sources of Infection : 1. From a previous case of measles. 2.
l^*roin fomites.

MUHPS.

IncabatioD Period: least, 14 days; average, 21 days; greatest,
^iS days.

Quarantine Period : 25 days from last exposure to infection.

Xnf ective Period : from onset of prodromal stage for 2 or 3
'vreelia sobsequent to appearance of parotitis. The chance of in-
fection diminishes progressively from the onset of the disease.

Sources of Infection: 1. From a previous cane. 2. From
toxnites.

OKBMAN XKA8LB8.

Incubation Period : least, 5 days; average, 18 days; greatest,
31 days.

Quarantine Period : 21 days from last exposure to infection.

Infective Period : from onset of prodromal stage to cessation
of desquamation.

Soozces of Infection: 1. From a prevlons case. 2. From
fomites.

INFLUSHZA.

Incabation Period: less than 24 hours; average, 3 to 4 days;
Kreatest, S days.

Quarantine Period : B days from last exposure to infection.

Infective Period: from earliest onset of symptoms till con-
'valescenee is well established.

Sources of Infection: 1. From a previous case of influenza.
2. From fomites.

WBOOPIHO-COVOH.

Incubation Period: least, 7 days; average, not determined;
greatest, 21 days.

Quarantine Period : 21 days from last exposure to infection.

Infective Period : the whole period of illness from onset of
earliest catarrhal symptoms.

Soorces of Infection : 1. From a previous case of whooping-
cough. 2. From fomites.

S]CAL]>POZ.

Incobation Period: least, 9 days; average, 12 days; greatest,
IB days.

Qnaiantine Period : 16 days from last exposure to infection.

Infective Period : from the onset of initial symptoms till all
■cabs have been removed. The period of greatest infectivity is
darine the acute sta^e (vesicular and pustular). During the
initial illness and until the appearance of the rash the liability
to impart infection is not great.

Sources of Infection : 1. From a previous case of small-pox.
2. From fomites. Infection can be carried by a person who l&s
been in contact with a small-pox patient, bnt who is not himself
a mffeier from the disease. 3. ra>ximlty to a small-pox hospi-
tal containing numerous cases in the acate stage.

CKICKBM-POX.

Incubation Period : least, 18 days; average, 14 days; greatest,
19 days.

Quarantine Period : 19 days from last exposure to infection.

Infective Period: from appearance of eruption till this has
completely disappeared.

Sonrces of Infection: 1. From a previous case. 2. Fomites.
The iofection may be carried by those who have been in con-
tact with the disease.

TYPEOn> FBVKB.

Incabation Period: least, 8 days; average, 12 to 14 days;
greatest, 23 davs.

Qnaiantine Period : 23 days from last exposure to infection.

Infective Period : the excreta are infectious through the whole
conme of the disease and until convalescence has been estab-
lished at least a fortnight.

Sources of Infection : 1. Water, food or air contaminated by
the specific virus contained in the excretions of a typhoid-fever
patient. 2. Fomites. Infection may persist for several weeks
In Infected clothing and bedding shielded from exposure to light
and ail.

TYPHUS FKVEB.

Incabation Period : average, 7 days.
Qoanuitine Period : 14 days from last exposnre to infection,
tafectlve Period : from beginningof illness till convaleaoence.
Sooice of Infection : From a previous case of the disease.
Fresh air and free ventilation rapidly destroy the virulence of

the contagion. Fomites probably do not propagate the con-
tagion.

ASIATIC CHOIiBBA.

Incubation Period: least, a few hours; average, 1 to 2 days;
greatest, 10 d^s.

Qoarantine Period: 10 days from date of last exposure to in-
fection.

Infective Period: from earliest onset of symptoms till com-
plete recovery.

Sources of Infection: 1. From water, food and air contami-
nated with the discharge of a person suffering from cholera. 2.
From fomites. 3. There is reason to believe that the virus
contained in the excreta at the time of leaving the body of a

Satient and for a short period afterward, is in a less active con-
ition and more easily destroyed by chemical agents than after
such excreta have been exposed for a short time to contact with
the air.

lEUportjEe or jfeocietiejet.

BOSTON SOCIETY FOR MEDICAL IMPROVE-
MENT.

J. T. BOWEir, K.D., SECBETABT.

Reqular Meeting, Monday, January 22, 1894, the
President, Db. C. F. Folsoh, in the chair.
Db. F. W. Goss reported

TWO CASES OF PDLMONART OONOBSTION AND (EDEUA
OCOCRRINO DDBINO FBEGNANCT.'

Dr. £. Bbynulds : This subject seems to me one
which rests upon a basis of clinical medicine and phy-
siology more than obstetrics. I came to-night prepared
to learn rather than to contribute anything valuable
to the discQBsion, and my impression that that would
be the case is strengthened by the paper. All that 1
can say on the question is derived from a theoretical
standpoint. We know that in normal pregnancy the
systemic circulation labors under an increased obstacle,
that that obstacle is thrown back through the left
heart on to the pulmonary circulation and the right
heart ; there is normally then an increase of tension
throughout the whole circulatory system. We know
that as pregnancy advances the heart normally enlarges.
Authorities are divided as to whether it is by dilatation
or hypertrophy ; the fact, however, being probably,
that it is usually a mixed process, though either factor
may predominate. Under these conditions it is easy
to see that any slight addition to the obstacle may in-
duce an oedema, especially in the pulmonary circulation
to which the whole obstacle is thrown back.

Such a complication occurring, the question of treat-
ment, it seems to me, should be primarily solved by a
resort to medical measures, everything to strengthen
the heart, everything which can relieve the system of
its added load ; depletion of the circulatory system so
far as that is consistent with the patient's general
strength. Bnt the question of the induction of labor
seems to me s very difficult one. We know that in
normal cases cardiac symptoms develop during labor in
a large proportion of all instances, from the fact that
during the contractions of the uterus, and during the
increased tonic pressure upon the uterine vessels in
labor, the extra load which the heart is already carry-
ing is actually increased again, and that many hearts
fail to compensate this extreme load even under normal
circumstances.

Where the heart has already given out during preg-
nancy, I should question much the wisdom of adding
to it the extra load of labor. I should feel I should

1 See page 336 of the Journal.

Digitized by

Google

842

BOSTON MSDIOAL AND SVBGICAL JOVSNAL.

[April 5, 1894.

not be willing to recommend the indnction of Ubor
until all medical means had been exhausted, and should
personally feel that I should be unwilling to do it until
after consultation with the best authority in clinical
medicine whom I could obtain. If, as in Dr. Gross's
second case, the woman recovered sufficiently to be in
fair condition, and yet not so thoroughly but that there
was a strong prospect of a recurrence of this very dan-
gerous complication, I should be inclined to induce
labor, but I should feel that in that case everything was
in favor of the most rapid methods, of those which
would least prolong the added strain upon the heart,
due to the pressure of the contracting uterus. Such
cases are, of course, unfit for anesthesia. In some
cases rapid delivery without ansesthesia is impossible
because the muscular fibres of the cervix resist dilap
tation too firmly. In other cases, and especially io
those in which the patient is already in a state of ex-
haustion, a moderately rapid dilatation of the os by the
hand can be carried on without anesthesia, to a degree
which at least will permit the introduction of one finger.
When one finger can be introduced into the uterus it
is usually possible to hook down the foot of the foetus
at six or six and a half months ; and by traction on
the foot, any os can be gradually dilated, the foetus act-
ing as a wedge, and exerting pressure from above. I
should be inclined to believe that such a method as
that would be mnph preferable to any gradual induc-
tion of labor, but as I said, I can speak of this question
only upon theoretical grounds and not from experience.
My own experience with pulmonary oedema as a com-
plication of pregnancy has been wholly limited to cases
of renal origin with which, as 1 understand it, this dis-
cussion is not concerned.

Db. C. M. Grbbm : I can add very little to the sub-
ject ; I came to learn. It has always been taught that
in such cases induction of labor should be the last re-
sort ; that medical measures should be the first recourse ;
and only on their failure and in critical condition of
things, as a last hope, labor should be induced. I am
reminded of a case which 1 saw in consultation, where
the cause of death was uncertain ; but the clinical his-
tory of the case was very similar to that of Dr. Gloss's
cases. The patient was Uken with serious dyspnoea.
There was oedema of the lungs and some lesion of the
heart, I believe. She was, however, more nearly ad-
vanced to term, and I am not sure she was not very
near to term. It was thought best to deliver her, and
it was done ; but the patient died after a few days of
the combined difficulty, which, I believe, was somewhat
of the kidney and somewhat of the heart. I should,
I think, in such cases place my chief reliance on medi-
cal measures, should relieve the lungs by action upon
the kidneys and bowels. The literature of the subject
is very scanty.

Db. a. L. Mason : I should like to ask, whether in
cases of extensive oedema of the lungs from pregnancy,
Bright's disease or other causes, there is any objection
to the use of pilocarpine subcutaueously.

Db. Goss : In the first attack of the second case
Dr. Clement used pilocarpine subcutaneously, hoping to
relieve the condition of the lung, and the patient was
relieved by its use. There was a profuse increase of
saliva, the woman bending forward and the secretion
running from her mouth. I suppose there is always
the risk of the patient being drowned, so to speak, by
the profuse secretion in the use of pilocarpine under
such circumstances. Regarding the indnction of pre-

mature labor in the second case, as far as the child was
concerned it seemed to me there was not much hesitancy
because there was every evidence that the child was
dead. I sought counsel before proceeding to induce
labor ; and in this case, at auy rate, relief was obtained,
and there has not been recurrence of the serious at-
tacks. Medical treatment had been thoroughly tried,
and the patient still remained in a precarious condition,
and it seemed to me that the induction of labor was
the only thing remaining to he tried. I think the
method pursued was safer than rapid dilatatioo aod
forced delivery would have been.

Db. Gbbbn : I have used pilocarpine in pulmonary
oedema of renal origin especially, and very rarely has
it seemed to do harm. I recall one case of extensive
oedema of the lung, in which I thought the patient
would drown, so extensive was the salivary secretion.
She, however, recovered. It seems to me that with
careful watching, to guard against the depressing effects
of pilocarpine, and by keeping the heart well supported,
it is a safe drug and acts very successfully.

Db. Rbtnolus : 1 should like to add the same ex-
perience with a single exception of one distressing case
that I saw in consulution, that did die: but I thiuk
the drug relieved the condition in a number of other
cases.

Dk. Mabon : Recently a case of a different nature
came under my observation, a man with Bright's dis-
ease and very extensive oedema of the lungs. The
question of pilocarpine came up. It seemed to me
there was. so much oedema that it was not a good drug
to use, and it was not used. I am glad to know that
it is generally safe.

A CASE OK APPKMDICITIS.

Db. C. F. Folsou : Last night (Sunday) I went to
my oflBce at 9.80, and found a lady waiting to see me
in reference to a member of her family who had slight
pain in the lower part of the abdomen, thought to be
due to having eaten a raw apple the previous evening.
She had vomited slightly Saturday evening, and had
had two loo^e discharges. She had been moderately
comfortable during the day. I said I should rather
see her before suggesting anything, but the lady said
it was quite superfluous, as there was nothing serious
the matter. I called and found a slight localized ten-
derness inside the crest of the ileum on the right side.
The patient looked perfectly well, pulse below 100,
had had a slight chill. I said I would see her again
in the morning. I found she had had a rather uncom-
fortable night, and the tenderness had become a little
more diffused, extended nearly to the umbilicus, but
also in the left side aud above the umbilicus and the
epigastrium. Temperature 101.5°, pulse 104, no vomit-
ing during the day or night or to-day, and there had
been no very great pain. No resistance could be felt,
nothing in the way of tumor. It seemed to me it
could not be anything else than appendicitis. Dr.
Porter saw her and concurred in the diagnosis. The
diagnosis having been made we both urged an early
operation. The operation was done this afternoon at
five o'clock. The striking features in the case in my
mind were the very slight symptoms as compared with
the gravity of the condition which Dr. Porter found.
It was difficult to persuade the patient that she had
serious trouble ; there were oo marked oonstitutioDal
symptoms and yet the appendix was found to be gan-
grenous. I should have said that there was no special

Digitized by

Google

Vol. CXXX, No. 14,] BOSTON MEDICAL AND SUB6I0AL JOURNAL.

343

tenderness, pain or sense of resistance at the so-called
McBorney point at any time.

Dk. C. B. Pobteb : The case was extremely inter-
esting because it had been induced, as the family
tbooght, by indiscretion in eating an apple. I foand,
on examination, that there was more resistanoe to
pressure over the region of the appendix, but there
was also extreme sensitiveness to the touch on the left
side above the umbilicus and just below the ensiform
cartilage. Considering the temperature, the localiza-
tion (especially at Dr. Folsom's first visit) in the right
iliac fossa, and not being able to thmk of anything
else it could be, it seemed to me wise to operate. The
very extensive sensitiveness seemed to me indicative of
a threatened general peritonitis (if it had not already
started), with its origin probably in the right iliac
fossa. I made an incision for the ordinary operation
for removal of the appendix ; and when I got down
to the junction of the small with the large intestine,
it was impossible to find any appendix. Upon turn-
ing the ascending colon upwards, I could feel the in-
duration underneath, and upon dragging it all out, it
was found that the appendix, which was very long,
was drawn back and was all adherent on the posterior
surface, but that there was no pus. As soon as I had
discovered a band running off to one side, I com-
menced to dig it out with my finger a little, and then
there came a puff of that foul gas, significant of any-
thing gangrenous, and I said, " My finger has touched
it if I have not yet seen it." Dissecting further I
found I had the base of the appendix laid bare near
the junction of the caecum and ileum, and down further,
behind the caecum, was the rest of it so imbedded that
I could not tell what was appendix and what were the
surrounding parts. I passed an anenrismal needle
underneath the base of the appendix, tied two ligatures
and cat between. I then dissected it away, and at
about the middle it broke entirely, it was so gangre-
nous, and left a piece deeply placed that had to be dis-
sected afterwards. As soon as the bowel was cut the
lumen at both ends was touched with a 95-per-cent solu-
tion of carbolic acid to prevent infection. Finally, I
succeeded in digging out the rest of the appendix. It
is interesting to see the extent to which the destrnction
had gone. I have operated on a few cases as gangre-
nous aa this, and one fully as much so within twenty-
four hours, and it goes to show how important it is for
cases which are suspected to be appendicitis to be
thoroughly studied with reference to immediate opera-
tion.

Dr. £. B. Bbackbtt read a paper on

THE USE OF GTHNASTICS IN THE TBBATMENT OF
LATEBAL C0BVATDBB.*

Db. £. H. Bbadfobd : My views are so thoroughly
in accord with Dr. Brackett's that it is hardly possible
for me to discuss, as I agree with everything he has
said. I think he has hardly laid stress enough on the
fact, which I think he was one of the first to call atten-
tion to, that is, the necessity in cases of this sort with
slight osseous change, of avoiding forward curving of
the spine. To express it in more common language,
what a patient with a rotary lateral curvature needs
to do, if it is desired to correct the deformity, is to
attempt to become what is known as a backward
athlete, namely, that class of athletes who can bend
the spine backward to a greater extent than is nor-

> 8«e page 329 ol tha Jonnukl.

mally possible. Any one who has examined the back
of one of this class of athletes will have noticed its
peculiar character, namely, not ouly how symmetrical
it is, but also how the physiological curves are dimin-
ished ; and the exercises and practices which are nec-
essary to produce this are what is needed in treating
rotary lateral curvature with any osseous change.
This is entirely independent of exercises for the devel-
opment of muscles. Exercises for the development of
muscle, as Dr. Brackett says, are useful and important
to enable the patient to maintain a correct attitude ;
but for corrective exercises attention should not be
paid so much to the muscles as to increasing the flexi-
bility of the spine and the contraction of the limb
muscles.

Db. £. M. Habtwbll : My belief is that ordinary
gymnastics are worth nothing, or next to nothing, in
the treatment of scoliosis, except in so far as they may
be made serviceable in giving tone and power to the
muscles of the back after the spine has been straight-
ened, or its deformed curves reduced by other more
appropriate and effective forms of procedure. By
ordinary gymnastics, I mean school gymnastics and
the various forms of light and heavy gymnastics that
are taught or practised in most gymnasia. The ordin-
ary gymnastic teacher or director is apt to be so
wedded to mere " muscle-building " as to be a blind
adherent to the doctrine that scoliosis is due chiefly to
disordered or impaired muscular action. Any one who
professes to treat a fully-developed scoliosis by means
of customary gymnastic exercises, having only the
resources of an ordinary gymnasium at his command
— be that gymnasium never so completely equipped
with pulley-weights and gymnastic machines — tran-
scends his functions and promises what he cannot per-
form. Even the so-called medical gymnastics should
be looked upon as an adjuvant therapeutic measure
chiefly, and not, as so many uncritical enthusiasts
would have us believe, as the sole or even the most
effectual means of reducing or abolishing a scoliosis.
I entirely agree with Dr. Brackett and Dr. Bradford
in holding that muscular exercise alone is totally in-
adequate to the task of straightening a scoliotic spine
in which any considerable degree of rigidity has de-
clared itself. That school and recreative gymnastics,
if they are well taught and diligently practised during
childhood and the first stage of adolescence, are of
great value in counteracting the deforming attitudes
imposed so often on school children, and so far, both
are efficacious in preventing scoliosis, I have net any
doubt.

It cannot be gainsaid, I think, that the Sjuk-gynmcutik
of the Swedes includes many mechanical procedures,
among those they call passive movements, that are
capable of rendering efficient aid in increasing the
flexibility of a not wholly rigid spine, so that its de-
forming curves may be corrected. If once the spine
is redretted massage and active exercise of the atonic
and atrophic muscles come into play as corroborative
measures. When torsion is present, or anatomical
changes have been wrought in the vertebrae and the
vertebral ligaments, the work of supplying and r«-
drtising the spine is tedious and expensive, often ex-
tremely so.

The medical profession owes a debt of gratitude to
Dr. Gustaf Zander, an acute and accomplished physi-
cian of Stockholm, for the patience and mechanical
genius displayed by him during the last thirty years

Digitized by

Google

344

BOSTON MEDICAL ASD SVSGJCAL JOVJtXAL.

[Apbil 5, 1894.

in developing the so-called Mechanical Medical 6ym-
naatics. Dr. Zander has invented and brought into
Dse a series of some seventy machines, by means of
which the ' appropriate effects of the more important
active and passive movements embraced in the Swedish
movement treatment can be secured more effectually,
certainly and cheaply, where numbers of patients are
concerned, than is possible under the conditions which
usually obtain in the practice of medical gymnasts, be
they never so skilful.

The Zander machines are divided into two main
classes, namely : (1) those that afford active exercise
to the patient, being set in motion by him ; and (2)
those that are actuated by a steam- or gas-motor, against
the " passive resistance " of the patient. The first
class includes thirteen machines for arm-movements ;
thirteen for leg-movements, and thirteen for trunk-
movements. The second class includes five machines
for distinctively passive movements ; and thirteen for
various, purely mechanical, manipulations. In cases
requiring massage, Dr. Zander has recourse to manual
massage, being of the opinion that machinery cannot
be successfully substituted for the band, in this branch
of mechano-therapy. The construction of both classes
of machines is snch that the work required of the pa-
tient in overcoming resistance can be accurately meas-
ured and hence adapted to his strength and needs. In
this respect the Zander machines are unequalled.

Dr. Zander has attained marked success in the treat-
ment of scoliosis, through the use of his so-called
orthopedic machines. These machines are ten in num-
ber and constitute a series qnite distinct from those
already mentioned. In the construction and use of
his orthopaedic machines for the purposes of correction
and redressing. Dr. Zander employs devices to secure
suspension, corrective posture, counter-pressure and
counter-rotation in varying degree, according to the
nature and state of the scoliosis present He also has
recourse to certain machines belonging to the two
classes mentioned above, for the sake of restoring and
increasing the action of the muscles concerned in
maintaining the normal curves and position of the
spine ; but mechanical support by means of fixed band-
age or corsets do not form a part of his treatment,
though it well might, it seems to me.

As an aid to testing and controlling the effects of
his treatment he makes frequent minute and searching
measurements to determine the relations of the bony
prominences of the spine, shoulders, thorax and pelvis
to each other. The results of snch measurement are
platted in the form of a mathematically constructed
chart, and are of great practical value. In making the
measurements alluded to Dr. Zander uses two very in-
geuions, and I must add expensive, measuring machines
invented by himself; they are shown in the collection
of pictures of the Zander apparatus, which I present
for your inspection. One of them enables him to deter-
mine the amount of deviation of the spine both in the
frontal and the sagittal plane measured in millimetres,
and the other shows the contour of the thorax at any
level that may be chosen — below the axillse.*

In general, Dr. Zander's treatment of scoliosis ac-
cords in principle with that of Professor Lorens of
Vienna, except that the latter makes use of fixed band-
ages and of very cleverly constructed wooden-oorsets,
of which the specimen presented is a sample ; while

' The coiistruotlon and working of Dr. Zander's prinoipal ortbopie-
dio maoblnee waa explained bj the aid of pleturea and diagrams.

Zander lays more stress on minute measurements for
purposes of control than does Lorenz, Both Lorenz
and Zander employ mechanical measures for corrective
purposes, and muscular exercises for tonic and reten-
tion purposes after redaction has been in some measare
secured. Lorenz employs forcible pressure or r«dreue-
menl/oret in the manner shown ou page 178 of Brad-
ford and Lovett's "Orthopssdic Surgery." Zander's
method of applying forcible pressure and counter-rota-
tion is less violent and more deliberate.

Zander's principal paper on the treatment of scoliosis
is entitled, " Om Den Habituela Skolioseris Behand-
ling Medels Mekanisk Gymnastik," and was published
in the Norditkt Medieirukt Arkiv., 1889, Band XXI,
No. 22. The article, which is well illustrated, is in
Swedish, but it is accompanied by an abstract in French.
Nebel's " Bewegungskuren mittelst Scbwediecher Heil-
gymnastik und Massage mit besonderer Beriicksichti-
gung der mechanischen Behandluug der Dr. 6. Zander,
Wiesbaden, 1889, contains the best and fullest account
■that has yet appeared of Zander's contributions to
mechano-therapy.

It is interesting to note that both Lorenz and Zander
hold that the principal provoking cause of scoliosis, in
those who are most afflicted by it, namely, growing
school girls, is found in the faulty positions they are
so often obliged to assume and maintain in writing.
Indeed, Loreuz declares that " the majority of habitual
scolioses are writing-positions become fixed." So far
as I am aware there are no comprehensive statistics to
show whether or not scoliosis is more frequent in the
United States than it has been shown to be in Germany,
Sweden and Denmark. It seems to me reasonable to
suppose, however, that the proportion of scoliotic girls
in our schools is needlessly great ; since our vicious
systems of teaching writing are frequently rendered
doubly dangerous owing to the careless and unscientific
way in which so many of our school-children are fur-
nished with chairs and desks.

I have recently had occasion to study the seating of
the children in the public schools of Boston. My ob-
servations confirm those of Dr. C. L. Scudder, who
showed that the assortment of desks and chairs in re-
spect to size, was quite inadequate to the hygienic needs
of pupils. I have examined the chairs and desks in
one hundred schoolrooms, taken at random and ranging
in grade from the high school to the primary school.
In only eighteen out of one hundred class-rooms did
I fail to find gross misfits. Of the pupils seated in the
remaining seventy-two class-rooms, no less than twenty
per cent, were misfitted. By misfitted, I mean that
either they could not place their feet flat upon the floor,
or they had their knees in contact with the under sur-
face of their desks. It seems to me hardly reasonable
to expect that sixteen to eighteen minutes of gymnastic
exercise daily, which is all that is permitted in our
schools, should prove adequate to counteract the de-
forming tendency of vicious postures in writing and
study, especially when so large a proportion of the
pupils are forced for more than two hundred minutes
a day to maintain exhausting and abnormal positions
because of the neglect of the authorities to provide
them with suitable desks and chairs.

Dr. Bradford : One word in regard to the record-
ing of lateral curvature. There is no question but that
the Zander recording appliance is the best that exists
for the purpose for which it is designed. There is one
difiiculty which has not been mentioned, and that is

Digitized by

Google

Vol.. CXXX, No. 14] BOSTON MEDICAL ASD SUBGIOAL JOURNAL.

346

true of all the recording appliances which have been
hitherto exhibited, namely, that the record is made with
the patient standing. It is absolutely impossible to fix
a patient perfectly still while he stands during the mark-
ing of the record. Schultez has written upon this
qaestion, and he states that while the record is made
the patient may alter his position a number of times.
Of course, with great care, as no doubt Zander uses,
fairly good results may be attained, but there is a very
simple way of obviating all this and making records
with simpler apparatus, namely, by having the records
made while the patient is lying down. This gives a
more accurate record of the rotation, and that is the
most important record. In regard to the subject of
Lorenz treatment with apparatus, I think what Dr.
Hartwell has said in regard to the matter shows con-
clusively that Lorens is right in claiming that mechan-
ical gymnastics should be supplemented by the use of
some appliances during the intervals of gymnastic ex-
ercises in all urgent cases.

lo regard to the wood corset, it may be said that is
one of the best that has been devised. It, however,
has one disadvantage in oar climate, and that is that it
does not bear hot weather so well as some of the other
forms ; and personally 1 am inclined to think the paper
corset which has been perfected by Dr. Weigel is supe-
rior to the wood corset.

Db. Goldthwait: I have been very much inter-
ested in the subject of gymnastics as applied to the
treatment of scoliosis, and have watched with a good
deal of interest the methods and the results obtained
in the hands of pure gymnasts ; and while I am a firm
believer in gymnastics in these cases, both for muscu-
lar development and to increase the flexibility of the
spine, at the same time I feel firmly convinced that
they represent only a portion of the treatment, and
that they must be supplemented by some apparatus.
I was very much interested in seeing Dr. Zander's ap-
paratus, and one cannot see it without being very much
impressed by the mechanical ingenuity of the man ;
but at the same time it seemed to me that results
equally good could be obtained with apparatus much
less complicated and much more at the command of the
average practitioner of orthopsedics than is Zander's
apparatus, there being only one such institute in this
country and that one in New York.

Db. Brackett, in answer to a question, said: The
discussion has broadened somewhat from what I in-
tended. I agree fully in relation to the lack of weak-
ness in the majority of cases. At the Children's Hos-
pital I have bad collected every case that has been
treated there for eighteen months, and we fail to find
a marked or any appreciable weakness in the majority
of these cases. It is true, however, that we find a
good many of them coming on in young and growing
girls, or after some exhausting disease, or during a
. period of a great deal of depression, in which very
likely we can attribute it to more of a general lack of
tone than to actual muscular weakness. On the other
hand, we have not found a decided unilateral weakness,
that is, we have tried to prove or disprove or to have
observations upon the question of unilateral weakness,
and so far the figures do not show enough of change
to consider it of any value. With reference to the
improvement in gymnastics alone, there is one condi-
tion I think we often meet with, that is a child who
will come for treatment and be given purely a gymnas-
tic treatment as we have tried as a matter of observa-

tion. There is no doubt that for a while there is a
decided improvement. I have been led to think that
that is due simply to the improved muscular tone, or
else to the improved energy and pride of the patients
by which they are able to hold themselves more cor-
rectly, that is, the effort is continued for so much
longer a time that the general condition of the case
seems improved. But as to the actual weakness for
which the muscular development is claimed by certain
people, I have never yet been able to find any basis
for it.

Hecent Eiteratiure*

JXssectioTU lUuilrtUed : A Grapkie Band-hook for
Students of Human Anatomy. By G. Gordon
Bbodie, F.RC.S. With plates drawn and litho-

fraphed by Pergt Hiohlet. In four parts. Lon-
on and New York : Wfaittaker & Co.
The author's plan has been to offer the student a
series of pictures of dissections, with a few diagrams
and some short descriptions. The plates are r^uoed
one-third from the natural sise. We have received the
first and second parts, which treat of the upper and
lower limb. The illustrations are beautiful. The dis-
sections are of the standard type. There are no sec-
tions nor " window-cuts." The areolar tissue and fat
have been removed and the parts shown according to
time-honored practice. Deep dissections follow more
superficial ones, so as to give the student the successive
layers. Such being the lines on which the work is
undertaken, we have nothing but praise for its exeoa-
tion by both the anatomist and the artist. T. D.

The National IHtpentaiory. Containing the Natural
History, Chemistry, Pharmacy, Actions and Uses of
Medicines, including those recognized in the Phar-
macopoeias of the United States, Great Britain and
Germany, with numerous References to the French
Codex. By Alfbkd StillIi, M.D., LL.D., Pro-
fessor Emeritus of the Theory and Practice of Medi-
cine and of Clinical Medicine in the University of
Pennsylvania; John M. Maisch, Ph.M., Pbar.D.,
Late Professor of Materia Medica and Botany in
Philadelphia College of Pharmacy, Secretary to the
American Pharmaceutical Association ; Charlks
Caspari, Jr., Ph.G., Professor of Pharmacy in the
Maryland College of Pharmacy, Baltimore, and
Henry C. C. Maisch, Ph.G., Ph.D. Fifth edition,
thoroughly revised, according to the Seventh Decen-
nial Revision of the United States Pharmacopoeia.
Imperial octavo, 19 LO pages, with 820 engravings.
Philadelphia : Lea Brothers & Co. 1894.
This encyclopedia of materia medica, therapeutics,
pharmacy and the collateral sciences has, through the
extraordinary energy of its editors and publishers, ap-
peared only five months after the publication of the
last revision of the United States Pharmacopoeia, and
but a single month after that o£Bcial work went into
legal effect.

As one of the best-known commentaries upon the
United States Pharmacopoeia, the late thorough revision
of that work has necessitated a like revision in this
commentary, yet the revision has been by no means
restricted to such necessary changes, but the latest
editions of the British, French and German pharmaco-
poeias have been exhaustively searched for materials of

Digitized by

Google

S46

BOSTOS MEDICAL AND SVBOICAL JOVJtHAL.

[Afbil S, 1894.

value, and ample apace has been given to gncb, and to
the new synthetic remedies and to the drugs, which
although as yet unofficial iu any pharmacopoeia are be-
ing largely used. The present edition is thus more
than one hundred pages larger than the previous one.

The descriptions of materia medica are clear, thor-
ough and systematic, as are also the explanations of
chemical and pharmaceutical processes and tests. The
therapeutical portion has been revised with equal care
and the statements of the action and uses have been
arranged not only alphabetically under the various
drugs, but for practical medical usefulness have also
been placed at the instant command of those seeking
information in the treatment of special diseases by be-
ing arranged under the various diseases in a therapeu-
tical index. The readiness with which any of the vast
amodnt of information contained in this work is made
available is indicated by the twenty-five thousand ref-
erences in the two indexes at the end of the volume.

For the physician and the pharmacist, for whose use
it was specially prepared, this edition will no doubt
prove to be more than ever valuable. B. F. d.

Hou> to Ute the Forcept. With an Introductory Ac-
count of the Female Pelvis and on the Mechanism
of Delivery. By Henbt G. Landis, A.M., M.D.,
Professor of Obstetrics and Diseases of Women and
Children in Starling Medical College, Columbus, O.
Revised and enlarged by Cbables H. Bcshomo,
M.D., Assistant Gynecologist and Pathologist to
Demilt Dispensary, New York. Illustrated. New
York: £. B. Treat. 1894.

This book is divided into three parts : Part I, Mech-
anism of Labor; Part II, the Forceps; Part 111, Ap-
plication and Cases.

Part I is interesting not only as a sample of the
way in which a single mind frequently strikes out new
truths which meet too tardy acceptance, but also for
its intrinsic worth. Although Dr. Landis's views of
fifteen years ago are at variance with the accepted
teaching of to<lay in some minor points, as, for instance,
in the importance which he ascribes to the parietal
protuberances in the production of rotation, they are,
in the main, in thorough accordance with the views
now held by most progressive teachers. The exposi-
tion of the mechanism of labor contained in this little
book is especially clear, and will be of value to every
one interested in the subject.

Part II contains a set of excellent directions for the
use of the forceps. It is clear, detailed and accurate,
though some of the views expressed are perhaps not
quite brought up to date. Most obstetricians of to-day
would consider that the chapter on " When to Use the
Forceps " is a little over-conservative.

The book so far is excellent, and will furnish valu-
able reading to any one interested in the subject. It
is a pity that as much cannot be said for Part III,
" Application and Cases," which adds but little to the
book, is sketchy, and rather crude.

The printer and publisher have done good work.

Operation Blanks. Prepared by W. W. Kkbn, M.D.,
Professor of the Principles of Surgery in the Jefferson
Medical College, Philadelphia, Pa.

By filling up these convenient forms, instructions
may be given to the nurse, the family physician and
the attendant. The plan of operation blanks is a cap-
ital one, but we fancy that the majority of surgeons
would prefer to select their own list of dressings.

THE BOSTON

jKedical anD ^utgfcal 3!ountau

THURSDAY. APRIL 5, 1894.

A J'ommal i»f JTetHeiiM, Surgem, and Allied Seieneu,inMi$lud at
Ba»to», iwcJcly , ty th» trndenlgntd.

SUBSCumoil Tamils: 98.00 jxr tear, i» advance, pottage paid,
f^ the United StaUi, Canada and Mexico ; M.Se per gear for all for-
eign oonntrie* belonging to the Pottal Union.

All eemimnnieationt far the Editor, and all bookt for review, itouU
ie addneied to the Editor of the Botton Medical and Surgical Jimmal,
283 Waehington Street, Boeton.

All lettert aontaining bntinett communication*, or referring to the
publioaXion, lubeeripUon, or advertiting department <tf thii Journal,
ihould be addreued to the underiigtud.

RemUlaneee ehould be meule bg moneg-order, draft or regiitatd
Utter, page^le to

DAMKEU, a UPHAM,
Ut Wasboiotoii Stsxkt, Bostok, Mass.

ANTI-VACCINISM.

Scabcblt a year has elapsed during the past ten
years in which the opponents of compulsory vaociua-
tion have not petitioued the Massachusetts Legislature
for a repeal of the existing laws. The unusual preva-
lence of small-pox, and the consequent increased inter-
est in vaccination during the present season, have led
to a renewal of the opposition, and at least four hear-
ings have been devoted to the subject by the Legisla-
tive Committee on Public Health. At the first bear-
ing two of the petitioners spoke at considerable length.
Their statements presented almost the same identical
arguments which have been used for nearly a century
in opposition to vaccination, and followed very closely
after their predecessors, Birch and Rogers, who, as
long ago as 1805, attempted to disprove the value of
vaccination. The statements were made up chiefly of
theory and dennnciktion, with such reasoning as the
following :

" The vaccinist's statistics are worthless, and may
be made to prove anything. You will find, if you
look into this point of the controversy, that the vuc-
cinist is hopelessly given over to a belief in the efficacy
of vaccination, and that he constructs his statements
unfairly, and solely with the view to support a precon-
ceived opinion. After the mind has given itself up lo
this absurdity, all that follows is easy, and passes witii-
ottt scrutiny, without analysis."

As much as to say that the careful statistical inves-
tigations of the German Government upon this ques-
tion (the most thoroughly vaccinated people in the
world), together with those of the Local Government
Board of England and those of the Hungarian statis-
tician, EorSsi, are all false and worthless.

One of these gentlemen made the remarkable state-
ment that " vaccination increases small-pox." Dr.
Alfred Russell Wallace attempted to prove the same
proposition before the present Parliamentary Commis-
sion of England, but when asked by .the Commissioa

Digitized by

Google

Vol.. CXXX, No. 14.1 BOSTON MEDICAL AND SURQIOAL JOURNAL.

347

to examine his figures more closely was compelled to
retract his statements, and honestly admitted the
wortblessnesB of his figures.

At the second hearing ten or a dozen persons pre-
sented testimony, prominent among whom was a mem-
ber of the Boston School Committee (not, however,
appearing as a represeatative of any action or senti-
ment of the Committee), who stated a considerable
unmber of alleged injaries and deaths from vaccina-
tion, in not one of which was any evidence given that
the alleged harmfnl results were anything more than a
coincidence such as might occur in a very large unm-
ber of vaccinations, and not necessarily a consequence
of the operation.

Considerable stress was laid upon the death of Dr.
W. Stokes, which occurred at the City Hospital in
1889, bat which has been repeatedly shown to have
had no connection with a previous vaccination in the
relation of cause and effect.

At the third hearing, Ex-Attorney -General Pills-
bury made a very brief argument for the petitioners,
his principal point being that vaccination as a prevent-
ive against small-pox should not be compulsory, so
long as similar preventive measures are not compul-
sory in the case of tuberculosis, rabies and other dis-
eases.

A half-hour was then given to the remonstrants
who supported the existing laws. Senator Buckley,
of Holyoke, in a very convincing five-minute address,
told the Committee of the practical necessity of vacci-
nation iu the paper-makiug, rag-consuming city of
Holyoke, and of the defenceless position in which that
city would be left without the protection afforded by
the present statutes.

The fourth hearing was entirely devoted to listening
to Mr. Pickering, an anti-vaccination missionary from
London, who has spent considerable time during the
past winter in Rhode Island, Indiana and Massachu-
setts as a vigorous opponent of vaccination. Much of
his argument had little reference to the subject, con-
sisting, as it did, of certain arrogant claims of ability
to cure cases of small-pox in marvellously short periods
of time by methods of his own. He appeared to be
quite incensed at the city authorities, who would not
allow him free admission to the Small-Pox Hospital of
Boston.

It is quite remarkable that nearly all opponents of
vaccination, not excepting those who have appeared at
onr State- House this year, in quoting foreign statis-
tics, and especially those which relate to Germany,
•re wont to pass over in silence the period which has
supervened since the Frauco-Prussian War. As a
matter of fact, the German compulsory law did not
take effect till 1874, since which time small-pox has
almost entirely disappeared from Germany, while the
partially vaceinated neighboring countries have suf-
fered severely from this cause.

On the day following the last hearing the Legisla-
tive Committee reported, " leave to withdraw."

As a comment upon this hearing before the Com-

mittee on Public Health of the Massachusetts Legisla-
ture, it is legitimate to quote the following from a
very recent editorial in the Neva York 7\met:

" H. Hitchcock, M.D., writes to us from the executive
office of the Anti-Vaccination League to ask a candid
question, to which we will give a candid answer. ' Are
you willing,' he aeks, ' to open your colamns to a discussion
of the question of vaccination?' We reply: 'No,' for it
would not be worth the doctor's while, nor ours. There is
at the present day no question of vaccination except in the
minds of the members of anti- vaccination leagues — gentle-
men and ladies who are engaged with perfect sincerity, we
have no doubt, in a futile attempt to head off human
progress and to reopen a question about which pretty
much all the world has made up its mind. The appeal of
the American Anti- Vaccination League is, in onr judg-
ment, an appeal to ignorance and prejudice."

THE UNFAVORABLE SEQUEL.® OF CERTAIN
RADICAL OPERATIONS ON THE GALL-
BLADDER.

The accidents and evils of biliary lithiasis are
among the most general of all hepatic affections, being
common to all nations and all climates. To rid the
afflicted of these evils, three radical surgical operatious
have of late years been devised : cholecystotomy,
cholecystectomy and cholecystenterostomy.

Cholecystotomy, first performed by J. L. Petit in
1743, in cases where the gall-bladder, distended by
calculi, was attached by firm adhesions to the abdomi-
nal wall, afterwards (1859) proposed by Thudicum as
worthy of wide extension, did not definitely obtain a
place in modern surgery for the otherwise irremediable
accidents of biliary lithiasis till the operation was suc-
cessfully performed and advocated by Marion Sims in
1878. It is the simplest and safest of all the r-adical
operations, is indicated in all cases of chronic lithiasis,
attended with frequeut attacks of hepatic colic and
other troubles, where, on careful examination, there
is found to be complete patency of the choledochus
duct.

In this operation, an external fistula is established,
by which there is an escape oi bile, and the principal
danger is that this fistula shall become permanent.
This danger is emphasized by the author of a recent
voluminous work on the liver, Labadie-Lagrave ; such
permanent fistula have occurred in the practice of
Walker, Robsou, Terrillon, Tait and others, though
infrequently, and Seymour, as the result of his per-
sonal experience, regards the danger as very slight,
believing '■ that it is only when an obstruction in the
common duct has been unrelieved that this can occur." *
It cannot be said that " ideal cholecystotomy," in
which the gall-bladder is opened and the calculi re-
moved, then the organ is carefully sutured with catgut
and restored to the abdominal cavity — it cannot be
said that this procedure is to be recommended if, ac-
cording to Langeubuch, it be attended with a very
serious danger. The ductus choledochus, he says,

> Hadieal Beoord, December 6, 1890.

Digitized by

Google

348

BOSTON MEDICAL AND SVB6JCAL JOCBNAL.

[^PEiL 5, 1894.

reacts to any excitation in a remarkable manner ; this
is the reason why this canal becomes swollen after the
excitation caused by an operation, the tumefaction pre-
venting the free flow of bile ; there is a regurgitation
of it, and the bladder fills up ; finally the sutures give
way and the bile is thrown into the peritoneal cavity,
and the patient dies. Lawson Tait also, in a recent
discussion on the surgery of the liver, regards " ideal
cholecystotomy " and cholecystectomy " as based on
fallacious reasoning and dangerous methods." * With
regard to cholecystectomy, the principal reason why
this operation should not be chosen in preference to
cholecystotomy, when tk* latUr it fsatibU, has been
given above ; and it seems agreed that the usefulness
of cholecystectomy is limited to cases where the tissues
of the gall-bladder are diseased and where this organ
cannot be sutured to the abdominal walls.

Cholecystenterostomy is an operation of still more
recent device, being first performed by Winiwarter in
1881, though Nussbaum, a year earlier, had conceived
of the operation and advised it in the following words :
" When the escape of bile through the natural duct is
no longer possible, it will be practicable to make an
artificial connection between the gall-bladder and in-
testine throu|r|i which the gall can again escape into
the intestinal tract" This operation, according to
Murphy's statistics,' had been performed by the old
method of sutures twenty-three times up to December,
1898, with a mortality of thirty-five per cent., or eight
deaths in twenty-three cases. Of the seventeen cases
where the operation bad been performed with Murphy's
anastomosis button (from June 11, 1892 to December
1, 1893), there was in every instance a good recovery.

This record, of course, speaks favorably for the
anastomosis button ; but what the public would like to
know more particularly is the after-history of the
successful cases. Were these persons restored to a
good degree of working vigor, or did serious infirmities
follow? In one of Mayo Bobson's cases, the gall-
bladder was stitched to the colon ; what was the effect
on this patient of the constant diversion of the biliary
secretion from the small intestine into which it is nor-
mally poured during a certain stage of the digestive
process ?

We have, fortunately, a full statement of results
from a well-known member of the profession, who has
lately gone through the operation for relief of jaundice
by retention due to irremediable stenosis of the chole-
dochus — we refer to the recent report of Dr. Dujardin-
Beaumetz to the French Academy, March 13, 1894.

The patient, whose gall-bladder has been made to
open into the intestine, is constantly menaced with
biliary infection. In the physiological state, although
the choledochus opens into the duodenum where
microbes exist in abundance, yet owing to the peculiari-
ties of its anatomical conformation, microbes rarely
penetrate the duct ; when there is a biliary fistula with
a free communication between the gall-bladder and

' Edinburgh Medical Jonrnal, October, 1893.
> Medleal Moord, January 13, 1»94.

intestine, the liability to microbic penetration and in-
fection of the liver is much greater. This infection
manifests itself by febrile accessions of a remittent or
intermittent type.

There is also more or less intestinal dyspepsia, re-
sulting from the fact that the biliary fistula opens into
the intestine at a variable distance from the ampulla
of Vater, and there u now want of concordance be-
tween the pancreatic and biliary secretions. Gastric
dyspepsia, more or less intense, is certain to follow ;
this is likely to take the form of acid dyspepsia (hyper-
chlorhydria).

For the hepatic infections and the febrile symptoms
resulting, Beanmetz advises intestinal antisepsis by
salol and the administration of quinine in lavements.
When there is acid dyspepsia, fifteen grains of bicar-
bonate of soda may be given one hour before meals.
The diet should be mainly vegetable. It must, bow-
ever, be borne in mind that the subject of this kind of
biliary fistula will never be in a really normal condi-
tion again, either in respect to digestion or nutrition,
but " they will be enabled to live, and in conditions
relatively favorable, thus deriving incontestable advan-
tages from surgical intervention."

MEDICAL NOTES.

Small-Pox in Chicago. — The number of cases
of small-pox reported to the Board of Health of Chi-
cago for the month of March was as large as that for
both January and February combined.

Attbmpt to Bubn a Hospital. — The third at-
tempt within a short time to burn the Topeka City
Hospital occurred recently, but the fire was discovered
in early season and no serious damage was done.

A Victim of Professional Enthusiasm. — Dr.
Adolf Meyer, assistant in the Schonborn's clinic at
Wureburg, died recently from diphtheria contracted in
doing tracheotomy. The tube became obstructed by
membrane ; and to save the patient from asphyxiation
Dr. Meyer put his mouth to the canula and cleared it
by aspiration. He died a few days later.

Soap and Water in Glasgow. — In a lecture
at the London Institute, on " The Chemistry of Cleanli-
ness," Prof Vivian Lewes said, when speaking of
the wasteful action of hard water on soap : " The in-
troduction of the new Loch Katrine water-supply to
Glasgow has saved the city several thousand dollars a
year in soap ; and, mind you, Glasgow is not a place
where they waste soap."

Increase in Scioidbs in New York Citt. —
The mortality reports of the New York Board 'of
Health show that while the total mortality of the city
has risen since 1883 from 34,011 to 44,370 per year,
the number of suicides has increased from 1 61 to 313.
In the last ten years, while the general mortality has
increased about one-fourth, the mortality from suicide
has increased nearly one-half.

Digitized by

Google

Vol. CXXX, Mo. 14.] BOSTOJf MEDICAL AS J) SURGICAL JOVRHAL.

349

Ttphoid Fbybb Epidbmio at Montclaib, N. J.
— Ad outbreak of typhoid has occnrred at Montclair,
N. J., some thirty families having one or more pa-
tients each. Nearly all the cases are said to have oc-
carred among the customers, of a single mill^mao, in
whose family two oases of typhoid fever are known
to exist The Board of Health has forbidden the sale
of milk from this source.

LiQcOB Riots in South Carolina. — The work-
ing of the new State Dispensary Law in Sonth Caro-
lina is not satisfactory to the people of that State, or
at least to a certain proportion of them ; and last week
several riots occurred in various parts of the State be-
tween the people and the State police. At Florence
a mob broke into the State Dispensary and destroyed
the entire stock of liquors.

Five Malk Gknbbations. — The five female
generations recently reported in this column have their
counterpart in a family in an English village where,
sccording to the Medical Pret$, there are now living
the following members of one family: T. D., aged
ninety-seven ; G. D., bis son, seventy-three ; 6. D.,
Jr., grandson, forty-eight; J. D., great-grandson,
twenty-six ; and G. D., great-great-grandson, six years
old.

Suicide In the Gbbmam Abut. — The number
of snicides in the German army is 6.3S in every 10,000
men ; while in the French army it is but 8.88, and in
the English 2.09. Saxony and Silesia furnish the
largest nnmber of suicides. According to the published
statistics, the causes lie, aside from the natural suicidal
tendency of the German race, in the fear of punish-
ment and the wretched treatment the private soldier
has to endure.

Death of Commandeb Camebon. — Commander
Verney Lovett Cameron, who was sent out to Africa
by the Boyal Greographic Society in search of Dr. Liv-
ingstone, was killed last week by a fall from his horse
while hnnUng in Bedfordshire, England. . He was the
first European to cross the entire breadth of the African
continent, in its central latitudes, beyond the western
■bore of Lake Tauganjika, to the Atlantic sea-coast of
lower Guinea, making the greater part of the journey
on foot.

Am Incident of the Cholera at Jedda. — An
sstoanding instance of the onconceru which was shown
towards the loss of life by cholera during the pilgrimage
in the East last summer has come to light in the sen-
tence by an English court of the captain of a vessel
conveying pilgrims home from Mecca and Jedda. In
• storm many were washed overboard aud others died
of disease, nearly two hundred in all perishing. The
captain made no mention of this in his log, for which
omission he was fined twenty-five dollars.

Dahaoes fob Imtalidibm from Shock. — The
Sopreme Court of Minnesota has ruled, that where the
evidence tends to show that prior to sustaining a per-
sonal injury a woman was healthy and active, but -by
such injury is rendered a helpless invalid, an award of

$10,000 damages is not so large as to warrant a review-
ing court in saying that they are excessive. In the
case on trial the injury for which damages were
awarded was in itself slight, but medical testimony sup-
ported the plainUtTs claim that the nervous shock re-
sulted in cardiac and neurotic disease.

The International Medical Congress. —
Harold Frederic, in his Loudon letter in the New Tort
Tinu$ of April Ist, says of the International Medical
Congress in Rome : " Italy may be wallowing in the
mire of poverty, but she manages none the less to give
the International Medical Congress the finest reception
it has yet had in Europe. Not much money has beeu
spent ; but the King and Queen, Crispi, and the Court
have been prodigal of personal attention and interest,
which had a much greater effect than mere financial
lavishness. Visiting doctors, both English and Ameri-
can, write me in terms of almost excited enthusiasm
over their experiences in Rome, where they are treated
as the guests of the whole city." As the Congress.met
on March 29th, Mr. Frederic's correspondents must
have written very promptly on going home from their
pleasant reception.

The Michigan State Board of Health and
Tuberculosis. — The Michigan State Board of
Health, in adopting its rule that hereafter all cases
of consumption or other diseases due to the bacillus
tuberculosis shall be reported by householders and
physicians, has acted in a most rational manner in
calling attention at the same time to the fact that iso-
lation of the patient is not looked for or expected.
The sole purpose of the new law is to secure to the
various boards of health information of the locality
occupied by each person affected with tubercular dis-
ease, with the view of giving him trustworthy infor-
mation as to how he may avoid re-infecting himself
and infecting others, and telling persons most endan-
gered how to avoid contracting the disease. In a
similar manner, the New York State Board compels
the registration of all tuberculous persons, but does
not attempt sanitary visitation aud disinfection except
under certain conditions. The Philadelphia Board
does not require registration, but simply attempts an
active educational campaign in the matter of prevent-
ing the disease.

The Practice of Medicine in Maine. — A cor-
respondent sends us the following clipping from the
Rockland (Me.) Courier Gazette, concerning the social
and financial status of the physiciau in one of the small
island towns: "There is talk of getting up a time to
raise money to help keep our doctor here another
year. He cannot stay on what practice he gets, and
we cannot afford to have him go. The most of us know
what it is to go to the main and Carver's Harbor for
doctors. Let's wake up and get up a good time aud
raise what money we can for the good cause! "

BOSTON AND NEW ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noun, April 4, 1894, there

Digitized by

Google

350

BOSTON MBDIOAL ASD SUBQIOAL JODBNAL.

[April 5, 1894.

were reported to the Board of Health of BostoD, the
followiug numbers of casei of acote infections disease :
diphtheria 88, scarlet fever 58, measles 4, typhoid
fever 2, small-poz 6 and tf deaths (all in nnvaccinated
persons). There are now twelve cases at the small-
pox hospital on Canterbury Street, and three cases at
Gallop's Island. No cases were reported to the State
Board of Health from places elsewhere in the State.

Beqdbst to the Ltnn Hospital. — The Lynn
Hospital and the Home for Aged Women have each
received a bequest of one thousand dollars, by the will
of the late Edward H. Johnson, of Lynn.

The Population of Boston and its Vai,de. —
According to the Cvmm* Bulletin on Finances of
Mnnicipalities, just issued at Washington, the popula-
tion of Boston is 448,477, and the assessed valuation
of real and personal property in the city is $822,041,-
800, which is an assessed valuation of $1,832 per
capita, not including the Public Library twins, who
possess no personal property.

NEW TORK.

The Academy Cohhittke and the Bill fob a
National Bdbeau of Health. — On March 28th a
delegation of the New York Academy of Medicine,
among whom were Drs. William H. Thomson, George
F. Shrady and Richard H. Derby, went to Washing-
ton and argued before the House Interstate Commerce
Committee in favor of the Academy's bill to establish
a National Bureau of Public Health. Dr. T. Gaillard
Thomas, the chairman of the committee of the Acad-
emy having the matter in charge, was not able to
leave New York, and a paper prepared by him was
read by Dr. Derby.

TcBERODLAB Mkninoitis fbom Milk. — An ap-
parently well authenticated case of tubercular meningi-
tis, the direct result of drinking milk from a tnberculoui
cow, is reported from Youkers. The patient, the four-
yearold son of Mr. William A. Harper, of the publish-
ing house of Harper & Brothers, who married a grand-
daughter of the late Rev. Henry Ward Beecher, gave
no sign of ill health until the Ist of March, when the
family physician was called in. The symptoms pre-
sented were those of tubercular meningitis, and later
the diagnosis of this disease was confirmed by Dr. M.
A. Starr, Professor of Diseases of the Nervous System
in the College of Physicians and Surgeons of New
York, who was called in consultation. The child died
March 27th. The milk used by the family was sup-
plied by two fine Alderney cows which were purchased
about a year ago, and which had always seemed to be
perfectly healthy. After the child's death, however,
the Koch lymph test was applied by Veterinary Sur
geou J. B. Lamkin, and the presence of tuberculosis
was indicated in both animals by the rise of tempera-
ture followiug the injection. A careful examination
also revealed evidences of tuberculosis in the udder of
one of them; and it is claimed by Dr. Brush and
other authorities that the milk of a tuberculous animal
cannot convey the disease unless the mammary gland

is affected. It is stated that several weeks ago Dr.
Lamkin reported to the Board of Health that he hsd
found tuberculosis among the cattle of Yonkers.

dl^tietcenattp.

PERFORATION OF THE HEART, WITH CON-
TINUANCE OF LIFE FOR THIRTEEN HODRS.

An unusual case of prolonged existence with a per-
forated heart is reported by Dr. Thompson, of San
Bernardino, Cal.' The man was a Mexican, tweoty-
nine years old, five feet seven inches in height, weigh-
ing one hundred and sixty pounds. After the shoot-
ing he complained of internal pain over the abdomea
and of great thirst. He was given morphia subcuta-
ceously for the pain and shock, and was carried by
wagon and train to San Bernardino, a distance of
some length. Fie died a few moments after reaching
the hospital, thirteen hours after being wounded.

The autopsy, four hours later, showed ''a bullet-
hole two and-a-half inches inside and one-third of an
inch below the centre of the nipple line; size of
wound at point of entrance, five-sixteenths of an inch,
almost round. The bullet penetrated the cartilage of
the sixth rib, near its juncture with the rib, breaking
it, and chipping a small piece out of the upper part of
the seventh rib. Entering the pleural cavity, the
course of the ball was downwards and slightly inwards;
this cavity was filled with blood. Passing through
right side of the pericardium, penetrating the right
ventricle of heart, one-and-a-half inches from apex, it
passed through the anterior wall, severing the right
coronary artery. Leaving the heart, the ball passed
directly downward, penetrating the diaphragm, enter-
ing and passing through the left lobe of the liver from
above downward, entering the small intestines. The
ball having perforated the wall of the intestines, fol-
lowed them through their action, and was found about
two inches up the rectum."

HYPNOTIC SUGGESTION IN THE CURE OF
ASTHMA.

The astonishing effect of hypnotism in the relief of
symptoms is well illustrated by a case of asthma re-
ported by Creed.*

The patient had received very little benefit from
treatment of any kind, even " Himrods' Asthma Cure,
which was resorted to by the late Earl of Beaconsfield
during his last illness," failing to more than mitigate
the paroxysms. He was hypnotized daily for ten days,
and appropriate suggestions made. On the third he
was much relieved, and slept on only one pillow ; while
on the tenth he was free from respiratory distress, and
could walk with considerable speed.

Nevertheless, the cure was not perfected, as he has
occasional modified attacks of dyspnoea so that he is
now provided with a written order "to sleep when he
reads it and to awake after five minutes, breathiog
freely." This he always carries, and says that it never
fails him. There are numerous polypi in both nostrils,
which have not been removed for fear of making the
cure by hypnotism questionable.

> Southern Californik PraotitioDsr, February, 18M.

> AnatrslulaD Medloal OaxetM, Jane, ISSS.

Digitized by

Google

Vol. CXXX, No. 14.] BOSTOD MSDIGAL AND SVttGlOAL JOtJtiSAL.

351

CorirejEtpotttiettce.

PROPOSED REDUCTION OF THE ARMY MED-
ICAL CORPS.

An Attbhpted Leoislativb Outkaoe.

Mr. Editor : — It is with indignation tliat all lovers of
justice will look upon the latest endeavor of certain mem-
bers of Congress to injure the efficiency of the Medical
Corps of the United States Army by reducing its numbers
35 men.

This measure, now pending, is a buncombe attempt to
gain credit for economy with poliiical constituents; and
the medical men are selected for attack because they, and
more is the pity, do not combine politically for self-defence,
and are therefore a safe mark, in this case the bill is a
most insulting one to these honorable physicians, implying
u it plainly does that 35 of their number draw pay with-
ont earning it.

It is well that the facts of the case should be clearly
formulated. The Army Medical Corps consists of 193
members, attending to various hospital routine work, drill-
ing the hospital corps detachment in field and other duties,
and ministering to the medical and surgical needs of the
28,000 soldiers, constituting the present United States
Army; and also attending their wives and families; a
total of soldiers and adult male civilians at United States
Army posts being to-day 43,431.

llivse 193 doctors are scattered over an area greater
than all Europe, and divided among the 120 military posts.

In event of field duty at any time, it is plain that one
surgeon, at least, must accompany the troops, from each
post, and another should stay behind to take medical super-
vieion of the hospital and of the women and children. It
will thus be seen how small — even too small — is the
present corps. Moreover, it occasionally happens that a
doctor (being human) falls ill; and thereby reduces the
effective list. Several are thus incapacitated at this time.
And again, the law permits officers to take a month's
vacation in each year without loss of pay. Therefore this
reduces by one-twelfth the list actively on duty, and about
16 medical officers are thereby relieved for a time. As a
matter of fact, such is the pressure of duty that the Sur-
geon-General must often refuse this well-earned vacation,
compelling continual duty.

A simple calculation will suffice to show that these
varioDd factors, and the present five vacancies, reduce the
number of (he active medical corps much below its nominal
strength of 193 members; and should the present bill re-
moving 35 more become a law, a grievous injury will be
inflicted, not only on the efficiency of the corps, but also on
the soldiers and their families, who must look to the United
States Medical Corps for attendance in sickness.

If it be alleged that contract surgeons — civilians — might
be appointed to fill tliese vacancies at a lower cost, the
reply is obvious ; that there is now no appropriation made
for contract doctors, though formerly this was the case ;
and even if there were, there is no provision of law
whereby they can be placed in charge of the medical de-
partment at a military post. Therefore thev cannot take
charge of the discipline and field drill of the hospital corps
detachment, nor be responsible for the post hospital with
its supplies. To effect economy as far as practicable, the
Sargeon-General has long employed only private physi-
ciuis at all the arsenal posts in the country ; these being
small ones. A further grinding down of medical estimates
ia worthy of the hearts and intellects from which the
thonght emanates.

Should this bill pass, it will, of course, stop the opera-
tion of the new Army Medical School which is doing such
good work and which employs itself with the special educa-
tion in sanitation of hospitals and troops, commissary
knowledge, bacteriology, military eurgery and other sub-
jects urgently needed by the new men among the assistant
anreeons.

Ko further comment is needed sav.e the statement that

upon March 15th, the Commanding General of the United
States Army, Gen. J. M. Schofield, addressed a letter to
the Secretary of War statins that this bill would be
" seriously injurious to the Military Service," also " the
Medical Corps of the Army is none too large for the neces-
sities of the Service." And yet it is considered likely that
this measure will pass the House I Medici;s.

BIETEOBOLOGICAL RECORD,

For the week ending March 24, in Boston, according to ob-
servations furnished b; Sergeant J. W. Smith, of the United
Stated Signal Corps: -

Baro-

'11iermoni-l Belatlve

Direction

Velocity
of wind.

We'th'r.

i
■g

meter

eter. humidity.

ul wind.

•

s

d 1 .

.

B
a

Date.

s

II

§

a

a

a
8

s

a
fa

a

a
fa

a
■i

a
fa

I

a

I

o

a £

38

.; 00

C
74

«•

«

m

•

X

p.

00

o.

.S..IS

80.16

60 62

61

87

sw.

S.W.

6

16

M..19

•.9.82

82 70

K<

88

60

74

S.W.

N.W.

16

13

<l.

0.

r..!(o

30.28

42 47

87

43

58

60

N.

R

14

11

o.

p.

W.21

30.14

41 4:;

.17

74

100

87

S.E.

N.E.

10

4

0.

R.

0.04

T. W

30.00

44 162

36

76

91

8x

N.

N.K.

IK

19

o.

o.n»

F..2.t

39.76

40 46

34

^Vs 62

IB

8.K.

W.

19

:9

R.

<!.

0.48

S..2t

30.16

86 43 30

36

69

62

N.W.

8.E.

IS

8

O.

C.

tar

SO.OB

jSij 38

71

0.66

• O.. olondTi C, elwrt F., Mri U.. tog

1 H.,l»iTi B.,unokTi B..nlni T..thrMt-

ntDiit N . moT. « iDdlutM trace of nlaf iH. a»- Mom (or week .

RECORD OF HOBTALTIT
Fob tkk Wbek BNDiMa Satdbdat, March 24, 18M.

Unieii.

New York .
Chicago . .
PhlladelpUlK
Brooklyn
St. Louis . .
Boeton . .
Baltimore .
Washington
Cincinnati .
GleTeland .
Pittsburg .
Milwaukee .
NaafaTille
Charleston .
Portland . .
Worcester .
Fall RlT»r .
Lowell . .
Cambridge .
Lynn . . .
Springfield .
LJiwrence .
New Bedford
Uolyoke , .
Salem ...
15rockt>on
HaTerblll .
Chelsea . .
Maiden . .
Newton . .
Pltchburg .
Taunton . .
Qloocester .
Waltham .
Quincy . .
Pittsfleld .
Everett . . ,
Northampton ,
Newburyport .
Amesbury . ,

1

1

^5

Per

centa)

e of d

saths from

11

k 8

.a

1

|l

58

8

1

1,091,306

S73

377

18.26 16.2»

7.48

1.08

3.19

1,438,UUU

—

-

— —

—

1.116.662

394

163

16.26 14.26

4.00

1.25

2.00

9;8,il94

826

121

19.60 1 20.4U

7.bU

4.rO

.60

6t>u,uOV

—

—

—

—

—

—

4h7,8»7

236

78

18.33

19.36

6.69

1.72

_

COU.UUV

—

—

—

—

_

__

3UI<,481

120

8.

9.11

26.66

3.82

306,000

183

44

10.60

13.60

3.00

_

290,000

»5

83

16.76

11.66

4.20

1.06

3.15

263,709

—

—

—

—

—

260,0l<0

09

48

23.44

19.04

2.24

3.36

87,764

.W

6

10.1,0

8.83

—

_

6i,l«6

32

9

9.89

12.62

—

_

„

40,000

—

—

—

-

.—

96,217

26

6

12.00

16,00

8.00

_

87,411

63

21

24.67

26.40

l.t4»

_

3.78

07,11)1

33

14

8.0J

2J.27

—

77,100

24

12

12.4s

20.00

4.16

4.16

62,666

U

6

11.28

8t..70

—

._

4l<,604

3

8

8.38

—

—

48,366

21

11

—

9.62

—

—

_

46,l<8«

10

4

10.0U

20.U0

—

10.00

_

41,270

—

—

—

—

—

__

32,283

11

1

».0»

9.09

«.0»

__

__

32,140

12

8

—

—

■^

_

^

31,896

18

6

—

6.79

■^

_

_

80,264

_

—

—

—

■~

_

__

29,994

8

1

—

25.00

—

—

_

27,666

8

2

—

—

—

—

_

27,146

6

1

—

—

—

—

_

26,972

9

1

—

—

■"

—

_

26,688

18

6

7.69

—

—

^

22,066

8

0

—

—

—

—

_

19,642

—

—

—

—

^

—

18,802

2

2

—

—

—

~-

16,686

9

8

22.22

11.11

—

_

__

16,381

8

U

—

—

—

—

_

14,073

—

—

—

—

—

—

_

10,920

6

1

—

40.00

—

—

—

Deaths resorted 2,613: under five yean of age 1,016; principal
infections diseases (small-pox, measles, diphtheria and croup,
diarrhoeal diseases, whooping-congh, erysipelas and fever) S9!>,
diphtheria and cionp 14B, measles 47, scarlet fever 47, diarrhoaai

Digitized by

Google

362

BOSTOJS MBDIOAL AJSD SUB6ICAL JOVRSAL.

[Afbil 5, 1894.

diseases 16, wbooping-congb 32, typhoid fever 32, small-poz Ifi,
cerebro-spiiial meoinKitis IS, erysipelas 10, malarial fever 1.

From dlarrboBal diseases New York 20, Fall River 7, Pbiladel-
pbia U, Brooklyn and NasbviUe 4 eacb, Washington and Clncln-
nati 2 eacb, Boston 1. From whooping-ooaeb New York 8,
Brooklyn 7, Philadelphia 6, Washington 1, Fafl River 2, Boston,
Cincinnati, Nashville, Charleston, Cambridge and Oloncester 1
each. From typhoid fever Cincinnati 7, New York 6, Philadel-
phia fi, Cleveland 1, Milwaukee and Charleston 2 eacb, Bobton,
Washington, Fall River and Lowell 1 each. From small-poz
New York 7, Brooklyn 4, Boston 3, Lynn 1. From cerebro-spfnal
meningitis New York fi, Cleveland 3, Milwaukee 2, Boston,
Worcester and Lynn 1 each. From erynpelas Boston 4, Brooklyn
3, New York 2, Somerviile 1.

In the thirty-three greater towns of England and Wales with
an estimated popnlation of 10,468,442, for the week ending
March 10th, the deatb-rate was 19.9. Deaths reported 3,983;
acDte diseases of the respiratory organs (London) 434, whoopimr-
congb 14fi, measles 111, diphtheria 82, scarlet fever 52, fever w,
diarrhoea 30, small-poz (Bradford 4, West Ham 3, Blrmingbam
2, Bristol, Oldham and Leeds 1 each) 12.

The death-rates ranged from 11.1 in Huddersfleld to 2B.1 in
Liverpool ; Birmingham 17.4, Bradford 18.9, Bristol 20.9, Croydon
17.2, Hull ld.9, Leeds 17.2, Leicester 19.3, London 20.4, Manches-
ter 21.7, Newcastle-on-Tyne 19.6, Nottingham 14.9, Oldham 18.8,
Portsmouth 11.6, Salfotd 22.0, Sheffield 19.1, West Ham 20.1,
Wolverhampton 23.9.

In the thirty-three greater towns of England and Wales with
an estimated popnlation of 10,408,412, for the week ending
March 17th, the death-rate was 19.2. Deaths reported 3,8SS:
acnte diseases of the reBpiratory organs (London) 373, measles
124, whoopingKiongh 118, diphtheria 71, scarlet fever 47, fever
39, diarrhoea 34, small-poz (Birmingham 8, London 3, West
Ham 2, Cardiff and Oidbsm 1 eacb) IS.

The death-rates ranged from 12.1 In Croydon to 26.6 In Livei^
pool; Birmingham 19.3, Bradford 18.6, Bristol 20.6, Leeds 18.2,
Leicester 16.8, London 19.3, Manchester 21.1, Newcastle-on-Tyne
12.1, Nottingham 16.3, Sheffield 18.2.

OKFICIAL LIbT OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U..S. ARMY, FROM MARCH 24, 1894, TO
MARCH 30. 1894.

By direction of the President, Libitt.-Col. Samdbl M. Hor-
TON, deputy surgeon-general, will report in person to the Presi-
dent of tbe Army Retiring Board at San Francisco, Cal., for ez-
aminatlon by the board.

Captain William R. Hall, assistant surgeon, is relieved
from duty as attending surgeon and ezaminer of recruits at San
Francisco, Cal., to tale effect upon the completion of his ez-
amination for promotion and will then report in person to the
commanding officer, Whipple Barracks, Arizona Territory, for
duty at that post.

SOCIETY NOTICES.

Boston Sociktt fob Mrdical Imfkovkiunt. - A regular
meeting of the Society will be held at tbe Medical Library, No.
19 Boylston Place, on Monday, April 9, 1894, at 8 o'clock, F. H.

Drs. M. H. Rlcbardson and G. L. Walton : " Tbe Operative
Treatment of Spasmodic Wry-Neck." Discussion opened by
Drs. C. B. Porter and J. J. Putnam.

Under oral communications Dr. W. L. Bnrraee wilt report
" A Case of Tuberculosis of the Female Bladder, Diagnosticated
and Treated by Howard Kelly's New Method of Direct Inspec-
tion and Catheterization of Ureters through Large Endoscopes."
JOHM T. BoWKN, M.D., Secretary.

SuFiroLK Distbict Medical Sociktt. — The annual meet-
ing will be held at 19 Boylston Place, on Saturday, April 28,
18U4 &.t 8 p M

Papers. - Dr. F. S. Watson, " Some of the Clinical Features
and ihe Surgical Treatment of Primary Tuberculosis of the
Urinary Organs." Discussion by Dr. P. Thomdike and others.
Dr. F. H. Williams, "Diphtheria." Dr. W. A. Morrison,
"Tbe Value of the Stomach-Tube in Feeding after Intubation "
— based upon twenty-eight cases. Discussion by Dr. F. B.
Harrington, Dr. Gannett, Dr. C. H. Whitney and Dr. Presoott.

Busineiu, — Report of the treasurer and tbe librarian. Elec-
tion of officers. Appointment of delegates to the American
Medical Association.

Supper after the meeting.

A. L. Mason, M.D., Prttident.
Jambs J. Minot, M.D., Secretary.

Philasblphia Pathological Socibtt. — Tbe semi-annual
conversational meeting of the Philadelphia Pathological Society
will be held in tbe upper hall of the College of Physicians Build-
ing, Thirteenth and Locust Streets, on Thursday, April 26th, at
8f. m.

Dr. Simon Flezner, Associate in Pathology in tbe Johns
Hopkins Medical School, will deliver an address entitled " An

Ezperi mental Study of tbe Nature and Action of Certain So-
called Tozalbumlns." Members of tbe medical profession ue
cordially invited to be present.

Auousrns A. Ecbmbb, Secretary.

THE CARTWRIGHT LECTURES.

The Cartwright Lectures of the Alumni Association of the
College of Physicians and Surgeons for 1894, will be delivered
at the New York Academy of Medicine, No. 17 West 43d Street,
on Wednesday evenings, April 4th, 11th and 18th, at 8 o'clock,
by Prof. Russell H. Chittenden, Ph D., of Yale Unlvenity.

Subject: "Digestive Proteolysis." L General Nature of
Proteolytic Enzymes; General Nature of Proteids. II. Proteo-
lysis by Pepsin - Hydroobloric Acid — with a Consideration of
the General Nature of Proteoses and Peptones, in. Proteolysia
by Trypsin ; Absorption of tbe Main Products of Proteoljais."
PhystcUms are cordially invited to be present.
Fbancu p. Kinnicutt, M.D., |
Waltbb B. Jambs, ~
D. Bbtson Dblatan,

[cutt, M.D., )
B, M.D., . \
'AS, M.D., )

Committee.

MUTTER LECTURESHIP OF THE COLLEGE OF PHY-
SICIANS OF PHILADELPHIA.

The nezt course of ten lectures under tbe bequest of tbe late
Prof. Thomas Dent Miitter, M.D., LUD., " on some point or
points connected with Surgical Pathology " will be delivered in
the winter of 1896-97, before tbe College of Physicians of Phila-
delphia. Compensation 9600. Tbe appointment is open to tbe
f)rofe8sion at large. Applications, stating subjects of proposed
ectures, must be nuule before July 1, 1894, to
William Hdnt, M.D.,
Clutirman, Committee on the MiUter Mutetim,

S. E. cor. 13th and Locust Sts., Philadelphia, Pa.

HARVARD MEDICAL SCHOOL.

EvBiriNO Lxctubbs.

The nezt lecture will be given on Wednesday evening, April
11th, at 8 o'clock, by Dr. F. C. Knapp. Subject, "Traumatic
Nervous Affections." Physicians are cordially invited.

RECENT DEATH.

Edwabd Bbown-Sbquars, M.D., died in Paris, April 2d,
aged seventy-fliz years. He was bom in the Island of Maaritios,
but received his medical education in Paris, graduating in 1840,
at which time be bad already acquired considerable reputation
as an ezperimental physiologist. He received five prizes from
tbe French Academy, and twice received the queen s grant for
the encouragement of science from the British Royal Society.
He engaged in the practice of medicine in Mauritius until 18H,
when ne travelled eztensively in England and in this country,
lecturing and giving private medical instruction. In London
he did much work as the bead of the Uoepital for the Pantlyzed
and Epileptic. In 1864 he was made Professor of the Physiol-
ogy and Pathology of the Nervous System in the Haxvaid
Medical School, a position which he held for four yeare. In
1869 he returned to France, where be was appointed professor
in the School of Medicine at Paris, and in 187;) came back to tbe
United States and began practice in New York, and with Dr.
Seguln commenced the publication of tbe " Archives of Scientific
and Practical Medicine." After a short residence in London be
returned to Paris where he has since resided. In lf78 he sno-
ceeded Claude Bernard as professor of ezperimental medicine
at tbe College of France. In 1881 he was awarded tbe Baly
Medal by the Royal College of Physicians of London. He was
for several years president of the French Academy of Sciences.
He nrote much and was a most enthusiastic investigator in
questions of physiological medicine. Among his published
volumes are " Lectures on the Physiology and Pathology of tbe
Nervous System," " Paralysis of tbe Lower Eztremities,"
" Lecture on the Nervous ASectlons." He established in Paris
the Journal de la Fhysiologie de I'Homme et del Animavx. A
few years before his death be discovered the true elizir of life
whion should rejuvenate and prolong human ezlstence.

BOOKS AND PAMPHLETS RECEIVED.

Retinitis Albuminuria. By L. Webster Fox, M.D. Reprint.
1894.

A New Dynamometer for Use In Anthropometry. By J. H.
Kellogg, M.D. Reprint. 1894.

Tuberculosis in Relation to Animal Industry and Public
Health. By James Law. Reprint. 1864.

Digitized by

Google

Vol. CXXX, No. 15.] BOSTOS MEDICAL AND SUMGIOAL JOURNAL.

353

#nginai %xxit\t^^

THE CHARLES SIVER IN ITS RELATION TO
THE ETIOLOGY OF INTERMITTENT FEVER.*

BT K. W. aBMHUiAV, l(.D., BOSTOir.

The etiology of intermittent fever is so little under-
stood to-day, that, excepting that a micro-organism has
been discovered in the blood of patients suffering with
the disease, we know but little more about it than did
onr predecessors of fifty years ago. Indeed, as -evi-
dsDced by certain articles in our journals and discus-
lions in our medical societies, it would appear that we
do not know as much.

With onr present knowledge of micro-organisms it
is a little singular that this corner of medical literature
should still be clothed with the phraseology of the past,
oftentimes containing a partial truth, but so imperfectly
expressed as to be misleading and inadequate for prac-
tical purposes.

Not a few writers are still urging, in otherwise ex-
cellent papers, hypotheses as diverse from each other
as inconsistent with observed facts.

Among supposed causative agents we still hear of
"atmospheric conditions," "marsh miasms," "river
mists," " sewage contaminations," etc ; also that in-
termittent fever is an " exotic of tender growth," a
" stranger in this part of the country," and the like.
It would be of the greatest interest if some one could
present a perfectly demonstrated theory of the whole
coarse of events, from the taking of the causative agent
from its habitat outside the body to its mode of entrance
into the body, and through the various stages of its
history in the body. The difficulties in the way of so
complete a demonstration are so great that I am en-
couraged to present the following views as to this ques-
tion, which, though not wholly proven, will serve to
co-ordinate distinct data and to give us a " working
hypothesis," sufficiently complete for practical purposes.
They were derived from a study of the conditions
found during a house-to-house inquiry along the banks
of the Charles Biver in the vicinity of Boston, and
from a comparison of the data thus ascertained with
the reports of observers elsewhere.

In common with other regions in and about Boston,
intermittent fever has not been present in the area
under consideration for a long time, until within the
past six or eight years. A common impression prevails
that the Charles River is in some way responsible for
its introduction. For instance, even in the utterances
of the profession, we hear of the disease "creeping up
the valley of the Charles." The offensive conditions
doe to the refuse of various factories, starch, grease,
etc., also the sewage contaminations and the exposure
of mad flats have all been held responsible as at least
having furnished a nidus fdr a causative agent " intro-
duced from elsewhere." There is no question that
each of these unsanitary conditions has existed, though
some of them have since been removed. My studies
have led me to conclude that there is equally no
question that none of these conditions are causative
agents, per se ; moreover, that we need not look else
where to find the offending cause. In other words,
that it is right here at home, has been here all along,
and is likely to show itself (as it has of late with us),
just as it does elsewhere, whenever we establish the

> Baad before a meeting of the OaiDbrl<lge Society foi Medical Im-
ptorement, Febnuu-7 2S, ISM.

conditions of its existence and introduction to onr
bodies.

Before presenting these views in detail, permit me
to call to your attention what appears to be a fully
demonstrated law applicable to, and most useful in the
study of the causes of epidemics ; namely, that when
a cause is general in nature, such as the contamination
of a water-supply, as in the case of the cholera epi-
demic in Hamburg, that the distribution of the cases,
when plotted on a map, is widespread, and shows what
may be called a markedly characteristic "curve."
This is most graphically shown in the data furnished
by Professor Sedgwick in the last Report of the State
Board of Health, which marks an era in the American
study of epidemiology. I will pass about the maps
showing the distribution of typhoid fever in Lowell
and Lawrence. In these cases the cause was fully
demonstrated. Furthermore, since the measures sug-
gested by the Board were adopted in the city where
their advice was fully taken, typhoid fever has prac-
tically become non-existent. On the other hand,
locally acting causes give rise to cases which when
plotted are seen to present an equally characteristic
" curve." Professor Sedgwick has also demonstrated
this in connection with epidemics in which the milk-
supply was shown to be the probable agent in the spread
of the disease. (See same Report.)

To apply this law to the conditions under consider-
ation, Townsend's exhaustive analysis of the 106 cases
in Boston in 1892 shows that two areas were particu-
larly affected, namely, the South Cove and the West
End near Poplar and Brighton Streets. He did not
explain their distribution. He simply considered that
many of them were imported, as from the Newtons ;
but the points applicable to our inquiry are that he
does not report any cases immediately along the river's
bank, moreover, that his cases were for the most part
grouped around local centres. In the discussion fol-
lowing Dr. Townsend's paper, Dr. John Homans, 2d,
referred to a few cases occurring on Marlborough
Street, subsequent to the digging up of the street.
These, with a single exception on Beacon Street, are
the only cases I heard of as having originated near the
water front. Further negative evidence as to the river
being a causative agent for Boston's cases is that the
park police, who pass a considerable part of their time
along the Cfaarles-bank have had no cases of the dis-
ease among their number. That this is not a question
of their lack of susceptibility is evidenced by the fact
that several of them were ill with it during the war.

Careful inquiry for some distance along the banks
failed to find a single case ; though in places unsanitary
conditions were found, yet intermittent fever was un-
known. Several families had lived in the same places
for many years, even twenty and thirty, and had been
free from malarial disease. The first locality i found
affected was at Barry's Corner. Here in a damp
neglected settlement, six cases had occurred within the
past three years. An interesting fact was, that still
nearer the river, on the same marsh, was a more cleanly
and drier settlement. In this place those of whom I
inquired knew of no cases.

No other cases of importance were found on this
side of the river until reaching Watertown. Here in
an extremely unsanitary area, including two sub-areas
near at hand, about a dozen cases were found. It is
noteworthy that in this area seven of Watertown's nine
I cases of diphtheria and one case of her seven oases of

Digitized by

Google

364

BOSTON MEDICAL AND SVSOICAL JOUBNAL.

[April 1'/, 1894,

Bcarlet fever had occurred since the first of the year.
Farther along the river were cases close by a pond
whose level bad recently been moch lowered. Still
further along, in a particularly dry and apparently
healthy place, the only case near at hand was in the
person of a gentleman whose occupation called him
daily to a particularly damp part of Newton. As you
are aware (and the details will doubtless be presented
this evening), there have been a great many more
cases in the Newtons away from the river's batiks than
in its immediate neighborhood. Some occur near
ponds and some occur on hillsides, but their relative
infrequency near the banks of the river certainly tends
to show that the river, ptr $e, is not a causative agent.

The last cases to which I would especially call your
attention on the south side of the river, occurred among
workmen engaged in digging up around a brook (the
Cheese-Cake Brook) in connection with sewer improve-
ments. Five or six men were aSected during the
summer of 1892, when the soil was first dug up.

Following down the north bank, a very similar out-
break occurred among workmen engaged in " improv-
ing " a large estate in Waltham near the Watertown
line. It is to be noted in passing that they were dig-
ging up what was practically a primeval soil, that is,
undisturbed, damp, forest soiL

Along this north bank long stretches were found
with no, or only a few cases. In the mills and at the
arsenal about one in fifty persons had had the disease,
but they were found to live in some especially malari-
ous centre elsewhere.

Passing down to Cambridge, a very interesting rela-
tion was found, similar to that referred to on the south
bank, namely, a far less number of cases near the river
than at a distance from it. You will recall the valua-
ble paper of Dr. Stevens on " Malaria in Cambridge
and Vicinity," published in the Botton Medical and
Surgical Journai, December 29, 1892. He showed
the prevalence of the disease in North Cambridge near
the clay-pits and near Fresh Pond. In some places
so many men were ill as to seriously cripple the work-
ing forces. Yon will observe, however, that he has
nothing to say of cases near the river. Moreover, in-
quiry of other physicians assured me that very few of
Cambridge's cases had occurred there. My personal
inquiry for the most part verified their statements.
Foul odors and other unsanitary conditions, even in
extremis, had existed in places along the banks but in-
termittent fever was relatively rare. About the only
cases I found were in a settlement just to the west of
the Cambridge Hospital. Here, in a little valley
formed by the sloping banks of a small water-course,
were several. At this place, besides the attendant
dampness, the most unsanitary conditions existed, for
example, one of the houses, a double one, had an uu-
walled privy in an old shed, just behind the rear and
on the shady side of the house ; on this side also were
the kitchens ; and on the easterly side was an old cess-
pool. In this house both families were sufferers, and
intermittent fever had also attacked the persons who
had lived there the year before. The other cases had
occurred further along the settlement. The only other
case I heard of in this neighborhood was in the house-
hold of the landlord of these houses. This case may
have arisen from the Fresh Pond centre, and skipped
over the intermediate households ; but certainly its
origin is far better explained as in some way due to the
infection among the tenants.

It would thus appear, first, that all the cases of in-
termittent fever on the immediate banks of the Charles
River are localized about special foci. This shom
most clearly when they are plotted as on this map, and,
according to the law expressed above, excludes any cause
that is general in its action, as would be the river per
te, or any of its especially unsanitary coDditions ; and,
secondly, that in each centre there was present some
local condition of especial dampness, as by recent dis-
turbance of the soil, as a possible associate of a caus-
ative factor.

Let us next consider what light is shed upon the
subject of the origin of these cases by studying the data
furnished by others.

Intermittent fever is a very widespread disease. It
occurs in one form or another in various tropical
countries. It ascends through the temperate regions
of both hemispheres, reaching into Canada in our hemi-
sphere, and into the countries bordering on the North
Sea in the eastern. One of the best accounts on this
part of the subject is that of Boudin in " G^ographie
et Statistique M^dicale," published in Paris in two
volumes in 1857. Though notably a disease of swampy
lands, as around the Isthmus of Panama, and l^e
Pontine Marshes about Rome, yet mountainous regions
are not exempt. But wherever found, the cases are
localized about special foci. Another fact stands oat
prominently in all accounts, namely, that some condi-
tiou of dampness is invariably mentioned. Either an
old mill-pond has been dried up, or a river has over-
flowed its banks and subsequently exposed an expanse
of damp soil, or a mass of forest vegetation has recently
been dug up, or a sewer or other excavation has been
made. No matter what the views of the author may
have been, whether he upholds the " ground-water "
theory, the " clay subsoil," " atmospheric agencies,"
or whether he has taken pains to tabulate the tempera-
ture, rains, winds, etc., one is almost sure of finding
mention of some condition of dampness.

Other facts in the distribution of intermittent fever
are closely oorrellated with the above. One of these
is that certain localities, even if surrounded by water,
if their soil is well drained, that is, is not marshy, are
notably free from the disease ; for example, in many
oceanic islands it is practically unknown. A similar
fact is that sailors and marines have a much smaller
percentage of cases than is found among troops stationed
on shore. Data of this sort show that dampness, per
ge, is not the cause of intermittent fever, but is only
an associate of the cause ; in other words, it appears
to be only such dampness as occurs on land in associ-
ation with organic matter, whether the dampness it-
self is due to rainfall, or to pond or river overflow.
Moreover, portions of countries if particularly dry, as
the Cape of Good Hope, or if with abundant river
drainage but without much marshy land, are notably
exempt from malarial diseases. Still another fact
showing the close relation of the disease with dampness
is, that where it has prevailed and the soil later has
been well drained the disease has disappeared. This
has been abundantly shown in the experience of Brook-
lyn, N. Y., in Washington, and in places in other
countries, as in the various parts of England.

In this connection I would call your attention to the
fact that in a new country, as in our West, intermit-
tent fever is very common ; indeed, in Wisconsin,
as I am informed by a physician whom I intend to
quote at length presently, this has so forced itself upon

Digitized by

Google

Vot. CXXX, No. 15.] BOSTON MEDIO AL AND SURGICAL JOURNAL.

365

the notice of settlers that they are anwilliDg to occapy
dwellings constrncted over cellars recently excavated
through the dihrit of vegetable growth, whether such
growth is in swampy land or on a tnoantain side.
Their experience has taught them that to do so would
most likely result in malarial illness in their household.
They wait till all is dry before occnpying their honses.

In the long respite from malarial diseases which is
now being broken in upon hereaboots, I fear we are
losing sight of certain facts which have a most impor-
tant bearing on the subject. We forget that when our
ancestors settled here they found conditions practically
the same as we are now finding in the West, and that
they found intermittent fever here. This is clearly
shown in the Boylston Prize Essay of our venerable
and honored poet-teacher, Dr. Oliver Wendell Holmes,
written in 1838, nearly sixty years ago, but standing
to-day as one of the best expositions of the etiology of
intermittent fever for practical purposes extaut.

We forget that all through our State, as shown in
the admirable reports of the Drs. Adams of Pittsfield
and Framingham, Dr. Cook of Natick, Dr. Chase of
Brookline, and others, that malarial diseases have been
foond in several places much longer ago than for the
pA8t six or eight years. Indeed, a comparison of the
Tarious papers shows that at no portion of the century
has there been a time when some towns in New Eng-
land have not furnished cases, which if the disease had
an etiology anything like that of small-pox or scarlet
fever, or to that of the supposed mysterious stranger,
a " materies morbi " which is said to be " creeping up
our river courses " in some extraordinary way to-day,
all of us would probably have been stricken with the
disease by this time.

We forget that the present renaissance of New Eng-
land activity, with its construction of metropolitan
sewers, its building of many suburban homes for mer-
chants of onr large cities, and the many problems in-
ddent to gas-pipe, drain-pipe and electric-railway coa-
stmctioD has practically arisen hereabouts within the
past six or eight years, and that previous to that time
Boston and Salem and Plymouth and Cambridge, as
r^ards building operations and the like, were practi-
cally in the condition that certain of our suburbs, as
Chelsea and Charlestown, are in to-day. Indeed to-
day intermittent fever is heard of chiefly in their newer
parts or those recently disturbed in connection with
local improvements, as digging up streets and the like.

The next point in our search for a causative agent
most be studied with the patients themselves. Not to
prolong this paper unduly, let me at once call your at-
teotion to the researches of Drs. Osier and Thayer of
Johns Hopkins, and of Professor Councilman formerly
Uiere also, but now with as ; let me refer to Professor
Binz of Bonn, and to Dr. Dock of Texas, and to the
repeated confirmatory observations of the microscopists
of our home hospitals in the last year or two. They
have demonstrated beyond a shadow of doubt that in
the blood of an intermittent fever patient is a micro-
organism which attacks the red corpuscles and is a
cansative factor of the disease. This is known as a
hiematozoon. At one stage of its life-history it closely
resembles an amoeba, and passes through a variety of
stages (crescentic, granular, etc), and then appears
oatside the corpuscle as a flaggellated form. This is
Dot a bacteriam. Its affinities are with the monads,
the lowest of organisms in the ascending scale of ani-
mal life. The action of cinchona alkaloids in destroy-

ing its life is known, but how it gets into the body and
where it lives when outside, are still matters of con-
jecture. Certain formidable, if not insurmountable,
difficulties are in the way of settling these points. One
of them is that as far as known no animal can be suc-
cessfully inoculated with the disease from human blood.
The other difficulty is equally formidable. When one
learns that there are many micro-organisms in the
ground, one is apt to conclude that it would prove an
easy matter to solve the problem: I at first so con-
cluded on finding in earth taken from the surroundings
of the instructive series of cases I am about to
call your attention to, amoeboid forms, granular bodies,
flaggellate organisms, etc., looking very similar to those
found in blood. For a moment I was greatly rejoiced,
thinking I could soon solve the difficulty, but on con-
sulting the authorities I learned that all previous in-
oculation experiments had failed because the soil in all
places is apt to be teeming with the bacillus of tetanus,
which soon kills the animals experimented upon. At
this point of the argument one is forced to say that
demonstration wholly fails. I do not see how these
points can be fully demonstrated.

When evidence such as has been advanced up to
this point in the inquiry fails, it is proper, for the
purposes of a " working hypothesis," to rely on what
the lawyers call "circumstantial evidence." It would
appear that such evidence justifies us in assuming that
the haematozoon has for its habitat outside the body
some form of animal or vegetable life such as is found
in swampy land or in decaying vegetation, as on a
forest-claid hillside.. It is known that such micro-
organisms live in organic tissues, both living and dead,
and it is not necessary for practical purposes to say
just what particular organism the heematozoon lives in.

Our complete argument would then stand in this
way:

(1) Intermittent fever is a disease always originat-
ing locally, thus excluding as etiological factors all
causes of a general character.

(2) Intermittent fever is always found to have asso-
ciated with its origin some conditions of local damp-
ness.

(3) A micro-organism, namely, the hasmatozoon,
has been demonstrated as occurring as a causative
factor in the blood of patients ill with intermittent
fever.

(4) These organisms belong to a group of animals,
many of whom are known to live in damp soil, or in
animals and plants living in damp soil, thus rendering
it extremely probable, especially if we consider our
first and second propositions, that the " hsematozoon "
has a similar habitat.

(5) Such micro-organisms may readily be taken into
the system in either of the following ways : (a) By
drinking water contaminated with moisture from such
damp, decaying soil, (b) By entering on food which
is contaminated from unclean hands. It seems to me
quite probable that, in view of the uncleanly habits of
laborers who sit down to their dinner-pails without a
thought of washing their soil-stained bands, we may
quite sufficiently account for what appeared to be the
case in my inquiry, namely, that, relatively speaking,
far more cases occurred among hearty laborers than
among other classes of people. Professor Sedgwick
refers to this method of self-inoculation under the
name of " secondary infection," as accounting for a
considerable number of cases of typhoid, (c) By cur-

Digitized by

Google

366

BOSTON MEDICAL ASD SUBGIOAL JOURS AL.

[April 12, 1894.

rents of air blowing within limited area* from roil rich
in the sapposed germs. In view of the widespread
opinion that air from malarious marshes is liable to
cause the disease, also in view of the cases to which
I shall soon call your attention, and of other cases
which have come to my notice, this latter seems a prob-
able way also.

You will observe that the first, second, third and
a portion of the fourth propositions in the argument
may fairly be considered as fully demonstrable and
practically already demonstrated; yon will also note
that the supposition in the fourth, idso the fifth propo-
sition, while not to be considered in that category, are
in a class of circumstantial evidence of the strongest
kind, namely, being wholly in agreement with similar
classes of data which have been demonstrated in other
lines of argument.

It is an axiom of science that if an hypothesis is
sufficiently strong to permit prediction which subse-
quent data confirms, and that if observations are suffi-
ciently numerous to guard against the probability of
individual mistakes, that such an hypothesis explaining
a sequence of phenomena, even if incapable of demon-
stration at every point, ceases to be an hypothesis, but
takes the rank of a theory. Indeed, it may become a
law ; such is the law of gravitation which at first was
the Newtonian hypothesis. Such is the theory of
evolution, which is an outgrowth with modifications of
the Darwinian hypothesis. The view presented in
this paper can scarcely yet be called a law, perhaps not
even a theory. 1 would summarize the present state
of our knowledge regarding the etiology of intermit-
tent fever as in the stage of strong hypothesis, almost
a theory; at all events, quite sufficient for practical
purposes, and what naturalists would call a " working
hypothesis."

In support of the view that the hsematozoon lives in
a damp soil outside the body, and whether in a swamp
or on a mountain side, let me offer the following cases.
They nearly complete the chain of evidence.

I did not see any of them personally, but state them
as reported to me by the physician in charge of the in-
stitution where they occurred. This institution con-
sists of several buildings standing on hilly land, much
of which, just prior to their construction, was covered
with forest growth. The cellar of one of the buildings
was excavated through boggy soil containing much de-
caying vegetable material, though situated near the
top of the hill. Intermittent fever broke out among
its inmates soon after it was occupied. Two of the
dormitories are situated on the highest hill, and form
■ides of a quadrangle. The one occupied by the boys
was built on land which had been cleared for many
years, and was well dried. In this scarcely any cases
occurred. The other, the girls' dormitory, was built
under exactly similar conditions as to date, plan, etc,
except that it was on damp forest-land, a considerable
amount of the dibrit of which was disturbed in exca-
vating for the cellar. In this five or six cases occurred
daily, until nearly all the girls were ill. The epidemic
ceased on digging a trench around the side of the
building towards the woods, so that no moisture from
them could enter the cellar. These cases may be con-
sidered as examples of air-transmission. Another in-
teresting series, illustrating the probable origin from a
cause associated with damp soil and decaying vegetable
material, occurred in this same institution, in an old
stone house situated near the foot of the above-men-

tioned hills. At the very foot, some hundred yards or
more from the house, was a swamp. No cases had oc-
curred in this house for many years, nor have occurred
within the past year, thus disproving any connection
with the swamp. But, just as with the other series,
numerous cases occurred in this house when local con-
ditions of a similar character were at hand. In this
series, the local conditions were the digging np of soil
rich in decaying vegetable matter necessitated in the
construction of a roadway and a sewer next to the
house.

In judging of the etiology of these cases, it is to be
noted that the institution is situated remotely, more
than a mile, from the Charles River, and that, although
caaes were to be found in neighboring towns, yet none
were particularly near at hand.

Had such a combination of presumably causative
factors, as were found here, existed in the West, sncb
cases would probably not have been allowed to occur.
Measures, such as delay in occupancy, and others to
ensure dryness of immediate surroundings, would have
been taken. In this case the physician in charge
feared intermittent fever, but he was overpersnaded,
having been informed that, though the disease had
been " creeping np onr river valleys in the past few
years," that it was almost unknown in that immediate
neighborhood, and never oocurred on hill-tops. He
permitted the immediate occupancy of the buildings,
and the results proved it to have been a sad mistake.
Such cases ought not to occur again in this locality.
A due attention to the steps of the hypothesis advanced
this evening, though it be not proven at every point,
certainly promises us a safeguard. With the present
activity in park and metropolitan improvements, and
with the growing tendency to building suburban resi-
dences, it is well to bear so promising a safeguard in
mind. It may prove that the present epidemic may
subside at once, as it is already beginning to in several
of the places already attacked. Such local subsidence
is to be expected in accordance with this hypothesis.
It is certainly the wise and prudent course to assume
that we have no more immunity from attacks of inter-
mittent fever than is the case with the rest of the
world, and that to guard against it we, too, must take the
best measures that experience teaches are protective.

TWENTY-SIX CASES OF INTUBATION OF THE
LARYNX.

BT FBAKK L. DAT, ILD., PBOTIDBHCE, B. I.

Up to the first of January, 1894, since October 10,
1890, 1 have seen (each time in consultation with one
or more physicians j 31 cases of laryngeal obstruction.
These do not include four oases where the child had
died previous to my arrival, once each with Drs. God-
ding, Carpenter, Moore and McKenna, nor one case
with Dr. Acres, where operation was refused.

Of the 81 cases seen, in five operation was not ad-
vised ; of these, three recovered and two died, as fol-
lows:

One child, age six, with Dr. Hanaford, of Appo-
naug, recovered.

Two with Dr. 6. E. Carpenter, in East Providence,
recovered.

One case seen with Dr. H. P. Abbott was instruc-
tive. Male, age five-and-a-half years. A septic case
where there hwl been laryngeal symptoms for twelve

Digitized by

Google

Digitized by

Google

a

■B

^3
11

I

ll

1^

CO

^1

I g
III

•J CO

a Pi

V a p a)
SgoaB

i
?

'3 I

11

MM O

i I

s s

§ I

H O

a
1

1

s

e

o

1

a

I

5

&

t

»

M

H _ H

O 4 O

ir

T] a
till'

111 i i IP iii & ^ & III t

& (3 S ■ ■ Sfi 38 . " « " gg"

M •

g : S> S
79 • n 79

I •Sc'ja t||§§§t§1

en £*'Seo laSaaS^i^S^aiXX

5 I 3

K CD

ooAOiSaiagSzioo

a
Is

a a
6 S

2 S

« «

"Si a

S B

5 5

I

S S S S S 5 S

Ck a, XI eiao.OiOi

aagaaaea

sssssssa

is s

s ►.us s

Oi -r g a o.

8 !2*5 I

S S i

§• igl

. . ^ H HI MB bril MB Bi«

s ii^ § S § I
8 1*5 S I S 8

(!> • IS K t«

•ft 04 C« ob 1^

*,

ao

00

Z, ^

>• (-

s s

8 o S 5
S- !5 t- ><

S M .

ovSSoSsSooSSSoSi)

X S"

I

If

§^ 1 =

-ISSf:
-" EXSg :

ft.'-

IF

"3

r

.2

^ i

o o
3 3

E E

ESSE

a s 9 a
o o o o
d ^ .d ja

£3 3

8 S

III

C B

31 S $

" a

S'O*

00 94

M 2 5. •

£• t*i

■a fe-O'O

-fi n lo

f hi I fill

ii^'i

;: 3

lo n CO V lo ra

ssss fv s heKft;asc>i6<afaS^ae«ssss»is!s

•o
a
2

—

ec

cc cc

??

s

o

S

•

a
a

1^

OQ

5l

►t

d

ll

pital
Ooddin

pital
Ooddin
Keefe

5

1

o

a

5

1

6-

9

a

iJ

fifeo

Sj

^

ss

SsSz^

te

N

M'

H

COi.^

»

6i

^

«d

"?

'^d

a .to . .

6

d

6

6

m05 a

&

►s

u

C u u

. hi

u

. i-

, u . u u

u

h

1-

u

b.

Q

coa

BiC

Q

asQ

xztiao

a

Q

Q

a

Q D

Q

a

* s « |as I S S S

^ i4 &| SGe>^ 0^ oj »; Oh'

&: 6J fc' 2'*^' oi rf « ai

a £ £ BJaa £ £ £ £

©" I-- of •»!' (DO* 2 S" °^ "^ ** =^" **" fc **" S" ^ * *^ ** t" ^ •• **^ •' sf

N « -t

Digitized by

'j

IliiL

1§'

«o r- » di »> £
le <D I* X A g

Issss

Google

7oL. CXXX, No. 16.] BOSTON MEDICAL AND SVROIOAL JOURNAL.

367

hoars. Seen by Dr. Abbott but a few boarg before
my visit As the dyspDoea was but moderate, we de-
cided to try steam-inhalatioD and other medical means
for a while. Everything went on well, until twelve
hoars later the parents took him away from the steam
and saw him choke to death without notifying Dr.
Abbott, as had been agreed if anything went wrong.
The lesson is this: Environment is an important
factor in estimating the advisability of operation ; and
in another case where competent nursing and care was
sot available, I should operate, even where the dysp-
noea was very moderate.

One case seen with Dr. S. A. Welch. A child of
two years had been sick but a few hours, a septic case
with only moderate obstruction. We decided fimt to
initiate medical means, and saw marked improvement
for some hours. The cbild died of sepsis within
twenty-four hours.

In twenty-six cases operation was advised, and these

are reported in the table which accompanies this paper.

TJiis series is far too small to be, by itself, of any

statistical value, but can only go to help make up, with

the reports of others, the great mass of statistics.

Nearly every case served to open up suggestions or
to enforce well-recognized points, and some of them
I have appended to this report.

Case 1. Here the child's strength had been nearly
exhausted by vomiting from repeated doses of ipecac,
persisted in the entire night previous to Dr. Munro's
first visit, by advice of the former attendant, an un-
educated man. It is not the inexperienced only, who
even to-day, when called to a case of diphtheritic
croup, administer an emetic, as often as otherwise to
satisfy the family. There may be cases where a
single emetic dose may be useful in helping the ex-
pulsion of membrane; but to persist in the use of
emetics, or to give them in a routine way, seems to
me unjustifiable and inexcusable. I believe the heart-
failure in this case is attributable to the weakness in-
duced by emesis.

Case 2. This is the only case where the dyspnoea
was not relieved, at least temporarily, by the tube.
At first a three-to four-year tube was inserted, quickly
removed, and a five-to-seveu-year tube at once intro-
doced. Neither gave relief, and tracheotomy was at
once done, partially relieving the breathing for a time.
This case serves to emphasize what has been repeat-
edly said, that the tracheotomy instruments should
always be at hand.

Case 4. No urine was voided here for twentj-four
hours preceding entrance, nor was any treatment effi-
cient to re-establish renal activity after entering the
hospital.

Case 13 also had suppression of urine, coming on
two days after the tube had been removed, and when
the child was doing well in every way. The family
attendant exhausted every means to establish the func-
tion of the kidneys without avail.

Case 6 was a very interesting one. The child was
desperately ill, and only recovered after a long stay in
the hospital. While wearing the tube, it seemed
daily, for several days, that he would die, and on one
of diese days several consultants advised that the tube
be removed, lest it be found obstructed. The charac-
ter of the respiration, which was very rapid, though
shallow, and the sound, inclined me to the belief that
the tube was dear, and that any extra manipulation
vonld wpigb ag^ainst recovery. The look of a child

struggling for air, usually a slower and labored respi-
ration, is far different.

Case 8. Here the tube became plugged on the
tenth day. There was cyanosis and labored breath-
ing. Prompt removal of the tube showed its lumen
to be nearly occluded by membrane, and was followed
by relief. It was not required afterwards.

In Case 16, could I have foreseen the great dys-
phagia which was to follow intubation, I should have
done tracheotomy at the start. It was the only
one where there was so great difficulty in swallow-
ing as to cause me to remove the tube for the pur-
pose of feeding — this after it had been in but
eight- and-a-balf hours. For two days he did well
without it, having only moderate dyspnoea; then I
was summoned in the middle of the night, and found
him struggling desperately for breath. I had no as-
sistance at the time, and the surroundings for immedi-
ate tracheotomy were unfavorable, so the intubation
tube was reinserted without any assistance, medical
or lay. I decided to leave the thread attached for a
few minutes, to facilitate removal if necessary. In a
fit of coughing the patient pulled it out, and with it
came much membrane. This case well illustrates the
danger of leaving the thread attached. Fortunately,
the tube had so reamed out the trachea that the ob-
struction was removed. Had anything been required
later, I was prepared to do tracheotomy, owing to the
O'Dwyer tube interfering with the taking of nourish-
ment.

Cases 17 and 21 were moribund at the time of
operation. They were cases where tracheotomy would
never have been considered. It seemed doubtful if
the latter would survive intubation even. The whole
operation did not require fifteen seconds. The child
rallied well, and lived a day and a half. These two
cases seem to me to justify the claim of intubation to
a definite place in surgery not occupied by trache-
otomy.

In Case 18 the tube was coughed up, and did not
require to be replaced for twenty-four hours. This
child finally died from sepsis. In Case 20 the tube
was likewise coughed up after sixty-six hours, but was
not needed afterwards. The child recovered.

Case 19 was an unusual one. The whole family
had been having influenza, and three weeks previous
to operation she had an attack. Her symptoms were
anorexia, weakness, insomnia, much gastric irritability
and fever, with a general eruption of petechias, maculae,
papulse and blotches. The eruption disappeared, but
she did not regain strength. I saw her first November
11, 1892. She had been croupy the day before, but
in the evening there was less dyspnoea. Same thing
repeated next day. My visit was in the evening, and,
as she was breathing pretty well, Dr. Munro and I agreed
that it was best not to operate. The following day there
was more dyspnoea, increasing towards night, when
there was marked cyanosis and retraction. No mem-
brane nor glands. Vomiting constantly. Pulse 145,
intermittent. Intubation gave entire relief to dyspnoea,
and she soon fell asleep, having had little or no sleep
for two or three days. Nourishment taken pretty well.
She did well for six hours. We gave a hopeful proo-
nosis. The following morning Dr. Munro was called,
and found she had just died, having for the five hours
previous grown progressively weaker, and having
breathed more and more rapidly, the parents stated.
No necropsy was obtaineti; but it seems probable

Digitized by

Google

368

BOSTON MEDIO AL AND SUROWAL JOURNAL.

[Afbil 12, 1894.

that death waa from palmonary cedema, following a
catarrhal laryngitis attending influenza.

This series of cases has been especially interesting
to me, in carefally watching the way in which the
children took nourishment. It cannot be too fre-
quently repeated, that once the tube is in place (whether
by tracheotomy or intubation) and obstruction over-
come, a case of laryngeal diphtheria resolves itself
into the systemic disease diphtheria in the vast majority
of cases, and now nourishment is the key to the situa-
tion, and the nurse holds that key. Everything else,
even stimulation, is subsidiary only. I have been
surprised to find in how large a proportion of cases
the patient, if in a favorable posture (usually lying on
the back or side, with feet elevated a little) can swal-
low with very little difficuUy if fed rather slowly.
Here everything depends on the tact and patience of
the nurse.

In 25 cases of intubation noted, there was

No dTtpbagla In 10

But little dygpbagla in IS

Hncb at lint, none later In 1

Imponlble to sirallow in 1

So, in 23 out of 25 cases, these children could take
nonrishment without great difficulty from the first.
This leads me to believe that the difficulty in feeding
has been overestimated by most writers. However,
much care and patience is often requisite on the part
of the attendant.

The tube, then, merely overcomes one of the inci-
dental symptoms, if you please. The disease itself
must be fought with food and stimulants, the latter in
very large quantity often. The only drugs necessary,
from our present knowledge, seem to be mercury and
iron. Peroxide of hydrogen is useful locally in the
throat.

While in most of the cases the introduction of the
tube has been easy, there have been enough trying
ones to enforce what is well known, that in young
children and in densely infiltrated throats it may be
attended with much difficulty.

Case 9 was especially difficult; the fauces were
greatly swollen, particularly on the left side, making
the glottis seem to be far out of the median line.
Here the tube was coughed up after two or three
hours, and was found plugged with a single piece of
membrane, which showed the bifurcation of the trachea.

Almost without exception, after operation the child
coughed a few minutes, then fell into a quiet sleep.
The relief of dyspnoea was complete in 22 cases,
nearly complete in 2 cases, incomplete in 1 case, and
none in 1 case.

By consulting the table, the size of the tube ised
will be seen in many cases to have been larger than
that indicated by the O'Dwyer gauge for a child of
that age. The development of the child is more impor-
tant than the age. I always use as large a tube as
can be placed with ease, and leave it in as short a time
as is consistent with unobstructed breathing.

As far as I know, there has been no permanent im-
pairment of speech. The average time of wearing the
tube in the eight cases which recovered was about five
and a half days. The percentage of recoveries was
30.8, but this is of little import. To illustrate the
fallacy of statistics in a limited number of cases, the
first 20 cases show 40 per cent, of recoveries. Again,
the last 6 all died. These were all in the country (in
East Providence and Reboboih), and in a locality

where the type of cases I have seen has been espe-
cially septic and malignant, these being a small part
of all the cases of diphtheria I have been asked to see
(the others not laryngeal) there during the past few
months.
The cause of death has been

Hepala in 7 «

Extension to bronobi in - 5 c

Uraemia In 2 <

Sepel* and extension in 1 ease

Sudden beart failure in I ease

(Edema of Inngi in I caae

Extension and exbaosUon In .... 1 esse

Especially true is it that the type of the disease pre-
vailing at the time determines the death-rate after
either intubation or tracheotomy. This is apparent
especially from the greatly varying percentages re-
ported by operators in Europe, where intubation has
been steadily growing in favor daring the past three
years.

By no means do I believe that tracheotomy is to be
driven into disuse by intubation, in relieving the'ob-
strnctive symptoms of diphtheria. It is a severer way
of accomplishing what, in a large proportion of cases,
intubation does ; but I would never intubate withoat
having the tracheotomy instruments ready for an
emergency, as their use may be imperative in any case.

Intubation involves less shock, requires no anaes-
thetic, requires no cutting, and is therefore often con-
sented to by parents who would not allow trache-
otomy. In very young children it holds out some
hope, where tracheotomy is almost always fatal.
Being a less severe measure, it may be resorted to
earlier, as well as later, than tracheotomy would be
justifiable. There is no wound to heal after the tube
is removed.

FOUR UNUSUAL CASES :«

I. Impkrfobatk Htmkn with H^matocolpos.

II. Mucous Ctbts of the Vaoina.

III. Recto-Vulvar Fibtula.

IV. Salivation op FRBaNANcr.

BT CHABLB8 H. OBBKK, If .D., BOSTOK.
I.

Thkouoh the kindness of Dr. C. W. Swan I saw
this case April 20, 1893. The patient was fourteen
years and five months of age, was well developed,
well nourished, and in excellent general health : she
attended school regularly, took long walks, waa fond of
dancing and of the out-door sports of healthy young girls.
Neither she nor her watchful mother bad seen any
symptom of the menstrual molimina; but for three
months there had been a noticeable enlargement of
the abdomen. For a week there had been a frequent
desire to pass the urine ; but there had been no dis-
turbance of defsecation, no bearing down, no pelvic
distress, in fact no discomfort whatever. Advice was
sought, however, on account of the gradually increas-
ing tumor in the lower abdomen and the non-appear-
ance of the menstrual flow. Dr. Swan found an ab-
dominal tumor, reaching nearly to the umbilicus, bat
narrow, and not extending into the iliac regions : the
hymen he found to be imperforate.

When I saw the case, I was unable to determine
positively whether we had to deal with a distended

' > Read iMfore tbe Bocton Sooietr for Hedloal ObwrTaUoa, Febm-
arr S, Itm.

Digitized by

Google

'oi. CXXX, No. 15.J BOSTON MSDIOAL AND StmOlOAL JOUMJifAL.

369

*Six>a simply, or whether the uteras and possibly the
Tallopian tubes were involved ; but the absence of dis-
reaaing syoiptoms and the probability that the girl
lad passed but a few months beyond the age of puberty
ed me to believe that probably the retained meustrual
alood was limited to the vagina. The hymen was
[ound to be bulging convexly outward : this I punct-
ured with a small trocar, and a dark-brown fluid
escaped. The discharge was not of tarry consistency,
as asually described in the books, owing, I presume,
to the fact that it had not been retained sufficiently long
for the blood serum to be absorbed to any great extent.
After the ahdominal tumor had somewhat subsided, I
enlarged the opening in the hymen by multiple in-
cisiona and thus thoroughly evacuated the vagina.
After washing ont the vagina with a weak carbolic
eolation I explored with an aseptic finger : the uterus
was found of normal size and the os non-patulous ;
the tubes could not be felt: it was clear, therefore,
that the case was one of hsematocolpos simply. The
vagina was enormously distended and seemed to fill
tbe whole pelvis.

The evacuated flaid was carefully collected and was
foand to measure three and one-half pints. Assuming
that there had been no marked absorptiou of the serous
conBtituent, and accepting the common statement that
the normal average amount of each menstrual flow is
about six ounces, we may infer that the fluid evacuated
represented approximately nine monthly periods, and
that the girl began her meustrual life at the age of
thirteen years and eight months.

After operation the patient was kept in bed for five
days and the vagina was carefully syringed with car-
bolized water. There was no febrile reaction and no
evidence of sepsis. Twenty days after operation a
normal, painless, and free menstruation took place,
lasting six days. Three days thereafter I found that
the vagina had contracted a good deal, but was still
qaite capacious : the vaginal walls were now more or
less thrown into folds, and gave ofi a thin, glairy secre-
tion : the uterus was normal in size and position.

These cases of coogenital hymeneal atresia are rare.
Carl Braun observed only four cases in his extensive
experience, aud Lombe Atthill, Master of the Dublin
Botunda, only one. Among careful, intelligent people
the anomaly should be recognized early ; and when
thus recognized, and aseptically treated, the results
should be good. In neglected cases, however, the
uterus and Fallopian tubes may become distended,
blood may thus escape into the peritoneum, and fatal
results ensue. In these cases, too, of hsamatometra
and htematosalpinx, there is danger of rupture of the
tube either by over-distention or by the force of a
rapidly contracting uterus after the hymen is incised.
To avoid this latter danger it is prudent to make at
first only a small openiog in the hymen, thus allowing
the fluid to escape very slowly, and also to avoid all
pressure over the nterns, either by the hand or by the
abdominal bandage which has sometimes been advised.
The greatest danger in all cases of menstrual retention
from hymeneal atresia, and the one most fatal in former
^ys, can now most happily be averted by rigid surgi-
cal asepsis.

It is probable that in earlier times these cases of
menstraal retention were sometimes overlooked and
tbe patient treated with iron and the various emmena-
gogaes until distressing symptoms demanded a physical
sxaminaUon. Sometimes the hymen has ruptured

spontaneously, and a natural cure thus resulted.
Mitchell * has recently reported the case of a girl of
sixteen who had never menstruated, and who had had
monthly attacks of spasmodic pains in the lower part
of the abdomen, irritation of ihe bladder, aud a con-
stant feeling of bearing down, associated with abdomi-
nal enlargement. During an attempt at vaginal ex-
amination the hymeu was ruptured, a large amount of
retained menstrual flow gushed out, and recovery fol-
lowed.

II.

Mrs. H., aged thirty-five, who had borne one child
several years before, was referred to me in tbe autumn
of 1893, by Dr. J. H. Woods, of Brookline. She had
been for some time in poor general health, and there
was well-marked nervous debility : the pelvic symp-
toms were backache and a constant feeling of bearing
down. Vaginal examination revealed a second degree
of retroversion with old adhesions, a alight laceration
of the cervix requiring no treatment, and two cysts of
the vaginal wall. The cysts were seated, the one on
tbe anterior wall just in front of the cervix, the other
on the right posterior wall at its upper third : the size
of the two cysts was about equal, that of a large horse
chestnut or small hen's egg. These cysts had proba-
bly been growing for several years ; but it was only
in the past year or so that the patient had been con-
scious of some obstruction in the vagina.

It was obvious that what was most needed in this
case was general treatment directed to the neuras-
thenic condition ; and incidentally it was thought best
to free the uterus, if possible, and restore it to its nor-
mal position. The cysts probably added little to the
patient's discomfort, except in so far as possibly to in-
crease the sense of weight in the pelvis and to inter-
fere somewhat with physiological functions. It was
evident, however, that their presence would interfere
with measures to raise the uterus and the subsequent
wearing of a pessary ; and it was reasonably probable
that before long they would reach such a size as to
occlude tbe lumen of the vagina. It was therefore
thought best to remove them. Under ether anaesthesia
the cyst walls were freely laid open, there appearing
to be no sac which could be dissected out. The cou-
tents of the cyst on the right posterior wall were of a
thiuish, mucoid character,_of a light chocolate color,
aud without odor : those of the cyst on the anterior
wall, thick, viscid, and almost semi-solid, of albuminous
color, and likewise without odor. This latter material
was submitted to the examination of Dr. W. T. Coun-
cilman, who reported as follows : " Contents of cyst
consist of a glairy mucus, enclosing great quantities of
so-called Drysdale's corpuscles and large leucocytes
filled with fat granules. It is very probable that the
cyst bad an epithelial lining, and that these Drysdale's
corpuscles are the nuclei of cells which have been
destroyed."

The cyst cavities were gently curetted, cleansed with
Dobell's solution and weak corrosive, and lightly
packed with iodoform gauze. After ten days the cavi-
ties had markedly shrunk, there was very little mucous
discharge and the openings were still patent : the pa-
tient was then sent home for general treatment pre-
paratory to dealing with the adherent retroversion.

Mucous cysts of the vaginal wall are fully treated
in the text-books, and I am able to contribute nothing

> Brltlsli Hedioal Joanua, Deosmber M, 1893.

Digitized by

Google —

360

BOSTON MSDICAL AND SVMGlCAL JOVMNAL.

[Apbil 12, 1894.

new to the knowledge of the Bubject. They must be
regarded as somewhat rare, althoagh some observers,
notably Lee, of New York, consider them fairly com-
mon : in an experience of sixteen years I have met
with but this one case. They occur, as a rule, singly,
more rarely two or three at one time. The anterior
wall of the vagina is the most frequent seat, the lateral
wall the least common. In sixty-six per cent, of the
cases the cyst is situated between the middle of the
vagina and the vaginal introitus, and when thus seated
may simulate rectocele or cystocele : in my case both
cysts were at the upper third of the vagina. The
cysts may vary in size from that of a pea to that of
the fist: isolated cases are also reported of still
larger cysts ; but they are usually discovered by the
time they reach the size of a ben's egg. They may
be superficially or deeply seated : in my case both
cysts were superficial. The contents of the cysts may
be thin, resembling that of hydrocele fluid, and of red-
dish, brownish, greenish or chocolate color ; or they
may be thick, viscid and albuminous.

Opinion is still divided as to the existence of glands
in the vaginal wall ; but the weight of authority seems
to be that in all probability there are no true glands,
but what are called vaginal crypts. Vaginal cysts are
probably not, therefore, retention cysts properly so
called, like wens or cysts of Bartholin's glands, but
are developed in the vaginal crypts, which are lined
with flattened epithelium, and which have in some way
become occluded, either by inflammatory processes or
by epithelial plugs. This subject is fully discussed in
an able paper by Butherfoord,' which is the latest con-
tribution I have seen.

Vaginal cysts, as a rule, grow very slowly, and
when small cause no symptoms : small cysts are there-
fore discovered, only by accident. Large cysts may
cause uterine displacements, may interfere with the
bladder or rectum and cause various pressure symp-
toms, may make coitus difficult or impossible, and,
when seated low, may protrude from the vagina and
cause discomfort : they may also constitute an obstrnc-
tion in labor.

The best treatment of vaginal cysts of any size is
undoubtedly enucleation ; but this is often difficult or
impossible when the cyst wall is thin or the cyst is
deeply seated. In such cases free incision and evacua-
tion is the most reliable - measure, followed by curet-
ting and packing with iodoform gauze : it is well also
to excise a small portion of the cyst wall to prevent
closure of the incision, after the patient has passed
from observation.

These tumors should be recognized without diffi-
culty ; but Winckel points out that they may be mis-
taken for cystocele, rectocele or small ovarian cysts.
Careful examination, however, will usually remove all
doubt, and doubtful cases should be aspirated before
incision. In large cysts there is well-marked fluctua-
tion.

III.

A. C, aged thirty-two, single, a bookkeeper by oc-
cupation, consulted me in November, 1891, and gave
the following history : The general health had always
been fairly good, and the menstrual function normal ;
she had suffered more or less with hcemorrhoids, and
twelve months previously had been operated on for
the cure of a fistula in ano. Since the operation she

• Traosaetlona of the ObstetrlMl Sooietr ot London, 1882, p*ce SB4.

had suffered with soreness about the vulva, and also
with incontinence of intestinal gases and semi-liquid
discharges. It was from this last annoyance that she
especially sought relief.

Physical examination disclosed a short fistulous
tract extending from the lower border of the sphincter
ani to an opening about two inches to the left of the
anus : further, the sphincter was entirely laid open at
its upper left border, and a gaping sulcus extended
from this point upward toward the left, along the
inner border of the left labium majus to a point oppo-
site tbe lower third of the left labium minus. There
was a small button-hole opening through the left
nympha : the hymen was intact. The symptoms and
lesions presented were essentially those of a complete
rupture of the perineum, although the vagina was in
no way involved. It was obvious that there bad
existed a fistula in ano extending from within the
sphincter upward and to the left between the labia,
that this fistula had been laid open, and that the sulcus
had subsequently failed to unite, although the surfaces
had cicatrized.

Through the kindness of Dr. E. J. Forster, who was
then on duty, the patient was admitted to tbe Boston
City Hospital, and I operated to close the sphincter
and restore the integrity of the parts. The necessary
denudation was made, the rectum was closed in with
catgut sutures, and the sulcus above with silver wire.
Tbe superficial fistula in ano was successfully treated
with the elastic ligature. The wire sutures were re-
moved on the tenth day, good uniou had taken place,
tbe deformity of the parts was removed ; and on dis-
charge, two weeks later, tbe patient had entire control
of the sphincter ani as regards both liquid fasces and
intestinal flatns.

This case is unique in my experience, and I have
never seen a similar one reported. Should a case of
recto-vulvar fistula ever present itself to me before the
sinus had been laid open I should adopt the method of
treatment proposed by Dr. £. W. Jeoks, of Detroit,
in 1883,* for the cure of fistula in ano. In view of
the fact that in so many cases treated by incision alone
the sphincter ani fails to unite, and the deplorable
condition of incontinence of faeces and flatus thereby
ensues, Jenks recommended the following method of
procedure : The sinus is laid open, care being taken to
incise at right angles to the sphincteric muscular
fibres ; the so-called pyogenic membrane and all adja-
cent abnormal tissues are dissected away ; and the sul-
cus is then closed with buried sutures passed entirely
around the fistulous tract, the sphincter to be closed
as in cases of complete rupture of the perineum. Dr.
Jenks does not claim that this method is applicable to
all cases of fistula in ano ; but it would seem to be
especially applicable to cases like the one above re-
ported.

IV.

Mrs. A. D., aged twenty-seven, first came under my
observation just prior to her first labor in 1891. She
was a fine specimen of womanhood, well developed,
accustomed to long walks, and, with tbe single excep-
tion to be presently mentioned, iu robust general
health. Early in her pregnancy, in place of the morn-
ing nausea and vomiting so commonly observed at this
time, she began to be troubled with salivation. This
symptom gradually increased in severity, interfering

* Traosaetlona o( tbe Ameriowi OrnveoloKioal Sooiaty. ToL S.

Digitized by

Google

Vol. CX.X.X, No. 15.] BOSTON MEDIO AL AND 8US610AL JOURNAL.

861

with her comfort by day, bat especially diBtarbing her
at Dight. la fact, the flow of saliva finally became bo
profase at night that the patient dared not lie down
for fear of choking, bat sat boUtered op in bed with
a towel placed to receive the salira. She was thus
able to sleep bnt little, although towards morning the
flow diminished somewhat, and she was enabled to
sleep for two or three hours. In spite of the loss
of sleep, however, the general health continued good,
and the appetite was unaffected. The submaxillary
glands were markedly enlarged and the contour of
the face thereby distorted ; the eyes, too, were some-
what heavy from loss of sleep, but otherwise the
patient looked as well as usual.

During all this time the lady had been under the
care of a well-known and able physician, who had
tried all the drug« recommended for excessive saliva-
ion without appreciable effect. The patient said she
had received more than a dozen prescriptions. It did
not therefore seem worth while for me to attempt any
further treatment. I found that the urine was mark-
edly diminished in amount, without other abnormality,
however. This diminution was undoubtedly due to
the great derivation of water through the salivary
glands, and I advised the free use of ApoUinaris or
lithia water, which increased the amount of urine
somewhat. The labor was in no way remarkable:
the 08 uteri was fully dilatable after twenty hours of
first stage labor ; but the head did not descend, and
after two hours of fruitless maternal effort I delivered
a ten-pound girl with high forceps and axis-traction
rods. During the next three days salivation occurred
two or three times, the flow lasting only a few
minutes ; it did not appear after the third day, when
lactation was fully established; from this time the
convalescence progressed normally, and mother and
child were discharged well.

Early in 1893 this patient became pregnant again,
and at the end of the second month salivation began
again as in the first pregnancy : there was no morning
sickness. By the fifth month the flow of saliva had
become so excessive as to cause great discomfort and
loss of sleep; but, as before, the general health continued
good. In view of her former experience, the patient
was indisposed to submit to drug treatment, especially as
I could offer no assurance that any treatment would
prove effectual. As before, lithia water was found to
be the most refreshing drink for the swollen gums and
oral mucous membrane. Labor began just 280 days
from the first coitus after the last menstrual period,
and with the invasion of labor pains salivation ceased.
The labor was uneventful, except that as before it was
necessary to deliver with high forceps, the child, a boy,
weighing ten pounds. On the second day there was
some return of salivation, and with the establishment
of lactation the salivary flow did not cease, as in the
former pregnancy ; on the contrary, it continued for
two weeks more or less profuse, never absent for an
entire day, and sometimes sufficient in amount to
cause vomiting when the patient was recumbent.
After two weeks the flow gradually diminished in
amount ; but it did not cease altogether until the end
of three months. Aside from this discomfort the con-
valescence was normal, and mother and child were dis-
charged well.

I have met with but one other case * of excessive

' Tbit cafe wu anlgned to my ctiarga In 1877 by the Obetetrloal
UepwUMot ut tbe UuWil >fc4lc*l Setiool. frol, WUltMn L.

salivation in pregnancy, and that was seventeen years
ago when I was a medical student. My experience
is therefore that of others, that excessive ptyalism of
pregnancy is a very rare affection. Winckel, in his
text-book of midwifery, says that salivation is mostly
associated with extreme nausea and vomiting: but
these latter symptoms were absent both in Dr. Richard-
son's case and in my own. The disorder is probably
a reflex neurosis, like many of the cases of ancon-
troUable nausea and vomiting. The amount of the
salivary flow in twenty-four hours may reach several
quarts and serioasly impair the general health. In
some cases of ptyalism, as in some of nausea and
vomiting, the disorder may cease spontaneously in the
fourth or fifth month ; in others, as we have seen, it
may continue throughout pregnancy, and cease soon
after the birth of the child or on the establishment of
lactation. Charpentier * mentions seven cases in which
ptyalism began with the pregnancy (as in Bichardson's
case), and persisted after delivery, once fifteen days,
once eighteen days, twice for two to three weeks, and
three times in the same woman for from three to four
months.

In regard to the treatment of this affection, while
many drugs are recommended by various writers,
reliance can be placed upon none. Galatin truly says
that pregnancy salivation " is apt to resist remedies."
Astringent mouth washes of tannin or quassia may
palliate, but cannot be expected to cure. Charpentier
recommends the frequent use of brandy as a gargle,
and the keeping in the mouth of small pieces of dry,
bitter, orange peel. Other recommended remedies are
pilocarpin (perhaps on the timilia limilibut theory),
iodide of potash, fluid extract of viburnum prunifolium,
belladonna, and atropia, the latter being best osed by
hypodermic injection near the affect glands. But
if the affection is a reflex neurosis, it would seem that
nerve sedatives would hold out most promise of success-
ful results. Schramm is said to have cured a case in
1886 with bromide of potash, after the iodide and pilo-
carpin had both failed; but if I remember rightly
Richardson used the bromides in his case, to which I
have alluded, without apparent effect. If I were to
meet with another case, however, I think I should
place most reliance on bromides and on large doses of
chloral hydrate, the latter exhibited preferably by
rectum.

REMARKS ON SURGICAL SPLINTING.*

BT SDWABD A. TBAOT, M.D., BOSTON, MASS.

That illustrions surgeon, Frank Hastings Hamilton,
whom I delight in quoting — for his work on " Fract-
ures and Dislocations," the first of its kind in the Eng-
lish language, does honor to American surgery — he,
speaking of the ordinary manufactured wooden splints,
said : " I wish at once, and for all, to disclaim any
intention of giving even a qualified apprqval of any of
those carved, polished, and generally patented wooden
> Read before the Maiden Medloal Sootety, January 29, 1R94.

RIohardaoD, at that time Inatruotor In ollnlcal obstetrics, was sum-
moned to my assistance and dellTered with forceps a face oresenta-
tlon, M. D. F, He recognised the patient as one whom he had been
treating for salivation in the outpatient department of the Massa-
chusetts Oeneral Hospital, and who was also affected with excessive
ptyalism In her former pregnancy. In this case Balivation eeased
\rithln half an hour after delivery. Dr. Richardson's report of this
interesting case may be fennd In tbe Boston Medical and Surgical
Journal for Jnly 12. 1877. , .. _

• Cyelopwditt of 0b6telrl>;»«n(J Oynaoology, vol. II, page fa,

Digitized by

Google

362

BOSTON MEDICAL AND SURGICAL JOVBSAL.

[Afbil 12, 1894.

aplinto, which are mannfactnred aud sold by clever
mechanics, and which one may see suspended in almost
every doctor's office, whether in the city or in the
coantry. Constracted with grooves and ridges, and
variously inclined planes, for the avowed purpose of
meeting a multitude of indications, such as to protect
a condyle, to press between parallel bones, to follow
the subsidence of a muscular swelling, etc., they never
meet exactly a single one of these, whilst they seldom
fail to defeat some other indication of equal impor-
tance. ... If carved wooden ' splints are employed,
they ought to be made especially for the case under
treatment."

These strictures apply, it seems to me, with some-
what lessened force to the metal splints we frequently
see nowadays. Hamilton further states his preference
for strips of wood cut to the proper length and width
by the surgeon, and so padded as to fit the inequalities
of the limb treated. This surgeon was an adept in the
use of gutta-percha for splinting; and the point to note
is that whatever he used, he made his own splints.
Most surgeons, I believe, think as Hamilton did in this
matter ; and Dr. Henry O. Marcy's dictum, " The sur-
geon must make a splint to fit the limb — aud not the
limb to the splint," aptly defines the proper practice
in surgical splinting.

The subject of surgical splinting is a vast one,
whether looked at from an historical or a practical
point of view. Had I the time and qualifications need-
ful, and you the patience, it might be clearly shown
you that surgical splinting, like navigation and print-
ing, had attained perfection undreamed of, in the happy
era preceding that of the Chinese philosopher Confu-
cius. But doubtless you will be better pleased if,
fancy being restrained, the practical aspect of the sub-
ject be dwelt upon. Indeed, I shall use further re-
straint, and confine myself to remarks on surgical
splinting as exemplified in the use of my wood-pulp
material, and that, I hope in a manner interesting and
profitable to yon all.

First, the material and method used shall be described,
and later a variety of splints made in accordance with
this method shall be shown you ; finally, if time permit,
I shall demonstrate the method by making a splint
before you.

In describing the material, time is saved by quoting
from a paper (to be published later) contributed by me
to the recent Pan-American Medical Congress.

The Material. — The basis of the material is wood-
pulp made preferably from the crushed fibre of the poplar
tree, and rolled in sheets in such fashion that the broken
fibres intertwine in every direction and loosely, so that an
increase of plasliuity is thus given to the product. These
sheets are further strengthened by having a fabric intro-
duced between the layers of the pulp, or by interweaving
with the short, crushed wood-fibre, a long jute or other
tough fibre.

Ihe sheets are rolled of different thicknesses, for adapt-
ability to all splint conditions. For convenience I shall
designate the thickness by number, each unit representing
a thickness of one millimetre : thus sheet No. 1 represents
the material with a thickness of one millimetre, — sheet
No. 2, with a thickness of two millimetres, and so on.

Characteristics of the Material. — The chief characteris-
tics of this material are stiffness or rigidity when dry, and
plasticity when moist. Its rigidity can be increased ad
libitum by the use of a silicate solution as a moistener. Its
plasticity has a limit. The limit is rarely experienced, and
only when moulding the material over certain complex
cifrved surfaces. To exemplify : a splint cannot be directly

moulded over the ankle-joint anteriorly, for there are two
large curves in opposite directions to be followed simultane-
ously— the convex curve from maleolns to maleolus, and
the concave from above downwards over the leg and instep.
This difficulty, when met, can be obviated in various ways.
I shall mention three of them. Take the case of the ankle-
joint : an anterior splint is required for it. The proper-
shaped blank shall be cut from sheet No. 1, and moistened
with one of the solutions described later. It then should
be applied to the limb, care being taken to keep its outer
border in contact with the skin, while the superfluous mv
terial over the anterior of the joint should be pinched be-
tween the thumb and forefinger, and all of it laid or pressed
over to one side ; a bandage should be singly applied to
perfect the moulding of the splint. This method of " pinch-
ing and folding over " has an important application in the
making of spinal jackets. A second method consists in
cutting away the superfluous material, in this case an ellipti-
cal figure, and bringing the edges of the cut portion to-
gether, to retain them so by means of a strip of the material
fastened over the cut edges. A third way is to cut a blank
for each important curve and after moulding to properly
unite them.

The material possesses, besides the above characteristics
that desideratum of a splint material — extreme lightness.
Its cheapness also deserves a passing mention.

MoiSTENERS. — Water or a stiffening solution can be
used to moisten the material.

Water. — The advantage of water is its omnipresence.
A serviceable splint can be made with its aid. Such a splint
should be protected from perspiration or other moisture,
lest it l>e softened and its usefulness destroyed. It can be
so protected by a covering of oiled paper or silk, mackin-
tosh, or best by a coat of varnish.

Sili'-ate Solution. — A stiffening solution having several

Junlities to recommend its use is that of silicate of potash
silicate of soda is almost as serviceable). Any desired
degree of rigidity can be imparted to a splint by using this
solution, the amount of rigidity depending on Uie strengdi
of the solution. A splint rendered ri^id in this manner, is
not affected by perspiration, nor indeed by momentary con-
tact with fluids, as in washing. Another advantage, especially
in cases of compound fracture, is that this solution renders
the splint antiseptic. In practice, the solution of silicate
of potash generally sold for surgeon's use, and further diluted
with water, can be employed. (The commercial solution
spoken of in this paper is regarded as a 100-per-cent. solu-
tion, and the percentage solutions spoken of in this paper
are to be made by diluting the commercial solution with the
proportion of water called for by the percentage: thus a
70-per-cent. solution is made by mixing 70 parts of the
commercial solution of silicate of potash with 80 parts of
water. The commercial solution should have a specific grav-
ity of 1.3 to 1.4.)

Dextrin Solution. — Another useful stiffening solution is
that of dextrin, in the proportion of about eight ounces to
a pint of water. This solution adds some tenacity besides
stiffness to the material treated with it. A splint made with
its aid can be remoistened with water and remoulded, quite
an advantage in cases where from subsidence of swelling or
other cause, a closer approximation of splint to the limb is
desired. In practice, dextrin (to be bad of paint whole-
salers) can be carried about in powdered form, and a solu-
tion in water extemporized when needed. An addition of
eight grains of corrosive sublimate to a pint of the dextrin
solution will render it antiseptic.

Moist KNiNG Process. — A few words descriptive of the
proper manner of moistening the material. The aim should
be to get barely sufficient moisture into the material to ren-
der it semi-plastic. If more moisture be absorbed, it be-
comes more difficult to maintain the moulded splint in the
desired shape while drying, and also unnecessarily lengthens
the time required to dry the splint. I find the best way of
moistening the splint blank, is to apply the fluid used, on
each side of it, alternately, by means of a flat paste-brush.
A little practice will enable us to judge the precise amqunt
of moistening best suited for our purpose.

Digitized by

Google

('"ot. CXXX, No. 16] BOSTON MMDIGAL AND SURGICAL JOURNAL.

363

Drtino. — The time required for drying the moulded
blank varies, for the different sheets employed, from ten to
forty minutes ; the thicker sheets, holding the more moist-
ore, require the longer exposure to heat to drive it out.
Any source of sufficient heat can be employed ; a good
kitchen fire b very efficient and, generally, convenient.
While the splint is drying it is serviceable to have yarn or
string wound around the moistened form after its removal
from the body, to aid it to maintain the desired form, until
drying permanently fixes it.

Fio. I. A ClaTleulo-Scapular Splint.

Having thns described the material and method
used, instead of quoting further the dry technique for
the varioDB head, trunk, upper and lower limb splints,
I shall show you some made in accordance with that
technique, " the observation of one of which is better
than a large demonstration of words," to quote old
Isaak Walton.

The most of the spliuts here shown were exhibited
at the Columbian Exposition ; your Society, and I am
grateful for the honor, has been the first to give me
an opportunity to display and explain them to brother
practitioners. [Splints for various part« of the body,
all of them moulded on the living subject, were shown
and discussed ; the following three are selected for
illDstratioD here.]

A CLAYICCLO-SCAPOLAR SPLINT.

This splint is part of an apparatus devised for the
the treatment of dislocation (upwards) of the acromial
end of the clavicle. The apparatus is fully described
in the Botton Afedical and Surgical Journal, Vol.

oxxviii, p. 186. An apparatus for fracture of the
clavicle has been devised on the same principle, that
is, to regard the shoulder as a pyramidal body, and to

Fio. II. A Thumb SpliDt.

SO treat it. lu a fracture, however, there is such short
bone leverage for effective pressure, that a modifica-
tion is introduced by which the apex of the pyramid
is raised upward and backward, and by suitable splint.
ing fixed effectively in the desired position.

A THUMB SPLINT.

This splint is intended for fixation of the thumb, in-
cluding its metacarpal bone. It embraces the thumb,
that portion of the dorsum of the hand shown in the
engraving, and some-
what more than the
thenar eminence of the
palm, care being taken
to keep below the cross-
palm lines that mark the
region of the meta-carpo-
phalangeal joints, so as
not to binder finger mo-
tions.

A SPINAL JACKET.

The blank for this
splint is of the simplest
pattern, having width
sufficient to envelop the
patient's body once and
a quarter around, and its
length governed by the
amount of spine we wish
to control. This particu-

Fio. III. A Spinal Jacket.

lar jacket was made for and worn by a boy of six years.
It was moulded on the boy's body and completed at
his home in less than forty minutes. The jacket's
edges are covered with chamois skin glued on. The
straps are of chamois skin also, and this material was
used because of the ready manner it can be attached

Digitized by

Google

864

SOSTOJf MBDIOAL AND SUMOIOAL JOVRHAL.

[Afbil 12, 1894.

to the jacket, and ita tougbneta and friction preventing
the giving or slipping of a bow-knoU

Before attempting a demooBtration of splinting bj
this method, I must state that it is handicapped by the
amount and quality of the material at hand. That
manufactured so far has been finished by hand-labor
at the palp mill. It has been distributed among Bos-
ton surgeons, several of whom have kindly signified
to me their pleasure in testing it. The supply is now
exhausted, I hope not for long. Mr. Charles H. Fisk,
of Manchester, N. H., the gendeman who has under-
taken to put the material on the market, has written
me that machinery will be constructed to manufacture
it cheaply and expeditiously.

[The making of a palmar forearm splint was here
demonstrated. The splint meets the indications which
Cheever emphasizes in the treatment of a Colles' frac-
ture. He says : " The important point would seem
to be . . . not to press the back of the wrist down in
such a way, by splints, that we shall lose sight of this
arch, which is so marked, under the radius. . . . This
arch must be well supported. . . . The splint should
terminate at the bead of the metacarpal bones, and
the thumb and fingers should be left free." ']

In concluding, fellow-practitioners, I thank you for
your kindness and energy in braving to-night's snow-
storm, to meet here ; and I ask you, if pleased with
this splint material, to take hold of it and develop its
various applications, which have been so briefly hinted
at; then, perhaps, in later years we can all look
back on work done, and done well, and feel that we
have done some little to advance surgery — American
surgery.

Clmicai aoepartmeiit.

A CASE OF MYX(ED£MA.

BT BOBIBT B. BBLL, X.D., LOWBLL, MASS.

Tbebk has been so much written on this subject,
and it is so prominently before the profession, that I
wish to report my one case, as it has presented some
features that I have not seen mentioned.

Mrs. B., fifty-four years of age, consulted me first
January 7, 1894. Family history good. Father and
mother both lived to be almost seventy ; two brothers
and four sisters living. She dates her symptoms from
about eighteen months ago. She comes to me because
she cannot see to read, and thinks her glasses need
changing. V^i^ i glasses do not improve her vision.
Ophthalmoscopic examination simply shows the fundus
somewhat paler than normal.

Patient says that about eighteen months ago her
face and hands began to bloat, and she had difficulty
in keeping hold of objects in her hands, was constantly
dropping dishes, etc. Then her limbs began to swell ;
and finally she noticed she could not get her clothes on
alone, her arms were so useless. She had become
very sensitive to cold. Her hands and arms pained
her so she could sleep but a few hours. Was dizzy,
and felt like falling if she attempted to walk. No
appetite. Urine at times was very heavy and almost
black. She could not go up stairs without getting out
of breath. When she came to me, there was pallor of

> Leotnru on Surgery. By Darld W. Cbearer, VLU. Soe Leotnre
X, Boston Medical and Surgical Jonmal, toL exxiz, p. i.

the face and a paffiness about the eyes. There was
cedema about the ankles and legs. The skin of the
hands was dry and rough. The hair had no lustre.
She talked very slowly and deliberately, and walked
as though completely tired. Examination of urine
was negative.

Supposing 1 had a case of myxoedema to deal with,
I ordered the thyroid extract of Parke, Davis & Co.,
in doses of five grains twice a day. At the end of
one week patient was better, but complained of some
nausea, and pain in her back and legs. I decreased
the extract to three grains twice a day, and kept it up
until the middle of February, then reduced it to about
two grains a day.

At the present time she considers herself well. I
certainly never saw a more marked improvement in
any patient. She eats well, sleeps well and breathes
well. Her vision is now all right with the lenses sailed

to her age.

•

REPORT OF PROGRESS IN GYNECOLOGY.

BT r. H. SAVBirPOBT, M.D.,
Iiutruetor te OyiUBcologi/, Harvard VnU/enUt,

THE CAUSE OF PKKITONEAL ADHESIONS AFTEB AB-
DOMINAL SECTION.

Waltbard > has conducted a series of experiments
in the Pathological Laboratory of University College,
London, to ascertain the cause of peritoneal adhesions
after abdominal section, with a view to discover the
way to avoid that complication. He found that pro-
longed contact of normal peritoneum with atmospheric
air caused necrosis of the superficial layer of cells.
This injury, even when strict asepsis is carried out,
favors the formation of adhesions. It speaks in favor
of rapid operating, but many gynaecological operations
and procedures for disease and damage to the intestine
cannot be performed quickly ; hence there must al-
ways be danger of peritoneal adhesions when the
course of the case is aseptic, and of suppurative peri-
tonitis when accidental infection occurs. The great
aim of the operator is to make sure that the peritoneal
cavity is thoroughly cleared of all fluid or semi-fluid
material by the usual " toilet." In short, the serous
membrane must be kept from the contact of fluid, but
not allowed to become dry by exposure to air. This
Walthard calls " dry asepsis."

When the cavity cannot be kept dry, as in many
long operations, " moist antisepsis " is required. In
other words, the peritoneum is flushed out with water
at 100° neutral, and preferably containing chloride of
sodium. The loss of its shiny appearance is the evi-
dence that the serous membrane is becoming dry.

UBETBEO-yAGINAL FISTULJB.

Hochstetter * has been able to find records of thirty-
nine cases of uretero-vaginal fistulas, of which twenty-
three were caused by difficult labors, ten followed
total extirpation of the uterus, two the opening of a
pelvic abscess, one the spontaneous breaking of an
abscess, one from ulceration caused by a pessary, and
in one case the cause was not given.

The frequent performance of vaginal hysterectomy

> Correapondonz. Blatt f . SchweU. AerUe zxziU, 18S3, reported In
Brltiah Medical Journal. December 2, 1893.

> Arch, fttr Oyn., zW Band, 1 Heft, ISM.

Digitized by

Google

Vot. CXXX, No. 16.] BOStON MEDICAL AlfD 8VR0I0JLL JOVttNAL.

365

makes the study of fiitulsi from this canse of interest.
Ligature of the ureter of one side is difficult of recog-
nition in the first days after the operation, since there
is often from other causes a diminution in the amount
of the urine. The cystoscope, or catheterizing the
ureters, would assist materially in making a diagnosis.
Ligature of both ureters is recognized by absolute
anuria. If such a diagnosis is made early, the imme-
diate removal of the ligatures may result in a restora-
tion of the function of the ureters and the avoidance
of a fistula. Two such cases are referred to.

The diagnosis of a ureteral fistula is an easier mat-
ter. The patient loses only a part of the urine, about
a half, the bladder is intact, as shown by iujecting it
full, and the sound does not pass from the fistula into
the bladder, but from the bladder through the fistula
into the vagina.

The treatment of such a fistula is, in the first place,
by cauterization, care being taken not to cause so
much swelling as to close the ureter. If the ureter is
not wholly cut through cure may follow, and several
such cases have been reported. If this fails, operative
treatment should be tried. Simon advised changing
the ureteral fistula into a uretero-vesico vaginal fistula,
and then closing, but his attempts failed. Landau sug-
gested passing a thin catheter from the vagina into the
ureter, carrying the free end through the lower seg-
ment of the ureter into the bladder and out through
the urethra, refreshing the tissnes on both sides of the
catheter and uniting them. There have been several
successes by this method.

A modification of this procedure by Schede consists
in making a vesico-vaginal fistula, and then turning
the open end of the ureter into the bladder. The de-
tails of this method should be read in the original in
the CmlralblaUfur Gynakologie for 1881, No. 23. A
case operated on by Schede, and one the account of
which is given in the article under review and three by
other operators were successful.

If such attempts at cure fail, there are two courses
open, the closure of the vagina below an artificial va-
ginal fistula, and the extirpation of the kidney of the
affected side.

TKMTSO-FIXATION OF THK DTEB08.

Napier and Schacht* divide ventro-fixation into
two great varieties, indirect and direct. The first
fixes the uterus by means of its ligaments or the
pedicle of an ovarian cyst, etc., in the course of an-
other operation ; the second requires suturing of the
uterus itself. Direct corporeal uterine fixation may be
either lateral or median. The authors favor the
median method, and the essential feature consists in
passing three sutures through the edge of the rectus
muscle, the fascia, peritoneum of the left side, the
uterine wall, and the same structures of the right side,
one at the fundus, one as near the intra-peritoneal cer-
vix as possible, and one midway between these.

The conditions which justify such an operation are
when uterine retroflexion or procidentia occasions such
symptoms as unfit a woman for her life-work, provided
other forms of treatment and minor operative measures
have proved non-curative. Age is an important factor.
Of twenty cases operated on by the authors, seventeen
were under forty years of age. There were eleven
cases of retro-displacement, nine of prolapse. Ten
had been done long enough before the report to judge
> BritUh Uedloal Journal, October 14, 1893.

of permanent results, and of these only one was a
failure, and that was due to the dragging of cervical
fibro-myoma. There were extensive adhesions in five
cases, in fifteen there were none or they were easily
separated. Two deaths occurred in the series, one
from sepsis and one from htemorrhage and shock.

CONSBBTATIYB TBBATHBMT OP DISEA8B8 OF THE
TTTBBINE APPBNDAOB8.

Pozzi * refers in this paper, in addition to operations
on the tubes and ovaries themselves, to methods of
treatment of the uterus diseased at the same time as
the tubes, which have for their object the cure of the
latter, such as curetting, cauterization and electricity.
Such measures Pozzi believes may be useful in the first
phases of acute catarrhal salpingitis, but illusive in
pus cases or in chronic cases where the walls are
thickened. Massage and electricity should be applied
to diseased appendages only in chronic cases where
the tubes contain no liquid. The conservative opera-
tion which has been proposed in cystic salpingitis in
order to induce the evacuation of the liquid by dilata-
tion of the uterus and of the ostium internum of the
tubes, is dangerous on account of the likelihood of
provoking inflammation of the neighboring peritoneum
and is usually impracticable by reason of the extensive
obliteration of the tubes in the vicinity of the uterine
cavity.

In discussing the main topic of the paper, namely,
operations bearing directly upon the ovaries or tubes
for removing the diseased and respecting the healthy
part, he considers two procedures, resection and igui-
punctnre of the ovary.

With regard to partial resection of the Fallopian
tubes, Pozzi eliminates it from the number of conserva-
tive operations. He believes that once having been
attacked by acute inflammation, it has become definitely
incapable of fulfilling its physiological rdle. The rdle
of the Fallopian tube is not that of an inert duct ; it
is essentially active ; the integrity of its texture, the
persistence of its vibratile epithelium and its contractile
fibres are conditions indispensable to its function.
Therefore an inflammation of some duration must
surely destroy or definitely paralyze these active ele-
ments.

It is entirely otherwise with the ovary. It is well
known that a small quantity of ovarian tissue sufiSces
to assure the regularity of menstruation and to permit
fecundity, hence there are more than theoretical con-
siderations in favor of partial resection of the ovary.
The persistence of menstruation is constantly remarked
if a fragment, however small, is left, and several ob-
servations prove that its fecundity is preserved.

It remains to be determined in what cases of lesions
of the ovary a partial operation can be made, and to
decide the nature and technique of this operation. The
first general consideration is that whenever the Fallo-
pian tube is healthy and the ovary alone diseased, it is
wise to preserve a part, and only at the last extremity
make a total sacrifice.

The most favorable cases are those in which the dis-
eased process has affected one region of the ovary
leaving an entire segment of the organ intact. A
typical lesion is an isolated cyst, in which case, after it
has been ascertained that the tube is completely per-
meable by the passage of a stylet, the surgeon performs
the resection of the diseaseid parts by two incisions

* British Medical Jonraal, September 16, 1883.

Digitized by

Google

866

BOSTON MSDIOAL AND SVSGICAL JOVSNAL.

[Apbil 12, 1894.

which circumscribe a cnneiform Begment. The two
lips of the wound are reunited by a coutioaous suture
in catgut Resection may also be employed in cases
of microcystic degeneration, in which the disease has
left a zone of orarian tissue intact. It is frequently
found that a large part of the organ is thus' affected,
whilst in the region of the hilum, a band of tissue exists
untouched by disease. An incision can be made along
this line, removing the greater part of the ovary, but
preserving the base of the organ. Pozzi, in addition,
in cases where it has been necessary to liberate the
Fallopian tube by tearing off adhesions, fixes the
ostium of the tube upon the ovarian stump by means
of a few points of suture, in order to prevent the tube
from falling away from the rest of the ovary and con-
tracting adhesions.

Lately, Pozzi has practised ignipnncture instead of
resection. He considers it more expeditious and doubt-
less more efficacious than resection. When the ovary
presents dispersed lesions such as cysts of small volume,
they are opened successively by the small knife or
thermo-cautery, and burned on their internal surface.
Where there is diffuse ovaritis it is advisable to make
the point of the cautery penetrate rather deeply into
the oedematous stroma. He has no doubt that the
actual cautery has a distinct influence in producing an
energetic melting of the chronic inflammations.

In answer to the objection that the cautery would
be liable to produce sclerosis, Pozzi says : " Assuredly
this might be the case were the cauterization followed
by the falling away of the eschar from suppuration
and granulation. But in the interior of the peritoneal
cavity the process is quite different ; it is essentially
aseptic. The eschar is reabsorbed, molecule by mole-
cule, without inflammatory process or embryonic pro-
liferation susceptible of becoming a nodule of fibrous
tissue."

The practical results in Pozzi's cases have been
satisfactory. He has performed resection of the ovary
six times and ignipuuctnre eight times. All the pa-
tients recovered, and in all, either immediately or
later, the pains ceased or were greatly diminished,
and in those who before had suffered from menstrual
irregularities there was improvement. One patient
became pregnant, in whose case he made twelve deep
points of ignipnncture in the left and eleven iu the
right ovary. The ovaries were white, smooth and en-
larged and affected with diffuse ovaritis.

His experience is recent and extends over a period
of a little more than two years. The results are, how-
ever, very encouraging, and taken together with those
of Martin, may serve to encourage operators in a new
path.

THE BO-CALLED " CON8EBTATITE OPEBATION8 " ON
OTAHT, TUBE AND UTEBUS.

The partial operations on ovary, tube and uterus in
case of tumors and other diseases, have, according to
Martin,' found so little favor that he has been led
to call attention to them again. The resection of one
ovary after extirpation of the other, in particular punc-
tion of bydropsical or hemorrhagic follicles, has been
performed by Martin twenty-seven times ; of twenty-
four operated on in the last method, eight became
pregnant later. As soon as the disease of the ovary
has left DO functionally-active ovarian tissue and espe-
cially where a parolent process has been recognized

• DentMb. Med. Woeb., sis, 80, 1883, reported in Sohmldt's Jalir.

the extirpation of the whole ovary is indicated; for
the small number of cases in which there is chronic
oSphoritis or circumscribed new growths, Martin re-
commends partial resection. The resection of occluded
tubes after extirpation of the other diseased tube
Martin has performed forty times ; one woman con-
ceived later. Of the one hundred and forty-one
enucleations of intra-parietal myomata, twenty-six
women died ; of the one hundred and fifteen that lived,
five developed new tumors and two conceived again.

Martin claims that these conservative operations
offer no greater dangers than the radical, that the
women are almost universally freed from their suffe^
ings and remain so, that relapses or affections of the
resected organs rarely oocnr, that the feminine func-
tions remain intact, that pregnancy is possible even
with such partially preserved organs and that finally
the birth occurs without especial danger.

ENDOHETBITIS IN THE MENOPAnSE.

Jacobs ' is opposed to the view that the menopause
has a curative effect on endometritis and leucorrhoea,
that being the exception and not the rule. He de-
scribes the degenerative changes of the genitalia in the
menopause, the symptoms of endometritis and their
differential diagnosis from carcinoma, and calls especial
attention to the fact that even in non-malignant disease
the discharge may be foul-smelling. As general
symptoms he mentions pallor, wasting away, indiges-
tion and obstinate constipation ; occasionally neuralgia
and mental disturbances occur. Chronic eczema,
urticaria, acne, pruritus vulvssand mucous polypi in the
uterus are frequent accompaniments. Usually the dis-
ease has existed before the menopause. As therapeutic
measures the author advises at first building up the
general health, then curetting followed by local treat*
ment.

ENDOXETBITIS PDBCLENTA SENILIS, SBD ATBOPUI-
CANS.

Patru,^ under this name, describes a disease which
has been noticed by only a few authors, notably Fritsch.
It has clinically, as well as pathologically, a resemblance
to ozsena and occurs iu women over sixty, especially
in those who suffer from cardiac affections. It can be
caused by bacteria of a type very little studied, which
develop in the atrophied mucous membrane and cause
a more or less foul purulent discharge which occasionally
is bloody. In the discharge are found various forms
of bacteria, red and white blood corpuscles aud a poly-
gonal, atypical, uterus epithelium. The discharge is
either constant and scanty, or intermittent and protnse.
The patients complain of moderate pain in the back
lower abdomen, the uterus is usually normal in size and
moderately tender. The complexion is sallow and
can, in connection with the fetid discharge, simulate
malignant disease, although the cervix is small and soft
and shows no swellings or ulcerations.

The vagina may be inflamed and adhesions of the
walls may occur ; perhaps the little studied vaginitis
adhsBsiva is only a secondary affection and result of
senile endometritis. The prognosis is favorable and
the disease gradually disappears with age ; whether
malignant degeneration occurs u not known, ^he
thing to be feared is sepsis from retained secretions
and cachexia from chronic secretion of pus. To avoid

• Cent. fUrGyn., 1S84, No. 4.

' Ker. mM. de Suisse rom., 1888, Mo. 6.

Digitized by

Google

Vol. CXXX, No. 16.] BOSTON MEDIO AL AND SUMGIOAL JOURNAL.

867

big the treatment ehould conBist in dilatation of the
cervical canal, caretting, cauterization of the inner
surface of the uterns and daily vaginal injections.

Vit^vtt^ of j&ociettej^.

CAMBRIDGE SOCIETT FOB MEDICAL IM-
PROVEMENT.

AiiBBBT H. TDTTUE, X.D., SKCSBTABT.

A MRETiNO of the Society, Febrnary 26th, with
Dr. Hbnht O. Marct in the chair, was specially de-
voted to a discussion of

THE MALABIAL DISEASES OF THE CHARLES BIVBR
TALLET: THE BEST UETHODS FOB THE IMPBOTE-
MENT OP THE SANITATION OP THE BITER.

Db. R. W. Greenleaf read a paper on

THE OBABLES RITER IN ITS RELATION TO THE ETI-
OLOGY OF INTERMITTENT FBVEB.*

Dr. H. C. Ebnst : By common consent, we must
consider the cause of most malarial diseases is a micro-
organism. My experience with the subject under dis-
cussion is derived mostly from cases seen at the Massa-
chosetts General Hospital, most of which came from
Mewton and regions about there already shown this
evening on the map, and described in Dr. Townsend's
report.

A Plasmodium is not a form of bacterium ; its exist-
ence in the blood has only been discovered a few years,
and it has no relation to the bacterial forms of micro-
organisms. They require special study, by new meth'
ods yet to be worked out. In many instances it is tm'
possible to make a diagnosis between typhoid fever
and malaria except by means of the microscope, which
may reveal with proper preparation the hsematozoon
of malaria.

In order to make this examination, a bottle contain-
. ing equal parts of alcohol and ether, and cover-glasses
should be taken to the bedside of the patient; the
cover-glass is to be carefully cleansed, a slight puncture
of the patient's finger is made with a fine needle until
a small drop of blood can be squeezed out, a thin layer
of blood is spread over the cover-glass and carefully
dried ; then the glass is placed in the bottle contain-
ing the alcohol and ether, and kept until time for
examination. To examine the specimen, it must be
doubly stained by first immersing in a saturated solu-
tion of eosin in alcohol, or placing a few drops of the
same on the cover-glass and allowing it to remain for
ten to fifteen seconds ; it is then washed off with
water and treated with a saturated alcoholic solution
of methyl-blue, when it is finally washed, dried and
mooDted. By this means the red corpuscle is stained
red and the plasmodium blue. Under the microscope,
it is found to be an amceboid form with dark pigment
spots in the centre, which divides, and just before
complete division assumes a seven-petalled, daisy-like
form.

Dr. Ernst exhibited under the microscope the plas>
modium of malaria.

Db. Stevens said he could endorse the observa-
tions of Dr. Greenleaf. Most of the cases he had seen
were a long way from the river, near fresh-water

> 8m |Mfa SB3 of t]ie JonriMl,

brooks, old water-courses which were now drained or
filled up, and standing water (as the old reservoirs in
Cambridge and on College Hill, Somerville, and espe-
cially in Arlington). Before 1886 he had seen very
few cases of intermittent fever in Cambridge ; then it
rapidly increased ; but daring the last five years it bad
greatly fallen off, so that at present there was not
over one-quarter of the cases that formerly existed.

Dr. Ddroin, in discussing the qnestion of im-
provement of the sanitation of the river, said that ofii-
cial attempts had been made to remove the drains
which emptied into the river from the Boston side
along Beacon Street, and that these attempts had suc-
ceeded in part The sewerage from the abattoirs of
Brighton was no longer poured into the river. Some
drains along Beacon Street were under discussion, and
action was delayed in their removal to prevent unnec-
essary expense on the part of the land-owners in case
the property behind their bouses on the river bank
should be taken by the Park Commission for improve-
ments on the river.

Dr. H. J. Babnes said he was glad to hear that
Boston had done so well toward improving the sani-
tary condition of the river. Last year 80 drains emp-
tied into Stony Brook, and thence into the Charles
lUver. It was not long ago that be looked into the
brook and saw a great amount of faecal matter floating
about, which made him think of the conditions at
Moon Island as he found them last summer.

During every great rainfall the flood-gates are
opened into the Charles ; the idea is maintained that
by this meaas a large quantity of water is forced
through the sewers, which are thereby flushed clear of
their contents and maintained in a good condition.
This is an erroneous conception, since except, per-
haps, iu times of drought, the ordinary circulation in
the sewers is sufficient to keep them clear; and as
their discharge into the river causes the accumulation
of a great quantity of slimy, dirty material about the
month of the drains which at times is very offensive,
they should be done away with. He would not like
to live in his honse on Beacon Street in the summer-
time from this cause alone. What he had said about
the mouths of the flood-gates was equally true of the
condition of Stony Brook outlet in the Charles. Some
people had informed him the smell about the place
was simply that of dock odor, and not injurious to the
health ; bat obTiousIy it was a product of decomposing
organic matter, and undoubtedly it was the reason that
the organisms so useful in purifying the river no longer
existed. At one time there was an extensive bed of
oysters in the river, but they could not live where the
sewerage rendered water so impure ; and be had made
the same observations at Moon Island, the shell-fish
about the gateway having all died out.

BOSTON SOCIETY FOR MEDICAL OBSERVA-
TION.

JOHM 0. MOXBO, U.T>., SBOBBTABT.

Reoulab Meeting, Monday, February 5, 1894, Db.
Inoalls in the chair.

CANCER OP THE CERVIX. — PATHOLOOIOAL 8PECI-
UENS.

Dr. Swift : I thought this specimen would be of
interest as it shows a number of pathological condi-

Digitized by

Google

3H8

BOSTON MBDIOAL AND 8VSGICAL JOUBNAL.

[Apbil 18, 1894.

tions occarring in one patient. It is « cue of cancer
of the cervix, in which there is also a fibroid on the
anterior wall of the womb. On the right tide there
was a tubo-ovarian cyst, and on the left a hydro-sal-
pinx. The case was also interesting as showing how
easily in these pelvic troubles a wrong diagnosis may
be made. This patient was first seen a year ago by a
gynsecologist in this city, the complaint being back-
ache. It was foQud that she had an epithelioma of the
cervix. He evidently felt this fibrous nodule and
these tumors in the sides of the peWia, for he told her
that she had cancer of the nteras, and that the dis-
ease had extended so far that she conld not be cured,
but benefit would be derived from operation, and he
was willing to undertake the operation of hysterec-
tomy. She consented, but her friends objected. As
time went on she became worse, and was taken into
the City Hospital. There the same diagnosis was
made and a radical operation was refused. The cer-
vix was curetted, but the symptoms (pain) continued.
She was practically bedridden. - She came to me at
the dispensary a while ago, and demanded that some-
thing be done. She said that with the history no
hospital in the city would take her in. They refused
her on the ground of her having cancer, an incurable
disease. I examined her and maide the same diagnosis
that had been made previously. She was auxious to
have the operation performed. Under ether it was
found that these masses on the side were movable,
evidently not attached to the pelvic walls, and there
was some hope of getting out the whole mass. The
disease by this time had extended down onto the ante-
rior wall of the vagina, and I began the operation by
dissecting up the vagina and removing all the diseased
tissue that I could. I opened the peritoneal cavity
from below, and patting mj finger in there, found this
large cyst on the right side perfectly free, and a
smaller cyst on the left side, also free. On opening
the abdomen these things came oat without any diffi-
culty at all, and if the operation had been done a year
ago, probably her chance of ultimate recovery would
be much greater than it is now. The operation was
done last Friday, and the woman to-day is in very
good condition.

Db. C M. Green read a paper entitled

FOnB CNDSnAL cases: I. lUPBBFOBATR HTUEN
WITH BJiltATOCOLPOS ; II. 1I0COD8 CT8TS OF
THE VAGINA ; III. BECTO-TDLTAR FISTULA ; IV.
SALIVATION OF PBEONANCT.*

Dr. Fobster : I was present with Dr. Green and
saw the third case. It was a very interesting one and
I took a sketch of it at the time which I think gives a
pretty fair idea of the condition of the parts. It looked
like a rupture of the perineum following labor, except
that the vagina was entirely intact. '

Dr. Whittikr: I was very glad to hear Dr.
Green's paper on this form of reflex neurosis. I have
never been able to understand why in the same indi-
vidual it should be so constant in succeeding pregnan-
cies when the chief of reflex neuroses, vomiting, is so
inconstant and so variable. I have had three cases
corresponding to the disorder described, and I think
Dr. Green will remember I ventured last season to
ask him with reference to the remedies that might be
employed. The first case was seventeen years ago
and in the aaoceeding pregnancy it was quite as an-
> S«e psge 308 ot 0e Jooriw),

manageable. Four years ago a lady with her first
pregnancy had among the earliest symptoms saliva-
tion, which continued during the whole period of
pregnancy to an extreme degree, withont the slightest
sign of reflex disturbance in any other direction, and
continued several weeks after the completion of preg-
nancy. I was of the opinion at that time that the con-
tinuance after the birth of the child was coincident
with and dependent upon sub-involution of the nterus,
which was present to a notable degree in that case. In
the succeeding pregnancy, the earliest symptom of
pregnancy preceding even the absence of the menstrual
period, was salivation. This continned during the
whole of pregnancy and lasted seven weeks after the
completion of it. A lady consulted me last week who
for five successive pregnancies, none of them com-
pleted, bad as the first intimation, salivation. I need
not say that we shall all accept Dr. Green's statement
that this condition is, so far as remedies are concerned,
quite unmanageable. I doubt if we may, with aoy
degree of hope, expect to apply to this any remedy,
such as those employed in the other so-called reflex
neuroses of pregnancy, with fair anccess, for from all
that I can learn of this disorder, it more nearly than
any other deserves the title, incoercible.

Db. Washbdbn : I have been very much interested
in this series of cases. In regard to the last one, I
have now under my care a patient who has been
troubled very much with salivation, and in that case
there was an excessive amount of nausea and vomit-
ing accompanying the salivation. The salivation was
not as excessive as in some of the cases Dr. Green has
spoken of, but.it was constant and extremely annoy-
ing, and would amount to from a pint to a quart in the
course of twenty-four hours. I tried a series of differ-
ent things to see if anything would have any effect
Nothing had much effect, bat I thought what gave the
most relief was a combination of bromide of sodiam
with the effervescent bromo-caffeine, given in doses of
ten grains of the bromide of sodium dissolved in water,
to which afterwards a teaspoonful of the effervescent
bromo-caffein was added. In ihat way it seemed to
agree with the stomach perfectly, and it gave a little
relief to the salivation.

In regard to the cases of cyst of the vagina, I saw a
case about two years ago, that showed the possibility
of error in another direction. A woman came to me
with a small enlargement on the anterior wall of the
vagina, about the junction of the onter and middle
thirds, which apparently was a vaginal cyst. Exam-
ination, however, showed that the contents of it could
apparently be squeezed out, and I found that a fine
probe passed into the urethra could be gotten to enter
this little sac. It would often be quite distended with
the urine and a little dibrit that collected there. It
gave her a great deal of discomfort in various ways
and I finally opened it and denuded the surface, and
sewed up the little fistula into the urethra, and the
thing healed very well, and she has been perfectly
comfortable ever since. But the first examination of
that gave every appearance of being a vaginal cyst.
A vaginal cyst which I saw recently was situated
almost at the vaginal outlet, and the size of an Eoglisb
walnut. In three or four cases I have seen, the cyst
has been along about the middle third of the vagina.
I think that the way to reach these always is by the
operative method, and my experience has been that of
Dr. Green, that very often you cannot find any cyit

Digitized by

Google

IToi-. CXXX, No. IS.] BOSTON MBDIOAL AND SUROIOAL JOURNAL.

369

rmll to dissect ont. You simply have to lay it open
nd^ take off a piece of the ootside, scrape it out and
Bt it granulate up in that way.

I>K. Buckingham: I have met with one case
ȣ aalivation in pregnancy, and like those of Dr. Green
tnd Dr. Whittier, it had appeared in a former preg-
lancy as well. It was so severe that the patient spent
ler whole time on the bed, with her head over the
^gPi and her mouth draining into a basin. She was
nach emaciated and the condition would have been
tlarming bat for her assurance that she had suffered
»veu more in her former pregnancy. Each time sali-
vation ceased about the fifth month. She was treated
with a number of drugs commonly used for the
neuroses of pregnancy, the only one doing any good
being atropia. I do not believe that that hastened
recoverv, but it gave considerable temporary relief,
and it could be repeated.

Hecent Ettgrature«

A TtxUBook of the Theory and Practice of Medi-
ein». By American Teachers. Edited by William
Pkppbb, M.D., LL.D., etc. In Two Volumes.
Illustrated. Vol.11. Philadelphia: W.B.Saunders.
1894.

The second volume of this important work makes
its appearance somewhat later than had been antici-
pated. It is a year since the publication of the first
volunae. In a certain measure this is compensated for
by the incorporation of the latest investigations and
studies in some subjects. The first 69 pages are devoted
to general considerations concerning the biology of
bacteria, infection and immunity, by Dr. W. H. Welch.
It ia interesting to compare this contribution with those
from the same pen on kindred subjects in the last edi-
tion of Flint's " Practice of Medicine," published in
1886. One may thus get a striking illustration of the
activity and advance of research in this department of
medical science during the short space of eight years.
Dr. William Pepper contributes 325 pages out of the
1,000 pages of text contained in the volume, aud writes
on diseases of the heart and its membranes, of the
blood-vessels, of the mediastinum, of the mouth and
tongue, the salivary glands, the pharynx and tonsils,
o{ the oesophagus, the stomach and the intestines. Dr.
B. H. Fitz treats of diseases of the peritoneum, the
liver and the pancreas. Dr. Francis Delafield has con-
sidered diseases of the lungs and of the kidneys ; Dr.
James C. Wilson, diseases of the nose, larynx, pleura
and bronchi ; Dr. William Osier, diseases of the blood,
of the supra-renal capsules and ductless glands ; Dr.
James W. Holland contributes a chapter on practical
Driuary examination; and Dr. Henry M. Lyman
chapters on dietetic diseases, the acid dyscrasia, rickets,
osteomalacia, obesity, biliary lithiasis, gravel, saccharine
diabetes, polyuria, rheumatoid arthritis, gout and rheu-
matism.

The title-page states succinctly the plan upon which
the work is made up ; the names of authors embrace
a number of the prominent teachers of clinical and
theoretical medicine in the chief medical schools of this
ootmiry, and may be held in a measure as a guarantee
of the character of the work.

The paper, the letter-press, and most of the Ulustra-
tioDs, which are numerous — are first-rate. E^ach vol-
ume has a separate and full index.

Holden'e Manual of the Dietection of Ae Human
' Body. Edited by John Lanqton, Surgeon to, and
Lecturer on Anatomy at, St. Bartholomew's Hospi-
tal, etc. Sixth edition, revised by A. Hewson, M.
D., Demonstrator of Anatomy at Jefferson'Medical
College, etc. 311 illustrations. Philadelphia: P.
Blakiston, Son & Co. 1894.
This new edition of a well-known work calls for no
very extended comment. The bulk has been reduced
by putting the more minute points in smaller type.
The binding is more simple and well adapted to the
dissecting-room. There is a great deal in this work
that explains its continued success. For our part we
think it would have been wise to omit all minute anat-
omy. The dissector can have nothing to do, for in-
stance, with the plan of the renal tubules, nor the blood-
vessels of an intestinal villus. All this is out of place,
if the book is intended to be merely a manual of dis-
section. We are least pleased with the treatment of
the abdominal viscera, and would particularly protest
against the implication that the back of the cascum is
often or usually destitute of peritoneum. t. d.

Healthy Hotpitali : Oburvationi on Some Points con-
nedted with Hoepital Conitruetion. By Sir Dono-
LAS Galton. With illustrations. Oxford : Claren-
don Press. 1893.

The author's object in writing this book was to place
on record those principles which ought invariably to be
followed in every good hospital, and to point out those
conditions of construction which sccording to recent
practice represent the minimum standard required to
be followed in building a new hospital. The author
does not enter upon the detailed requirements of hospi-
tals for special diseases, entailing in some cases sepa-
ration of patients, in others special curative adjuncts.
He recognizes the probability that a large number of
new hospitals for infectious and other diseases will
have to be built in the next few years, and endeavors
to impress the importance of simplicity of design and
moderation in cost. The book is one which those inter-
ested in hospital construction should consult.

The Phytician't Wife; and the Thingt that Pertain
to Her Life. By Ellbn M. Firebadqh. With
portrait of author and 44 photo-engravings of original
sketches. In one crown octavo volume of 200 pages.
Philadelphia : F. A. Davis Co. 1893.
Mrs. Firebaugh has expanded what was probably a
very interesting paper, as read to a club, into the pro-
portion and dignity of a book.

It is difficult to believe that the author is really the
wife of a physician, so much has been omitted that
could have been said in regard to the peculiar duties,
hardships and rewards of the life of a doctor's wife,
and so many anecdotes contained in the 186 pages
could have been related as well of the wife of a banker
or a grocer. For instance, it is not clear why the fact
of being a physician's wife should cause the lady in
question to insist that cabbages should not grow in her
front-yard, or why her husband, because he is a physi-
cian, should be equally determined that they should.

For a busy doctor's young wife, who is beginning
to learn that her husband's time, and, it often seems,
his interests also, must belong to his patients rather
than his home, there is little to aid or comfort ; while
to the wife of many years much in the book will ap-
pear trivial and commonplace.

Digitized by

Google

370

BOSTON MSDICAL AUD SUBGJOAL JOVSHAL.

[Apsil 12, 1894.

THE BOSTON

fSLzWial anD ^tirgtcal ^outnau

Thursday, April 12. 1894.

A Jofuimal o/MedieUu, Surgery, and Allied SvttHea.pubUthed at
BottOK, vetklf, b)i tKe mtdenigned.

ScBSCBiPTiOH Tbsmi : ys.OO per year, in adranoe, pottage paid,
for the United State*, Canada and Mexico ; (6.66 per year for all for-
tign eountriei belonging to t?u Poital Union.

All eommwticatioM for the Editor, and all bookt for revieu), thonld
be addreeted to the Editor of the Boiton Medical and Snrgieal Journal ,
283 WathingUm Street, Bolton.

All lelteri containing bueineet oomm>Miaation$, or referring to the
publication, lubecription, or adverUiing department itf (Atj Journal,
should be addreeted to the undertigned.

Bemittaneei thould be made by money-order, draft or regitlored
letter,payable to

DAMRKLL ft UPHAM,
188 WASHiirGTON Btbut, BoiTon , Ham.

BROWN-SfiQUARD'S TEACHING.

Im the recent death of Brown-Seqaard — so -well
known personally to many of the readers of the Jour-
nal as having been a citizefi, practitioner and medical
teacher for several years in this city, and a frequent
visitor to this country — the world has lost the last of
a distingnished band of experimental physiologists, with
all of whom he had been contemporary, and who have
helped to make this centnry fruitful in scientific dis-
covery. The mere mention of the names of the most
coDspicuous in this band — Flourens, Mageudie, Claude
Bernard, Yulpian, Longet, Charcot — recalls some of
the most valuable acquisitions in neuro-physiology of
the past sixty years.

We shall not repeat the facts in Brown-S^quard's
medical career mentioned in the Journal of last week.
His memoirs on the physiology of the nervous sys-
tem in both French and English (he wrote with equal
facility in both languages) are very numerous. He is
best known in this country by his work " On Paralysis
of the Lower Extremities," his "Experimental Be-
searches applied to Physiology and Pathology " (New
York, 1853), and his " Lectures on the Physiology
and Pathology of the Central Nervous System," first
delivered in London in 1858, and published in this
country in I860. This is an " epoch-making " book,
and sums up his most important investigations on the
spinal cord. In 1856, he delivered a course of lect-
ures in Boston, on "The Pathology of Epilepsy,"
which attracted much attention ; these were published
in the Journal in 1856 and 1857.

Probably of all his works, that on the " Physiology
and Pathology of the Nervous System " has been the
most read, and we well remember the eagerness with
which it was sought for and read by students of medi-
cine at the time of its publication, thirty-odd years ago.

It is impossible to overestimate the advantage which
has accrued to science from these researches, so replete
with originality, on perhaps the most difiScult part of
nervous physiology. We may point particularly to the

anatomical and experimental facts set forth in those
lectures, showing the relative share of the gray matter
and of the various columns of white matter in the
transmiasiou of both sensory and motor impressioos,
and to the demonstrations there given : (1) That the
conductors of sensory impressions from the trunk sod
limbs decussate in the cord and not in the encephalon
[Brown-S^quard, by the way, subsequently took this
all back, and affirmed that the decussation does not
exist*]; (2) that in the dorsal region, the varioas
parts of the cord except the posterior columns are in-
struments of volition ; (3) that a small part of the
cord may contain conducting elements from all parts
of the body on the same side ; (4) that the anterior
columns have a share in the transmission of sensory
and, particularly, tactile impressions ; (5) that in cases
where the gray matter is destroyed, sensibility is lost;
(6) that the fibres of the sympathetic going to the
blood-vessels of the head originate in the spinal cord
from the roots of the last cervical and first and second
dorsal nerves, etc. Brown-Sequard's investigations of
the vaso- motor and cervical sympathetic nerves, and
his doctrine on the " Transfer of Sensibility " are of
the highest interest. With regard to the vaso-motor
nerves, following Claude Bernard, he established that
the effects of excitation of these nerves consist essen-
tially in a contraction of blood-vessels with diminution
in the blood flow, in the temperature, and in the activ-
ity of nutrition. He was the first to galvanize the
sympathetic nerve. He showed, also, that irritation
of the nervous system is a powerful direct or reflex
cause of a great many morbid changes in nutrition,
secretion, etc.

Brown-S^quard was the first artificially to produce
peilepsy iu animals by injuries to the spinal cord in
certain regions, and to demonstrate the existence of an
" epileptogenous zone " in guinea-pigs. His views as
to the pathogeny of epilepsy are of the highest interest,
though they have been in many points contested. Thus
the "contraction of the blood-vessels of the brain
proper," precursor of the loss of consciousness, was
disputed, if nut disproved by Yulpian, and the weight
of authority to-day is against the view that the primary
seat of epilepsy is in the medulla oblongata instead of
in the cortex cerebri.

Dr. Bro wn-S^uard followed the teachings of Flourens
respecting the functions of the cerebrum. According
to Flourens, all the properties of the cerebrum are in-
herent in every part, and from this standpoint he made
vehement war on the localizationists of the time, the
phrenologists. Brown-S^quard was never willing to
accept the modern views of localization, as they were
expounded by Ferrier, Nothnagel, Charcot, Seguin and
others; in fact, he always bitterly opposed these
notions of cerebral physiology ; and he has been cited
as a striking example of the baneful influence of a
strong prepossession or bias. As Agassis could never
see any force in the arguments of the evolutionists, so,
to Brown-S^quard, Ferrier's experiments on monkeys

1 London lanoet, August, 1880 (Am. Sd.), p. 188.

Digitized by

Google

Vot. CXXX, No. 15.1 BOSTON MEDICAL AND SUROICAL JOUBNAL.

371

were only illaatratioDi of reflex inhibitory aotioD, not
of direct irritation or of destrnction of well-defined
centres. He had accotnalated facta which led him to
believe that paralysis, anaesthesia, amaurosis, aphasia,
and other effects of brainnlisease are not dependent on
loss of function of either the centres or conductors
specially employed in voluntary movements, perception
of sensations, power of expression of ideas by speech,
etc. He taught that a lesion of any part of the brain
may produce any symptom, and that, on the other baud
the same symptom may appear, no matter where the
seat of lesion may be. A lesion in any part of the
brain can produce paralysis, either on the same side or
on the opposite side of the body. A paralysis may
appear on one side, then on the other side, although
the lesion remains in one-half of the brain. As re-
gards vision, facts, according to Brown-Sequard, show
that a disease iu one-half of the brain can produce
hemiopia either in both eyes or one, and in the corre-
spooding or the opposite halves of the retine, or a com-
plete amaurosis of either of the two eyes or of both to-
gether, so also, anaesthesia, aphasia, loss of conscious-
ness, etc., may arise from lesions in almost any part of
the brain. One of the doctrines that he stoutly main-
tained was this, that the seat of each special function
of the brain, instead of being a duster of cells localized
in a small part of the brain, is disseminated, so that
the cells belonging to each are spread over a consider-
able extent, if not the whole extent of the brain.*

We have not space here to comment on these views ;
the work has been done by Charcot, Segoin, Foster,
Sonry, Ludani, Ferrier and others. It is enoagb to
say that Brown-S^qoard baff a comparatively small
following; that his peculiar teachings in which he
combated with acerbity the views of bis opponents were
always listened to with respect and patience, bat with
incredulity by medical audiences ; and that the physi-
ology of to-day is moving forther and farther away
from his positions. Brown-S^qoard will always de-
serve a large place in the anni^s of medicine for the
many facts with which he has enriched science, but,
like Magendie, he was not a philosophic thinker, and
thoogh a good observer, he did not always correctly
interpret the facts which he observed.

THE INTERNATIONAL MEDICAL CONGRESS.

The Twelfth International Medical Congress came
to a brilliant close on April 5tb, and there seems to be
litde doubt that as regards the friendly relations of all
the members and the generous hospitality of the enter-
tainers, it has been the most successful meeting yet
held.

The Congress was formally opened on Thursday,
March 29th, in the presence of the King and Queen
of Italy and the officers of the Court. Professor Bac-
celli delivered his inaugural address in Latin to an
andience of six thousand persons. Prince Ruspoli,

* Sm Browii-S^qiuurd'i la«tim in tba Luuwt, April S, 18T6, and the
LaiMM's oomment oa the lastnre.

the Syndic of Rome, extended to the members the
welcome and hospitality of the city.

The immediate glory of the meeting; the dinners
given by the foreign ambassadors to tbe officers of the
various sections ; the splendid lawn party given by the
Queen to the whole Congress ; the many private en-
tertainments and public hospitalities of open gallery
and museum ; and the final banquet in the great court
of the Baths of Caracalla when seven thousand per-
sons were gathered together in the vast dismantled
ruins of that unequalled athletic club of Imperial Rome,
— all these, brilliant as they might be, were but rich
appointments of the true feast.

Of the actual work of the Congress ; its nineteen
sections, each sitting for five days from 8 a. m. to S
p. M. ; its sixty-nine pages of titles of papers to be
read ; its five general meetings to listen to addresses by
Babes, fiizzozero, Bouchard, Danilewski, Michael
Foster, Abram Jacobi, Laache, Nothnagel, Stokvis,
and Virchow, — it is too soon to speak. The value of
such addresses and such extensive sectional work can
only be appreciated after they have become widely
known, thoroughly read and studied in full. Brief
epitomes of such papers are apt to give, not merely
unsatisfactory, but often false impressions of the state-
ments, the arguments, the conclusions therein con-
tained. On the arrival of our carrier pigeons, a thou-
sand of which were set free at the close of tbe final
banquet in the Thermee, we may give our readers even
more details than could have been sent by special
cable. Tbe list of speakers and papers was a most
promising one for the real worth of the Congress.

MEDICAL NOTES.

A Long Mkdical Life. — Dr. Schupmann, who
died recently in Geseke in Westphalia, was probably
the oldest physician iu Germany. During the first
fifty years he was in practice it is stated that he never
left his district for a single night, and he did not finally
retire from active practice and the charge of tbe local
hospital until he was past ninety years of age.

Dangeb fkok Heated Cabs. — The introduction
of heating apparatus iu some of the public carriages of
this city, while of great comfort to the rider, makes
worthy of note the following cases reported to the
Acad6mie de M^decine of Paris, by M. Dr. Brouardel :
" On the 81 St of last December a cab^river who went
to sleep in his cab for half an hour after closing the
windows was found dead, and the autopsy showed that
the death was due to poisoning by carbonic oxide gas
from the heating apparatus. On the same day a phy-
sician, after an hour's consultation, entered his heated
carriage without notidng that the windows were closed.
In a few minutes he became dizzy, nauseated, and was
seized with such muscular weakness that he could
scarcely lower the window. The serious effects of
this brief exposure to tbe gas lasted some ten days."
In the discussion following this report it was stated

Digitized by

Google

372

BOSTOm UBDICAL ABD SUBGICAL JOLRhAL.

[Apbil 12, 1894.

that from five to eight deathi are reported every winter
in Paris from gas-poisoning in heated cabs. Another
physician since then has nearly lost his life in a similar
manner, being found by the driver, unconscious on the
seat.

Medical Chasitieb of London. — The present
discussion in English medical journals' on hospital and
dispensary abuse can be better appreciated after
realizing the large number of institutions of direct
medical charity. The Directory of Metropolitan Char-
itie$ gives the following list of hospitals and dispen-
saries in London, not including foundling asylums or
diet-kitchens: "Twenty-five charities for the blind,
seven charities for deaf and dumb, five charities for
incurables, two charities for idiots, sixteen general
hospitals, eight consumption hospitals, five ophthalmic
hospitals, three orthopedic hospitals, five skin hospi-
tals, sixteen hospitals for women and children, four
lying-in hospitals, twenty-nine miscellaneous special
hospitals, twenty-nine general dispensaries, thirteen
provident dispensaries, six institutions for surgical
appliances, twenty-six convalescent institutions, seven
nursing institutions." They number 206 in all.

boston and nkw bnoland.

Acute Infeotiocs Diseases in Boston. —
During the week ending at noon April 11, 1894, there
were reported to the Board of Health, of Boston, the
following numbers of cases of acute infectious disease :
diphtheria 42, scarlet fever 45, measles 9, typhoid
fever 10, small-pox 3 (with 3 deaths). There are at
present ten cases in the Small-Pox Hospital. During
the week one case of small-pox was reported to the
State Board of Health from Cbicopee.

The Massachusetts Hoikkopatbic Medical
Society. — The programme of the annual meeting of
the Massachusetts Homoeopathic Medical Society in-
cluded a luncheon at the State Insane Hospital at
Westborough.

The American Association fob the Advance-
ment or Physical Education. — The ninth an-
nual convention of the American Association for the
Advancement of Physical Edncation was held last
week in New Haven, Conn., with an atteadance of
nearly four hundred delegates.

A Suit fob Damaoes in a Case of Small-
Pox. — A suit for $15,000 damages has been brought
against the Selectmen of Ansonia, Conn., by the father
of a boy who was taken to the small-pox hospital of
that town by order of the selectmen in 1892. The boy
died of the small-pox, and the father claims that the
removal was the cause of death.

New Enqland Almshouses. — The Boston Alms-
house is not the only one at present under investigation
as to the methods employed to give the inmates the
full benefit of money appropriated for their care. The
Portland, Me., city government has been asked to
investigate the almshouse, and to restrain the board of
overseers of the poor from holding their regular

monthly dinners at the almshouse at the cost of the
city.

A Case of Catalepsy in Lowell. — A woman
was found apparently dead in Lowell last week ; and
on the arrival of the ambulance gave none of the or-
dinary symptoms of life when examined by the aar-
geon. Just as the ambulance drove np to the under-
taker's establishment, the surgeon noted a flicker of
the eyelids, and the patient was carried, still insensible,
to St. John's Hospital, where after several hours' treat-
ment she rallied from her cataleptic state.

Town Clebks and Medical Obthogbapht. —
Massachusetts town clerks have a fearful struggle with
the nomenclature of disease as presented to them in
the certificates of death returned to them by physi-
cians. The following are some of the diseases of
which citizens of this commonwealth were said to
have died in the year of our Lord 1893, taken verba-
tim et literatim from town reports : In Wellesley —
taber dorsalis, extensive bronis, acute aystitis, asphyxia
neonatonim, gasdrentiritis, chronic parenchymatoes ;
in Milford — sewiclity (aged seventy-two), nutral dis-
ease of the heart, gastertis, caranomia, snppressaricella
[Query, Was this Ayer's Sarsaparilla ?].

Bbpobt of the Pebkins Institute. — The sixty-
second annual report of the trustees of the Perkins
Institution for the Blind shows a continued increase in
the number of pupils and in amount of work done at
the school and kindergarten. There are now one
hundred and forty popils in the school proper at Soath
Boston and sixty-four in the Sandergarten at Jamaica
Plain and seventeen in lAe workshop for adults. The
director's report says that the progress of the three
blind and deaf children, Edith Thomas, Willie Robin
and Tommy Stringer, has been more than satisfactory.
They have been placed in the regular classes and sub-
jected to the same rules as others, the only difference
being the presence of their special teacher as inter-
preter. Their progress compares favorably with that
of their classmates, and doubt can no longer be enter-
tained of the feasibility of educating children thus de-
prived. The number of these is sufficient to make it
a doty to seriously consider the means of their educa-
tion. The schools for the deaf generally have no pro-
vision for the blind child, or the schools for the blind
for a deaf pupil.

new yobk.

Tubbboulous Cattle Dischaboed by the
State Boabd of Health fob Lack of Funds
to Inspect Them. — It is greatly to be regretted
that the present Legislature has neglected to make
a suitable appropriation for the further carrying
out of the act passed last year, which conferred ex-
traordinary powers on the State Board of Health for
the purpose of stamping out tuberculosis and other
contagious diseases among cattle. For some time past
the Board has been seriously crippled for lack of
funds, and last month, when it was notified of the
existence of tuberculosis in tbo cows of Colonel

Digitized by

Google

Vol. CXXX, No. 16.] BOSTOH MEDICAL ADD SURGICAL JOVhUAL.

373

Beecher, at Yonkera, whose grandchild died of taber-
colar meningitis, the Secretary of the Board, Dr.
Balch, wrote in reply that it would be impogsible for
the State officials to make an examination of the
animals mentioned for some months at least " This
department," he said, " is working under a very small
appropriation for tuberculosis, and unless the present
Legislature makes au additional appropriation, it will
take us several months to attend to the requests
already on file." And now, under date of April 6th,
the Board has issued an order directing the release of
cattle suffering from tuberculosis and the discharge of
cattle inapectors, because of the insufficiency of the
funds at its disposal. This order has naturally caused
great indignation among cattle-owners, many of whom
have sacrificed some of their most valuable stock for
the purpose of exterminating the disease, and it is
feared that the most serious consequences will ensue.
A large number of tuberculous animals have been
quarantined awaiting slaughter, and the order to re-
lease them permits their sale and distribution through-
out the State and the country at large.

A CoHHissiON TO Investigate Tenement-
Houses. — The Legislature has passed a bill which
provides for a committee of seven citizens, including
Dr. Cyrus Edson, Commissioner of the Board of
Health, for the purpose of investigating the condition
of tenement-houses in New York. The commission is
authorised to employ counsel and a stenographer, and
to compel the attendance of witnesses, and $10,000 is
appropriated for its expenses.

THE INTERNATIONAL SANITARY CONFER-
ENCE.

The closing session of the International Sanitary
Conference at Paris was held on April 4th, and an
international convention was signed by all the dele-
gates, those from the United States and Great Britain
making reservations in regard to a few details.

The measures deal with three aspects of the cholera
question, and are reported to be minute in their re-
quirements. The first series provides for a thorough
inspection and control over the embarkment of all
pilgrims from Indian ports for Mecca, and for proper
medical service on all vessels carrying pilgrims. The
second series provides for the reorganization of the
Turkish lazarettos on the Bed Sea. The quarantine
of pilgrim ships from India, formerly varied irom two
to seven weeks, whether the vessel had a clean bill of
health or not. By the terms of the new convention a
ship with a clean bill of health will be delayed only
long enough for medical inspection, and contaminated
or suspected vessels will not be detained in quarantine
more than five days. The third series relates to pre-
cautionary measures in the matter of the return of pil-
grims from Mecca by the lazaretto of Tor in Arabia
Petrea, on the east shore of the Gulf of Suez. The
conference has earnestly urged the Turkish Gk>vern-
ment to reorganize its sanitary administration thor-
oughly, with the view of preventing the introduction of
cholera into Europe by land. With what result ?

99iJ(»Hanp*

THE USE OP ANTIPYRETIC METHODS IN THE
TREATMENT OF SCARLATINA.

Db. John Cabslaw, of Glasgow, in a paper on
" The severer forms of scarlet fever, with special refer-
ence to antipyretic methods of treatment," ^ based on
the study of six hundred and thirty cases, draws the
following conclusions in regard to the external use of
applications of cold and tepid water :

(1) That, in the large majority of cases, they are
not required.

(2) That, even in simple cases, and in anginous
eases, tepid spongings are useful in allaying restless-
ness and giving comfort — if the rash has not developed,
the addition of mustard being au advantage.

(3) That mustard spongings are particularly useful
during the earlier stages of an attack in which nervous
phenomena are prominent.

(4) That for the hyperpyrexia of such (nervous)
attacks, especially if the rash has developed, repeated
cold wet packing is a convenient and efficacious method
of treatment, general improvement often following its
use.

(5) That local applications to the head may some-
times be of assistance.

(6) That, in all cold applications, there is need for
the exercise of the greatest care.

> aUi«ow Uadioal Journal, Noi. I and II, ISM.

THE TREATMENT OF CHRONIC RINGWORM
OF THE SCALP.

In the Dermatological Section of the British Med-
ical Association, held at Newcastle-on-Tyne, August 2,
1898, the above subject was introduced by Dr. Calcott
Fox, and discussed by various members. Dr. Fox, in
considering the parasiticidal treatment, asked whether
it was possible to make strong parasiticides penetrate
the hair follicle and to bring them into contact with
the diseased root and thus to destroy the parasite, as
has been denied by Besnier. He was not wholly
prepared to accept the latter's view, but yet regarded
purely parasiticidal treatment as a slow means of cure.
Irritative treatment was commended as effective, but
would be more advisable if the desired amount of
irritation could be produced at will. He also recom-
mends shaving. Treatment by croton oil in obstinate
cases had yielded the speaker brilliant results, but it
should always be kept in the hands of the physician.

Some of the speakers who followed favored the use
of strong irritants and croton oil, others did not. Dr.
Alder-Smith declared that in 90 out of every 100 cases
that he had really cured, he had had to employ some
croton oil sooner or later, or had had to needle out
some isolated stumps left after other remedies had
failed. Dr. Radcliffe Crocker considered croton oil a
valuable remedy, most useful in very disseminated
cases, but one which must be very carefully employed.
He recommended oleate of copper, and for older chil-
dren, salicylic collodion. Dr. Brooke uses as a base a
modified Lassar's paste, with kaolin substituted for oxide
of ziuc, so as to make the preparation more sticky ;
he adds to this sulphur or creolin as a parasitieide.
He was doubtful as to the value of epilation, and con-
sidered the croton oil treatment admissible only when
the patient could be seen daily by the physician. Dr.

Digitized by

Google

874

BOSTON MBDIQAL AND SURGICAL JOURNAL.

[April 12, 1894.

Thin considered it necessary for the care of ringworni
to set up an inflammution abont the hair follicle suffi-
cient to kill the parasite; but this inflammation must
be carefully controlled, as he bad seen cases where
large areas of permanent baldness had been prodaced
by croton oil. He did not favor therefore the use of
crotou oil, except in very exceptional cases, and in
very exceptional hands. He had found that ringworm
hairs that had been soaked in croton oil for a week,
still caused a growth of the fungus iu cultivating media,
and therefore its effect must be due to its irritating
and not to its parasiticidal properties.

A FAMOUS COUNTRY OBSTETRICIAN TWO
CENTURIES AGO.

In the second volume of the " Philadelphia Hospi-
tal Reports," recently published, Dr. Theophilus
Parvio contributes a sketch of the work of Maaqnest
de La Motte, a famous French obstetrician of the last
half of the seventeenth centary. Althongh he was
educated in medicine at the Hdtel-Dien in Paris, he
returned to the small country town of Valognes in
Picardy to practise. Leading the busy and arduous
life of a country doctor, he gradually acquired fame as
an obstetrician " by adding reading to practice, obser-
vations to reading, and reflections to observations."

Id 1726, when he was seventy-one years old, he
published bis "Traits des Accouchements," making
this modest claim for its merits : " I have waited a
longer time to publish this work, hoping to make
greater progress; but my advanced age has decided
me to issue it as it is, fearing that an foreseen death
may deprive me of the pleasure of giving some light to
my successors, trusting that the Lord will reward, not
living in a place in which fortune can fulfil the desires
of those who sacrifice to this idol."

What was the variety of work done by this physi-
cian, who frequently rode twenty or thirty miles on
horseback to attend a case of labor, is exemplified by
the reports of over 400 cases, written in a most inter-
esting and vivid manner. The following passages will
meet the ready appreciation of the tired doctor of to-
day:

" Mother and child saved, but I almost died ; and I
was so fatigued and exhausted I could not use my legs
and arms for eight days. ... I believe I would have
died when this accouchement, in which I had exhausted
my knowledge and my strength, ended. I could
scarcely breathe, and it was necessary to put me upon
a mattress in front of the fire and to rub me with
warm cloths. . . ." Of the closing moments of a labor
he says, " The child escaped from the vulva as readily
as an eel slips through your hand." So great was bis
regard for the feelings of bis patient in conducting a
labor, that it was said that " he would not so much as
see the patient's feet when her slippers were off."

He was a master in podalic version, which was his
favorite and chief obstetrical operation ; and he asserted
that, in obstructed labors, " in any other presentation
than that of the head, the Lord had given him the
means of extracting living children if he were called
in time." The forceps devised by Palfyn he had
heard of, but condemned, as he said he did not see
" how an instrument of steel or other material could be
passed to the place where the head is arrested and

wedged, usually in the strait formed by the isehia, the
sacrum and the pubis, so closely that a sound to evaca-
ate the urine which has been retained for several days
cannot be introduced, nor a canula for rectal injectioo,
not even a myrtle leaf; how can such an instrument
be applied and used to remove the infant from the
peril to which the narrowing of the parts ezposes it?
... Its nse would be as impossible as to pass a cable
through a needle's eye."

He was one of the first to reco^ize the narrowed
pelvis as a cause of dystochia. Throngbont his book
are related unnsnal and interesting cases ; one woman
dying of fright consequent on his attendance; one
woman who had thirty-two children before she was
forty-five, when she lost her husband. Patience and
refraining from meddlesome midwifery were the chief
characteristics of bis work. His self-independence
and practical opinions he recorded in these words :

" As I have lived at the extremity of a province
surrounded on almost all sides by the sea, and have
worked most frequently in the depth of a country with-
out physicians or snrgeons who could aid me by their
counsels, I have been compelled to conduct my prac-
tice moat frequently in seeking to aid nature and to
calm the accidents of pregnancy and labor, so far as
common-sense and my reflection have furnished the
means, without too great subjection to authorities and
making myself a slave to common usuages, at leut
when I did not know the necessity for conforming to
them iu reference to the disease, the constitution of
patients and other circumstances from which practical
considerations can be drawn."

THE NECESSITY FOR A WELL-PAID MEDICAL
PROFESSION.

In an address before the Southwest London Medi-
cal Society Mr. Thomas Bryant urged the importance
of physicians being well paid for their services.^ He
said:

" Let OS never forget that oar patients' interests are
those we should always primarily consider, and that in
all our practical and scientific professional work the
public good is its ultimate object ; but at the same time
let us bear in mind that iu order to realize this leading
purpose it is all important for the interests of the pub-
lic, as well as for the due exercise and dignity of onr
profession, that every practitioner of medicine should
hold a perfectly independent but responsible position,
and that in his professional work he should be left per- -
fectly free from lay control, although amenable to lay
censure. It is also equally necessary that he should
be adequately paid for his professional services by all
classes according to their means. Under these circum-
stances all measures, whether under the guise of char-
ity or called 'provident,' and all hospitals, general,
special, or private, which encourage the public to seek
professional advice for little or nothing, are to be dis-
couraged as helping to pauperize and degrade the pub-
lic at large ; and all members of our profession who
induce or tempt the public so to do by means of private
hospitals, competing private dispensaries, touting clubs
and associations, or who are ready to accept at a re-
duced figure, over the heads of their neighbors, appoint-
ments which have been put up by laymen, as it were,
to auction or competition, adopt Uie surest means with-

> LuiMt, February 10. 18M.

Digitized by

Google

Vol. CXXX, No. 15.] BOSTOS MEDICAL AS J) SURGICAL JOUBSAL.

875

in their power to lower the position of their profession
in the estimation of the public, and at the same time
do injustice to the profession and public by not giving
to the latter the best services the former can supply,
whilst they must, iu addition, lose their own self-re-
spect, even if they happen to gain cash by their un-
worthy actions. For let me ask. How is it possible
for a man who is ill-paid or overworked, or both, either
to give, in the interests of the public, the professional
attention it is essential for him to bestow on every case
be has undertaken to attend ; or to maintain, in the
interests of the profession, the position to which he is
entitled and his own self-respect? We all know that
any measure which encourages, either in a profeBsioii
or trade, underpay and overwork, leads to bad work.
In our profession such deficiencies are no less harmful
— nay, they are more so, as its issues to the public
are either life or death, health or ill-health, and to the
profession either a position of pleasure, honor and
respect, or one of degradation and unrequited labor."

CROTALD8 HORRIDU8.

The following description of the initial steps iu the
Becariug and preparing of the "mother tincture of
OrotaUu Horridu* " receives the sanction of two homce-
opatbic medical journals. A box of twenty-four large
rattlesnakes was received by a museum proprietor in
Rochester. Having provided a long hempeocord, a
bottle of ammonia and some whiskey, " to be prepared
for an emergency," the owner, known as "Rattlesnake
Pete," unfastened the lid of the box and, as a large
snake darted out, seized it by the neck and carried it
to a table, while the long lithe body coiled round his
arm and the rattles were " singing away like grass-
hoppers."

Now comes the interesting part of the performance.
A piece of common window-glass was placed near the
snake's open mouth, and the rattler struck his wicked-
looking fangs, which were nearly an inch in length,
sgainst the glass, a thin stream of yellowish looking
liquid spurting upon it at each stroke. " Oh, he's full
oi it," said Pete. " There's poison enough right there
to kill twenty men." While he spoke he walked to-
ward the den, and giving the snake a quick twist, re-
leased him. The poison on the glass was absorbed
with sugar of milk, scraped into a bottle and carefully
lealed. The poison thus obtained is sent to certain
London homoeopathic physicians, who use it in their
practice as a medicine for diphtheria and other diseases
of a similar nature. The poison is supposed to be very
valuable. The process just described was repeated
with snake after snake, until all in the box were trans-
ferred to the den. After the first three or four were
taken out, Pete plunged his hand among the mass of
wrigglers with seeming impunity, dragging out his next
victim with a quick but certain motion. " These fel-
lows will give up their poison more readily to-morrow ;
they are a little sluggish on account of having been
kept in such close quarters for the past forty-eight
hours," said Fete, in response to the writer's query.

" Besides selling the poison, which I have told you
about," added Pete, " when a snake dies, I try-out the
fat of the reptile, and obtain from one and a half to
two ounces of a very penetrating oil, from a fair-sized
snake. This oil is worth eight dollars per ounce, and
if used as a specific for deafness."

HETEOBOUX3ICAL RECOBD.

For the week ending March 31, in Boston, aooording to ob-
servations furnished by Sergeant i. W. Smith, of the United
States Signal Corps:—

Baro-

Tbermom-' Relatire

Direction

VelooltT
of wind.

We-th'r.

meter

eter.

hnmldltr.

of wind.

•

Date.

\

i

9

i

i

*

1

M

M

a

>i

a'

a

>.

>%

1

a

•i

tu

K

•*

a:

■i

h

.4

i>

■i

■J

a

a

S

s

«

8

s

s

s

s

S

a

0

s

s

00

«■

C

<£

00

00

oo

<£

<i

R..2B

•.'9.89

42(62

33

84

88

86

8.

N.W.

10

16

0.

o.

M..2e

29.90

32

37

2)1

se

83

66

N.W.

W.

12

15

o.

c.

T..«

30.26

26

32

20

39

46

4^

W.

W.

16

19

c.

c.

W.28

30.47

30

40

21

44

40

42

w.

S.W.

16

11

c.

F.

T..29

30.03

38

40

33

78

100

89

s.

w.

12

4

N.

N.

F..30

30.00

39

47

31

66

41

M

w.

w.

12

-.4

o.

C.

S..31

30.01

46

67

36

46

63

64

w.

8.W.

7

16

p.

O.

tr

30.08

43

29

60

s

I

0.01
0.02

0.20
0.02

0.26

*0.,elead7t Colesri F..falrt O.,fosi H..has7i a,imok7i a.,mlBt T..thr««t-
cnlngt N.. inow. t IndlOfttM tra«« of r«mfall. V* Mmb for wook.

RECORD OF HOBTALITT
Fob tbb Waax aiiDixa Satubbat, Masoh 81, 1894.

i

to
1

1^

f

Percentage of deaths from

Cities.

1^

a

11

11
53

p

New York . .
Chicago . . .
Philadelphia .
Brooklyn . .
St. Louis. . .
Boston . . .
Baltimore . .
Washington

Cleveland . .
PIttsbarg . .
Milwaukee . .
NashTlUe . .
Charleston . .
Portland. . .
Worcester . .
FallBlver . .
Lowell . . .
Cambridge . .
Lynn . . . .
Springfield . .
Lawrence . .
New Bedford .
Holyoke . . .
Salem ....
Brockton . .
Harerhlll . .
Chelsea . . .
Halden . . ,
Newton . . .
Fltchbnrg . .
Taunton . . .
Qlonoester . .
Waltham . .
Qnlnoy . . .
Pittsfleld . .
Everett . . .
Northampton .
Newburyport .
Amesbury . ,

1,891,306

1,438,000

1.116,662

8TB,8W

Seo.uoo

4H7,397

eou.ooo

308,431
3U6,U00
290,000
!63,7u9

66,165
40,000
96,217
87,411
87,191
77,100
62,666
48,684
48,366
43,886
41,278
,12,283
82,140
31.S»ti
30,2«
29,394
27,666
27.148
26,972
26,688
22,068
19,642
18,802
16,686
16,331
14,078
10,920

S21

46S
340

2W

106
101
89
76
81
24

25

32
31

9
12

8
IS

11

17
10

10
11

8

7
2
2

s

354

140
123

71

32
41
36
40
10
6

1

8
IS

7
3
2
6

1
4

6

2
5

2

5

0

1
0

16.92

13.64
18.85

».40

4.70
15.84
16.68
11.97
22.61

4.00

9.W
22.61

8.33
26.00
15.38

9.m

10.00
10.00

12.50
60.00

16.76

12.10
14.79

26J8

15.04
10.88
16.110
20.00
12.92
12.48

20.00

18.78
12.82
33.33
8.'J3
60.00
16.38

11.86

4aoo

20.00
27.27

12.50

60.00
60.00

1.68

1.10

.87

.47

.89
3.36
2.68
3.28

3.23

26.00
15.38

9.09
12.50

8.40

7^6

8.70

6.17

2i2
1.98

7J2
6.46

20.00

6.46

z

IJW

1.98
2.61

1.41

4.96

4.48
:.33
3.28

^

Deaths reported 2,602: under five years of age 936; principal
infectious aiseases (small-pox, measles, diphtheria and croup,
diarrhoaal diseases, whooping-con^h, erysipelas and fever) 969,
acute lung diseases 116, consumption 2tiU, diphtheria and croup
157, scarlet fever 62, measles 37, diarrhoeai diseases 36, whooping-
cough 26, typhoid fever 21, erysipelas 16, small-pox 8,

From measles New York '24, Brooklyn 7, Philadelphia and
Milwaukee 2 each, Cleveland and Pittsburg 1 each. From
whooping-cough New York 7, Brxwklyn 6, Philadelphia 4, Cam-
bridge 3, Cleveland and Pittsburg 'i each, Somerville 1. From
typhoid fever Philadelphia 6, BoBton and Pittsburg 3 each,
New York, Cincinnati, Cleveland and Lowell 2 each, Springfield
and Maiden 1 each. From erysipelas New York 6, Brooklyn 6,
Boston, Cleveland, Ptttsbnrg and Plttsfield 1 each. From small-
pox New York 4, Brooklyn 8, Boston 1.

Digitized by

Google

876

BOSTOS MSDIOAL AND SURGICAL JOURSAL.

[Apkil 12, 1894

In tha tbirty-tbree greater towns of Engluid and Wales with
an estimated popnlation of 10,4S8,U2, for the week ending
March 21th, the death-rate was 19.8. Deaths reported 3,!n9:
acate diseases of the respiratory organs (London) 3iff, measles
162, whooplng-oough 123, diphtheria 81, scarlet fever 3H, fever
38, diarrhoea 26, small-pox (Birmingham and Oldham S each,
London 1} 11.

The death-rates ranged from 10.6 in Derby to 2S.1 in Salford ;
Birmingham 21.0, Bradford 17.6, Cardiff 18.2, Hull lti.2, Leeds
18.9, Leicester 19.8, Liverpool 23.0, London 20.3, Manchester 23.8,
Newcastle-on-Tyne 20.1, Nottingham 18.0, Portsmonth 13.1,
Sheffield 17.1.

OKKICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
UKPAKTMENT, U. S. ARMY, FROM MARCH 31, 1891, TO
APRIL 6, 1894.

Captain Edwabd C. Cabtib, assistant sargeon, will proceed
at once to Fort Spokane, Washington, and report to the com-
manding officer for temporary dnty.

Leave of absence for twenty-one days, to take effect on or
abont April 11, 1891, is granted Major Chablss L. Hxizxaxii,
surgeon, U. S. A.

The following named officers are detailed to represent the
Medical Department of the Army as delegates to the Association
of Military Surgeons of the United States, to meet in Washing-
ton, May 1, 18U1: Likct.-Col. William H Fobwood, deputy
surgeon-general ; Majok Robkbt M. 0'Rkil(.y, Majob Jossph
K. CoBSON and Majob Waltkr Rbxd, surgeons ; Caftaim John
L. Phillips, Captain G. L. Edu, assistant surgeons.

Fibst-Lixut. Hknrt O. Sntskb, assistant surgeon, is re-
lieved from duty at Fort Reno, Oklahoma Territory, and ordered
to Fort DuChesne, Utah, for duty at post, relieving Captaiii
Samdkl Q. Robinson, assistant surgeon.

Captain Robinson, on being relieved by Fibst-Likct.
Sntdbb, will report in person to the commanding officer,
Davids bland. New York, for duty at that poet.

Majob Pxtkb J. A. Clkabt, surgeon, will be relieved from
dnty at Fort McPherson, Georgia, by the commanding officer of
that post, on the receipt by him of this order, and will report in
person to the commanding officer, Fort Custer, Montana, for
duty at that post.

Fibst-Ijkut. Edwabd L. Munson, assistant surgeon, will
proceed without delay to CampMerritt, Montana, ancT report to
the commanding officer, for temporary duty at that post.

Fibbt-Likut. Cbablbb F. KumB, assistant snrgeon, hav-
ing reported at Hdqrs. Dept. Dakota, is assigned to tempiarary
duty at tit. Paul, Minn., and will report to the medical director
of the department for instructions.

SOCIETY NOTICES.

Masbacbdsbtts Mkdical Socibtt, SurFOLK District. -
The Section for Clinical Medicine, Pathology and Hygiene will
meet at 19 Boylston Place, on Wednesday, April Isth, at 8
o'clock

Dr. E. O. Cntler will report " Two Unusual Cases of Malaria,
one of Remittent Fever followed by Death, the other Success-
fully Treated." Dr. W. T. Councilman will show pathological
specimens and Dr. A. P. Chadbouroe will report on " The Clini-
cal Use of Halscin."

F. C. Shattdck, M.D., Chairman.

Hkwt Jackson, M.D., tiecretary.

AMERICAN MEDICAL ASSOCUTION.
San Fkancisco Mbktino.

The Committee of Arrangements for Transportation report
that after strenuous endeavors to secure for members of the As-
sociation a round-trip ticket to San Francisco for the cost of a
single full fare, they have so far succeeded that about one-half
of the railroads have favored the committee's petition. These
are chiefly the lines west of the Missouri, from which points
thirty-day tickets can be had over various lines for but little
more than a single fare. II arrangements can be made with
Eastern lailroads, over which there is more local travel, the
entile journey can be made for a very low price.

The Committee desire a concerted effort of the members in
the East to secure such reduction over lines east of the Missouri
River.

An Ezccbsion Train trom Chicaoo.

Dr. Liston H. Montgomery, of Chicago, announces that ar-
rangements have been made for a special train to leave Chicago
on luewiay, May 29th, at 10.30 p. k., arriving at Omaha,
Wednesday noon, and Etonver on Thursday morning at 7.30 of
the 31st. Stop overs will be granted to visit any of Uie sanitary

or pleasure resorts throughout Colorado. At Denver there will
be opportunity for a side excursion to any of the sanitaria or to
Silver Plume over the Georgetown loop. From Denver the
route is via Cheyenne, Ugden and Salt Lake City, where a stop
over a ill be made to visit the Lake and Garfield BMch. From
Utah the route is over the Southern Pacific and the train is doe
at San Francisco. The return will be made by the Shasta route.

BOOKS AND PAMPHLETS RECEIVED.

Report of Board of Health, City of Seattle, Fiscal Year End-
ing December 31, 1893.

Twenty-sixth Annual Report of the New York Ortbopsdie
Dispensary and Hospital, 1893-91.

Sixteenth Annual Report of the Presbyterian Eye, Ear and
Throat Charity Hospital, Baltimore, Md. 1893.

Annual Reports of the Manajjers and Officers of the New
Jersey State Hospital for the Year Ending October 31, 1883.

The Application of Graphics to the Fetal Heart Sounds. By
Hugh Hamilton, M.Sc., H.D., Harrisbarg, Fa. Reprint. 1893.

The Tannate of Mercnrr In the Treatment of SyphiliB. Gan-
grene of the Scrotum. By Charles W. Allen, M.D. Reprints.
1892-91.

Tariff Bill 1891 - H. R. 1,861, a* It Passed the House otBepre-
sentatives, February 1, 1891. Washington: Government Print-
ing Office. 1891.

The Proceedings of the Third Annual Meeting of the Associa-
tion of Military Surgeons of the United States, neld at Chicago,
Ul., August 8, 9, 10, 1893.

Bnrdett's Hoq|>ital and Charities Annual, 1891. Edited by
Henry C. Burdett. London : The Scientific Press. New York:
C. Scribner & Sons. 1894.

Longevity, with a List of Persons Known to have Lived One
Hundred Years or More. By Archer Atkinson, M.D., of Balti-
more, Md. Reprint. 1891.

Germania, a Monthly Manzine for the Study of the German
Language and Literature. Vol. V. 1893. A. W. and E. Span-
hoof, Editors, Manchester, N. H.

Reports of the Trustees and Superintendent of the Butler
Hospital for the Insane. Presented to the Corporation at its
Fiftieth Annual Meeting, January 21, 1891.

Transactions of the American Orthopedic Amoclation, Seventb
Session, held at St. Louis, Mo., September 19, 20 and 21, 1893.
Philadelphia: Published by the Association. 1891.

Three Years' Experience with the Electrical Treatment o(
Fibroid Tumors of the Uterus, with a Report of Forty-foor
Cases. By W. L. Bnrrage, A.M., M.U., Boston, Mass. Reprint.
1891.

Addresses by the President, Samnel C. Bnsey, M.D., at the
Celebration of the Seventy-fifth Anniversary of the Medical
Society, D. C, and at the Banquet, February 16, 1891. Wash-
ington. 1891.

The Human Element in Sex: Being a Medical Inquiry into
the Relation of Sexual Physiology to Christian Morality. By
Dr. Elizabeth Blackwell. New edition. London: J. & A.
Churchill. 1891.

Tait's Perineal Flap Operation. Critique of Macroscopic Ex-
amination of Specimens Removed in Thirty-two Consecutive
Laparotomies. Uy F. Byron Robinson, B.S., M.D., Chicago, 111.
Reprinte. 1893-91.

A Primer of Psychology and Mental Disease. By C. B. Burr,
M.D., Medical Superintendent of the Eastern Michigan Asylam;
Member of the American Medioo-Fsychological Association.
Detroit: Georges. Davis. 1891.

A Case of Contusion and Rupture of the Ileum with Peritonitis
without External Wound, Successfully treated by Coeliotomy
and Primary Enterectomy, Followed by Circular Enterorrha^y
(Maunsell's Method). By Frederick Holme Wiggin, M.D. Re-
print. 1891.

Lectures on Genito-Urinary Diseases. By J. C. Ogilvie Wile,
H.D., CM., F.R.S E., Consulting Snrgeon to the Aberdeen
Royal Infirmary, and Examiner in Surgery in the University of
Aberdeen. With numerous illustrations. London : The Scien-
tific Press. 1891.

A Case of Suprapubic Cystotomy in which the Bladder was
Distended with Air instefld of Water and Four Hundred and
Ninety-five Calculi Removed. Four Cases of Brain Tumor, In
Three of which Operation was Done [Two Operative Recoveries ;
Ultimate Death in All. By W. W. Keen, M.D. Reprints. 18M.

Aero-Tberapentics, or the Treatment of Lung Diseases by
Climate ; being the Lumlelan Lectures for 1893 Delivered before
the Royal College of Physicians, with an Address on the High Al-
titudes of Colorado. ISy Charles Theodore Williams, M.A.,M.D->
Ozon., F.R.C P., Senior Physician to the Hospital for Consump-
tion and Diseases of the Chest, Brompton ; Late President of
the Royal Meteorological Society. London and New York:
MacmiUan « Co. 1891.

Digitized by

Google

Vol. CXXX, Mo. 16.] BOSTON MEDICAL AJfD SURGICAL JOOBNAL.

877

Anginal ^ctideif *

FLAT-FOOT.i

BT S. H. BBADrOBD, II.D,

If both feet of a standing person are placed side by
side, they, with the two hollows which constitute the
arch, form a circle, the oater sides of the feet forming
weight-bearing rima. If one of the feet is removed
and the whole weight ia thrown upon the other, it will
be seen that the semicircular rim, or the portion which
touches the floor, becomes wider as the whole weight
of the body is thrown upon the limb. This is dae to
the fact that the centre of the axis of the leg falls to the
inner side of the weight-bearing portion of the sole ;
when one leg carries &e weight, the ankle sags to the
inside slightly, and the portion of the foot which
touches the floor is correspondingly widened. This
increase in the width of the contact portion of the
sole is accomplished chiefly by the eversion of the foot
in front of the medio-tarsal articulation and is checked
by the tibiales muscles and the ligaments. If these
muscles are weakened, the eversion of the foot will
increase if weight is thrown upon it, the check be-
coming the ligaments which bind the scaphoid and
metatarsals to the os calcis and astragalus.

If for any reason the muscles which hold the normal
posiUon of the foot are weakened, whenever the super-
inenmbent weight becomes too great for the muscles
to bear, the strain falls upon the ligaments, and this
in time causes pain and tenderness. This pain and
tenderness varies in severity, also in location. Id
some instances it is felt on the inner side of the foot
in the region of the scaphoid, often at the head of the
astragalus ; sometimes the pain is referred to the outer
side of the foot beneath the external malleolus. In
some instances it is felt at the insertion of the plantar
fascia to the os calcis, and sometimes a contracted
band in the sole of the foot, similar in all probability
to the fibrous cords to be felt in Dupoytren's contrac-
Uon.

An examination of a dissected foot will show that
the so-called arch of the foot is in reality two arches,
an outer and an inner, united to each other firmly by
ligaments, the outer arch being much lower than the
inner. The outer arch consists of a truss composed
of the five metatarsals, the cuboid and the os <»lcis ;
weight falling upon this passes through the astragalus,
which sits upon the end of the os calcis. What may
be termed the key-stone of this arch is the os cuboid,
which articulates with the head of the astragalus
slightly in front of the centre of pressure transmitted
throng the middle of the astragalus.

In the inner arch of the foot, the bow consists also
of the curve of bone from the head of the first meta-
tarsal and the os calcis, but the key-stone is slightly
anterior to that of its outer arch, and is the scaphoid,
which articulates with the astragalus on one side and
the cuneiform on the other. There is also a transverse
arch of the foot which, as has been pointed out by Dr.
Goldthwait, is of some importance clinically. When
weight is thrown upon the foot, the foot and leg can
be compared to a leg with two claws, the weight not
falling directly over either, but passing through the
astragalus, which sits side-saddle, as it were, over the
end of the os calcis. When the weight of the body is

' Bod before the Borgloal Section of the Suffolk Dtitrlot Medloal
Soeiety, V«bnuU7 T, 18M.

thrown upon both feet, but little sagging is noticed.
When the weight is borne upon one foot, either the
body is inclined to the outer side so as to bring the
centre of gravity directly over the outer arch, or the
foot falls to the inside and the base is broadened,
the inner arch descending and a movement of the in-
side taking place at the medio-tarsal articulation.
This sagging inward consists of the dropping of the
front of the astragalus with the scaphoid, that is, the so-
called plantar flexion of the astragalus occurs. There
is also a slight amount of inward movement of the
heads of the astragalus and os calcis. This motion of
sagging would continue until the heads of the astraga-
lus and the os calcis rested upon the ground, with com-
plete eversion of the foot if it were not that this is
checked by ligaments and by the tibiales musdes.

Flat-foot is developed not only by the weakening
of these muscles, as by a gradual stretching of the
ligament. Individuals stand in what Annandale has
called the attitude of rest. In this attitude, if the
muscles are weak and not in action, the foot may be
turned outward, and a greater amount of strain comes
upon the ligaments which are not relieved by the ten-
sion of strong musdes. After a while the ligaments
stretch, and the exciting cause remaining the same, a
deformity is produced by alteration in the shape of
the bones. It is probable, also, that faulty attitudes,
positions with the foot turned out, are brought about,
not only by occupation, but also by imperfect shoeing.

If a number of people be watched where they can
be seen walking towards the observer from a distance,
it will be noticed that peculiarities of gait are quite
marked, that at least four per cent, will be seen to toe-
out badly ; that an equal number will toe-in with one
foot ; a smaller percentage will toe-in slightly with
both feet ; a large number will be seen to walk straight,
that is, without eversion of the feet ; a number will
be seen to turn one foot out and the other foot in ; the
majority of children will be noticed to walk with the
feet straight The percentage of persons walking with
the feet out is larger among women than among men,
probably on account of the imperfection of shoes worn
by women.

Anything which may weaken the muscular strength
of the legs, or the musdes which are attached to the
feet, will indirectly influence the causation of flat-foot.
An increase of the superincumbent weight beyond the
muscular strength may directly cause flat-foot. Rapidly
growing children frequently show everted and flattened
feet. Athletes who lift unusual loads in feats of
strength develop flat-foot. In neither of these in-
stances, however, is pain usually observed, provided
the strain upon the ligaments is not too great. If,
however, the weight of a rapidly growing child in-
creases out of proportion to the muscular strength, or
if the muscular strength of the athlete is weakened in
his legs, strain comes upon the ligaments and pain de-
velops. Certain occupations develop flat-foot, espe-
cially those which necessitate continued standing upon
the feet. Flat-foot is characteristic of waiters, and is
frequently seen in hospital nurses. An important in-
direct cause of the development of flat-foot is imperfect
shoeing, particularly the lacing of boots tightly around
the ankle and some distance up the leg.

DIAON08I8.

Although there is no difficulty whatever in the recog-
nidon of flat-foot in its pronounced stage, yet in the

Digitized by

Google

878

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Apbil'19, 1894.

earlier Btages, especially in children, it is not infre-
quently overlooked. A careful examination is there-
fore important, as not infrequently cases of flat-foot
are not recognized, but also other affections of the foot
are considered and treated as flat-foot. The following
means will enable the physician to avoid mistake :

If a sheet of white paper is blackened over the flame
of a piece of burning camphor, a sooty surface is fur-
nished on the sheet of paper. If the patient be directed
to stand with the bared foot upon this smoked sheet of
paper, and the foot quickly removed without disturbing
the paper, an exact imprint of the foot will be seen.
In the normal foot not only is there a hollow extend-
ing two-thirds of the width of the foot and fully one-
third of the length, but the line on the outer side of
the foot should be straight or slightly convex with the
convexity outward. When there is eversion of the
foot this outer edge of the foot becomes slightly con-
cave with the concavity outwards. Where in addition
to this the scaphoid and the metatarsals come more in
contact with the ground, the hollow of the foot will be
diminished in size ; in extreme cases it may be entirely
lost.

It is important to recognize the amount of eversion
of the foot and to what extent that is to be seen. This
can be determined by examining the patient from be-
hind, placing the child erect upon a table and drawing
a line down the middle of the leg as far as the level of
the malleoli, and then from the heel upwards along the
middle of the line of the tendo-Achilles. In the nor-
mal foot these two lines should make nearly a straight
line ; if there is eversion of the foot, or rather, if the
OS calcis is thrown out of place, falling inwards, these
lines form a noticeable angle. Eversion of the foot
can also be recognized by marking a line along the
middle of the front of the leg, and also along the
middle of the foot. These in normal limbs should
form one and the same straight line ; if there is ever-
sion of the foot, they form an angle.

It is also important to determine, for the purposes
of comparison, the height of the hollow portion of the
foot, that is, the distance of the scaphoid from the
ground, both when the weight is applied upon the foot,
and also when no weight is so applied. This can be
readily done by measurements by means of a small
caliper. It will be readily seen that the amount of in-
ward sag when weight is thrown upon one limb varies
with different people. It exists to a slight extent in
all persons normally. The amount of inward sag is,
of course, proportionate to the amount of eversion, and
it is desirable to determine this, and also to note its
increase or diminution.

To recapitulate then, the examination of the foot
should consist first, of a sole imprint; second, in a
determination of the amount of eversion ; third, the
recognition of the depth of the hollow of the foot, and
next, of the amount of inward and downward sag
of the inner malleolus or inner surface of the scaphoid
when weight is thrown upon the foot. It is also ad-
visable to determine the amount of motion at the medio-
tarsal joint. In severe cases of flat-foot no inversion
is possible, and the foot is rigidly held everted.

PBOON08I8.

In growing children, flat-foot not infrequently cor-
rects itself. In many instances after flat foot has de-
veloped, no pain is caused and no acute symptoms, or
the reason that the muscles are sufficiently strong to

prevent exaggerated strain falling upon the ligaments
although the bones are displaced. Ordinarily, how-
ever, the affection is one which tends to become aggra-
vated and to increase, developing disturbances of the
foot in old age which cause much discomfort. Mal-
formation in the shape of the bones is also observed,
particularly in the head of the astrskgalus and os calcis.
Disarrangement in the length of the ligaments follow-
ing faulty position also takes place.

TREATMENT.

The treatment of this affection necessarily varies
according to the severity. In the lightest cases in
children no treatment is necessary beyond the furniab-
ing of proper shoes, and gymnastic exercises to develop
the tibiales and muscles of the feet.

As is well known, the shoe should be made with a
sole which is straight on the inside. In cases with
tendency towards flatpfoot, the sole should be made not
simply straight on the inner edge but with the inner
edge forming a curve with the concavity inwards ; all
tight lacing of the boots around and above the ankle
should be avoided. Gymnastic exercises of the feet
and legs are advisable together with massage. In cases
o£ children with pain in the feet and ankles, or where
an increase of the deformity and osseous change is to
be dreaded, support on the arch of the foot is needed.
This is also true in adolescents, and in cases in adalts,
where, as it is usually termed, the arch of the foot is
breaking down.

From the before-mentioned facts it would appear
that the cause of the development of flat-foot is the
inability of the arches of the foot to sustain the super-
incumbent weight without yielding more than is nor-
mal. This yielding is manifested by a dropping of the
heads of the os calcis and astragalus downward and in-
ward. If this is not checked a sensitiveness and strain
of the ligaments must follow. An examination of the
foot will show that, to prevent this sinking downward
and inward, support must be given to the foot, to
prevent this descent of the os calcis and astragalus. It
is manifest that if a support is placed under the hollow
of the foot existing when no weight is thrown upon
the foot, and this support sufficiently strong, it will
prevent any sinking down and in, when weight is
thrown ufmu the foot. Where the foot is not flexible
and is fixed in a position of eversion and such support
is supplied, the normal flexibility and position of the
foot must be regained.

The treatment of flat-foot consists, therefore, in the
severer cases, first, of means to restore the normal
position of the foot, and second, in means to prevent
the abnormal sinking of the foot under the superin-
cumbent weight. The first of these can be carried out
ordinarily by correcting the position of the foot with
the hand and applying of a pi aster-of- Paris bandage.
This bandage can be removed at the end of a week
and a second one applied. Ordinarily in the course of
three weeks, a sufficient flexibility of the foot will be
attained to render further treatment by fixation un-
necessary. Correction can, if necessary, be done under
an anaesthetic ; and in the severest cases osteotomy is
rarely necessary.

The second stage of treatment, namely, the furnish-
ing of proper supports to the feet is one requiring
some little attention. The supports vary according to
the shape of the arch of the foot. In the lighter cases,
a leather sole-plate can be made to answer. This pad

Digitized by

Google

Vol. CXXX, No. 16.] BOSTON MEDICAL AND SURGICAL JOURNAL.

379

can be made ia the following way : a piece of dressed
cow-hide is cut of a size sufficient to extend under the
sole and up the inner side as high as the scaphoid. It is
moistened and placed in the shoe, and the leather adapts
itself in a measure to the shape of the foot. This is
trimmed, dried, and the edges smoothed oS. A piece
of steel, which is bent so as to arch somewhat more
than the foot when the patient stands, fitting the inner
arch of the foot when the foot is slightly everted and
sustaining no weight, should reach from the front of
the portion of the os calcis which strikes the floor to a
short distance behind the head of the second metatarsal.
It should have arms which extend transversely across
the foot from the level of the scaphoid to beyond the
proximal end of the fifth metatarsal. The leather-
sole which is designed to protect the foot can be moist-
ened at any desired part and molded upwards as may
be desired to fit the sieel, the steel truss can be riveted
to this. When this is done, a strong support will be
furnished which, properly made, will not be uncomfort-
able and can be placed in any shoe. The steel after
it is fitted should be spring-tempered and should be
sufficiently strong as to bend but slightly under super-
imposed weight. If necessary, a second strip can be
riveted to reinforce the first.

It will be seen, however, that these plates are not
as firm as what can be furnished by metal. Metal
plates are more difficult to apply, but more lasting after
they are thoroughly fitted. In order to understand
the exact method of furnishing metal plates, it is neces-
sary to call to mind the anatomical conditions of flat-
foot. It will be seen that the heads of the os calcis
and of the astragalus should be prevented from de-
scending, that is to say, a pressure upward and slightly
outward should be exerted under the inner arch. In
order that this should not be painful, this pressure
should fall where the bones are less prominent, and it
will be found that this is slightly behind and below the
scaphoid. As the transverse arch of the foot at this
point slopes in a carved line downwards and outwards,
it is manifest that the support should transversely have
this same curve.

It must also be remembered that the so-called flat-
foot is in reality an everted foot, and that whatever
plate or support is worn, eversion of the front of the
foot must be prevented. In lighter cases this is readily
done by means of the ordinary shoe, which supports
the foot in a measure laterally. In the severer cases,
however, this will not be 8ufiicient,and shoes are neces-
sary so constructed that they force the foot in the posi-
tion of eversion of the front part. A combination of
a metal plate and these shoes will be needed in the
severe cases of flat-foot. The metal plate, it is need-
less to say, should be made so as to press only where
pressure is required and not where pressure causes
pain. The shape of the plate necessarily depends
upon the shape of the distorted foot, and the amount
of flattening of the arch as well us the amount of
eversion of the front of the foot. The plate is made
from a cast of the foot. It can be made either of
silicon bronze which can be polished, and will not
tarnish, or of bard rolled aluminum plates, but the
strongest and best plates are made of steel hammered
opon an iron cast of the foot taken from the plaster
cast. Care is necessary in taking the cast of the foot
that it should be put as far as possible in a corrected
position, otherwise the plates will not fit accurately.
In some instances it is necessary that the plaster cast

be shaved so as to increase the pressure at a desired
point ; this is, however, a matter which a little experi
ence will naturally suggest.

In the severest cases, however, something more
than this is required, for the reason that no plate can
be worn which exerts, in these cases, as much upward
pressure as is desirable. A series of successively
higher plates can be used, but the result can be more
speedily obtained by the use, in addition to plates of
moderate height, of the oblique made by raising the
sole on the inner side of the boots by lifts which are
shaved off to the inner side so that the outer edge is not
raised at all. In an adult the thickness should be in
severe cases as much as three-fourths to one inch on
the inner side. When this is applied, the patient is
obliged to walk on the outer edge of the foot and ever-
sion is prevented. As the patient's symptoms improve,
the strained ligaments become rested, the weakened
muscles strengthened, this sole can be removed and a
metal plate substituted.

The satisfactory treatment of flat-foot does not con-
sist simply in furaiahing a support to the arch of the
foot, but in placing the foot in such a position that the
superincumbent weight does not fall upon a widened
surface of the hollow of the foot which eversion at the
medio-tarsal articulation brings in contact with the
ground, but upon the normal semicircle which the outer
part of the sole constitutes, together with the ball of
the foot and the heel.

OSMORRHAGE INTO THE PANCREAS AS A
CAUSE OF SUDDEN DEATH.»

With Report of a Cask of HiEMORRHACic and
Ganorbnous Pancreatitis.

BT W. F. WHITIfEY, M.D., BOBTOy.

Fbou its hidden position, the pancreas is, perhaps,
the one vital organ which is most frequently overlooked
at the post-mortem, and yet its lesions are so important
that no autopsy is regarded as complete without a dis-
tinct mention of its condition. This is especially neces-
sary in a legal examination, where a person in pre-
viously apparent good health is found dead. And
in making an examination, it should be the invariable
rule after inspecting the greater peritoneal cavity to
separate the layer of omentum between the stomach
and large intestine, and explore the lesser peritoneal
cavity. At the posterior part of this cavity the pan-
creas should be seen, extending from the duodenum
almost to the hilus of the spleen. It can readily be
made out as a lobulated gland, the separate lobules of
which stand out in slight relief against the fat tissue in
which it lies imbedded; its more reddish-gray color
also distinguishes it. Its shape is roughly like a ham-
mer, the head being spread out along the duodenum,
and the handle (or tail) stretching towards the spleen.
Its length is about 7f inches, its breadth If inches,
and its thickness f of an inch. Its weight is 2^ ounces.
Its duct, which will admit a fine probe, opens with
the common duct of the liver in the papilla, about six
inches below the pylorus, in the duodenum. The
mouth of this duct is slit-like, and is not esksily
found, in practice, a good way is to pass a probe
down into the intestine through the gall-duct, which
can always be easily found by its bile-stained wall ;

> Bead tx a meeting of the Uansobnsetu Medloo-Legal Sooiety,
February 7, 18H.

Digitized by

Google

380

BOSTOS MEDICAL AUD SURGICAL JOUBSAL.

[Apbil 19, 1894.

then to 8lit ap the papilla for a little digtance on this
gnide ; and upon carefnl search, a little opening will
be found about one-eighth to one-quarter of an inch
from the tip through which the probe easily passes
into the pancreatic duct. Occasionallj the duct has
a separate opening of its own into the intestine, and
then it ia more difficult to find. But pressure on the
gland will often force out a drop of fluid on the intes-
tine near the papilla, and thus its seat can be located.
Examination of the duct should also always be made,
as its occlusion or inflammation may be the cause of
important changes in the gland itself.

After death the pancreas rapidly undergoes decom-
position, and its cellular elements are frequently so
altered that but little reliance is to be placed on the
microscopic examination.

The pancreas is often the seat of cancer, and fatty
degeneration is recorded, an increase of the connective
tissue causing a cirrhosis of the organ ; then, too, the
duct is freqnently tortuons and dilated, or the organ
may be partly or wholly transformed into a cyst. All
of these changes require time for their completion,
and the physician has usually been called long before
death, not always able, perhaps, to diagnosticate the
exact condition, but, at any rate, convinced in his own
mind that death, when it came, was from natural
causes.

There have, however, been a series of cases reported,
rare, it is troe, where a person died suddenly after an
illness of which the time had been fixed as varying
from half an hour to twenty-four honrs, and where the
only lesion found was a greater or less haemorrhage in
and about the pancreas. Fitz, in his monograph on
acute pancreatitis,' gives sixteen cases which he has
collected. Since then (1888) only three or four cases
have been reported, showing that the condition is one
of the rarest that occurs.

From an examination of these cases, it appears that
the pancreas is red, usually somewhat enlarged, and
the outlines of the lobules mapped out by dark-red
lines, for the hemorrhage almost always follows the
interlobular connective tissue, wtiich can be seen micro-
scopically to be infiltrated. The amonnt of blood
poured out was, in the majority of cases, comparatively
little, perhaps one or two ounces, not enough to be the
direct cause of death. There are two or three excep-
tions to this, one recently published by Seitz, where
over two quarts flowed out upon opening the abdomen,
and the source of the haemorrhage was from the region
of the pancreas. And this is the only case on record
in which the haemorrhage is sufficient to account for
death.

As to the cause of the haemorrhage, we are as yet
entirely in the dark, and also as to the reason of death.
None of the theories advanced cover all the cases.
One, that the flow of the blood over the cardiac axis
causes compression of the great sympathetic ganglion
and arrests the heart, does not seem to be borne out
by the condition of that organ, which is found filled
with blood. Another, that the haemorrhage is due to
disturbance of the central nervous system, similar to
the haemorrhages of the lung, meets with little support,
as it was associated with this condition in only one
case. To say that it is due to a trophic nerve disturb-
ance is to confess our ignorance, as the physiologists
have failed to demonstrate any trophic nerve other

> Flti, B. H. : Aoote PanoraatlUs. Oapples uid Hard. Boston.
1888.

than the vaso-motor nerve. And until this is done,
their lesions can hardly be spoken about. The alco-
holic habit has been marked in a number of the caset,
but drunkards are not the only ones who have died io
this way. Fat persons and lean ones have alike sac-
cnmbed ; the preponderance of the sex, however, it
male, and usually past middle life.

What we know on the subject can be briefly sammed
up as follows : lu rare instances, death has suddenly
followed attacks of greater or less severity referred to
the epigastric region. At the autopsy, a haemorrhage
of varying amonnt has been found in the pancreas and
its vicinity as the only lesion.

This was the conclusion arrived at by Dr. F. W.
Draper several years ago,' and, as far as I have been
able to learn, nothing new has been added to it. His
cases are the beet single series that have ever been
presented and give ns more real knowledge than any
others.

Although the above covers the entire subject of
pancreatic haemorrhage, I should like to trespass a few
moments longer on your time and call attention to the
subject of acute haemorrhagic pancreatitis and its se-
qualae, which have been so well worked out by Dr.
Fits in his monograph. I have seen a number of
cases, and I have the specimen here of a case of this
comparatively rare lesion of which I made the autopsy
last week. In haemorrhage into the pancreas the ex-
travasation is the only lesion found. There are no
evidences of an inflammatory condition in the organ,
no cellular infiltration. In acute haemorrhagic pancre-
atitis, in which the symptoms are of longer duration,
from twenty-four hours to two or three weeks, usually,
however, terminating within the first week, we do find
alterations in the organ which point to an inflamma-
tory condition. The organ, as a rule, is enlarged.
There are single or multiple haemorrhages throughout
its substance, but they are not recent. The blood is
not fresh ; it has already been changed and very often
it can only be made out from its coloring matter and
not from the presence of any of the red corpuscles.
With these there may be more recent haemorrtiages,
and a greater or less infiltration of the connective tit-
sue with round cells — evidences of an inflammatoiy
condition of the organ. With this is also almost inva-
riably associated a condition which is called fat necro-
sis. Throughout the fat tissue, especially in the neigh-
borhood of the pancreas, in its interlobular fat tissue,
in the root of the mesentery, at times in the omentum,
and (in one case reported, all the fat tissues of the
body were involved) are found opaque, white areas,
quite distinct from the ordinary tissue. The pres-
ence of this necrosis has given rise to a theory, ad-
vanced first by Balzer, that it is the primary condition,
and the haemorrhagic pancreatitis is the secondary one.
He considers that the changes in the fat tissue are due
to disturbance in nutrition in fat people (and it should
be mentioned that these cases of acute htemorrhagic
pancreatitis are very frequently associated with an
overproduction of fat) in whom the fat has gradually
undergone degeneration, has eroded the vessels in their
neighborhood, and in this way the haemorrhage has
occurred. Fitz, on the other hand, regards the areas
of fat necrosis as dae to the action of pancreatic juice
or some of its products on the fat tissue itself. Fiu's
theory has this point in its favor, that in the greater
number of cases the necrosis seems to start first in the

> ^Xlaos. Ahoo. Amerloan FhjiioUuiB, voL 1 (1886>, t*S» 243.

Digitized by

Google

Vol. CXXX, No. 16.] BOSTON MBDIOAL AND 8USGI0AL JOURNAL.

381

neighborhood of the pancreas, where it ig always the
most extensive, and when it is found in moderate
d^;ree it is in that region alone. This would point to
its being a local condition, and one referable to the
pancreas rather than part of a general condition. On
the other hand, anch a case as Formad's, where the iat
necroses were found throughout the entire fat substance
of the body, does point to some cause, central in
origin, which causes its destruction in these small
necrotic areas. It is possible that some ferment of the
pancreas may be absorbed into the blood, and in this
way, of course, receive a general distribution. For
the present, we have to consider each of these as a
possibility. There is no question about the associa-
tion of these fat necroses with hsemorrhagic pancreati-
tis. For the causal relation, we shall have to have
more light on the subject from the careful observation
of future cases, and now that attention has been at-
tracted to it on both sides of the water, it will un-
doubtedly be found.

In the specimen I have just passed about, we
find that the hemorrhagic pancreatitis is largely
of the organ as a whole; the size is rather in-
creased if anything, but there is no question that it is
the pancreas that we have to do with. On the other
hand, there is a series of cases (I made the autopsy in
one last week), in which, apparently after one of these
attacks of pancreatitis, the pancreas became entirely
necrosed, remaining simply a slough. It lies almost
as a foreign body in the place where the pancreas had
been, and if it were not for the knowledge of what
might occur, we should have difficulty in recognizing
that it was the pancreas. The notes of this case,
which occurred in the practice of Dr. Bush, have
kindly been given me by him, and are as follows :

"The case is that of a widow, aged thirty-three,
whose family history is good, with the exception of
father, who died of cancer of the rectum.

*' December 18, 1893. The history obtained' was
that for a year and a half she had eaten very little
food, having had a very small appetite, and hsid kept
np with stimulants. She would not eat regularly ; in
fact, the sight of food or the odor of cooking produced
nansea. Yet at times she would help herself to sar-
dines, cold chicken and sach cold lunches as she could
pick up from the cold closet or the refrigerator.

" When I saw her she was suffering from an attack
of vomiting, accompanied by urticaria, which was very
troublesome. The wheals were all over her body.
The legs were somewhat swollen about the ankles.
There was insomnia. The tongue had a light brown
coat, and there was constipation. These symptoms,
with the exception of the inability to sleep, rapidly
disappeared upon treatment.

" There were no renal complications and no pain.
There was a great deal of lassitude. Under appro-
priate treatment, these features disappeared to a
marked degree, and she was able to take nourishment,
the quantity of stimulants taken being diminished, and
with the exception of not being able to sleep, she was
feeling better than she had been for two years.

"January 14th, she was up and about the house as
usual, and in the afternoon was taken with severe pain
in the left hypochondriac region. The pain was so
severe that it required large doses of morphine, given
sttbcutaneously, to quiet it. At one time two grains
of morphine were given within forty-five minutes, the
pain being so acute. There was emesis and abdominal

extension. There was pain on deep pressure over the
above region, and the bowels were constipated. The
abdominal pain and vomiting lasted four days, accom-
panied with marked tympanites ; at the end of that in-
terval there were a few movements of the bowels.
The general pain seemed to subside, but there was
always pain upon pressure from the left back through
to the front. The temperature was taken twice a day
regularly, and sometimes of tener, but was never found
to be higher than 101.8°. The rate of the pulse
averaged 90. Shu was able to take a certain amount
of milk in small quantities, and there was no vomiting
for eight days, at which time she obtained some
whiskey, of which she drank considerable, and the
pain, distention and vomiting recurred. The matter
ejected was of a green color, something like creme de
menthe, and was mixed with mucus. The stools were
extremely fetid in character. There were no urinary
symptoms. Death occurred February 1, 1894."

At the autopsy, the abdomen alone was examined.
Upon opening it, there was no evidence of any general
peritonitis; the whole lower portions of the bowels
were perfectly smooth and free, but on looking at the
upper part the stomach appeared to be very much dis-
tended, and was greenish in color. On puncture,
there at once came up a yellowish, thin pus, by esti-
mate two quarts, and, exploring further, it was found
not to come from the stomach, but from the lesser
omental cavity. Then I suspected it was a case of
pancreatic disease. The specimen was removed entire,
and afterwards dissected. The stomach and duodenum
were opened, and nothing of marked importance
found. A probe was passed through the gall-duct,
and by this guide the opening of the pancreatic duct
was found, which is a little whitish track running
about one-half au inch and then opening freely, with
a slightly jagged edge, looking as if eaten off, into the
cavity of the lesser peritoneum. In this lies a sphac-
elated mass, all that remains of the pancreas. A little
portion of pancreatic tissue is still adherent to the in-
testine, and the black discoloration is evidence of the
hemorrhage which had taken place at some time into
that organ. The pus had burrowed into the root of
the mesentery on both sides, but had not broken
through into the general peritoneal cavity.

On looking at the case, there is no question that the
grave symptoms are of only two weeks' duration ;
that this extensive destruction of the pancreas could
have occurred within that time, seems almost incredible.
But we have reason to think that is probably the case.
It is possible and even probable that the earlier attack
in December was one of acute hsemorrhagic pancreati-
tis, and the condition continued until the necrosis of
the organ began at the time concurrent with the
second attack (January 14th), when the pus began to
form and the peritoneal cavity to be distended. So
this gangrenous pancreatitis is to tte looked upon as
the result of the hsemorrhagic pancreatitis.

There is still one other form of inflammation of the
pancreas associated with the formation of the pus
within the organ, which is spoken of as suppurative
pancreatitis, and in which the disease is usually of long
duration. It is a question, perhaps, of months — some
deaths, however, occurring within the first month.
But, as a rule, it has a longer course than acute hsem-
orrhagic pancreatitis. It is very rarely associated
with any evidence of bleeding into the organ itself,
and only rarely with any evidence of fat necrosis.

Digitized by

Google

382

BOSTON MBDIOAL AND SURGICAL JOURNAL.

[April 19, 1894

THE LEACH CASE.»

BT THOMAS M. OOBKLL, II.D., OP ■OKSBYII.LB.

On the erening of April 26, 1891, abontsix o'clock,
I was called to the house of Dr. H. M. Leach, in
Somerville, by the doctor, who told me that a servant-
girl at his house had been taken with a fit. He said
that he had used ordinary restoratives and that they
had failed. I went with the doctor to the house and
upstairs into a back room. At the head of the stairs
we were met by Mrs. Leach, wife of the doctor, who
said, " The girl is dead, she died while you were away."
Dr. Leach then told me a most plausible story, which
was corroborated by his wife, of the girl's previous ill
health — that she had had a severe attack of the
grippe, was a sufferer from chronic lung-trouble, and
was subject to attacks of fainting.

I examined the heart, and found that it had ceased
to beat. 1 also examined the pupils, aud in so doing
noticed that the nose was very cold.

The whole story was apparently so straight — and
there was really no cause for suspicion, except a very
remarkable degree of excitement on the part of the
doctor and his wife — that I told them that I would
sign the certificate, and went away.

Later in the evening, the relatives of the girl called
upon me, and told me an entirely different story about
her sickness and death. According to their account,
the girl had been well up to within two weeks of her
death, and they had known nothing about her sickness
except what had been told them by the Leach family.
They said that the family had told them that Mary
was sick, and that the doctor had given her ether to
extract a tooth, but that no one of her friends had been
allowed to see her before her death.

While this was going on, the undertaker came and
said that the bed-clothes and the girl's clothing was
saturated with blood.

With these statements I deemed a further examina-
tion necessary ; and on the following morning I made
an autopsy in the presence of Drs. W. D. Swan and
John F. Couch.

Autopiy. — Mary Murphy, twenty-two years old.
About seventeen hours after death. Rigor mortis
present. Dependent parts of the body bluish-purple
color. Bloody froth exuding from mouth and nose.
Right side of ueck swollen. Pupils moderately and
equally dilated. Abdomen prominent. Breasts small
and flat ; areolee slightly marked ; whitish-yellow fluid
exuded from nipples on pressure. There was a quan-
tity of gas in the peritoneal cavity. The parietal
peritoneum was opaque and gray. The blood-vessels
were injected, and covered over with yellow, fioccnlent
masses. The omentum was dark and friable, glued
to the intestines ; loops of the intestines were matted
and glued together. There was considerable grayish,
turbid fluid in the pelvic cavity. The luugs were nor-
mal. The heart was empty : its right side was flabby ;
there was a firm mixed clot in the right side ; other-
wise it was normal. Spleen soft. Kidneys normal.
Liver soft ; there was a circumscribed patch on the
external aspect of the right lobe, corresponding to a
spot on abdominal parietes, covered with sloughing
yellowish material.

On raising the uterus an irregular shaped hole was
observed in its posterior surface. Immediately behind

s Read before the MaaaaohnHtU Medloo-Legal Soeiaty, February
7,1894.

this, lying transversely in the pelvic cavity, was a
laminaria or sea-tangle tent. This tent was about the
size of the thumb; one end of it was irregular in shape
and corresponded exactly in shape to a hole which was
seen in the walls of the uterus. The vagina was of a
dirty slate color, and at the posterior commisaare was
an abrasion through the mucous membrane, the Result
of violence. The os uteri was patulous and was lacer-
ated by many radiating fissures (the result of violent
dilatation). The uterus was three and three-eighths
inches in breadth at the fundus and four and one-half
inches in depth. The internal surface was covered with
decomposing material ; and uear the fundus were por-
tions of placental tissue, also decomposed. The tubes
were normal. The left ovary was normal ; the right
contained a corpus luteum in the state of a cyst of
about the size of a cherry. The hole in the uterine
wall was plainly to be seen on the inner surface, aud
extended directly through the substance of the organ.
The bladder contained a small quantity of bloody
urine; the organ was normal. The brain was nor-
mal.

The death was due to septic peritonitis, the result
of an abortion.

The case has been tried twice ; and both times the
jury have returned a verdict of " Guilty." The first
verdict was set aside on exceptions, and the exceptions
on the second case are now pending.

Some very interesting questions were raised at these
trials. The most important of these was the denial of
the pregnancy by the defence, and the attempt to show
that the material found in the uterine cavity was the
result of a membranous dysmenorrhoea. A disease
which Dr. Thomas says that he thinis he has recog-
nized five times in bis whole life, aad of which Dr.
Davenport, in his very valuable book on " Diseases of
Women," doubts the existence ; and yet a disease with
which the men and women who testified for the defence,
werd very familiar; one young homoeopathic man
having had fifty or a hundred cases of it in a town in
Maine of about six thousand souls. This claim was
readily set aside ; yet I am convinced that in another
such case I should have a microscopic examination
made by au expert.

Another question was as to whether a girl, pregnant
for the first time, advanced three or four mouths in
pregnancy could introduce a sea-tangle tent into her
own uterus. This was strongly denied by the govern-
ment ; and yet a man of good standing in Boston came
onto the stand for the defence and swore that from
statements made to him by other women, he considered
it not only possible, but probable, that this could have
been done.

Another of the questions was as to the method in
which the tent got into the pelvic cavity. My own
theory was, that the tent was put in, and after a time
an attempt was made to withdraw it, and in so doing
the string was pulled out (the string was gone, the end
of the tent split, and there were marks of forceps-teeth
or something of that kind on the same end) ; that then
the operator became frightened and made a desperate
effort to get the tent with the forceps, aud that in his
efforts be pushed the tent through the already softened
uterine wall. This theory was supported by the direc-
tion of the wound, that is, in the axis of the outlet.
The defence claimed that the girl put it in herself, aud
that it worked its way up into the cavity (?) of the
uterus and then ulcerated its way through. If this were

Digitized by

GoDgle

Voi. CXXX, No. 16.J BOSTON MSDIOAL AJSD SUM6I0AL JOmtlTAL.

888

posaible, the direction of the hole would have been just
opposite to what it was.

The case was most obstinately fought by all the
forces which money could provide, with able counsel
and all sorts of so-called medical testimony ; and yet
a verdict was secured in both cases.

Nora.— Since writing the above the Supreme Conrt has over-
mled the ezceptioni in the second case, and the prisoner has
been sentenced to seven years' hard labor in the State Prison.

T. M. D.

Clinical SDqiartment.

TWO CASES OF LITHOLAPAXY."

BY QAKDICBa W. ALLBH, K.D.,

Smytim te tht Otaito-Urinarg Department, Boston Diepentary,

The following cases seemed to present some points
of interest, and may, perhaps, be considered worth
reporting.

Cask I. A. S., fifty-seven years old, has been under
my treatment for chronic cystitis and stricture at in-
tervals for about four years. Micturition has been
abnormally frequent and more or lessdi£Bcult for many
years, requiring occasionally the use of a catheter. lu
February, 189<i, I advised internal urethrotomy, as the
stricture, which admitted a Mo. 24 sound with difi^nlty,
was not only a source of irritation, but interfered with
catheterization. This proposition was declined by the
patient, and a little later he purchased a catheter at a
price which seemed to him a bargain. The first time
he used it, it broke oS iu the urethra. After many
futile attempts at removal ha was seen by Dr. Burrell,
who the next day did perineal section and removed
that portion lying in the urethra, an inch or more being
still left in the bladder. Not being prepared for cys-
totomy, Dr. Burrell desisted from further attempts at
removal, and urged the patient to go at once to the
hospital, which he declined to do. After this he suf-
fereid considerable and steadily increasing discomfort
until July 16th, when I found him in great distress.
Micturition was very frequent and diiScult, and accom-
panied by an amount of suffering which was painful to
witness. The passage of a sound immediately dis-
closed the presence of stone. The patient refused to
go to the hospital, and as I was obliged to be away for
several days 1 was unable to arrange for an operation
until July 25tb. On that day 1 did litbolapaxy with
the assistance of Dr. W. £. Chenery and two sons of
the patient. The possibility of being obliged to cut
for the stone suggested itself, and I also rather expected
to begin with an internal urethrotomy ; but as the li-
thotrite and No. 23 tube would pass, though with dif-
ficulty, it was decided not to complicate the operation.
The patient took ether very badly, and it was impossi-
ble to get him thoroughly ansesthetized. His constant
writhing and the difficulty of breaking up the stone
with its rubber nucleus sufficiently to pass through the
small evacuating tube caused considerable delay, so
that it was two hours and a half before the bladder
seemed clear. The detritus removed consisted of frag-
ments of phosphatio material mixed with pieces and
bits of red rubber and, when dry, weighed 124 grains.

The patient was much relieved by the operation, al-
though, of course, he still had his cystitis, considerably
aggravated by the experiences of the last few months.

> Bead before the Snigioal Seotion of the Solfolk Dlatriot Medical
Boeletr, Febmar; 7, 18*4.

He passed fragments of stone and bits of catheter at
intervals, and an attempt to pump out the bladder with-
out ether about two weeks after the operation was
unsuccessful on account of pain. Internal urethrotomy
was done August Slat, and the calibre of the urethra
brought up to 34. After recovery from this, the
searcher still seeming to show fragments in the bladder,
the patient was etherized September 28th and the blad-
der pumped out through a No. 31 tube. Only a small
amount of sand was brought away, — no fragments.
After this, repeated examinations with the searcher
failed to reveal any foreign body, and for a while the
patient's condition seemed much improved. But the
cystitis gradually grew worse, in spite of treatment,
until marked relief was afforded by injections of iodo-
form.

Case II. The patient was a Syrian, twenty-eight
years old, totally ignorant of the English language,
and apparently of rather less than average intelligence.
Through an interpreter it was made out with some dif-
ficulty and vagueness that when ten years old he was
supposed to have a stone in the bladder and that an
American surgeon in Beyront wished to do lithotomy,
but the parents would not consent. After that he had
no symptoms until about a year ago, when he began to
have frequent and difficult micturition gradually getting
worse until he was obliged to urinate every fifteen or
twenty minutes, with great pain. When he came to
the dispensary, August 15, 1893, he was having a mild
chill and complained of abdominal pain. The tem-
perature taken a few hours later was normal. The
urine was loaded with pus and was very foul, filling
the room with a fetid odor. Examination with the
searcher showed stone in the bladder.

The next day the patient was seen at his home. He
complained more of abdominal pain, most severe in
the left inguinal region. Examination of the abdomen
was negative ; the abdominal walls were retracted and
bard, and not especially sensitive to pressure. No
great importance was attached at the time to this ab-
dominal pain, which was supposed to be of a colicky
nature. The temperature was now 101'', the pulse
rapid and rather weak, and the tongue dry. There
was evidently constitutional disturbance, which was
attributed to septic absorption from the bladder ; and
it was thought best to remove the stone and wash out
the bladder at once.

The operation of litholapaxy was done under ether,
with the assistance of Dr. R. F. Chase and ten or a
dozen Syrians, friends and relatives of the patient.
After the first crushing there was some difficulty in re-
moving the lithotrite, and there was then first noticed
a bright red tumor, the size of a large orange, behind
the scrotum. It was rather a startling discovery, but
was soon made out to be a prolapsed rectum. It was
easily reduced through the very patulous anus, but
immediately reappeared every time the patient strained
in the least, which was very often. One of the assis-
tants was detailed to hold it constantly up, but it pro-
lapsed as often as his attention was distracted by any-
thing of interest in the proceedings, and it proved
quite an annoying complication, delaying the operation
considerably. The interior of the stone was very hard
and was crushed with difficulty. The operation was
rather long, but the patient stood it well. The blad-
der was washed out with a boric-acid solution.

The stone was apparently about the size of an Eng-
lish walnut, and consisted of superficial layers of phos-

Digitized by

Google

384

BOSTON MSDtOAL AlfJ) SURGICAL JODRJfAL.

[Apbil 19, 1894.

phatic deposit with a bard, dark-browo nnclen* a*
large as a bazel-nnt, preaomably aric acid. A good deal
was lost daring tbe operation ; tbe remainder, when
dried, weighed 188 grains.

The next morning tbe pulse was fair, temperature
normal, and tongue coated bat moist. Tbe character
of tbe urine was improved, and mictarition was less
frequent and painful. The patient complained less of
abdominal pain. In tbe afternoon there was recur-
fence of abdominal pain accompanied with hiccough.
Tbe abdominal walls were still retracted and tbe pain
continued most severe on tbe left side. The patient
vomited once and bad no appetite. Temperature nor-
mal. Tbe bladder was irrigated with borio-acid solution.

Tbe second day after the operation, August 18th,
the abdominal pain bad increased. There was great
seusitiTeness to tbe touch, and tympanites bad de-
veloped during the night. There bad been no more
vomiting. The tongue was moist. Tbe temperature
was normal ; the pulse very rapid and weak. The
urine had become foul again, but there was no difficulty
with micturition. The bladder was washed out as
before. Tbe patient failed rapidly during the day and
died at 8 p. m.

Looking back at this case after it was all oyer, it
seemed evident that there bad been from tbe beginning
a grave aiid probably necessarily fatal abdominal com-
plication which was not appreciated, partly on account
of tbe difficulty of communicating with him and partly
because the urinary symptoms not only overshadowed
all others but appeared to account satisfactorily for
his general condition. That the state of the bladder
bad at least a share in tbe causation would seem to be
indicated by tbe apparent temporary improvement
after tbe operation.

RECENT PROGRESS IN SURGERY.

ttt a. I. BaKRBLI., II.D., AMD H. W. CVBHIMO, M.D.
KTHKB AND OHLOBOrOBU IN ANABTHK8IA.

KoBTE ^ has read an interesting communication on
this subject, in which he shows tbe tendency to sub-
stitute ether for chloroform. The statistics, as pre-
sented before tbe Association of Gierman Surgeons,
were: 138,122 cases of chloroform anssstbesia, with
46 deaths, or 1 death for 2,894 cases. According to
the statistics of Kappeler, 53 deaths occurred in 152,-
260 cases, or 1 in 2,878.

He gives a subcutaneous injection of morphia before
ansesthesia. In using ether, as much as from 30 to 50
grammes (1 to 1'^ fluid ounces) should be poured on
the apparatus at first, but once tolerance is established,
tbe amount required is small. Tbe patient should be
allowed to make several deep inspirations at tbe begin-
ning of etherization. At the end of one minute, tbe
mixture of gas in the apparatus becomes constant, con-
sisting of 2.8 to 4.7 per cent, of ether, 16.6 to 18.7 per
cent, of oxygen, and 1.2 to 1.7 per cent, of carbonic
acid; in other words, less than a tenth part of the
carbonic acid necessary to exert an injurious influence.
Tolerance is established somewhat more slowly with
ether than with chloroform, requiring seven and a half
minutes. Since Dr. Korte has used ether he has ansea-

1 DratMb* Med. Zeltung, Febmary U, 18M ; The UnlveiMl
Medical Joamal, March, ItiM.

theticed 600 patients, each operation - requiring from
100 to 200 grammes (3.25 to 6.5 fluid ounces) of ether,
according as tbe operation lasts one-half to one hour.
All tbe patients bore the anasstbetic well. There wu
no slowing or weakening of the pulse, blood-pressnre
being sometimes even elevated.

However, there is a special action on respirstioii,
the bronchial secretion increasing under ether, a rhon-
ous being at first produced, which would necessitate
the suspension of chloroform ansestbesia, but which
has no significance when ether is used. Vomiting was
observed only sixty times in the 800 cases. The period
of excitement is longer, but the sleep is calmer. In
32 cases only were the patients restless, exhibiting
signs of discomfort. In one case, complete narcons
could not be obtained, though 430 grammes (14 fluid
ounces) of ether were used. In three cases tetanic
muscular contraction rendered the operation more dif-
ficult. In such cases about 20 drops of chloroform
placed on the mask will cause the cessation of tbe con-
tractions. After anaesthesia, tbe awakening is pleasant,
and is soon succeeded by a natural sleep, due prpbsbly
to the preliminary injection of morphine. It has been
stated that ether produces nephritis; and in order
to test the troth of this assertion. Dr. KSrte examined
the urine in a series of cases, before and after narcosis.
Of these, 203 had no albuminuria either before or
after operation. In seven patients there was albumin-
uria before etherization, but the nephritis from which
it originated was in no way modified. Albnminaris
was observed after ansestbesia in only six cases previ-
ously free from it. The influence of ether upon
bronchial inflammation is incontestable, although it
cannot be said that pneumonia is more frequent after
ether narcosis. Recent bronchitis, however, should be
considered a contraindication. Ether was given to
patients suffering from empyema, in whom chloro-
form would have been dangerous on account of tbe
heart. In such cases, nevertheless, the ether should
be at once suspended as soon as a large quantity of
fluid is observable in the bronchi.

As regards tbe inflammatory nature of ether, this,
is but a minor inconvenience, requiring only the simple
precaution of avoiding the use of the Pacquelin thermo-
cautery about tbe face, mouth, nose, etc. Patients
who have submitted to both ether and chloroform,
state that the sensations of anaesthesia by the former
are more disagreeable, but tbe awakening is less pain-
ful. The writer's experience confirms this.

COOAINB IN HEMOPHILIA.

Yon Manteuffel* (Dorpat) reporu the successful
treatment of a severe case of prolonged bleeding follow-
ing tbe extraction of a molar tooth of a boy aged
twelve years. After two days of unsuccessful treat-
ment by various devices and drugs it was determined
to use s Pacquelin cautery. A preliminary injection
of cocaine at three places in the gum about the site of
the extracted tooth caused the bleeding to immediately
stop. The injection bad to be repeated, however, at
intervals of five or six hours for some time before the
bleeding was permanently controlled.

ON THE INDICATIONS TO BK DBAWN FBOM TBK
UBINB AS TO THE 8AFETT OF ANJE8THXTICS.

At a meeting of the Clinical Society of the New
York Post-Graduate Medical School, Dr. W. H. Po^
> Deatioh. Med. Woeh., ItW, No. ».

Digitized by

Google

Vot. CXXX, No. 16.] BOSTOBT MBDIOAL AND SUROIOAL JOURNAL.

385

ter * presented a paper on anaeBthetics and the indica-
tions as to their safety, presented by the state of the
urinary excretion. The paper is worthy of careful
consideration, and he draws the following practical
dedoctions from this chemico-physiological analysis of
chemical phenomena :

(1) That ether and chloroform act upon the same
principles, but with results developed by slightly dif-
ferent methods.

(2) That both are capable of producing death at the
time of the anaesthesia; chloroform more frequently
than ether.

(3) That ether causes as many, if not more, deaths
than chloroform, but the fatal issue is delayed until
the patient has been removed from the operating-table.

(4) That by a careful study of the density of the
urine and its causes, we are in possession of exact in-
formation by which w« can determine the precise nutri-
tive condition of the system, and be forewarned as to
the possible outcome of the anaesthesia. It also enables
as to judge which anaesthetic is best adapted to the in-
dividual case in qnestion.

(5) We are taught that neither ether nor chloro-
form should be administered until the glandular organs,
in their necessarily damaged states, are put in the best
possible condition to endure this extra strain. When
this is a general rule, many cases that now prove fatal
will be saved.

(6) It teaches that every public institution should
have a paid physician who is competent to examine
the nrine, and determine through it the status of the
physiological economy before giving the anaesthetic.
It should also be the duty of this same physician to
administer the antesthetic, for he alone knows best
which anaesthetic to select with a given condition of
the system, and is also better able to gnide the patient
safely through the autesthesia than one who knows
nothing of the constitution of the patient except from
a second party.

(7) While it is clear that death in some instances is
directly due to the primary effects of the ether and
chloroform, and in others to secondary effects, it should
not deter as from using them, but stimulate us to be
more thorough masters of their actions apon the sys-
tem, and thus to guard against their ill-effects. When
all this is accomplished, chloroform will probably hold
the first place as an anaesthetic.

OPERATITK PB00EKDIN08 IN iLDTANORD A.OE.

Gibson * has presented an interesting paper on this
subject, having collected 65 cases, all aged seventy or
more, with a mortality of 16; and of these, eight
deaths were due to urtemia, the death occurring, on an
average, on the fifteenth day. There is an absence of
shock as the cause of death, and the use of iodoform
is to be avoided in advanced age.

THK 8UBOICAL TBBATHKNT OF PCLM ONABT 0ATITIR8.

N. P. Dandridge,* in a paper presented to the New
York State Medical Association, presented this subject,
and arrives at the following conclusions :

(1) A certain number of lung cavities can be success-
fully dealt with by incision and drainage.

(2) Tubercular cavities in the lower portion of the
lungs — if single and superficial, and the general con-
dition of the patient permits — should always be

> The P(Mt-Qndiiat«, Jalj, 18SS ; Annali of Surgery, October, I8S3.
• AjuuUs of Sargerr, toI. ztIU, No. 4, October, lgS3.

> DM., Febnury, UWt.

opened. Cavities at the apex should only be opened
where free and persistent expectoration is present, and
has resisted treatment, and the rest of the lung is not
involved.

(8) Abscess, gangrene and hydatid cysts should be
opened and drained whenever they can be located.

(4) Closure of the pleura should be present before
evacuation of a cavity is attempted.

(5) In cases of pyo-pneumothorax the fistulous tract
should be explored, and any cavity freely laid open by
the cautery.

(6) Cavities that have been opened are best treated
by packing with gauze, preferably iodoform.

(7) The further careful trial of such agents as iodo-
form, chlorine gas and chloride of zinc is desirable to
determine as to whether the tubercular infiltration may
not be modified by them.

(8) It is very desirable, for the further extension of
surgical interference in pulmonary cavities, that the
means of locating such cavities and of determining their
size, and the exact character of the tissues that over-
lies them, should be perfected by further study, and
for the accomplishment of this the surgeon must look
to the physician.

OA8TBOSTOMT IN ONE 8TAOE.

F. T. Paul * has contributed an illustrated article,
and recommends the following method of opening the
stomach at one operation, with power to feed the pa-
tient at once :

" The proceeding is very simple. The preliminary
stages of the operation are conducted as usual, but
when the stomach is picked up, a portion of it is drawn
out of the wound, and two running sutures of fairly
stout silk are passed in a circle round the site of the
intended opening, with their ends in opposite directions,
care being taken not to include the mucous membrane.
The opening is then made, and, each side of it being
grasped with artery forceps, one of my small (3-8 in.)
intestinal glass drainage-tubes is inserted, and the liga-
tures are drawn tight and tied. The exposed portion
of the stomach is now washed and returned into the
abdomen, the external wound drawn together with fish-
ing-gut sutures, and the ends of the stomach ligatures
tied over two glass rods crossing the wound, in order
that the stomach may be kept in close contact with the
peritoneal surface of the abdominal wall. The wound
is then powdered with iodoform, dressed with cyanide
gauze and salicylic wool, and a bandage applied, a
piece of jaconet being placed outside over the dressings
to preserve them from becoming soiled. The experi-
ence of many bowel cases has shown me that these
tubes separate between the third and seventh days ;
therefore, from the moment of the completion of the
operation to the third day, the administration of food
or washing out the stomach may be carried on with
impunity. On the morning of the third day, the wound
should be dressed, and from this time until the tube
separates, and it is clear that good adhesions have
been formed, discretion should be exercised as to the
amount of food given and the care with which it is ad-
ministered."

ENTEBO-ANA8TOM08I8 FOB MALIGNANT 8TEN08I8 OF
TUB DIOK8TXVE TBACT.

F. H. Markoe ^ has contributed an interesting paper
upon this subject, exhibiting two patients upon whom

* Laooet, Deoember SS, IStS.

* AddsIi 01 Snrgery, IVtbrnary, ISM.

Digitized by

Google

886

S08T01H MEDICAL AND SURGICAL JOVJtJfAL

[Afril 19, 1894.

be bad operated for Bymptoms due to maligDant atrict-
are of the digestive canal. He gammariEes aa follows :
As a resalt of experience, we endeavor to operate aa
early in the diaeaae aa poBsible, or if debility is already
preaent, poatpone interference until, by mean* of ays-
tematic lavage with carefal gastric, supplemented by
rectal nonriaQment, the general condition improves.
We have alao learned :

(1) That the size of the anastomotic opening must
be huge on account of the tendency to contraction.

(2) That in case of the stomach it should be aa near
aa possible to the greater curvature and nearer the
fundus than the pylorus, so as to be not only aa far
distant as possible from the disease, bat at tbe same
time, in the most favorable situation for the passage of
tbe contents of the stomach into tbe intestine.

(8) That tbe jejunum, about thirty inches from the
pylorus, ia the proper portion of tbe inteatine to ap-
proximate, and that ita opening ahonld be placed mid-
way between mesenteric attachment and extreme con-
vexity.

(4) That in the approximation the loop mnat be ao
arranged that ita periataltic wave corresponds with
that of the stomach.

(5) That the tide of opinion seems to favor a union
which shall represent, as far as possible, that of the
different anatomical layers (the ideal operation), rather
than through the medium of artificial uda (Wolfler,
Halsted, Barker, Abbe).

(6) That as in all intra-abdominal operations, our
manipulations must be so performed as to favor tbe
slightest degree of ultimate adhesions between adjacent
atructnrea.

NON-PARASITIC CT8T OF THB LITBB.

A rare and interesting case was reported by MttUer
at tbe twenty-second German Snrgiod Congress.' It
was probably a cysto-adenoma of the biliary dncts in a
woman aged fifty-nine. Tbe tumor was quite large,
of alow growth, and at the time of operation (ten years
after tbe growth was firat noticed by the patient) it
filled the abdominal cavity and part of the pelvis. It
was mistaken for an ovarian tumor. At operation the
tumor was found to be a large cyst containing over
six litres of a chocolate-colored fluid (bEemorrhage into
the cyst), and was attached to the liver, which appeared
normal, by a thick, hollow pedicle. The cyst wall was
thick, bled profusely when cat, and was formed of tbe
remains of hepatic tissue with cystic dilated biliary
ducts. Tbe tumor was benign, that is, non-recurrent.
The patient was free from recurrence at the end of
one and one-half years.

8FBIN0TBBPLASTT AFTBR EXTIRPATION OF THB BEO-
TUH.

Willema, of Gent,* in order to avoid the diatreaa
ing rectal incontinence occaaionally seen after extir-
pation operations, has attempted to form a muscular
sphincter by following and modifying the suggestion
of V. Hacker for gastrostomy and colostomy. He has
successfully demonstrated his plan on the cadaver, but
not on the living subject. It consists in bringing the
resected end of the rectum out through a slit in the
fibres of the gluteus muscles, near its origin from the
border of the sacrum, and suturing it to the skin.
This slit he would make two centimetres long and
parallel with the muscular fibres.

• BelUss s. Oantbl. (. Obir., UM. Bd. xz. M.

• GentbL f. Ghlr., 1893, Bd. zx. Ml.

This waa reported in April, 1898. In March,
Gerauney operated in Vienna by a method which was
intended to overcome the aame difficulty, namely,
rectal incontinence.** He aolved the problem by
twiating the proximal end of the reaected rectum on
its long axis till its lumen was sufficiently closed.
This was determined by the introduction of the finger
during the torsion. When this waa aocompliahed the
end was sutured to the skin. Gersuney operated on
two patients suffering from rectal carcinoma. The
sphincter ani was destroyed, but the rectal stump coald
be broDght down to the skin. Both cases rapidly re-
covered without the sutures giving way. One had no
incontinence from the first. The other at first was
unable to control liquid dejections, but later (at tbe
end of eleven weeks) recovered perfect control over
the contents of the rectum.

These two procedures seem to offer a means of
overcoming this painful and disagreeable sequel which
has deterred many from operating on these patients,
and they deserve conaideration. They can be com-
bined, perhaps, to advantage in some cases, since the
Gersuney method is applicable to tboae caaes where
the excised end can be united to the skin in the usual
way. The Grersuney method can also be used in
forming an artificial anus where the intestine is resected
so aa to leave a free end.

INTB8TINAL BE8E0TION.

Haasler reporta a successful resection '* where it was
necessary to remove fifteen centimetres of the ileum
with ita meaentery, the ileo-cecal valve, caecum, vermi-
form appendix, ascending colon, hepatic flexure, and
one-half of the transverse colon with the attached
mesentery. The disease was an adeno-carcinoma which
involved all the above tiaaues with the mesenteric
lymph and retroperitoneal glands. The patient was
well one year after tbe operation.

8DTURB OF WOUNDS OF THB LIVER.

At the recent Surgical Congress in Rome, Micheli ^*
showed a case in which he had succeaafuUy sutured a
wound of the liver. Laparotomy having been per-
formed, it was found that the wound was situated on
tbe convex 'surface of the left lobe, near the free mar-
gin ; it waa four centimetres in length and two in
depth, and was directed vertically towards the lower
margin of the organ. A moderate amount of hemor-
rhage had taken place. The edges of the wound in
the liver substance were brought together with fire
silk sutures and the abdomen closed. The patient (a
woman) made an uninterrupted recovery and was dis-
charged cured in twenty days. In a case of gun-shot
wound of the liver, the author applied fifteen silk
sutures and the haemorrhage was so thoroughly con-
trolled that no trace of bleeding having taken place
could be found four days after the operation, when
death occurred from peritoneal sepsis.

THE TBBATMBNT OF EXUDATIVE TDBBRCULOUS PERI-
TONITIS BT HEAN8 OF INTRA-PERITONEAL INJEC-
TIONS OF STBBILIZBD AIR.

Nolen ** baa arrived at the concluaion, after a num-
ber of obaervations, that curative results can be ob-

w C«ntbl. f . Chlr., ISSS, Bd. zx, fifiS.

>> C«utbl. r. Chtr. Bellage, 1S83, Bd. zz, 81.

>• Rlf. Mad., Norember 7tli; BrltUh Uadloal Joariul, DM«mb«r >.

tsas.

•>,.B«rl. kUn. Wodi., US3, No. 34, p. 8U.

Digitized by

Google

Vol. CXXX, No. 16.] BOSTON MEDICAL AND SUltQlOAL JOURNAL.

887

taiued bj injecting sterilized air into the peritoneal
caTity through the opening made for the evacnation
of the ascitic floid. He has tried this method in three
cases successfully. In two cases the cure was perma-
nent ; in the third, the patient was too much exhausted
prior to the treatment to have recovered.

The method is as follows : Sterilized air, contained
in a glass jar, is expelled by means of hydrostatic
pressore and passed through sterilised cotton, then
tbrougG warm, sterile water, and finally passed, by
means of the puncture needle, into the peritoneal
cavity. This is carried out until the abdomen is tense.
The process is reversed by removing the hydrostatic
pressure.

BESKOTION OF THK KIDNBT.

Kiimmel has reported his experience in this method.^'
After successful experimentation on animals, from
which more or less of the renal parenchyma had been
removed without detriment to their general condition
or impairment of renal function, he operated on two
patients. One was a woman forty-one years of age.
The operation showed extensive suppuration, abscess
formation and a renal calculus. About one-third of
the kidney was excised. The patient was well at the
end of three years after the operation. The other pa-
tient was a man fifty-four years old. Here a piece
the size of a walnut was removed from the upper ex-
tremity of the right kidney. The remaining defect
waa dosed by suture. He recovered from the opera-
tion in three weeks, but was not relieved. He was
later found to have carcinoma of the bladder, which
caused his death ten weeks later. The autopsy showed
that the right kidney had perfectly healed, but was
affected by interstitial nephritis. The excised portion
of this kidney showed also the same process. In a
third case, a woman aged thirty-four, an echioococcus
cyst, the size of a ben's egg, was removed from the right
kidney in a wedge-shaped section. The defect was
closed by sutures. About one-half of the kidney was
removed from the centre of its convex border without
injuring the pelvis. The patient recovered. Other
successful cases by Czerny, Bardenhauer, Socin and
others, were reported by Kttmmel.

Bloch (Copenhagen) has resected a small portion of
a kidney which, on microscopic examination, showed
bacterial infection. The operation was done for diag-
nostic purposes ; and notwithstanding the infected
condition the defect, which was closed by five or six
cat-gut sutures, healed by first intention.

Siister has also removed an embolic infarction by
resection from a patient aged thirty-two.

Kftrnmel recommends the convex border of the kid-
ney as the most favorable site for resection, on account
of the coarse of the renal vessels.

CBANOBS AMD DBOKNBRATIOM8 IM MAYI.

Beboul '* states that in a certain number of cases
the Dwvi disappear after birth. If any changes occur
in them, or whenever they show signs of extension of
malignant degeneration, they should be removed.
They are most likely to undergo malignant degener-
ation of the melanotic variety. They should be re-
garded as infectious, and great care should be taken
to prevent a local infection becoming general and lead-
ing to a fatal termination.

" C«ntbL f . Chlr., 1888, Bd. XX, p. T8.

" Arab. a«n. da MM. ; Brltiiih Madloal Joonial, Ootobw 21, 18>8.

SURGICAL TRBATHENT OF OBRVIOAL, THOBAOIO
AND ABDOMINAL ANEURISMS.

C. B. Nancrede ** has presented the above subject to
the Surgical Association, and submitted to them for
their discussion the following propositions :

The TVeatment of Cervical Aneurisnu.

(1) All methods should be supplemented by recum-
bency and diet.

(2) Proximal compression, when feasible, should
always be tried, and where the arterial coats are seri-
ously diseased should supersede ligation.

(3) " Needling " should supplement pressure when
the case is progressing rapidly ; possibly it is advisable
in all cases suitable for compression, and is certainly
to be employed where this method fails in cases with
highly atheromatous vessels.

(4) Proximal ligation, having been rendered much
safer of late by the use of aseptic precautions, less
absorbent ligatures and the avoidance of all injury to
the arterial walls by employing the "stay-knot," is
permissible when the arterial walls are relatively sound
until experience decides whether or not " needling " is
superior in its results.

(.5) Since recurrence after proximal ligation almost
certainly results from non-deposition of white thrombi,
and their maintenance in contact with the aneurismal
wall from lack of proper changes in its lining, " nee-
dling " is then clearly indicated.

(6) Where the location prevents proximal arrest of
the blood current " needling " is the best operation ;
possibly distal compression — rarely feasible — aught
aid in the deposition of thrombi.

(7) For the reasons already given, although occa-
sionally successful, the indications for the permanent
introduction of such foreign bodies as wire, horse-hair,
etc., into aneurismal sacs are so much better met by
"needling" that such procedures had better not be
adopted.

(8) The modern revival of the older method of ex-
tirpation of aneurisms should not be attempted for
spontaneous cervical aneurisms.

Tht TVealmmt of Thoraeic Aneurisms.

(1) All methods should be aided by the employment
of rest in bed and diet.

(2) The permanent introduction of foreign substances
should not be employed.

(3) "Needling" should be tried, aided by distal
compression, when feasible, during use of the needles ;
if this fails, distal ligation should be resorted to.

(4) Distal interruption of the blood current by
simultaneous ligation of the carotid and subclavian
arteries may be tried.

(5) " Needling " is indicated when complete or par-
tial failure follows distal ligation.

7%e IVeatmeiU of Abdominal Anettrismt.

(1) All methods should include recumbency and diet.

(2) "Needling," when this can be done without in-
jury to the hollow viscera, is the most promising plan.

(3) Proximal or distal compression may be tried,
with or without " needling," but to be effectual must
be done under anaesthesia.

(4) The permanent introduction of foreign bodies
into the sac is unadvisable (see proposition No. 7,
Carotid Aneurisms).

ITobteoiUlMUtd.)
u Annals of Sargary, Saptembar, I8SS.

Digitized by

Google

388

BOSTOSr MEDICAL AND SVRGIOAL JOVltSAL.

[Apbil 19, 1694.

SURGICAL SECTION OF THE SUFFOLK DIS-
TRICT MEDICAL SOCIETY.

OHABLBS L. BODDDBB, K.D., BBOBKTABT.

Rboclab Meeting, Wednesday, February 7, 1894,
Dk. Abnek Post in the chair.
Db. G. W. Allen read a paper entitled,

TWO OASES OF LITHOLAPAXT.'

Dr. H. L. Burrell : The patient that Dr. Allen
has so inccessfully operated upon came under my care
last March with a catheter lodged in his urethra at the
junction of the membranous and bulbous portion. The
patient showed us the portion of the catheter which
was broken off, and which was one of those dangerous
catheters sold by pharmacists, composed of rubber and
sulphur, which become friable upon keeping.

He was advised to have a perineal section done and
the catheter removed. This, however, he declined,
and went home. I was induced, much against my
will, to try to extract the catheter at his home per
urethra. A portion of the catheter was removed by
forceps, but it finally broke off, and undoubtedly a
piece of the catheter slipped into his bladder and
formed the nucleus of the stone which Dr. Allen has
removed. The operation was completed by opening
his perineum and washing out the bladder, with the
vain hope that the fragment would be removed. He
was told that it would be necessary to have a further
operation performed in order to secure the lost end of
the catheter that rested in his bladder. This he de-
clined, and he is, of course, to be congratulated on the
successful removal of the fragment and the calculus
which has formed about it.

Dr. Watson : Dr. Allen's first case, that in which
a bit of a red-rubber catheter formed the nucleus of
the stone, suggests a matter in connection with the
choice of operation for stone which is interesting, I
think, and which I feel should receive rather more at-
tention than it sometimes does. I refer to the method
of removing stone after rapid fragmentation through
the wound of an ordinary external perineal urethrotomy.
This method, which dates back for a long period, has
been advocated by Mr. Reginald Harrison, and still
more recently by Surgeon Major Keith, under certain
conditions, the most important one being obstructive
prostatic hypertrophy of such nature as to make the
passage of instruments from the meatus especially
diflficult ; or again, where there is present some condi-
tion which makes the stone very difficult to crush,
such as its having a foreign body for a nucleus, a scft
substance, like that in Dr. Allen's case, or a bit of
lead, for example, or in cases in which there is a large
stone, the crushing of which by the ordinary means
would require a long time. Under such conditions
this very simple perineal operation recommends itself,
and the surgeon should not hesitate to adopt it, even
after having begun to do the usual crushing operation,
whenever these conditions arise. The only death I
have had thus far from operating for stone would, I
think, very likely have been averted had I employed this
method of operation. It was a case in whidi the pros-
tatic urethra was exceedingly difficult to pass a lithAtrite
through without some injury, owing to the encroach-
ment of an enlarged prostate, and I think the deep
' Sm pace 883 of tbe Jounutl.

urethra was slightly wounded, and that death was the
result, probably, of the injury.

Dr. Post ; It is a little curious to me to see how
nicely Dr. Allen succeeded in pulverizing that catheter.
My own experience would lead me to think a catheter
was an extremely difficult thing to pulverize with s
lithotrite. Generally enough elasticity remains to
make it difficult to break up into small enough frag-
ments to remove through the ordinary apparatus.

Dr. E. H. Bradford read a paper on

flat-foot.'

Dr. Harrington : For myself, I have always liked
the metallic foot-plates better, for the reason that the
other foot-plates, I think, are apt to give way. Yoa
often get relief from a new pair of well-fitting boots,
but as they are worn and sag they get misshapen, and
cease to give relief. I think the same trouble comes
with plates which are not metal. The subject has
been treated more from the anatomical point of view,
and without much reference to symptoms. They who
do not study flat-foot might expect all feet which need
support to show deformity. We sometimes get the
most painful feet with very little of what we woald
call flattening, very little that would show from trac-
ing or measurement.

Dr. Fitz, of Cambridge : In order to test the ques-
tion of the occurrence of flat-feet, I have been mining
arrangements to get footprints of Indians, negroes and
whites on a large scale, to see how far the occurrence .
is distributed. For that purpose, I have experimented
somewhat as to a method for quickly taking large
numbers of footprints, and have devised one which
may be of interest to the Society. I have in mind
getting the ratio between the length of the feet and
the breadths of the ball of the foot, the arch and the
heel, and summing this up for the different races, to
see whether there is a distribution of flattening, and
how it occurs in relation to age as well as to nation-
ality, and especially to see if it occurs more or less
frequently among those wearing an arch-supporting
shoe.

Dr. Nbwkll : I have been very much interested in
hearing Dr. Bradford's very interesting observations,
and also to see the method of making the various im-
pressions in the way just described by Dr. Fits. 1
have been always very much opposed to the use of
plates in any form for flat-foot. It seems to me these
observations under the varying degrees of pressure
show conclusively that the arch of the foot is an elastic
movable apparatus that changes its height in accordance
with the amount of weight you bear upon it. Although
I have seen a good deal of flat-foot in the physically
reduced cases, it seems to me the pain was due to ab-
normal tension, to weakening of the ligaments, and the
condition has been one of wasting away of muscles or
ligaments or both, and one which in almost all cases in
my experience has shown marked improvement in
improved physical conditions. I think there is no
question that as a temporary means of relief a plate
for flat-foot is useful except that it has the disadvan-
tage that being placed under the foot it presents a very
abnormal condition iu the shape of a rigid, inflexible
arch that keeps up a constant pressure atrophy, and
patients who have come to me wearing flat-foot plates
I have known to suffer a great deal from pressure
atrophy ; so that it seems that except as a measure of
' 8«a page 177 M the JonmaL

Digitized by

Google

Vol. CXXX No. 16.] BOSTON MBDIOAL AND SUJiGICAL JOVRNAL.

38d

temporary relief the lue of plates of any kiod is con-
traindicated.

Db. Harrimoton : We ase foot-plates a good deal
as we use crotches ; we do Dot use them after the pa-
tient can get along without them. Among the severe
cases of fiat-foot there are many cases in which it
woold be absolutely impossible to get relief without
foot-plates. I believe most thoroughly in the proper
position of the feet, proper methods of walking, etc.
The danger from pressure is not great, if the press-
ure is improper we get callosities and we soon find it
out from the patient. The foot-plate is only a tempo-
rary means of support. Many patients wear plates
for a few months and then give them up entirely or
use them only from time to time.

Dr. Goldthwait: Very little remains to be said
upon the subject of flat-foot, after Dr. Bradford's paper,
as flat-foot is generally understood, that is, an oblitera-
tion of the lougitudiual arch of the foot. Much less
attention has been paid to the transverse arch which is
an anatomical fact, and which at times becomes oblit-
erated, and requires treatment of as definite a nature
as in the cases in which the longitudinal arch alone is
flattened. It is to this special point that I wbh to
confine my attention.

Normally, across the metarso-phalangeal articulation
is a slight arch which becomes obliterated as the weight
is borne upon the foot, but which re-forms as soon as
the weight is removed. In this way the weight is re-
ceived upon the inuer and outer sides of the foot.
The normal tracing, or impression, of the foot has this
sharp re-entering angle with this tongue running up
under the ball of the foot. When the arch is obliterated
this sharp angle is lost, and the weight is borue more
upon the middle of the foot. This condition is almost
invariably present in the cases of metatarsalgia, and
the acute pain is at once relieved by the correction of
the arch. A specially constructed metal plate or
leather pad has been used in this condition.

Db. Bbadfobd: I am glad Dr. Newell brought
that point out, for I meant to have laid stress on the
fact that it is important that patients with flat-foot
should be treated with gymnastic exercises and massage.
The treatment of flat-foot varies accordiug to the se-
verity. In the mildest cases shoes and gymnastics are
all that is needed. In the less mild cases I think some
slight means of throwing the foot over are needed and
in these cases the soft plate is sufficient. In the severer
cases, temporarily a strong support is important, and I
am inclined to think we shall be able to get along very
well with the leather strengthened by steel. The
strong metal plate will probably be needed in the
heavier cases. I do not quitb agree with Dr. Newell
that this necessarily causes pain. If adjusted right, I
do not think pain is caused. Although, of course,
there is danger of muscle atrophy during the use of a
plate, the same may be said as to the application of
any appliance, which is only to be used when this is
unavoidable.

Dr. Nbwbll : I have been misunderstood if I made
any one think I thought the plate caused pain. My
experience has been that the plate relieves pain. What
i referred to is pressure atrophy. I have seen patients
who have worn rigid metal plates a long time and the
muscles and soft parts have been very much atrophied
from non-use and constant pressure over a rigid metal-
lic arch. What I have always found best is correction
of position and the use of flexible springy supports.

especially the leather ones. I once had a baby two
years of age brought to me with a beautiful pair of
aluminum bronze flat-foot plates in its shoes.
Db. O. K. Newell read a paper on

THE INTEBMITTENT RAPID DILATATION OF OBETHBAL
STBICTDRB.

The paper called attention to the generally admitted
fact that all strictures which can be at once treated by
the introduction of metallic sounds are best effected by
gradual dilatation. That true organic urethral strict-
ure, like OBSophogeal and rectal strictures, is incurable,
and let alone tends with greater or less rapidity to re-
contraction. The paper then described a method of
treating all very small calibre strictures where no prog-
ress with metallic sounds can be made, or where they
have progressed to partial or complete retention. This
method consisted in using a series of dilators similar
in operation and construction to Dr. Newell's divulsor
described some time ago. These dilating staffs range
in size from No. 10 F. to No. 80 F., and their purpose
is to do away with the old operation of immediate full
divulsion by intermittent rapid dilation, say first from
Nos. 10 to 14 or 18, then from Nos. 18 to 20 or 24,
and so on. All strictures are thus made practically
amenable to gradual dilatation. No detention in bed
is necessary, even where there is retention, and pa-
tients are able to avoid being incapacitated from work.
Also when the dilating staffs are passed in on the
guide, the danger of making false pockets, as with a
free metallic sound in small calibre strictures is avoided
and the operation is made mechanically certain. It
being only a question of how much stretching to do at
each sitting.

Db. Watson: I should like to ask in how many
cases Dr. Newell has tried this method.

Db. Newell : I have adopted it now during the
last two and a half years. I have in that time treated
no case of stricture in any other way. I suppose I
have treated seventy to eighty cases in this way. I
never yet have had any case that has not been able to
keep at work. It is true, as Dr. Watson cites from Sir
Henry Thompson's and his own experience, that slight
disturbance of very small strictures often causes more
trouble than radical interference. But by this method
we do not interfere slightly, but moderately. Dilating,
for instance, with retention, from the filiform up to
Nos. 16 or 18 F. This relieves the retention, but is
not violent enough to disable the patient, who may go
about his work after the procedure.

Db. Watson : Would you claim greater immunity
from mortality when this method is used?

Db. Newell : I do not think there is any mortality
from divulsion.

Db. Watson : The reason I ask this question is to
bring out one matter with which Dr. Newell's experi-
ence in this series of cases differs widely from that of
some other surgeons ; for example, from Sir Henry
Thompson's, who states very clearly, what other sur-
geons have also held and what I find to be true in my
own operations, namely, that frequently far greater
constitutional disturbance and more serious symptoms
arise (especially in cases of the tighter strictures) after
an incomplete operation than you will have after a full
divulsion or internal urethrotomy or dilatation, et& If
Dr. Newell can show in a large number of cases that
that is not true, it will te of decided interest to me.
When I first began to do rapid dilatations and internal

Digitized by

Google

890

BOSTOm MEDICAL AUD SVMGICAL JOVB^AL.

[April 19, 1894.

urethrotomies, I osed to be a little afraid of carrying
the operation! to their fall limits ; but I found that
the least constitutional distnrbance occurred when I at
once fully restored the calibre of the strictured por-
tion of the urethra to its normal size, and the most
serious followed upon partial restoration only.

I do not quite understand whether Dr. Newell classes
this method which he describes as divulsion or dilata-
tion ; nor do I understand what Dr. Newell means
when he says that the operation of internal urethrotomy
is not applicable to structures of small calibre — for,
of course, it is well known, that with the instrument of
Maisonnenve any stricture through which a filiform
bougie can be passed can readily be divided by an in-
ternal urethrotomy,

Dk. Docqlas Gbaham : These cases are entirely
out of my line of practice. The method of Dr. Newell
is evidently a sort of internal massage. Several years
ago some foreign surgeons reported a number of cases
of stricture of the urethra successfully treated by mas-
sage after the so-called failure of other means. As
soon as a bougie could be passed through the stricture
this made a good substratum over which to use massage
from the outside. By this combined method of grad-
ual dilatation from the inside, and massage externally,
thickening, narrowing and spasm were got rid of.
Where practicable it would certainly seem to be a ra-
tional and natural procedure. But the mere mention
of massage in such regions is su£Bcient to incite in some
minds the idea of immorality, as it probably reminds
them of some indiscretion of their youth which must
have been a very different thing from mattiting a
stricture. " Evil to him who evil thinks."

Da. Newkll : Intermittent dilatation ; no divulsion
is done at all. This is not a divulsor. I think it has
been the experience of surgeons in the last few years
that when they sterilized things there was very little
heard of the so-called catheter chill. When I have
seen it, it has seemed to me to be of the reflex class.

Dr. Newell said in answer to questions that this
method was applicable to strictures regardless of their
situation. One had to go slowly with penile ones, and
there was rapid progress with the others usually.

He was opposed to cutting a stricture under any
form. One must have a pretty large stricture in order
to cut it. The mere linear incision of a stricture only
added a cicatrix to what was already a cicatrix.

MASSACHUSETTS MEDICO-LEGAL SOCIETY.

r. W. DBAPBB, M.D., SBOBBTABT.

Beodlar Meeting, February 7, 1894, Da. Z. B.
Adams, the President, in the chair.
Dr. T. M. Ddsell reported

THE LBAOH ABORTION CASE.*

Da. W. F. Wbitnet : In regard to the question of
membranous dysmenorrhoea. If the examination of
the membrane shows the presence of villi of the
chorion, that is indubitable proof of the existence of a
pregnancy, for these are only formed from the ovum ;
they can never be formed by the uterus itself or by
any of the processes of menstruation. On the other
hand, a membrane is not infrequently discharged from
the uterus composed of ^Is of a character like those
in the decidua of pregnancy, the uterus being one in

1 8m page 382 of the Jonnul.

which, as far as can be learned, no pregnancy has taken
place. I have made some observations of this kind
myself, in which, from the structure of the membrane,
I supposed pregnancy to have been present; bat this
diagnosis later events proved to be an error. The
presence of villi of the chorion, which are formed alone
from the ovum, and not by the uterus, is the only in-
dubitable proof of pregnancy.

Dr. W. a. Dolan : I have had one case of abor-
tion in which the opening was through the cul-de-sac
into the peritoneal cavity, and death, as in this case,
was due to septic peritonitis. I took the precaution to
have the tissue of the uteras examined microscopically,
so that if there had been any question of pregnancy
we could have had that to fall back on.

Dr. W. F. Whitmet then presented a oommunica>
tion on

BiBHOBRBAOE INTO THE PANCREAS AS A CAUSE Or
SUDDEN DEATH.*

Dr. J. G. PiNKHAM : I am not able to throw any
light on this subject. I am very much interested in
the paper. I have witnessed autopsies in two cases.
The first one was some years ago, before this subject
was particularly understood, and the autopsy was
made by one of my fellow practitioners. The case
was not fully understood at that time, but as I remem-
ber it, the pancreas seemed to be simply a mass of
blood-clot. The mass was as large, perhaps, as a
man's arm. I judge now from thinking of the case
that the haemorrhage into the tissues was very exten-
sive indeed, so that the organ was very much enlarged
in this way, and was extremely brittle as we took it
out. The case was sent to some one in Boston, but
was not diagnosticated as it would be at this time. It
was supposed that the hemorrhage was in the neigh-
borhood of the pancreas, and that that organ was
wasted, destroyed by disease, but I think now that the
hsemorrhage was in the substance of the organ, and
that that produced the peculiar condition that was ob-
served.

In the second case I was the attending physician.
The patient was a baker, a fat man. He was taken
with violent epigastric pain, vomiting and great de-
pression. He was treated, as those cases usually are,
with remedies to meet the symptoms, and died after
about five days. The autopsy showed the condition
which has been described here, the opaque white spots
which are not limited to the pancreas, but were visible
in the omental fat, and very generally throughout the
abdomen. I think other portions of the body were
not examined because that was before the attention of
the suburban practitioner^ at any rate, had been called
to this peculiar condition of acute pancreatitis with
hemorrhage. But that evidently was the disease, and
that specimen was sent to Dr. Whitney, and upon bis
diagnosis the certificate of death was based. As a
matter of interest, there was some dissatisfaction
among the friends in regard to the fact that the man
died from such a cause, and the case was reported to
a distinguished homceopathic physician of Boston, who
said there was no such disease.

Dr. B. H. Hart well : I have never seen a case
of what has been described by Dr. Whitney, but I
think that we are under a great deal of obligation to
him for bringing anew this matter to our minds. We
see a great many cases of sudden death, and I am sure
> See page 879 of the Jonnal.

Digitized by

Google

7ot. CXXX, No. 16.] BOSTON MEDICAL AND SUB6J0AL JOURNAL.

391

we are passled sometimes after an autopsy to state
the absolute cause of death. I am sure hereafter we
shall not only look more carefully for disease of the
pancreas in our autopsies, but sball be better able to tell
whether the pancreas enters as a factor in the case,
and if any of us should fail to find the pancreatic duct,
I am sure there would be some consolation to us in the
fact that so eminent a pathologist has difficulty in find-
ing it.

Db. F. W. Drapes : I am reluctant to say a word,
because all the necessary words have been said either
by Dr. Whitney or by the other members of the So-
ciety. Two practical points, however, have occurred to
me in lutening to what Dr. Whitney has said : one is that
all sudden deaths by natural causes are not to be set
down hastily as deaths by " heart disease " ; and the
other is that an autopsy is not a complete autopsy un-
less it includes the examination of the pancreas ; that
it is incambent upon us as medical examiners to be
thorough in our work, and where occasion comes to
make an autopsy, to make it so that it can be worthy
the name.

So far as these cases of pancreatic haemorrhages are
concerned in their relation to sudden death, I think the
anatomical diagnosis is not at all a difficult one when
the lesser omental cavity is opened as it always ought
to be for inspection ; the case declares itself almost at
once ; there is no reasonable room for doubt as to what
one has before him. The organ itself, normally a pale
yellowish white, is in these cases discolored red, and
on either side and around the end of it will be found
in the retro-peritoneal connective tissue an infiltration
of blood that is unmistakable, which one cannot but
see if he has ordinary eyes ; so that it is not a matter
of difficulty in diagnosis, but ordinarily a matter of
neglect in the pathologist, that these cases escape ob-
servation. In some 4,000 cases of death of all sorts,
I have seen 19 cases in which there was some pan-
creatic hasmorrhage, but in not all those nineteen was
it to be assigned as the one cause of death. It was
in company with other conditions, conditions relating
to the liver or to the kidneys, or to the heart or to the
lungs, which were complications, so to speak, making
the post-mortem diagnosis a little more difficult ; but
in some nine or ten cases there was no other cause of
death. Those were the purely typical illustrative
cases Dr. Whitney has described so well. They are
the cases of persons found dead, about whose clinical
history one knew nothing. In only one instance that
I recall at this time did I know the clinical side of the
case, and that was, as it happened, the first case I ever
came npon. That has been published. I will only
state the facts that the symptoms were precisely as
Hr. Pinkham has related — great depression, amount-
ing almost to collapse, epigastric pain, with nausea
and attempts to vomit, which generally were unsuc-
cessful, a sinking which resulted in death in forty-five
minutes after the onset of the attack. The patient, a
man, died in the carriage on the way to the hospital,
having been seized suddenly, and the appearances were
typical and conclusive, nothing else being seen that
was abnormal except this pancreatic hssmorrhage into
and around the organ.

Db. Z. B. Adams : It seems to me that there are
two very valuable points for the medical examiner in
the study of this thing, and the first of these is that
sudden death may occur from pancreatic haemorrhage.
It should be borne in mind, and when the medical

examiner is called to a case and cannot come to any
positive conclusion about it, he should not be content
unless he examined this organ after making the usual
examination of the heart or other organs. He should
not forget that sudden death may occur from haemor-
rhage into the pancreas, something, I think, few of us
have heretofore taken into account, but since attention
was called to it we have waked up to that. Another
point is in reference to the cause of death. That, as
Dr. Whitney has said, is still a very obscure point ;
but it seems to me, if many of these cases should come
into our hands, we should soon solve that problem.
The cases are so rare, however, that we know little or
nothing about that. Speaking of the other forms of
pancreatitis, suppurative, etc., I am reminded that
some fifteen years ago I had a very stout patient who
died after a short illness. I secured an autopsy, and
found pas at the head of the pancreas, but at that time
I had heard nothing about this acute form of haemor-
rhagic pancreatitis, and really did not know what to
call it. I found quite a sac of pus there, and that, to
me, appeared to be the only lesion. The symptoms
were those of distressing pain in the epigastrium, with
vomiting and inability to retain food, constipation, and
that was all. He died within a very few days, greatly
to my surprise, as I could see no sufficient reason for his
death, and that was what I found. As soon as Dr.
Fitz's paper came out I said, " There was my case."

Dr. W. F. Whitnet: In making a post-mortem
examination, I should say the pancreas ought to be
examined before the heart or any other viscera have
been distnrl)ed, because one is very apt to get a false
extravasation, which might mislead as to the source of
haemorrhage. The rule should be, after the greater
cavity of the peritoneum bad been inspected, the lesser
cavity should be opened and the pancreas examined at
that time.

In reply to Dr. Adams's question, I would say that,
personally, I have not seen any cases of sudden death
from haemorrhage into the pancreas from violence or a
blow. There are some cases where violence in the
neighl)orhood of the pancreas has been found to be
followed by a haemorrhage into the organ. Dr. Fitz
has recorded the autopsy in the case of a man who
had a railroad injury, and the splenic artery or artery
of the pancreas had been torn ; he found evidences
of fat necrosis in the neighborhood of the pancreas ;
this had developed very speedily, and is one of the
strongest arguments in support of bis theory that the
necroses are dependent upon lesions of the pancreas.

There are a number of cases reported of extensive
injury of the pancreas in which patients have recov-
ered without untoward symptoms.

THE NKW YORK NEUROLOGICAL SOCIETY.

Stated Meeting, held at the New York Academy
of Medicine, Tuesday evening, March 6, 1894, Dr.
M. Allen Starr, President, in the chair.

Dr. J. Artbdb Booth presented

A CASE OF EXOPBTHALHIO GOITRE : THTROIDECTOUT.

The patient was a female, aged twenty-four, single.
Family and personal histories negative. About two
years ago the woman first noticed an enlargement of
the throat, and three months later the eyes became
affected. The patient is positive that there were uo

Digitized by

Google

392

BOSTON MEDICAL ASD SVBGJCAL JOUSNAL.

[Afhil 19, 1894.

heart Bymptoms until six month* ago, when palpita-
tioD, throbbing of the vessels of the neck, shortness of
breath and flushing of the face appeared. All these
symptoms gradnally increased in (ererity, and the
patient became irritable, easily excited, auxions and
unable to sleep because of the tumnltnous action of the
heart. When the woman first came nnder my obser-
vation both the eyes were very prominent, especially
the left, and the lids did not follow the movements of
the eyeballs (Graefe's symptom). The pupils were
moderately dilated, reacting to light and accommoda-
tion. Fundus normal. Visiou not impaired. The
enlargement of the thyroid body was marked, the
right lobe being the larger. Pulse 150, of high ten-
sion. Apex-beat of the heart diffused; no murmur.
Bespiration 24. No tremor of hands or fingers. Ex-
amination of urine negative. The patient was given
daily applications of galvanism, and received one two-
hundredth of a grain of aconitia twice daily, and fifteen
grains of iodide of potash three times daily. She was
also instructed to practise foil inspiration frequently,
and to rest as much as possible during the day.
Under this treatment there was decided improvement
in the symptoms, but only temporary in character, and
00 November 8, 1893, thyroidectomy was performed
by Dr. B. F. Cnrtis at St. Lnke's Hospital, the right
lobe of the thyroid being removed. The patient made
an uneventful recovery, and during the four months
that have elapsed since the operation there has been a
decided improvement in all her symptoms. The pnlse-
rate now ranges between 96 and 110. Many of hpr
nervous symptoms have entirely disappeared. She
sleeps well, does not suffer from palpitation, and is
able to attend to her housework. The eyeballs are
much less prominent. The left side of the thyroid
has diminished in size to a slight extent since the
operation.

Db. Robert Saffobd Newton presented

A CASE OF EXOPHTHALMIC QOITBB : THTBOIDECTOUT.

The patient was a girl aged twelve. In this case
almost complete extirpation of the thyroid was per-
formed, only a small supernumerary lobe being left.
Since the operation, the exophthalmos, which was
very pronounced, has almost entirely disappeared.
Before the operation the pulse-rate was 180, and the
child suffered from cyanosis. The systolic and dias-
tolic heart-sounds were almost synchronous. The
operation was performed by Dr. Fowler on October
21, 1893, and the child was out of bed three days
afterwards. Her pulse now averages about 100.
She is able to attend school, and is much improved in
every way.

The President stated that the absolute contrast
between the symptoms in exophthalmic goitre and
myxcedema makes it seem very probable that many of
the symptoms of the former disease are due to an ex-
cessive secretion of the thyroid gland, just as those in
myxcedema are due to its suppression. Up to the
present time there are not enough cases on record to
permit us to make definite statements regarding it.

Db. Gbobob W. Jacobt presented

A CASE of pboobessive mcsoulab atbopht of

THE PERINEAL TYPE.

; The case was that of an illegitimate child, a girl
aged twelve years. The mother states that the child's
father was a large, well-proportioned man, but that he

was rejected for military service abroad because his
muscles were weak. This is the only hereditary fac-
tor obtainable. The history of the case, in brief, is as
follows: There was no trouble at the child's birth.
When two years of age, some months after an attack
of measles, she complained of pain in the lower ex-
tremities, which was so severe that she could not
stand. This lastetl about six weeks, and from that
time on she appeared to have di£Bculty in walking.
She has always been able to move her legs in every
direction. When she was four years old it was
noticed that one leg was weaker and thinner than the
other. Abont one year ago it was first noticed that
there was an atrophy of the thigh on the side opposite
to that of the affected leg. She holds the leg in a stiff
and clumsy position. There is a lack of symmetry
between the two buttocks. She had marked lordosis
and slight lateral curvature. The muscles oF both
thighs are in a continual state of unrest, almost like
fibrillary twitching. The right foot is in equino-varut
position. There are no sensory disturbances. There
is partial reaction of degeneration in the affected
muscles. The arms are not affected. The superficial
reflexes are normal. The tendon reflexes are present,
but somewhat reduced on the affected side. In con-
clusion, Dr. Jacoby said that while he regarded the
case as one of progressive muscular atrophy of the
perineal type, it was not an absolutely typical one, io-
asmuch as the atrophy, although bilateral, is asymmet-
rical, one leg being affected and the opposite thigh.

Dr. B. Sachs said he agreed with Dr. Jacohy's
diagnosis. The atypical distribution of the atrophy
should not militate against the diagnosis, as that is
really the last thing to be conddered, although still so
much insisted on by many writers. The distribation
of the atrophy is largely a matter of chance. He has
seen six cases of progressive muscular atrophy of the
perineal type, which is, perhaps, the rarest form of the
disease. In none of these was there a cross-distribu-
tion of the atrophy, as in Dr. Jacohy's case.

Dr. Alexander B. Johnson rc«d a paper describ-
ing

A CASE of NEUBALOIA OF THE OBBAT OCCIPITAL
NEBTE, WITH STMPTOMS OF A DESTRUCTIVE LE-
SION OF THE CERVICAL STMPATHETIO.

The patient was a man sixty years old, married, a
railroad conductor by occupation. Denies venereal
disease ; no alcoholic habit. Had malaria thirty years
ago. No distinct history of rheumatism. No signs of
organic disease. Over the chest and back he has
several old, white, depressed scars, which be states are
the result of abscesses he had many years ago, and
that they were a long time in healing. The patient
presented himself on November 1, 1893, complaining
of a severe pain in the right side of the head, which
made it impossible for him to work. This trouble be-
gan three years ago. The pain is of an aching char-
acter and occurs in paroxysms. It is referred to a
point about two inches behind the lobule of the right
ear, and radiates upward and backward to the vertex.
There is marked tenderness on pressure over this area.
The patient further complained of inability to see well
with the right eye, and the upper eyelid on that side
droops so far as nearly to cover the pupil when the
patient looks straight h«fore him ; the lower eyelid is
slightly elevated. The right pupil is contracted,
smaller than the left, and does not react to light. The

Digitized by

Google

Vol. CXXX, No. 16,] BOSTON MEDIO AL AND SURGICAL JOURNAL.

393

eye is watery, and the right side of the face is redder
than the left. Tliere is no paralysis of the face ; but
the skin and muscles appear less full, and feel flabby
in comparison with the left side. The patient was ex-
amined by Dr. M. Allen Starr, who located the lesion
io the cervical sympathetic, and advised an exploratory
operation, as the patient had undergone medical treat-
ment of various kinds without relief.

On November 4, 1893, an incision, three and one-
half inches in length, was made along the posterior
border of the right sterno-mastoid, beginning just be-
low the mastoid process. The sterno-mastoid muscle
and internal jugular vein were drawn forward and the
internal carotid artery lifted up. The superior cervi-
cal ganglion was found to be included within the sheath
of the internal carotid, to which it appeared to be dis-
tinctly adherent. The adhesions were divided and the
ganglion freed, as well as the cord below to the extent
of two inches. No abnormality in appearance could
be recognized either in the ganglion or cord, and the
wound was closed. The neuralgic paint and the ten-
derness of the scalp disappeared at once after the opera-
tion. The lacrymation and flushing of the face ceased.
The pupil on the right side reacted slightly to light
and became a little larger, and the right upper eyelid
drooped so little that it was scarcely noticeable, and
did not at all interfere with vision. At the end of six
weeks, however, all the symptoms had returned ; and
at the present time the patient finds himself in no way
improved.

in closing his paper, Dr. Johnson said that while the
symptoms in this case were fairly typical of paralysis
of, or a destructive lesion of the cervical sympathetic,
it is possible that they were due to a lesion of a des-
tructive character situated in the spinal cord, the exact
location of which it is at present impossible to deter-
mine. He was unt^ble to explain the immediate tem-
porary benefit of the operation in this case, excepting
that it was the result of a powerful peripheral impres-
sion.

Dk. William M. Leszynskt referred to a case
which he presented some years ago, in which there
was hsemorrhage into the cervical portion of the cord,
with decided symptoms of involvement of the cervical
sympathetic on the same side.

The Pbesidbnt said that Krouse {ZeiUehrift fur
Klinitehe Medicin, 1891) reports nine cases of crush
ing accidents to the spinal cord, involving the lower
cervical and upper dorsal segments, in which there
were marked symptoms referable to the cervical sym-
pathetic. Regarding the case narrated by Dr. John-
son, Dr. Starr said his own impression was rather
against the idea of a cord lesion, on account of the ab-
aence of other cord symptoms, although that was not a
valid reason for excluding it entirely.

Dr. Booth presented

A CASK OF HYSTERIA, WITH PECULIAR EPILBPTOID
ATTACKS.

The patient was a male, aged tweuty-two, jeweller,
a native of Germany. During the past two months
he has had attacks when he suddenly begins to sing,
to slap his knees with his hands (either one or both),
and to stamp his feet. The attacks come on without
apparent cause, and occur frequently during the day
and occasionally at night. Each attack lasts only a
few seconds, and ends with a screech. Patient does
not lose consciousness. When he was eight years old

he had similar attacks, extending over a period of nine
months : again, three years ago, be had them for a
period of about one year. At that time be went
under treatment at Strasburg, Germany, but received
no benefit. The attacks ceased of themselves. Pa-
tient does not smoke ; drinks moderately ; practised
masturbation to some extent when be was younger,
and contiuaed it for three years. Family history
negative. Never had a blow or fall. Denies venereal
disease.

ELECTRICAL REACTIONS AND THEIR VALUE IN DIAG-
NOSIS AMD PROGNOSIS.

The President stated that the subject of electrical
reactions, and their value in diagnosis and prognosis,
which bad been taken up at the last meeting, was such
an important one that it had been decided to continue
it at this time.

Dr. Frederick Peterson said that in the main
he agreed with the previous speakers regarding the
reaction of degeneration, and with the conclusions re-
cently published by Remak, in particular. We have
found that both nerves and muscles may respond to
both the faradic and galvanic currents, and yet degen-
eration may exist. With the galvanic current, polar
changes are inconstant ; CCC may be greater than
AuCC. In normal muscles we occasionally find, on
the other hand, that AnCC may be greater than CCC.
There is one sign that may be considered as always
present where there is degeneration in the spiuo-mus-
cular portion of the motor tract, and that is, the slug-
gish, vermicular contraction of the muscle. Further-
more, in the great majority of cases of degenerative
lesions in the anterior horns or peripheral nerves, the
faradic reactions are diminished or lost. Dr. Peter-
son felt that not sufficient stress had been laid upon
the actual value of electro diagnosis in distinguishing
cerebral palsies from the degenerative cases. He was
convinced that most neurologists found it of the same
value as heretofore, though we had modified our opin-
ions as to the manifestations.

One of the speakers at the last meeting called atten-
tion to the occasional occurrence of atrophy with de-
generative reactions in cerebral palsies, as cited in two
cases by Eisenlohr some years ago. It was interesting
to know that Eisenlohr had recently made autopsies in
both of these cases, and found degeneration in the
peripheral nerves. Other observers have found atro-
phic changes in the ganglion cells of the anterior horns
in cases of hemiplegia with muscular atrophy. There
is no evidence in those rare instances in which muscu-
lar atrophy accompanies cerebral palsy that the trophic
change is produced by an afiection of the trophic centres
in the brain. On the contrary, all the evidence at
hand shows that the atrophy depends upon degenera-
tive lesions in the spino-muscular portion of the motor
tract. The value of the electrical examination remains
therefore as before.

The electric reactions are certainly of great value in
the distinction of the primary muscular dystrophies
from progressive spinal atrophies.

Dr. J. F. Terriberby continued the discussion.
He confined his remarks to the value of electrical re-
actions, as regards diagnosis and prognosis, in paraly-
sis of the facial nerve, and gave the following conclu-
sions, which he had deducted from an analysis of
twenty-four such cases coming under his observation :

(1) That we have in electricity an agent of the

Digitized by

Google

394

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Afkil 19, 1894.

highest value as an aid to diagnoaig in paretic troables
of Che seventh nerve.

(2) That the valae of electricity as an aid to prog-
nosis in facial paralysis is comparatively slight. Less
than one-half the cases reported could be prognosti-
cated, and even those with considerable hesitation.

(3) That those cases in which the degree of paraly-
sis is slight are the ones of which we can speak with
most confidence by the aid of electricity.

(4) That it is impossible to foretell the issne of
severe cases by means of the electrical examination.

(5} That the teachings of Erb respecting the diag-
nosis and prognosis of the lesions of the motor periph-
eral nerves by means of electricity are the best at
our command, althongh very imperfect

Dr. William J. Morton sent a communication on
the subject of electrical reactions, which was read by
the Secretary. He stated that in case of degeneration
of the nerve, the faradic and galvanic excitability is
diminished or lost, while in case of degeneration of the
muscle the faradic excitability is lost, bat there is an
exaggeration of the galvanic excitability and an inver-
sion of its normal polar action. This abnormal reac-
tion of an abnormal muscle was, indeed, a most brilliant
discovery by Erb, but it has always seemed to him that
an over-refinement of diagnostic and prognostic signifi-
cance has been attached to it. As regards diagnosis,
the electrical reaction is often the only means of decid-
ing that a given nerve or muscle is in process of de-
generation. In traumatic neuritis, in multiple neuritis.
Id the sciatic, facial and many other neurites, in the
dystrophies and spinal lesions due to affection of the
nerve cells of the anterior cornu, it is certainly a great
satisfaction to feel sure that the degenerative process
exists, and this satisfaction is easily acquired by aid of
the electric reactions. He did not, however, con-
sider the reactions of much value in making a differen-
tial diagnosis between one and another of the above
affections, or between a multiple and migrating neuri-
tis, or between sub-acnte or chronic anterior poliomye-
litis and a progressive muscular atrophy, or lastly, be-
tween a cerebral and spinal lesion. As regards the
prognostic value of electrical reactions. Dr. Morton
believed that overconfideuce is placed in the deduc-
tions to be drawn from " the complete " and the " in-
complete reaction of degeneration." In its complete
form, as we sometimes see it in grave facial paralysis
and in infantile spinal paralysis, our prognosis is un-
mistakably bad and fairly exact. It is in the incom-
plete reaction of degeneration that we are often
proven to be mistaken if we indulge in a too exact
prognosis. In cases where the electrical reactions of
both nerve and muscle have been completely lost, be
has known the muscle to regain some part of its former
volume and the normal electrical reactions to return
by means of long-continued local treatment by aid of
sparks from an influence machine. He considers that
the earliest sign of reaction of degeneration is the fail-
are of a muscle to respond to a spark which will set a
corresponding normal muscle into contraction.

Dr. Lesztnskt said that in making the differential
diagnosis between peripheral and cerebral lesions in
cases of facial paralysis, the quantitative changes
should be taken into consideration : in the peripheral
cases there is a quantitative diminution, while in the
cerebral cases Aere is a quantitative increase. In
paretic conditions he still relies on electricity, both as
regards diagnosis and prognosis. There are cases in

which we make mistakes, but in the vast majority of
instances the laws laid down by Erb are correct.

Dr. B. Sachs said that if the discnosion of this sub-
ject at the last meeting had a nihilistic tendency, it
was due to the fact that it was treated from the neu-
rologist's point of view, and the speakers were attempt-
ing to make out in what way the current would be of
value in refinements of diagnosis. He expressed the
view that all of us still recognize the vast importance
of electricity in the differential diagnosis between cere-
bral and peripheral cases, or cerebral and spinal cases,
and also its great value in functional cases.

Dr. E. D. Fisher said that in the main he agreed
with the statements made by the previous speakers.
In certain diseases, such as dystrophies, chronic ante-
rior poliomyelitis and progressive muscular atrophy,
the electrical reactions are of great value. It is true
that in the dystrophies we do not get an absolute loss
of the faradic response until very late in the disease;
with marked atrophy we may still get a response to
the faradic current wherever the fibres remain. As
regards the differential diagnosis between cases of pro-
gressive muscular atrophy and chronic poliomyelitis,
in the former we do not, as a rule, get a complete re-
action of degeneration — we may get a partial one-^
while in the latter we are very apt to get complete re-
action of degeneration. In differentiating between
cerebral and spinal lesions, electricity is of value, al-
thongh not always essential.

Vitttnt Eiterature.

HotpitaU, Diipeniaries and Nuning. Papers and
Discussions in the InternatioDal Congress of Chari-
ties, Correction and Philanthropy, Section III, Chi-
cago, June 12 to 17, 1893. Edited by Johk S.
BiLLiNOs, M.D. and Henrt M. HnRD, M.D.
Baltimore : The Johns Hopkins Press. London :
The Scientific Press (limited). 1894.
The seven hundred and ten pages of this report con-
tain seventy-five papers, with the discnssions on them,
so condensed as to make the volume a necessary refer-
ence-book on the subjects to which it pertains, and so
full of matters of vital interest on all questions con-
nected with the care of the sick that it can he read
with profit by every one who wishes to keep informed
on modern social science. It should be studied by
physicians, and hospital officers and visitors engaged in
solving the difficult problems discussed therein. We
cannot enumerate by title, with our limited space, the
many excellent essays which were read ; nor can we,
as we would like, call attention in detail to the able
treatment of the several topics of argument and debate.
The admirable papers on the function and duties of
the modern hospital by Dr. Billings and Dr. Cowles
are fully supplemented by thirty-five others covering
all points of hospital administration, including the eda-
cation of physicians and surgeons and training schools
for nurses. The greatest advances in the last two
decades have naturally been in the way of hygiene,
cleanliness in its broadest sense, in development of the
system of training highly-qualified nurses, and in a
more general use of cottage hospitals in the smaller
cities and towns. The next movement must lie in the
more intelligent control of infections diseases by abol-

Digitized by

Google

Vol. CXXX, No. 16.] BOSTON MEDICAL AND SURGICAL JOURNAL.

895

ithing the " pest-house " and bj the construction of
isolation hospitals for scarlet ferer and diphtheria par-
ticularly, of which there are so few in this country.
Dr. Thome Tborne had hardly mnde the remark that
a small-pox hospital should not be within a mile of an
inhabited bouse, as quoted by Dr. Rowe, before more
recent researches showed such over-caution to be only
consistent with the pest-house idea ; while Dr. Davis
regards a furnace for garbage, rooms for disinfection
by superheated steam and a crematory for the dead
quite essential within the grounds of every hospital
for infectious diseases.

The one hundred and eighty-six pages given to the
consideration of nursing of the sick will amply repay a
careful reading.

Dr. Field's description of the reception pavilion for
the insane at Bellevue Hospital, with his appeal for
the establishment of similar detention hospitals for de-
ciding questions of insanity, and the proper treatment
of each person examined in them, in every large city of
the United States, and Miss May's six pages on nurs-
ing of the insane, comprise all of the volume which is
devoted to that important branch of hospital care of the
sick. The search-light that has been so well directed
to the general hospitals has not yet fully reached the
hospitals for the insane, although the advances there,
too, have been great.

Medieed Jaritprud«nee, Forentic Medicine and Toxi-
colofft/. By R. A. WiTTHAUs, A.M., M.D., Profes-
sor o( Chemistry, Physics and Hygiene in the Uni-
versity of the City of New York, etc., and Tba.ot
C. Becker, A.B., LL.B., Counsellor-at-Law and
Professor of Criminal Law and Medical Juris-
prudence in the University of Buffalo. With the
aid of numerous collaborators. In four volumes.
Vol. I., New York : William Wood & Co. 1894.

The obvious intention of the projectors of this ex-
tensive work has been to collect in one publication all
matters concerning which law and medicine have a
hyphenated interest through their mutual relations one
with the other, embracing all topics which usage and
propriety designate as medico-legal. And it is a pleasure
to state at once that if the standard of excellence illus-
trated in this initial volume is maintained in the three
volumes to follow, the two professions of law and medi-
cine will have at their disposal an encyclopaedic work
of the highest, character. The critical reader finds
iDDcb to praise ajati little to censure in the plan and
execution of so mudh of the treatise as the present
Tolnme exhibits. As is usually the case with a book
of composite authorship, there is some inequality in
the various chapters ; a few appear to have been written
hastily and under stress of a pressing requisition for
material to be supplied before a stated time, but nearly
all the contributions show care, study and finish. Taken
as a whole, this volume represents wide research, judi-
cial fairness and freedom from dogmatic self-assertion.
The announced list of contributors leads us to anti-
cipate a continuation of these characteristics in the
remaining volumes and to declare that as a comprehen-
live reference-book relative to all medico-legal subjects,
this will stand without a peer.

The title of the work offers a novelty in nomenclat-
are. It has been customary to regard Medical Juris-
prudence, Forensic Medicine and Legal Medicine as
interchangeable and synonymous terms, and this cus-
tom still prevails. But it is explained in the introduc-

tion to this volume that there is a real difference which
should be recognized, that Medical Jurisprudence treats
of " medical law " and that Forensic Medicine deals
with " the application of medical, surgical or obstetri-
cal knowledge to the purposes of legal trials." We
cannot avoid thinking that this differentiation is arbi-
trary and unnecessary. That its adoption would be dlT-
ficult among medico-legal writers and students is well
illustrated by the fact that it is not uniformly respected
in this volume or, indeed, by the editor himself in the
later pages of his introduction.

But the distinction above mentioned offers a con-
venient opportunity for a broad classification of legal
and medical topics in the body of the book. Under
the caption of Medical Jurisprudence, several able
legal writers have contributed chapters which set forth
the legal principles, the judicial decisions and the
statutory regulations which govern and control medical
practice. The legal rights and duties of medical men
in the care of the sick, in the court-room, in the au-
topsy-room and wherever else they exercise their pro-
fessional knowledge, are fully and satisfactorily defined.
It is interesting to note, in passing, that in the admi-
rable digest of the laws governing the practice of medi-
cine, Massachusetts and New Hampshire are designated
as the only States which are without special statutes
designed to protect the public from quackery.

In that portion of the book devoted to medical rather
than legal themes, are chapters on medico-legal au-
topsies, personal identity, wounds, death by heat, cold,
electricity, hanging, strangling, suffocation, drowning,
and starvation. All these subjects are elaborately
treated and some of them, like the Medico-Legal Rela-
tions of Electricity, for example, have special value
because of the contemporaneous interest in the topic
and the thoroughness of the author's method in discuss-
ing it. The entire volume shows a manifest purpose
Mi the part of its contributors to present whatever they
liave found to be of medico-legal utility in the latest
advances in medical science and all concerned in the
preparation of the work, editors, collaborators and pub-
lishers, can be congratulated cordially upon the genuine
success which has marked their endeavor.

The PrineipUt and Practice of Surgery. By John
" AsBHVRST, Jb., M.D., Barton Professor of Surgery
and Professor of Clinical Surgery in the University
of Pennsylvania; Surgeon to the Pennsylvania
Hospital ; Senior Surgeon to the University Hos-
pital and to the Children's Hospital ; Consulting
Surgeon to the Woman's Hospital, to St. Chris-
topher's Hospital, etc. Sixth Edition, enlarged
and thoroughly revised. Philadelphia: Lea Broth-
ers & Co. 1893.

This is the sixth edition of a work which has been
very popular. The author has endeavored to incor-
porate many of the more important recent observa-
tions in surgical science. "An entirely new chapter
has been introduced, on Surgical Bacteriology," by
Prof. Charles B. Nancrede of the University of Michi-
gan. The specialties on the eye and ear have been
scrutinized and revised by colleagues of the author.

The author " ventures to express a hope that in its
present form, his volume, though necessarily compen-
dious in its mode of dealing with different subjects,
may be considered as affording a satisfactory represen-
tation of modern surgery." The work is one of those
few works which have survived the advent of modern

Digitized by

Google

396

BOSTON MEDICAL AND SVBOICAL JOURNAL.

[Apbil 19, 1894.

methods; aod while much of value is retained which
existed before antiseptics, yet a strenuous effort has
been made to introduce the valuable parts of modern
methods. In this we do not believe the author has
fully succeeded. The book is condensed, well written,
and intended to cover the whole field of surgery ; but
we cannot help believing that it would be improved by
omitting the parts on special surgery. As a matter of
example, the presentation of the subject of diseases of
the joints and of orthopaedic surgery is lamentably
behind the times. In this work Americans stand welt
towards the head ; and the apparatus which is repre-
sented and the methods spoken of are those of the
English school of orthopaedics of thirty odd years ago.
The book has a distinct value in that the author re-
tains many of the points and bints of treatment with
which the older books were filled; but, as a whole, it
cannot be considered a work representing modern sur-
gery.

Lt/ectioiu Dtteate$, Nolificalion and Prevention. By

Louis C. Parkeb, M.D., London, U.F.H. Pp.

185. London : U. K. Lewis. 1894.

This compact and handy manual contains all the
existing English laws npon the sanitary management
and control of infectious diseases. Part I presents
these laws, together with full explanatory notes by the
author. Part II contains much useful information in
a condensed form, upon various practical subjects relat-
ing to the diagnosis and the prevention of infectious
diseases. The special topics treated are Incubation
Periods, Quarantine, Infective Periods, Sources of In-
fection, Infectious Outbreaks in Schools, Isolation at
Home, Disinfection, the Relation of the Medical Officer
of Health to the Medical Practitioners of his District.

The clear and intelligent arrangement of the de-
scriptive matter under the different infectious diseases
will commend the book to every practical sanitarian.
The tables were collated from the report of a committee
appointed by the Clinical Society of London to inves-
tigate the periods of incubation and contagiousness of
certain infectious diseases.

This extremely practical hand-book should be in the
hands of every American health-officer, and will be
found very useful to the general practitioner.

Diteaut of the Eye. A Practical Treatise for Stu-
deuu of Ophthalmology. By Georgk A. Bbrbt,
M.B., F.B.C.S. Ed., Ophthalmic Surgeon, Edin-
burgh Royal Infirmary, etc. Second edition, re-
vis^ and enlarged, with colored illustrations from
original drawings. Pp. 727. Philadelphia: Lea
Brothers & Co. 1893.

This book is emphatically what its subtitle states it
to be, "a practical treatise for students of ophthalmol-
ogy." It is comprehensive and concisely written, and
a judicious proportion has been observed in the allot-
ment of space to the different subjects. The illustra-
tions which are incorporated in the text are, in the
main, colored prints from original drawings. Those
representing the external diseases of the eye are, with
a few exceptions, satisfactory, and much superior to
any we remember to have seen in students' text-books.
The plates representing diseases of the fundus are even
better, and are beautiful specimens both of drawing
and reproduction.

With regard to the much-discussed question of
whether to do au iridectomy or not in cataract opera-
tions, our author has but one opinion, and that is, that

a small iridectomy should always be done, and dis-
misses the whole subject as follows: '* The only dis-
advantages (of an iridectomy) are, therefore, a wound
in the iris and a less beautiful pupil. . . . The coi-
metic advantages of a round, active pupil, when it can
be obtained, are altogether trifling in those elderly in-
dividuals who are the usual subjects of cataract extrac-
tion. The game is, in fact, not worth the candle."

In regard to the after-treatment of cataract, he
places his bandage only over the operated eye, at, in
his opinion, the pain caused by moving the eyes about
before the anterior chamber is re-established is suffi-
cient to compel the patient to refrain from using bit
eyes. He believes that the patient should be kept in bed
" at least two days," and the room in semi darkuess.

The subject of treatment throughout the book ia
clearly and conservatively written. In the treatment
of trachoma, while excision of the retrotartal fold it
described, no mention is made of expression ef the fol-
licles, as is so commonly done in America ; and we were
surprised to note that no mention of antiseptic collyri*
or ointments is made.

Upon the whole, however, the book is an eminently
satisfactory text-book.

A PracticcU TreeUxte on Medical Diagnoti$, For
Students and Physicians. By John H. Mcsseb,
M.D., Assistant Professor of Clinical Mediciue in
the University of Pennsylvania, Philadelphia ; Presi-
dent of the Pathological Society of Philadelphia,
etc. Octavo, 873 pages, 162 engravings aud 2
colored plates. Philadelphia : Lea Brothers & Ca.
1894.

The number of treatises on the Theory and Practice
of Medicine by American authors is rapidly increas-
ing. The one before us by Dr. Musser on Medical
Diagnosis u in many respects a very good book. Its
arrangement is simple. It is divided into two parts :
Part I is devoted to General Diagnosis, and cousiets
of chapters on General Observations ; the Data ob-
tained by Inquiry; the Data obtained by Observation;
Bacteriological Diagnosis ; the Examinations of Ex-
udations, Transudations, Cystic Fluids ; the Morbid
Processes and their Symptomatology. Part II is
devoted to Special Diagnosis. The first seven chapters
deal with Anatomical or Regional Diagnoses ; chapter
eight deals with Diseases of the Blood and Ductleti
Glands ; chapter nine with Constitutional Diseases ;
chapter ten with the Infectious Diseases; chapter
eleven with Diseases of the Nervous System.

The book emphasizes the extent to which instru-
ments of precision and laboratory processes have super-
seded, or at least simplified, the older and slower
methods of minute observation and elaborate systems
of differential diagnosis. But we do not wish to iu-
dicate by this statement that the author underrates
the importance of careful inquiry and observation.
The pages merely show plunly, what every hospital
physician or teacher of long experience realizes daily
more and more, that the last ten years have revolu-
tionized in many ways the means, the methods and the
details of diagnosis. This is nowhere more apparent
than in diseases of the blood, than in the information
to be bad from microscopical examinations of the blood
and exudations. A differential diagnosis of typhoid
fever, or the stage of a pneumonia, may be determined
in the laboratory ; and even the stethoscope and the
thermometer are being shorn of some of their glory.

Digitized by

Google

Vol. CXXX, No. 161 BOSTON MBDtOAL AND SURGICAL JOURNAL.

397

THE BOSTON

imeofcal anD ^utgfcal ioutnal.

Thursday. April 19, 1894.

A Jmmuii qfMedieiiie,Stuvery,and AUUd Seie»eei,p»liUtlud cU
BoiUm, wetklji, 6y the utuUnigned.

Sdbsckiptioii Tkbhi: 9i.0O per year, in advanee, pottage paid,
for tie United State*, Canada and Mexico ; Ve-Se per year for ail for-
eign cotmtriee belonging to the Pottal Union,

All eommtmieatione for the Bdtlor, and all bookt for reviete, thonld
headdreuedtotheKditcrqfthe Boeton Medical and Snrgieal Journal,
SSS WaiUngton Street, Boiton.

All Utter* eamtaining bntineBt oommmnictUioni, or referring to the
pnblieation, mtoeripMon, imt advertiiing department ef tki* Jowmal,
*houU be addre**ed to the nndertigned.

Btm/Utane** ihonld be made by money-order, draft or regittered
letter, peuitMe to

DAMSELIi * UPHAH,
188 WAlHUtctTOx Stbbst, Bostob, Ha»».

THE DOCTOR IN FICTION.

It is well worth the contemplation of an idle boar
to consider the position held by the medical man in
the fiction which, in the reading world of to-day, plays
so important a part. We have all of as seen the doc-
tor appear in the drama — the apostle of science, the
wise connsellor to the interesting invalid, the good
elderly walking-man of the piece ; and we have all no
doubt wondered whether we individnally appear to
the world at large, such mild inaoities. In fact, it
mast be admitted that the doctor has hitherto not been
accorded a very prominent place in light literature,
especially in English literature, when compared to
that granted to the clergyman or lawyer. Perhaps
the reason for this is that English society, which the
novel tries to depict, still lingers in the miasma of
feudalism, and the doctor whose career leads neither
to place nor power has no proper position in a society
which grants precedence to title inherited by primo-
geniture or to the dignity of landed estates.

To Richardson, Fielding, Addison, Goldsmith and
Sterne, the doctor had little that was picturesque or
interesting : and the earlier great writers, Chaucer,
Spenser, Milton, of course, found little use for the
leech or the barber-surgeon. Shakespeare, who mirrored
all life, used the doctor only occasionally as in a minor
part, finding him of no more importance than the
apothecary, or the wise woman who was consulted in
regard to FalsUS's health.

Now and then, in later literature, a mention is to
be found of a medical man, as when Cowley, in poetic
frenzy, compares Dr. Scarborough cutting for stone to
Moses striking the rock. Mr. Samuel Warren, as is
well known, a physician of repute and note of the past
generation, has written at least one novel "£10,000 a
Year" which has outlived his time, and has vitality
to-day. But these are exceptions. The great novel-
ists, Scott, Thackeray and Dickens, found little em-
ployment for doctors in their works, although the
former must have lived in an atmosphere in Edinburgh

redolent with the fame of surgeons. Thackeray dedi-
cated one of his novels to his physician who had
" brought him through " a severe illness ; but to him
doctors were apt to be socially off color, and it is put
to Pendennis's credit that he did not deny the fact
that his father drove a gig and visited patients.
Dickens exercised some of his humor upon doctors,
making the doings of the young " Sawbones " amuse-
ment for a generation. TroUope, considering how
much he wrote and that, too, in the low tone of mild
realism, with sober tints well suited to the sombre
character of the doctor, made but little of the physician
as compared with the clergyman or lawyer.

Charlotte Bronte introduces a physician prominently
in " V illette." George Eliot, however, makes a great
exception in " Middlemarch " ; her character of Lydgate
— one of her most interesting creations — illustrates
well the aspirations of a young and ambitious physi-
cian, and the pitfalls and easy path to failure. Miss
Evans always worked carefully and evidently in thor-
ough sympathy with medical life ; and in her descrip-
tion of Lydgate's treating a case of delirium tremens,
the authoress gave evidence of her thorough study of the
subject, for she makes her medical hero anxious to try
the treatment advocated by Dr. John Ware, of Boston,
in a monograph which, if known in the medical think-
ing world of that day, is almost forgotten now, even in
his native city.

In France, doctors seem to have always been in
popular favor, even in the days when their absurdities
were such as to be made famous by the wit of Moli&re.
Their prominence in the community inspired the criti-
cal genius of the dramatist ; ancf the medical profession
of succeeding generations are his debtors for the im-
mortal life he gave to those errors and follies which
the successful practitioner, to-day as in the seventeenth
centary, should seek to avoid. But of all writers of
fiction Honore de Balzac, the greatest of the novelists
of the modern school, as well as the founder of that
school, was most in sympathy with the physician. He
was fond of introducing in his " Com^die Humaine "
the mythical Biancbon, the enthusiastic student in the
]Scole de M^icine, laboring hard at the cliniqnes and
laboratories, while his contemporary, Rastignac, was
seeking to advance his fortunes by intrigue in the
salons and boudoirs of the Fauburg St. Grermain or at
the Tuileries. IJater, Bianchon becomes the famous
surgeon, who lives a successful life devoted to pro-
fessional work, while fortunes and intrigues have
fallen in the foolish worldly game of personal advance-
ment. To Balzac's mind evidently the physician lived
a life of calm content in his own work ; and in his
devotion to that science which was above the folly of
courts, outlived revolution and dynasties and fulfilled a
career high in its purpose and broad in its soope, with
the ideal enthusiasm of a religions devotee. In the
" M^decin en Campagne," Balzac has presented not
only the highest type of a phy^ician in fiction, bat has
given to posterity a figure to be respected by all. A
strong man is portrayed whose life was blasted in early

Digitized by

Google

398

BOSTON MEDICAL AND SVSGJCAl JVlSNAl.

[Apkil 19, 1894.

youth by the coDseqaences of youthful indiscretion,
but who rose from the chastisement to the noble work
of elevating a community, not only helping the sick,
but teaching by example and by personal influence the
wisdom of a sane life. Beloved and respected by all,
not a self-seeker, but arbitrary in enforcing what was
best for the health of his patients and of the commu-
nity, broad, far-seeing, strong and self-sacrificing, M. de
Benassis will live to remind the reading world of the
possibilities in a medical career — possibilities which
the annals of the medical biographies in every com-
munity show not to be simply figments of the brain
of a romancer.

Recent French literature has produced nothing
equal to Balzac, and no medical figure equal to his
" Country Doctor " ; but one of the most dramatic
scenes in that best of recent novels, '' Les Bois en
Exile," is laid in a physician's office, where the last of
one of the royal families of Europe is brought incog-
nittu to seek advice, bearing the curse of a malady in-
herited from a father who thought more of the Jardin
Mabille than his lost throne ; the queen-mother sits in
the waiting-room of a celebrated surgeon with peasants
and tradespeople, and, when her turn comes, hears
from the oracle of that science which knows nu kings
or royalty, that her son's blood, the noblest blood in
Europe, is tainted.

In America, the doctor has always been a man of
influence, and we should expect he would receive doe
attention in literature. The American novel, how-
ever, is of recent growth ; for Cooper worked on
European models, his matter, except in descriptions of
scenery, was not American, or at best only what
Cooper thought was American. Hawthorne, our great
romancer, did not study real life in the commonplace
world around him ; he was a morbid psychologist, a
mental pathologist with wonderful beauty of language.
He has, however, left us a sketch of a medical recluse
in " Dr. Grinuhaw," which shows the handiwork of a
master even in its outline. An excellent physician
appears in " Elsie Venner," alive with the intelligence
of the author, our honored Professor Emeritus, the
Autocrat of the Breakfast Table. Our working Amer-
ican novelisu, James, Howells and Cable, have all
tried their bands on doctors. Mr. James, who is
essentially the novelist of good manners, and who
writes from the point of view of a man of the world,
evidently recognizes the fact that the doctor in Amer-
ica may perfectly well be a man of good society, which
appears not to be the case in London. Stili Mr.
James's attempts at creating doctors have not been
successful ; they are doctors only by title, without any
medical vitality. Mr. Howells has done better with
Dr. Mnlbridge in " Dr. Breen's Practice " ; but to our
minds. Dr. Sevier, the central figure in one of Mr.
Cable's best stories, is a creation of much more than
passing excellence. The force, the quick and broad
sympathy, the impatience of shams, the una mdig-
natio at the silliness and imbecility of the average of
mankind, are not only well depicted, but true to the

type of physician. The Creole is represented m bwng
a man of large practice, of a lonely life, of mnch
sorrow, and with the acuteness to see that his sorrow
was earned by violation of the laws of health and maat
be manfully borne. Miss Jewett has produced a valua-
ble study with an abundance of local color, in her
*' Country Doctor " ; and Judge Grant, in his " Reflec-
tions of a Married Man," intimates that in American
society, even among " smart " people, the presence of
a few distinguished specialists is desirable to com-
plete the social gathering. In this author's last hook,
" The Opinions of a Philosopher," there is a "snap"
pen-pictnre of Miss Cora Jacket, M.D., "a regulsr
practitioner in the allopathic line," and Winona, the
hero's pretty daughter, becomes a practising Christian
Scientist Crawford, in his last story, "Eatherine
Lauderdale," the scene of which is laid in New York,
gives us a pleasant glimpse, in the person of Dr.
Booth, of the general practitioner who is the family
friend and adviser, whose aid and counsel are sought
in a delicate and perplexing emergency, and who
saves the honor of. his patient by a letter to the
newspapers, as he saves his health by dietetic pre-
scriptions.

The female physi<»an has already been served up in
several different forms ; bat she will probably appear
again, as the subject is one which is not yet exhausted.

A fact to be noted is the dihmt in the world of
fiction of our celebrated specialists. Dr. Weir Mitchell
and Dr. Hammond. The latter, in addition to those
novels already written, promises to write two every
year, thinking that physicians have an inexhaustible
fund of knowledge of human nature, dealing as they
do in humanity as their staple commodity and sampling
it in different grades, for the stamp of different treat-
ment. There seems to be no reason why physicians
should not write novels, now that novel writing is be-
coming a pastime, like bicycling or base-ball or tennis.
Of coarse, the professionals are the masters, but the
amateurs may make a good deal of fame for themselves.
We shall have all the neurologists and alienists illus-
trating their views of life by some horrid example held
up to the terrified public. It affords an amusing
relaxation, and will do but little harm. In fact, it
must steady the nerves harassed by care ; at least.
Lord Beaconsfield found it so, and consoled himself
when vanquished by publishing " Endymion." Why
should not physicians also partake of this new anodyne,
if they can find the time after their severer labors ?

THE DISCUSSION ON THE PARASITISM OF
CANCER AT THE ELEVENTH INTERNA-
TIONAL CONGRESS OF MEDICAL SCIENCES.

Onk of the most interesting discussions at the
Eleventh International Congress of Medicine, held
recently in Rome, was that on the parasitism of can-
cer, in which Pio-Foa, Cornil, Duplay, Cazin, Buffer
and others took part. It is known that Pio-Foa,
referee, is one of the most strenuous advocates of the

Digitized by

Google

Vol. CXXX, No. 16.1 BOSTON MEDICAL AND SUROIOAL JOURNAL.

399

paruitic or infeotions natare of malignant neoplasms.
The " parasites " are certain protoplasmic bodies —
when fully developed enclosed in a distinct capsule —
contained in the cancer cell, sometimes within, sometimes
without, the nucleus, and resembling the spores of pro-
tozoa. Soudakevitch, Buffer, Walker, Clarke and
others have described such elements, which they re-
gard as sporosa, bearing a resemblance to the baema-
tozoa of malarial fever. These parasites are common
to almost all cancers of glandular origin. The periph-
eral portions of the neoplasm contain parasites of
small dimensions, while at some depth from the sur-
face are found large sporocysts.

In parts which are rich with parasites, karyokinesis
is wanting or is little marked. On the other hand, in
parts where the proliferation of the tissues is active,
the parasites are wanting, or are few in number. This
shows that they live, but in tissues whose- vitality is
low. Arguments were advanced to prove that these
strange bodies were not degenerate cell nuclei. Pio-
Foa claims to have followed all the stages of develop-
ment of these parasites from a little corpuscle the
size of a nucleolus, to the sporooyst as large as a full-
Hzed cell nucleus. Thus far, it has been impossible to
obtain cultures of these parasites. Cancer is not in-
oculable by grafting, except in individuals of the same
animal species.

Though parasites may not be found in all tumors
manifestly cancerous, they doubtless exist there in the
state of spores difficult to distinguish from nuclei.
These spores " infect other cells, and are transported
with them into the secondary nodules where the para-
site develops anew, and where it infects other histolog-
ical elements. The cells containing the parasites
eyentually die and disintegrate, while the surrounding
cells uildergo a process of active proliferation.

Professor Cornil, of Paris, declares himself as yet far
from convinced that the forms which Foa and others
described were parasites. We find in cancer a great
number of modifications of the form of cells and of
nuclei which might easily be taken for parasites. The
nuclei of cancerous cells divide sometimes into two,
sometimes into three, four or more secondary nuclei,
and these divisions end in the production of two or
more cells, each containing a nucleus, or in the produc-
tion of several nuclei inhabiting the ' protoplasm of
several cells.

The nndei of the cells undergoing division are
small, rich in chromatic material, bnt they soon be-
come fimbriated on their borders, knobbed, with pre-
dominance of liquid in their interior ; they may be-
come completely achromatic. They will then present
the moat varied shapes, from crescents to double sacs,
crowns, little knobby or spherical masses (secondary
nuclei) containing little coloring substance. These
transformed nuclei sometimes present an cedematous
appearance (hydropic nuclei).

Much of Comil's description we omit as being too
long and too technical. The result of dose observa-
tion with staining methods has convinced b>iff (b^t

Foa's parasites are only metamorphosed nuclei, a
product of morbid karyokinesis. According to Cornil,
there are found also in cancer degenerated cells whose
protoplasm stains red, and which contain in place of
nuclei granules, filaments, or masses of nuclein repre-
senting the different forms of indirect division, with-
out the occurrence of achromatic filaments or of clear
space around the divided nuclein. These are cell de-
generations arrested in one of the phases of indirect
division of the nuclei. Cornil remarked' that even
migrating leucocytes interposed between cancer cells
had been mistaken for parasites, especially when they
had retrograded and had broken up into fragments of
nuclein.

Dnplay and Cazin, of Paris, stated that their re-
searches on the structure of the constituent elements
of epithelial cancers had led them to the same conclu-
sions as those of Professor Cornil. The coccidia of
Foa and others are only forms of cell degeneration,
products of " indirect division," and have no parasitic
character.

Ruffer, of London, spoke in support of the claims of
Pio-Foa, corroborating his conclusions, while Morpurgo,
of Turin, as stouUy confirmed the position of Cornil,
Duplay and Cazin. So that the parasitic, and in par-
ticular the psorospermic origin of cancer, may be con-
sidered as still nAjudiee. We have to oppose to the
weight of Professor Cornil's assurance that the " or-
ganisms " are simply altered histological elements, the .
decided opinion of Metchnikoff and Sims Woodhead
that they are " undoubted coccidia." Admitting the
nature of these bodies to be parasitic, it might be
claimed that they are only accompaniments of malig-
nant growths, not the cause. The conditions of their
growth and development, according to Dr. Sims Wood-
bead are a lowered condition of the vitality of the
epithelial elements in which they make their habitat.
Finding a suitable soil, they multiply, secrete their
toxines, and by their irritant action on the parts which
they invade, resemble certain well-known pathogenic
microbes, especially Koch's bacillus, in the degenera-
tive processes and products which they entail. One
extremely weak link in the chain of evidence, as Dr.
Woodhead admits, is that hitherto inooiilation ex-
periments with cancerous material have very rarely
been successful in producing any cancerous reaction.

VITAL STATISTICS OF ENGLAND FOR 1893.
The Registrar-General of England publishes an ad-
vance-sheet or abstract of the vital statistics of Eng-
land and Wales at a much earlier date than that of the
annual report, which is rarely published till a year
later. From this advance-sheet, jast received, we
learn that he estimates the population as 29,731,100
at the middle of the year 1893, this being an increase
of 728,575 over the number of the population as
taken by the Decennial Census of April 6, 1891.

The marriages iu 1893 were 218,251; the births
were 914,189 ; and the deaths were 569.923, These

Digitized by

Google

400

BOSTOJf MEDICAL AND SVBGICAL JOVBHAL.

[Apbil 19, 1894.

figures give a marriage-rate of 7.S4 per 1,000 of the
estimated popalation (14.68 persons married), a birth-
rate of 30.75, and a death-rate of 19.17. Estimating
the excess of females over males to hare maintaiued
the same rate of increase as for the ten-year period
1882-1891, the death-rate of males was 20.27, and
that of females 18.14 per 1,000, or as 1,000 females
to 1,117 males io equal numbers living.

The figures for London were as follows (1898) :
marriage-rdte, 8.58 (persons married, 17.17); birth-
rate, 80.86 ; death-rate, 20.83.

The healthy excess of the birth-rate over the death-
rate in England, amounting to nearly 50 per cent.
(48.1), presents a strong contrast with the vital statis-
tics of France, which are as follows for the years
1891 and 1892:

1891 1892

Uanlscw M5.4S8 StO^lS

Birtlu 886,377 81(6,847

Dealhi 876,882 876,888

Ezoai* of deaths OTer birtlu . . 10,606 29,M1

HarrUge-nte 7.4 7J

(Penoni nuurriad) I4J U.0

Birth-rate 22.S S2J

Death-rate 21.8 2t.T

MEDICAL NOTEB.
Small-Pox at Simo Sing. — Three new cases of
small-pox occurred this week among the men working
in the rag department of Sing Sing Prison.

Unitbd Statbs Qoakantinb Pht8ician8 for
EuBOPBAN Ports. — The detail of surgeons from the
Marine-Hospital Service for duty at European ports
daring the coming summer has been made. Three of the
appointments are the same as last year : Dr. Woodward
to Hamburg, Dr. Stimpson to Botterdam, and Dr.
Brown to Havre. The other appointments are as fol-
lows : DiC Magruder to Naples, Dr. Perry to Genoa,
Dr. Vaughn to Bremen, Dr. Garmichar to Antwerp.

BOSTON AN1> NBW KNOLAND.

Boston City Hospital House-Offiobss. — The
rales of the Boston City Hospital have been changed
•o as to open the competitive examinations for posi-
tions as house-officers to graduates in medicine of not
over three years' standing.

AcuTB Infectious Diseasks in Boston. — Dur-
ing the six days ending at noon, April 17, 1894, there
were reported to the Board of Health of Boston the
following numbers of cases of acute infectious disease :
diphtheria 28, scarlet fever 87, measles 11, typhoid
fever 15, small-pox 1 (with 1 death). There are now 6
patients in the hospital. During the same period 8
cases of small-pox were reported to the State Board of
Health, 3 from Chicopee and 5 from Holyoke.

The Boston School Coumittbe and Vacci-
nation. — At a recent meeting of the Boston School
Committee the question of enforcing the present statute
requiring vaccination of pupils in the public schools
was brought to a vote, and was decided most properly
in the affirmative. Six members of the board voted to

do away with the regulation. They were Miss Hast-
ings, Miss Pingree and Messrs. Blanchard, Estes, Win-
ship and Wise. A most excellent example, surely, to
set the young aspirant for citizenship, to disregard the
law at the very threshold of the public school ! ! "As
the twig is bent" —

DiPBTHEBiA AT Wabehak. — So many cases of
diphtheria have occurred daring the last week at
Warebam, Mass., that the public schools have been
closed.

The Small-pox at Chicopee. — The number of
cases of small-pox at Chicopee has become so large
that the Board of Health has decided to build a quar-
antine hospital, as first proposed in the winter ,but re-
jected on account of expense.

The State Supervision of Vaccine Fabmb. —
The Committee on Public Health of the Massachu-
setts Legislature, in response to the hearing at which
committees from the Norfolk and Suffolk District
Societies presented petitions with the draft of a bill to
establish State farms for the production of vaccine
Tiros, has reported, not the desired measure, but a bill
to place "all vaccine institutions in the commonwealth
ander the supervision of the State Board of Health."
Such an act, if passed, will make the last state of the
matter worse than the present one. The bill confers
no defined powers and prescribes no penalties. It es-
tablishes a supervision which does not supervise, and
private institutions will be the sole gainers, in being
able to claim for their products State guarantee, while
the public at large will be led to rest in a false
security.

The Rhode Island Anti- Vaccination Bill. —
The Anti-Vaccination Bill before the Rhode Island
Legislature came dangerously near being passed by
the House last week. Although a bill carrying such
a menace to the public health was under consideration,
there was such a disgraceful apathy on the part of the
legislators that the House was obliged to sit for four
hours with looked doors to compel the attendance of
members. After a bitter discussion, the bill was
finally lost on the deciding vote of the speaker. That
such a proceeding could have occurred in a civilized
community in the year 1894 is not a fact to be passed
over lightly. If anything marks the true advance of
a community towards a higher plane of social enlight-
enment, it is the attention which such a community
pays to questions of public sanitation and hygiene.
The average community is not overprotected by proper
and sensible statutes regarding public health; bat if
there is one such, it is beyond question the enforce-
ment of vaccination. To abolish any such regulation
is to step back two centuries.

Condition of thb Mathbb Scboolhousb. —
The Committee appointed by the Boston School Board
to inquire into the sanitary condition of the Mather
Schoolhouse, in view of the numerous oases of conta-
gious disease among the pupils during the early winter,
has reported as follows : " The Mather Schoolhouse is

Digitized by

Google

Vol. CXXX, No. 16.] BOSTOS MEDICAL AUD 8VSG1CAL JOlUhAL.

401

an old bailding, &r too Bmall for the number of rooms
into which it is divided ; the lot is about one-half the
size of an ordinarj gchoolhoose lot. Each class of
fifty-six pupils is occupying floor space equal to about
two-thirds the area of a modern schoolroom. The
windows in the rear of the school building are close to
the sanitaries. The windows of the police station,
which ventilate the cells, open on the schoolhonse-yard
and emit foul odors a few feet from the schoolhonse
windows.

Thk Siztt-first Tear of the Boston Ltino-in
Hospital. — The annual report of the Boston Lying,
in Hospital for 1893 shows a continued high record of
usefulness. The year just closed is the first completed
in the finished new hospital, and the building has proved
in every way to be admirably adapted, for its purposes.
Five hundred and one women were treated in the
hospital, an increase of one over 1892. There were
505 children born during the year. In the Out-Pa-
tient Department 1,352 women were cared for — an in-
crease of 274. Out of this total of 1,858 patients only
4 died, a mortality of less than one-quarter of one per
cent. One woman died in the hospital in convulsions
from chronic Bright's disease twenty-eight days after
entrance. Among the out-patients two women died of
pulmonary embolism and one of eclampsia. In addi-
tion to these, three oat-patients were sent to the general
hospitals suffering from septicssmia : one recovered,
one died from mania, and one of old cardiac and pul-
monary disease. Certainly such a record is one to be
proud of. The work, especially among the out-pa-
tients, has increased so much that the number of house-
officers has been raised to three — each officer now
serving two months as junior in the house, two months
as assistant physician to out-patients, and two months
as senior house-officer. The house-patients were 206
Americans and 295 foreigners. Three hundred and
eight were married, 193 single. The training-school
for nurses gave diplomas to fifteen graduates.

MEW TOBK.

Vaccination Required of the Cbbwb of
Nethbrland Steamers. — Dr. Jenkins, Health Of-
ficer of the port, has notified the Netherlands line, two
of whose steamships have recently arrived with cases
of small-pox on board, that their vessels will not be
allowed to enter the port of New York unless their
crews have been vaccinated before leaving Rotterdam.
He has also notified the United States Consul at Rot-
terdam that clearances for New York should not be
given to the Netherlands line steamships uutil this
provision has been carried out and uutil disiufection of
the persons of all their passengers and seamen has been
made.

Mobtalitt. — The general health of the city con-
tinues unusually good for this season of the year.
During the week ending April 14th there were reported
83<i deaths, which was 21 less than in the previous
week, and represents au annual death-rate of 22.37
per thousand of the estimated population. The cold and

stormy weather had apparently some effect in increas-
ing the mortality from pneumonia, which caused 125
deaths, a larger number than occurred from any other
one disease. Diphtheria caused the largest number of
deaths among the contagious diseases, 41. The mor-
tality from scarlet fever amounted to 20, and from
small- pox, to 7. During the week 1,012 births were
reported.

VACCINATION IN THE JAPANESE NAVY.

The annual report of the health of the Imperial
Japanese Navy for the twenty-fifth year of Meiji
(1892), just published, gives some interestiog details as
to the success or failure of over 5,000 cases of vaccina-
tion.

Of the vaccinations for the first time, 38 were suc-
cessful and 65 unsuccessful (36.89 and 63.1 1 per cent.) ;
of the cases vaccinated for the second time, 220 were
successful and 457 failed (32.50 and 67.50 per cent.);
of third vaccinations, 404 succeeded and 973 failed
(29.34 and 70.66 per cent.); of fourth vaccinations,
386 took and 854 failed (31.13 and 68.87 per cent.);
of fifth vaccinations, 195 were successes and 562
failures (25.76 and 74.24 per cent ; of those vaccinated
for the sixth time or over, 141 were successful and
498 unsuccessful (22.07 and 77.93 per cent.). In
cases in which there was an uncertainty as to scars
from smallpox, 119 vaccinations took and 193 failed.
In all there were 1,503 successes and 3,602 failures, a
percentage of 29.44 and 70.56 respectively.

The ratio of success or failure per hundred cases of
vaccination during the period of nine years from 1883
to 1891 was 38.98 and 61.02 for all cases ; the ratios
for the various classes of first, second, thincl, etc., vac-
cination being 58.68 and 41.32, 46.80 and 53.20,
35.67 and 64.43, 32.86 and 67.34, 28.25 and 71.75,
26.83 and 73.17.

This last series particularly shows that while the
chance of successful vaccination steadily diminishes
with each repetition, namely, from 58 to 26, there is
still more than one chance in four that even a sixth
vaccination will take — a fact which should emphasize
the importance of a general revaccination of persons
of all ages at the time of any public need.

TAPPING OF THE LATERAL VENTRICLES.

No longer abashed by the fear of entering the
peritoneal cavity the surgical Charmides now seeks to
penetrate other sanctuaries — even into the inmost
recesses of the brain. Tapping through a fontanelle
for hydrocephalus is no new procedure ; but it is only
within a few years that any technical perfection has
been reached in withdrawing fluid from an overdis-
tended cerebral ventricle. Dr. Frank, of Chicago, re-
ports • two interesting cases of his own, in which the
results obtained were sufficiently marked to justify the
operation, although both patients died. One was a
case of acute hydrops ventriculi resulting from severe
injury to the head with multiple fractures of the base,
which were made out post-mortem only. After tre-
> Annals of Sugary, April, MM.

Digitized by

Google

402

BOSTON MSDIOAL AND SUROIOAL JODRNAL.

[April 19, 1894.

phining, the ventricle was opened by an aspirating
needle oorresponding to a No. 3 catheter (American
scale), and about three onnces of fluid withdrawn.
There was considerable relief from the pressure symp-
toms. The second case was one of idiocy following
hydrops Tentricttlorum dae to cerebro-spinal menin-
gitis.

After reviewing the history of this radical thongh
rational procedure and discussing the sargical ease and
safety with which it can be done, he draws the follow-
ing conclusions, which are of interest :

" Trephining and tapping the lateral ventricles —

"(1) For distention of the ventricles from acute,
simple or tubercular meningitis, is a therapeutic meas-
ure clearly indicated, and other things being equal,
promises recovery.

" (2) For effusion of blood into the ventricles from
trauma or disease, makes recovery a possibility.

" (3) For abscess, involving the ventricles, is imme-
diately and imperatively demanded.

" (4) For effusion into the ventricles, from brain
tumors, may afford relief to symptoms.

'* (5) For chronic hydrocephalus, moderate disten-
tion of the ventricles, without enlargement of head,
may afford relief.

" For chronic hydrocephalus, great distention of
ventricles, enlargement of head, will lead to a fatal
result."

SURGICAL TREATMENT OF PULMONARY
CAVITIES.

Tbk surgical treatment of pulmonary cavities is a
department of therapeutic technique which has much to
commend it to careful attention. While experiments
upon animals and a few remarkable cases have shown
that considerable portions of lung tissue may be re-
moved without serious impurment to health, there has
been great hesitancy in applying surgical treatment to
cases of pulmonary disease which are properly open
to it.

In a paper read before the New York State Medical
Association, N. Pendleton Dandridge, M.D., of Cin-
cinnati,^ gives the following conclusions concerning
operative treatment :

( 1 ) A certain number of lung cavities can be success-
fully dealt with by incision and drainage.

(2) Tubercular cavities in the lower portion of the
lungs — if single and superficial, and the general con-
dition of the patient permits — should always be
opened. Cavities at the apex should only be opened
where free and persistent fetid expectoration is pres-
ent, and has resisted treatment, and the rest of the
lung is not involved.

(3) Abscess, gangrene and hydatid cyst should be
opened and drained whenever they can be located.

(4) Closure of the pleura should be present before
evacuation of a cavity is attempted.

(5) In cases of pyopneumothorax the fistulous track
should be explored, and any cavity freely laid open by
the cautery.

(6) Cavities that have been opened are best treated
by packing with gauze, preferably iodoform.

(7) The further careful trial of such agents as iodo-
form, chlorine gas, and chloride of cine, is desirable to
determine as to whether the tubercular infiltration
may not be modified by them.

> Annsls of Siirg*rT, Febroar; I, UM,

(8) It is very desirable, for the further extension of
surgical interference in pulmonary cavities, that the
means of locating such cavities, and of determiniog
their size, and the exact character of the tissue that
overlies them, should be perfected by farther study,
and for the accomplishment of this the surgeon matt
look to the physician.

TWO ATTACKS OF TYPHOID FEVER IN THE
SAME PERSON.

The few opportunities for accurate observation of
two attacks of typhoid fever in the same patient, espe-
cially under similar conditions, make reports of soch
cases of considerable interest.

Drs. Hand and Patek report ^ such a case from the
service of the Grerman Hospital in Philadelphia. The
patient, a woman aged nineteen years, entered the hos-
pital March 29, 1893, having been unwell for several
weeks, and in bed six days. She bad a typical mild
attack of typhoid fever, and was discharged in good
health five and a half weeks after entrance. On Sep-
tember 21, 1893, she was readmitted. On the ninth
day she had a second attack of well-marked typhoid
fever. This ran an uncomplicated course, and she
was discharged in four weeks. In each attack there
was enlarged spleen, gurgling in the right iliac fossa
and typical rose-spots. The treatment was the same
daring each attack : a bath every three hoars when
the temperature was over 102°. Daring the first ill-
ness she had forty-three baths, and in the second
thirty-eight. The temperature reached normal on the
same day on each occasion.

THE MUNIZ COLLECTION OF SKULLS.*

The nineteen trephined skulls selected from the
large collection of over a thousand crania gathered by
Sefior Manuel Antonio Muiiiz, M.D., Surgeon-General
of the Peruvian Army, form the largest and most in-
structive collection of specimens of primitive trephin-
ing thus far brought together. They show distinctly
three types of operation.

The first is that in which a rectangular button was
removed by means of four linear incisions made in
parallel pairs intersecting at right angles. The inci-
sions are narrow, v-shaped in cross-section, and gradu-
ally increasing in depth from ends to centre, thus indi-
cating that the instrument was a pointed bit of stone
or arrow-head held vertically and operated by recipro-
cal motion. This type of operation is rude and the
resulting traumatism is jagged, each incision extending
perhaps half au inch beyond the button at each extrem-
ity. There is no indication of the purpose of the opera-
tion of this type in any case, and nothing to suggest
that if the operation was ante-mortem the individual
survived.

In the second type of operation the incision was evi-
dently made also by a rudely-pointed instrument, prob-
ably of stone, held vertically and moved reciprocally ;
but as the cutting reached and penetrated the inner
table, the locus of incision was moved forward and at
the same time the direction of the sawing was changed
so as to produce a rudely-curved cat and, when two

I Hedlo»l Newt, April 14, 1894.

> Bnlletin of the Joims If opkip* ^loeplM, toI, v, No. V,

Digitized by

Google

Vol. CXXX, No. 16.] BOSfOH MMhlCAL Atlh StJttGtCAl JOVtttlAL.

403

8aoh incisions were made, an irregnlarly elliptical but-
ton.

The third type of operation was performed largely
or wholly by scraping in snch manner as to remove the
outer table and diploe and reduce the inner table to a
feather-edge. Some of the examples suggest that the
scraping, which may easily have been effected with
stone instraments and gives no indications of the use
of metal, represents the final part of an operation
began by the curved incision. The deftness of the
operators may be inferred from one specimen in
which, although the skull is fully a quarter of an inch
thick, the parallel incisions are not more than three-
eighths of an inch apart. Several of the skulls show
that the patient bad survived one or even two tre-
phinings only to perish during a later operation.

The collection is of especial value as demonstrating
certain points heretofore obscure, and warranting the
following conclusions: (1) That the operation was
ante-mortem, since five individuals out of the nineteen
represented certainly, and two or three more probably,
survived one or more operations ; and (2) that the tre-
phining was surgical. Two provisional conclusions of
importance are also indicated by the collection : (8)
that the operation was used in a medical way to relieve
a general pathologic condition ; and (4) that the opera-
tion was, as indicated by the total absence of marks
of metallic instruments, anterior in date to the Spanish
invasion and thus essentially prehistoric. Two of the
crania are to be given to this country, one to the
Bureau of American Ethnology and one to the Army
Medical Museum.

€occe^i>otiIiettc(.

THE MASSACHUSETTS HOM(£OPATHIC MEDI-
CAL SOCIETY LUNCHEON.

Boston, April 14, 1894.
Mr. Editor : The following appears in your number of
April 12, 1884 : " The programme of the annual meeting
of the Massachusetts Homoeopathic Medical Societv in-
cluded a luncheon at the State Insane Hospital at West-
borough."

I wish to say that the luncheon alluded to was paid for
by the Maasachusetts Homoeopathic Medical Society, and
not by the State Insane Hospital at Westborough.
Bespectfully yours,

Charles B. Codman,

Chmrman ofihe Board of Trustees of the

Westborough Insane Hospital.

THERAPEUTIC NOTES.

To Bemdbk Castob Oil Palatable. — An

ordinary dose of castor oil may be rendered odorless
aod tasteless by simply shaking it thoroughly in a
flask with warm milk.

Tbeatmbnt of Mkaslkb Br Edcaltptus Ikdnc-
TION. — Dr. C. £. Shelly reports ' the use of eucalyp-
tus inunction in a series of cases of measles. The
favorable reports of other observers were not confirmed.
The total number of cases observed was seventy-three.
Of these, five received the treatment by eucalyptus.
InoDction was begun directly they came under obser-
vation, night and morning for three days, and subee-
qaently once a day for the first week. Eucalyptus
emulsion was given internally, some of the fiuid was
placed in saucers about the room, and when cough was
troublesome eucalyptus inhalations were given. The
results were not at all favorable. There was unusual
drowsiness: "all five patients sleeping almost con
stantly, being aroused with some difiiculty to take their
food, and remaining awake only just long enough to
consume it." All five had tongues thickly coated with
white fur, contrasting markedly with the tongues of
others under different treatment. The eruptiou of the
rash was delayed in four of the cases and in all there
was a relatively prolonged pyrexia. Convalescence
was in all five cases more tardy than usual, and des-
quamation much more profuse. In general the symp
toms " seemed to indicate an undue retention of morbid
products, rather than that speedy and complete destruc-
tion of the infective poison which the advocates of this
treatment claim as one of its special advantages."

> PtaMlttoMr, Novembar, isn.

RECOBO OF MOBTALITY
Fob thk Wbbx bmdino Satubdat, Apbil 7, 1894.

CttlM.

New York . .

Chioaso . . .

PUladelphts ,

Brooklyn . ,

St. Loidi. . .

Boston . . .

Baltimore . ,
Wuhlngton

Glnclnnstl . ,

GleTeland . ,

Pitubnrf . ,

Hllwankee . ,

NatbTlUe . .

Gharleiton . .

PortUnd . . ,

WoroMter . .

FsllBlTar . ,

Lowell . . .

Cam bridge . ,
Lynn ...

Springfield . .

Lawrenee . ,

New Bedtord ,

Holyoke . . .

Salem . . . ,

Broekton . ,
HaverUU .
ChelM* . .
Halden . .

Newton . . ,
Fltehbnrg .
Taunton . .
Qloneeater .

Waltham . ,
Qnlnoy . .

Pittafleld . .

Ererett . . .

Northampton .

Newbnryport ,

Amesbnry . ,

l,S»l,8«6

1,438,000

I,116.JS62

978,284

seo.uoo

487,387

eoo.ooo

808,131
308,000
290,000
283,708
2fiO,0UO
87,764
63,lt>5
40,000
90,217
87,411
87,191
77,100
62,686
48,684
48,368
48,886
41,278
32,233
82,140
31.386
80,284
29,394
27,886
27,146
28,972
26,688
22,068
19,642
18,802
16,688
16,331
14,073
10,920

h
P

^1

a >

f

860

108

18

339

11

11

Pereentage of death* from

17.76

12.88
18.76

8.IU
10.06
16.64

8.82
6.26

16.00

2.M
20.00
21.04
11.11

10J2
11.11

14.28
16.66

20.00
10.00
33ji3

60.00
14.28

33.33

18.36

10.81
U.78

16.20
23.76
11.96

16.07
4.16
3.1S

20.00

32.31

8.00
10.62
27.77

16.78

6.26
66.66
I6J8
11.11
14.28
16.66

20.00

33.33

li
59

7.92

6.21
7.00

3.C0
2.16
1.84
8.86

4.00

2.94
4.00

1<US2

18.66

14.38

1^

2.62

2.07
3.60

1.36

M

4.60

4.16

4.00

14.28

33.33

3.00

1.38

4.C0
6.86

4.00

:8S.S3

Deaths reported 2,Bt/7 : ander five years of age 967 ; principal
infections diseases (small-poz, measles, diphtheria and croup,
diarrboeal diseases, vboopfng-cQUgh, erysipelas and fever) 382,
consumption 328, acute inng diseases 317, diphtheria and croup
147, scarlet fever 60, measles SI, diarrhosal diseases 28, typhoid
fever 36, whooping-cough 20, cerebro-spioal meningitis 16,
small-poz 14, erysipelas U.

From diarrhoea! diseases New York 11, Brooklyn and Mil-
waukee 4 each, Philadelphia, Washington, Cambridge and
Taunton 2 each, Cleveland 1. From typhoid fever PhilMelpbia
7, New York 8, Milwaukee 3, Brooklyn and Boston 2 each.
Washington, Nashyllle, Worcester, Cambridge, Springfield and
Brockton 1 eadi. From whooping-cough Brooklyn 6, New York
ft, Philadelphia, Cleveland and Nashville 'i each, Bobton, Wash-
ington and Charleston 1 each. From cerebro- spinal meningitis
Washington S, New York, Cleveland and Lynn 2 each, Worces-
ter, Somerville, Gloucester and Plttsfield 1 each. From small-
e>z Brooklyn 7, New York S, Bceton 2. From malarial fever
rooklyn 0, New York 4, Philadelphia 2, Springfield 1.

Digitized by

Google

404

BOSTOIS MEDICAL ASD SVMGIOAL JOVRSAL.

[ApxtL 19, 1894.

In the tbirty-tbree greater towns of England and Wales with
an estimated population of 10,468,412, for the week ending
March 3l8t, the death-rate was 20 0. Deaths reported 1,010:
acute diseases of the respiratory organs (London) 317, measles
210, whooping-cough 168, dipbUierla 06, scarlet fever 61, fever
46, diarrhoea 10, small-poz (West Ham 6, Birmingbam 8, Bristol,
Manchester and Oldham 1 each) 11.

The death-rates ranged from 12.2 in Portsmonth to 26.8 in
Salford ; Birmingham 20.0, Bradford 17.2, Bristol 14.6, Croydon
m.6, Halifax 21 3, Hull 18.1, Leeds 16.0, Leicester 19.8, Liverpool
24.6, London 20.8, Manchester 22.7, Newcastle-on-Tyne 21.2, Nor-
wich 1».2, Nottingham 20.8, Plymouth 23.7, Sheffield \8.6, Sun-
derland 19.9, Swansea 16.9, West Ham 16.8.

METEOBOLOOICAL RECORD,

For the week ending April 7tb, la Beaton, acoording to ob-
servations furnished by Sergeant J. W. Smith, of the United
Stated Signal Corps:—

Baro-

Thennom- Belative

Dtreetton

TaloeiCT
of wind.

We'th'r.

1

meter

eter. Ihumtdtty.

of wind.

•

Date.

i

g

i

a

1

i

i

*

i

i

a'

a

a

a

a'

a

a
1

1

I

a

i

s

K
1

<

i

t,

■i

*>
S

00

R.. 1

19.68

i»

63

47

54

46

60

w.

N.W.

14

16

0.

o.

M.. 2

30.00

.18

46

31

56

32

4t

N.

N.

14

15

o.

0.

T.. 8

30..11

H

46

23

SO

50

60

N.W.

S.W.

10

16

c.

c.

W.4

29.8K

42

83

32

63

90

76

8.

8.W.

17

17

0.

B.

OJl

T.. (1

29.8S

52

n6

47

74

69

66

W.

W.

18

12

0.

0.

0.13

F.. «

2y.96

12

15

38

70

64

62

w.

N.

•

:s

0.

0.

0.02

8.. 7

30.16

11 32

30

47

66

61

N.W.

8.

10

16

0.

0.

tr

29.M

49

35

63

0.46

•O.,oload7i Colcu; r.,(>lri tt.,fo(i II.,liu7i 8..BiMk7i lUralBi T-.thiwI-
•Blact N . , mow. t lBdl«t« tKM of nlafall. 4^ Haas for wook.

OFFICIAL USX OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM APRIL 7, 1894, TO
APRIL 13, 1894.

Leave of absence for one month Is hereby granted CArTAm
OoDBH Raffebtt, assistant surgeon, with permission to apply
for an eztenalon antil the 20th of May next.

The following named officers of the Medical Department will
report in person for temporary duty until further orders, as
follows: FiBST-LiBUT. Cbaklks Willcox, assistant surgeon,
to the commanding officer, Angel Island, California. Fikst-
LiauT. Chablbs E. U. Klaoo, assistant surgeon, to the com-
manding officer, Alcatraz Island, California.

THE INTERNATIONAL ASSOCUTION FOR THE AD-
VANCEMENT OF HYGIENE.

The Ninth Exposition of Hygienic and Alimentary Products,
under the auspices of this Society will be held at Rome, in Jane
next. In the Palais des Beaux-Arts, under the Presidency of Dr.
Baccelll, Minister of Public Instruction.

Authors and editors of publications relative to hygiene are
reqnested to send copies of their works to M. Louis De Vrlese,
Administrator-General, Rue des Bignesses 3, & (}and, Belgium.

HARVARD MEDICAL SCHOOL.

EvBirnfQ Lbctubbs.

The next lecture will be given on Wednesday evening, April
2eth, by Assistant Professor T. M. Rotch, at 8 o'clock. Subject,
" Infant Feeding." Physicians are cordially invited.

SOCIETY NOTICES.

BosToir SociBTT fob Mbdical Impbovkmbmt. - A regular
meeting of the Society will be held at the Medical Library, No.
19 Boyrston Place, on Monday, April 23, 1894, at 8 o'clock, r. M.

Ur. A. Thomdike: " Acute Arthritis in Infante, in the Hip-
Joint." Discussion opened by Drs. B. H. Bradford and H. L
Borrell.

Dr. G. H. Washburn : " An Interesting Obstetrical Case."
Discussion by Drs. J. Q. Blake, C. E. Stedman, E. Reynolds.
JoHir T. Bowbk, M.D., /Secretory.

Thb BosToir Mbdico-Pstcholooical Socibtt will hold ite
next meeting on Thursday evening, April 19, at eight o'clock, at

the University Club, 270 Beacon Street, Drs. Walter Channbig,
B. T. Edes, E. V. Scrlbner and C. E Woodbury, entertainiag.

The Society invites the Faculty of the Harvard Medical
School and the Staffs of the Massachusetts Gtoneial Hospital
and City Hospital to be present.

Dr. H. M. Hurd, of Baltimore, will read a paper eatitled,
" Some of the Mental Disorders of Childhood and Youth."

Members are requested to inform the Secretary whether or
not they can be present.

H. C. Baldwin, M D., Secretary.

PBVNSTLVAiriA Statb Mkdical Socixtt.— The annual meet-
ing of the Pennsylvania State Medical Society will be held In
Philadelphia, May 15, 16, 17 and 18, 1891. The annual addieaaea
before tJie various sections will be given by the following
gentlemen: "Medicine," W. S.Foster, M.D., Pittsburg; "8ur-

Siry," Q. D. Nutt, M.D., Wllllamsport; "Obstetrics," E. E.
ontgomery, M.D., Philadelphia; " Mental Disorders," T. M.
T. McKennan, M.D., PitUbnrg; " Hygiene," J. H. Wllnn,
M.D., Beaver ; " Ophthalmology," Geo. E. de SchweinlU, II.D.,
Philadelphia.

RECENT DEATHS.

Dakikl E. Mabston, M.D., died in Monmouth, He., April
14th, aged fiftr-eight years. He gradoated from Bowdoin In
1869 and served In the army during the rebellion.

CoBTDOH C. Fon>. M.D., for forty years Professor of Anat-
omy and Physiology In the University of Michigan, died at Ann
Arbor, April 14th, aged eighty-one years.

JcsBPH H. WoBEMAM, M.D., died April 16tb, aged eighty-
nine years. He was the first President of the Ontario Medical
Council and was for twenty-five years Snperintendent ol the
Toronto Asylum for the Insane.

Sbbastibm DmiBB Lbbbitibb, M D., died in Paris recently,
aged eighty-five years. He was private physician to Nnmleon
in and a prominent member at the court doring the Seoond
Empire. He was inspector of the mineral springs at Piomhiirei.

BOOKS AND PAMPHLETS RECEIVED.

Pernicious Malarial Fever. By George Doek, M.D., of Ann
Arbor, Michigan. Reprint. 18M.

Charaka-Sambita. Translated into English and published by
the Avinasb Chandra Kaviratna. PartVn. Calcutta. 1894.

The Johns Hopkins Hospitel Reports, Vol. IV, No. I. Report
on Typhoid Fever. Baltimore: The Johns Hopkins Press. 1891.

Faradlsm as an Analgesic in the Loosening of Joint-Adhe-
sions. By Douglas Graham, M.D., Boston, Mass. Reprint.
1893.

The Hospitei at 24 McLean Street, A Statement of lu History,
ite Managers, ite Doings and the Result of Ite Work In 1893.
The Sixty-first Year of the Boston Lying-in Hospitei. Boston.
1894.

Lectures on Surgery. By David W. Cheever, A.B., M.D
(Harv.), Professor of Surgery, Emeritus, in the Medical School
of Harvard University ; Senior Snrgeon of the Boston City Hos-
pitei, ete. Boston : Damrell & Upham. 1894.

Clinical Manual of the Study of Diseases of the Throat. By
James Walker Downie, M.B., Fellow and Examiner In Aural
Surgery for the Fellowship of the Faculty of Physicians and
Surgeons, Glasgow. New York : Macmillan & Co. 1894.

Transactions of the American Dermatological Association at
ite Seventeenth Annual Meeting held at Milwaukee, Wis., on
the 6tb and 6th of September, 1^3. Official Report of the Pro-
ceedings by George Thomas Jackson, M.D , Secretary. New
York. 1894.

Gonorrhoea; Being the Translation of Blenorrbcea of the
Sexual Organ and ite Complications. By Dr. Ernest Finger.
Decent at the University of Vienna. Third revised and enlarged
edition, with seven fnll-page plates In colors and thirty-six wood
engravings in the text. New York: William Wood & Co. 1891.

A Manual of Practical Obstetrics. By Edward P. Davis,
A.M., M.D., Professor of Obstetrics and Diseases of Children In
the Philadelphia Polyclinic ; Clinical Lecturer on Obstetrics in
the Jefferson Medical College ; Clinical Professor of Diseases of
Children In Woman's Medical College, ete. Seoond edition, re-
vised and enlarged, with 134 Illustrations and 16 full-page plates,
several of wbiiSi are colored. Philadelphia: P. Blakiston, Bon
& Ck). 1894.

Methods of Pathological Histology. By C. von EAhlden, As-
sistant Professor of Pathology in the University of Frelbuig.
Translated and edited by H. Morley Fletcher. H.A., MJ>.,
Canteb., M.R.C.P., Casualty Physician to St. Bartholomews
Hospital and Assistant Demonstrator of Physiology in the Med-
ical School. With an introduction by Q- Sims Woodbead, H.D.,
Director of the Laboratories of the Conjoint Board of the Bonl
Colleges of Physicians (Lond.) and Surgeons (Bng.). London
and New York : Macmillan & Co. 1894.

Digitized by

Google

Vol. CXXX, No. 17.] BOSTON MSDIOAL AND SURGICAL JOURNAL.

406

Original Slrticle^.

OBSERVATIONS ON CASES OF FIBROID TUMOR
OF THE WOMB.i

BT FKASOU KISOT, II,D.

In offering some remarks on the cases of uterine
fibroid which have come under my notice, I do not
pretend to advance any new views as to the etiology,
the symptoms or the treatment of the disease. I shiUl
chiefly allude to certain points in connection with its
diagnosis, and to some of the symptoms which appear
to me to be of interest, and to indicate their practical
valoe.

It is remarkable that a structural disease of the
womb, causing a considerable enlargement of the
organ, sometimes giving rise to an annoying disfigure-
ment, especially if the patient be unmarried, and gen-
erally accompanied by a more or less profuse haemor-
rhage which often lasts for years, should in many
cases not only be free from danger to life, but that it
should often interfere but little with the occupations
and the comfort of the patient.

I regret that out of a large number of patients with
fibroid tumor, who have come under my observation
daring a practice of forty years, I have preserved suf-
ficiently detailed notes to be of value in only thirty-
four cases. Of these, the number of patients who
were, or who had been married, is twenty-one, their
average age being thirty-six years. The oldest pa-
tient was flfty-two years ; the youngest, twenty years
old.

The age at which the first symptoms of the disease
appeared in twenty-six cases of which trustworthy
statements could be obtained, varied from twenty
years to fifty-two years. Arranged according to dec-
ades, the first symptoms were noticed :

Between the ages of 20 and SO . In 10 eaaas

Between the aee* of 30 and 40 .... InlSoasee

Between the agea of 40 and BO .... in 2 oaset

Between the agea of DO and 60 .... In 1 eue

In one case the first symptom appeared at the age
of twenty years and two months ; in another at twenty-
two years ; in another at fifty-two years. The average
sge was about thirty years. So far as this small num-
ber of statistics goes, it appears that the social state
has bat little influence in the etiology of uterine fibroid,
and that the disease may appear at any period of life
after twenty, perhaps most frequently between thirty
and forty, and either in single or married women.

The diagnosis of uterine fibroid is in many cases
comparatively easy. The combination of profase
menorrbagia, often passing into metrorrhagia, with a
bard tamor connected with the uterus and felt through
the abdominal wall, is usually enough to remove all
doubts as to the disease. Both of these symptoms,
however, may be absent.

(1) There may be absolutely no menorrbagia, or
the flow may amount to no more than is often o^erved
in patients who are free from uterine disease, as in the
following case :

A lady, twenty-eight years old, single, was brought
to me March 11, 1873, by her physician, in conse-
quence of a feeling of distention in the abdomen and
the discovery of a tumor in the left iliac region.
There was no menorrbagia. A large, rounded tumor
occupied the left pubic region, extending nearly to the
* Bead before the Obstetrloal Sooietj of Boeton, Febraarr 10, 18S4.

navel, and a little to the right of the median Tine. It
was irregular, but not distinctly lobular, cervix uteri
very low, just beneath the pubes. The posterior
region of the pelvis was tilled by the tumor, as was
evident by rectal examination. The tumor was some-
what movable above. August 17, 189S (more than
twenty years afterwards), the patient's physician
wrote to me : " There has been occasionally some in-
crease of menstrual flow, but never amounting to ex-
cess ; she is nearly reduced to her natural size, is in
fair condition and enjoys life."

April 29, 1875, I saw in consultation with the late
Dr. D. H. Storer, a patient with a 'Marge aterine
tumor, divided into several distinct lobules, distending
the abdomen as much as a pregnant uterus at the fifth
or sixth month ; no hsemorrhage ; no pain."

The first symptom noticed may even be a suppres-
sion of the menses. A young woman, twenty-one
years old, was brought to me by the late Dr. Snow of
Newburyport, August 14, 1888. She had had no
catamenia since the previous November. In all other
respects her health had been good. There had been
progressive enlargement of the belly. The abdomen
was distended by a smooth, hard tumor, occupying its
lower half, which was found by bimanual examination,
to be connected with the uterus. The navel was nearly
obliterated, as in pregnancy at the eighth month. No
fcetal heart-beat and no placental murmur could be
heard. The breasts were virginal in appearance, the
hymen was intact, ballottement gave no evidence of
pregnancy.

(2) As regards abdominal tumor, we must remember
that this is usually absent in uterine polypus unless
the latter be extremely large; and if there be no
hsemorrhage, it might not be suspected. I saw, with
the late Dr. A. B. Hall, June 21, 1868, a mulatto
woman forty years old, who for a year previously had
complained of uneasy sensations in the pelvis and a
profuse vaginal mucous discharge. There was no
haemorrhage, and no abdominal tumor could be felt,
but the vagina was completely filled with a firm mass,
connected with the interior of the uterus by a pedicle
one inch thick. The pedicle was severed close to the
aterine wall with scissors, and the tumor removed with
very little loss of blood. It was an ordinary fibroid,
about the size of the fist. The patient did well.

An intro-mural tumor may be so small as not to be
felt, either by external or internal examination, and
yet give rise to much haemorrhage. Several years ago
a domestic in the family of Dr. Davidson of Gloncester,
twenty-eight years old, married, had had for more than
a year abundant and frequent uterine haemorrhages.
There was no tumor to be felt by Dr. Davidson, who
accordingly dilated the cervix uteri with sponge tents,
and detected a tumor in the uterine wall apparently
about the size of a boy's marble. He sent her to the
Massachusetts General Hospital, where the tumor was
removed. It was an ordinary fibroid, " as large as a
very large horse-chestnut." The patient did well.

The diagnosis of aterine fibroid may be obscured by
the prominence of symptoms which are not character-
istic of that disease. Iday 24, 1889, I was called to
see a nursery-maid, thirty-six years old, who had al-
ways enjoyed good health. Menstruation rather free,
but otherwise normal. She had never bad any blad-
der trouble before, but on that day, on rising, she was
unable to make water. After breakfast she had a
movement of the bowels, as usual, but still could make

Digitized by

Google

406

BOSTOH MBDIOAL AND SURGICAL JOURNAL.

[April 26, 1894.

no water. Although feeling uncomfortable, she took
one of the children to school. In the course of a few
hours, the discomfort amounted to distress, in which
condition I found her at three o'clock p. m., and drew
off with a catheter about two quarts of urine without
any difficulty, and a tumor was felt, per vaginam,
nearly filling the pelvis. Externally, the tumor was
felt occupying nearly the whole of the supra-pubic
region, and extending halfway up to the navel, with a
projection towards each flank. April 11, 1890, nearly
a year afterward, I was called to see her again for the
same difficulty, and drew off about three pints of urine.
During the interval between my two visits she had
had no difficulty in micturition. She had had no un-
usual fatigue, and no exposure to cold. Since my
previous visit, the tumor had extended upwards as far
as the navel, and also downward in the pelvis ; the os
uteri was low down and closed, and the cervix was
obliterated. The catamenia were regular, profuse,
lasting eight or nine days. Quite recently I have been
informed that the patient has had no farther recurrence
of the bladder difficulty, and is in good health.

Urgent urinary symptoms have been comparatively
rare in cases of uterine fibroid under my observation,
but in several instances there was more or less irrita-
bility of the bladder; several patients complained of
painful and frequent micturition. One case was com-
plicated with pelvic inflammation and cystitis. One
patient had frequent micturition day and night. In
another case, the first symptom noticed was frequent
micturition ; the patient made water every few hours
during the day, and several times daring the nighL
There was no pain in the act, but much pain if she
was compelled to hold her urine long.

Interference with the functions of the rectum was
reported by none of the patients of whose cases I have
preserved notes.

The diagnosis between fibroid tumor of the womb
and pregnancy is generally easy, though not always so,
and it is hardly necessary to say that the most careful
examination should be made in such cases before giv-
ing an opinion which might compromise the reputation
of a patient. I have already mentioned the case of an
unmarried woman whose external appearance, caused
by a large uterine fibroid, was strongly suggestive of
pregnancy. Another case was that of an unmarried
lady, a teacher of a young ladies' school, who con-
sulted me on account of the disfigurement caused by a
large fibroid of the womb.

Cases of fibroid complicated with pregnancy are not
very rare, and it is remarkable that the latter is often
not interfered with, that the labor may be attended
with no serious difficulty, and the child be born alive.
In April, 1876, 1 saw with Dr. Winslow of Groton, a
lady who, four weeks previously, had been confined at
full time, the child being alive and well at the time of
my visit. There had been some delay in the passage
of the head, which was found to be caused by a fibroid
growth of the size of the fist, attached by a pedicle to
the posterior wall of the uterus. A few days after the
labor, the patient was attacked by phlebitis of both
arms and one of the legs, and she died a week after I
saw her, but there seemed to be no connection between
the presence of the tumor and the phlebitis.

In March, 1887, 1 saw a lady who had been married
somewhat over a year. A short time before her mar-
riage (the menstruation having always been remark-
ably regular, without pain, and normal in amonnt),

she had noticed a tumor in the abdomen, which had
remained of the same apparent size ever since. The
last appearance of the menses was about three months
before my visit, and the patient exhibited the oioal
subjective and objective symptoms of pregnancy. The
tumor was smooth, rounded, hard, not tender, and wu
situated above the right pubic ramus, towards the iliac
fossa. The upper margin was about three inches be-
low the navel. It was somewhat movable, and was
connected with the womb, as was shown by bi-manoal
exploration. The patient was a stranger visiting
Boston, and I have not heard of her since-
Fibroid tumor of the womb may, of course, give
rise to abortion. A woman twenty-six years old, who
had been married eight mouths, consulted me Jaduarj
10, 1879. She had never had monorrhagia, tboagh
frequently dysmenorrhcea, before marriage. Twice
since marriage, she had suspension of the catamenia
for one or two periods, followed by hsmorrhage and
the expulsion of a mass. In the left iliac region was
a roand, hard movable body of the size of a horse-
chestnut, and a large tumor occupied the left side of
the pelvis, reaching as high as the brim, connected
with the uterus and with the smaller one. There was
no external enlargement from the tumor.

Of the symptoms connected with fibroid disease of
the womb, perhaps the most serious, certainly the
most rebellious to treatment and the most annoying to
the patient, is metrorrhagia. Patients are sometimea
encouraged to believe that after the period of the
menopause, there will be a permanent suppression of
the hssmorrhage. This, no doubt, often occurs, bat in
my experience there have been several exceptions to
the rule, and I have at present four such under my
observation. A remarkable feature of the symptom,
in many cases, is its capricious behavior. It may long
resist treatment, and then, after treatment has been
abandoned, it may cease spontaneously for years, only
to return again, to the despair of the patient and of
the doctor. In two cases which have been under my
observation for many years, there have been interval)
of complete suspension of haemorrhage lasting in one
patient, for eight years, and in the other for two years,
apparently not due to treatment; but in each there
was a subsequent return of the bleeding. Id some
cases, the haemorrhage is replaced by a profuse serooi
discharge, which is hardly less annoying to the patient.
As a rule, the treatment for haemorrhage from oter^
ine fibroids is unsatisfactory. It is rarely that a pa-
tient is cured, though in many cases, an arrest of the
bleeding for a longer or shorter time may be obtained.
Among the various remedies which have been recom-
mended, ergot has the highest reputation. It will
often check the haemorrhage temporarily, but I have
not met with an instance of cure following its nse,
unless in patients who have nearly reached the period
of the menopause, when there is in many cases a spon-
taneous cessation of the flow. Chian turpentine has
also in my hands proved a valuable remedy, perhaps
superior to ergot, but I have not had enough experi-
ence in its employment to be sure of this. To be of
any nse, these remedies must be given in full doses
and several times a day.

We should suppose that restriction from active ex-
ercise would be essential in the treatment of the htem-
orrhage, but two of my patients assured me that exer-
cise had no effect in increasiug iL One of them had
spent several weeks in the Adirondacks, during which

Digitized by

Google

?oi. CXXX, No. IT.] BOSTON MEDICAL AND 8UROIOAL JOURNAL.

407

time she not only took long walks, bat did a good
deal of moantain climblDg, without any unfavorable
effect. She is forty-eight years old, and has had a
large tomor for many years, with, at times, profuse
haemorrhage, which has not yet wholly ceased.

As to the treatment of the anaemia and debility,
which are the results of the long contiuoed loss of
blood, I have nothing to say which would justify me
for trespassing any longer upon your attention.

The surgical treatment of uterine fibroid has until
lately been rarely attempted, on account of the large
mortality which attended it; but the great improve-
ments ia abdominal surgery which have accompanied
the adoption of antiseptic methods, justify the hope
that many cases of this disease in which life, even if
not in actual danger, ia an almost intolerable burden,
may be permanently relieved by such means.

THE NON-SURGICAL TREATMENT OP CHRONIC
PELVIC INFLAMMATIONS AND THEIR SB-
QU£L.JE:.i

BV r. H. DAVBHPOBT, K.D.

Sous of the most perplexing problems in gynaecol-
ogy are the common ones which meet us in the course
of our every-day practice. There are, of course, the
grave cases where the physician is called upon to
decide the question of an operation involving life and
death, bat these, fortunately, are rare. On the other
hand, the majority of the cases we are called upon to
treat are of such a nature that the appropriate methods
of treatment suggest themselves, and the consensus of
medical opinion, justified and backed up by experience,
approves the choice. The retroversion is rectified,
and the displaced organ held comfortably in its normal
position by a pessary. The lacerated cervix, causing
< long train of local and general symptoms, is sutured,
and the troublesome symptoms gradnally disappear.
The rupture of the perineum which has destroyed the
integrity of the pelvic floor is repaired, with gratify-
ing result. A uterine polypus is snipped off, and a
troublesome, perhaps dangerous, haemorrhage is in-
stantly checked.

These are familiar examples of that class of cases
where the trouble instantly suggests the appropriate
measures for its relief. They are the most satisfactory
to the physician and the patient as well.

Between these two sets of cases occur in moderate
frequency those where there is no well-recognized line
of treatment, and where the consultant is obliged to
choose, out of a large variety of therapeutic measures,
that which seems best adapted to the case, with the
hope that it may afford some measure of relief.

These rather trite general considerations have been
suggested to my mind by my experience in the last few
years in the treatment of the secondary results of
chronic pelvic inflammations. Not that I feel that I
Can claim any new or royal road to success in such un-
promising cases, but with enlarged opportunity and ex-
perience one unconsciously weeds out what seems
superflaons, and in following large numbers of cases
for a length of time, can estimate final results with a
more unprejudiced mind. It is also with a hope of
learning from other men what they have found of
value in such cases that I have ventured to discuss this
ruiher threadbare subject.

' Bead before the Obctetrlcal Society of Boeton, Febroary 10, 1894.

And, first, I would like to define as clearly as I may
what I mean by chronic pelvic inflammations and their
sequelae.

Pathologically, we can in general say that the start-
ing-point is some more or less extensive localized pelvic
peritonitis. As a consequence of this, we have adhesions
between the layers of the peritoneum investing the
pelvic viscera, resulting in displacements and thicken-
ings. These processes may be so extensive that the
whole pelvis is affected, or they may be confined to
one side, or to a single limited area of one side. Thus
the uterus, ovaries, tubes and anterior wall of the rec-
tum may be so matted together that they form one
mass, in which the various organs are indistinguishable
by bimanual examination, or there may be present but
a single thickened point to mark the presence of a
former inflammation. These are the cases which ten
and fifteen years ago were all classed under the head
of pelvic cellulitis. We now recognize that they are
the effects of a localized pelvic peritonitis, the cause of
which may be obscure, but which in the majority of
oases is the result of the extension of some inflamma-
tory process from the uterus through the tHbes to the
peritoneum. Gk>norrh(Bal abortions, septic processes,
the result of meddlesome or uncleanly treatment, or
trauma, are the most common sources of such affec-
tions. While adhesions are the most evident results of
the peritonitis, yet the uterine, tubal and ovarian con-
ditions which precede or accompany the peritonitis go
to make up the complete pathological picture, and may
be considered as part of the disease to be treated. It
is the general condition of the whole pelvic organs,
the congested uterus, the catarrhally-affected tube, the
adherent, prolapsed ovary, and the thickened, glued-
togetber layers of the peritoneum, which I consider
under the title of chronic pelvic inflammations and their
sequelae.

As a rale, these women come to us only when their
symptoms have existed so long and have become so
burdensome that relief is imperative. I need not go
into a detailed account of the symptoms complained of.
They are those common to the majority of pelvic
lesions, and there is nothing pathognomic among them.
Even a history of any acute attack is often wanting.
In a general way they are : pain of all varieties and
degrees of intensity, menstrual disturbances, leucor-
rhoea and reflex fuuctional disorders. To attempt to
describe tbem in detail would be to give a list of
almost all the possible ills that "flesh is heir to."

On examination, what do we find? Very often
there is so much sensitiveness that our examination is
very unsatisfactory. We may find, and perhaps this '
is as common a condition as any, a congested, sensitive
uterus in a position of retroversion or flexion, partially
fixed or quite immovable, and very probably the seat
of a catarrhal endocervicitis. In the neighborhood,
either at the sides or behind, are sensitive swellings.
What these are it is usually impossible to say at our
first examination, for the extreme sensitiveness pre-
cludes all possibility of making any differential diag-
nosis.

Such is the clinical aspects of these cases, and such
the anatomical condition as far as our examination
can reveal it. I purposely in this paper exclude pyo-
salpinx, believing that for that condition palliative
measures rarely are sufficient, and that the line of
treatment to be outlined later has in it an element of
danger.

Digitized by

Google

408

BOSTON MEDICAL ASD 8UBG10AL JOURNAL.

[April 86, 1894

Suppose saoh a patient presents herself for treat-
ment, and on examination we find the complex condi-
tions which I have described. All that we can say
certainly is that the uterus is displaced backwards and
bound down, and that in the immediate neighborhooa
there are sensitive swellings. In the absence of direct
evidence that we have pus tubes or ovarian or par-
ovarian tumors to deal with, 1 claim that our progno-
sis, though guarded, should not be discouraging, and
that oar treatment should be conservative.

As the main obstacle to a more accurate diagnosis
is the sensitiveness, our first e£Forts should be towards
overcoming this. No agent has proved half so effica-
cious in my hands towards this end than glycerine.
The hot-water douche cannot begin to compare with it
in efficacy, first, because the principle on which it acts
is not the correct one, and second, because its effect is
not so lasting. The douche, by contracting the blood-
vessels, drives the blood out of the parts, to be sure,
but probably acts only on the surface and a short dis-
tance below it, and fails to reach the deeper tissues.
Glycerine, from its affinity for water, draws from the
blood-vessels the serum, and thus, by directly unload-
ing those in the immediate vicinity, promotes a more
regular and natural circulation in the part. To ac-
complish this end, however, a large amount of glycerine
must be used, and in such a way as to be easily borne.
For this purpose I use a prepared wool, which has the
great advantage over cotton that it is very elastic, does
not mat, and will hold a large amount of glycerine in
its meshes. This I roll up into such a sized tampon
as will suit the case, tie a string about it, and thoroughly
soak it in glycerine. Such a tampon will need half an
ounce to do thoroughly good work. I place this in the
vault of the vagina, and direct the patient to wear it
for forty-eight hours if it is comfortably borne. If
it becomes uncomfortable, she may remove it and take
a douche.

A tampon of this size will usually cause enough
watery discharge to necessitate the use of from four to
six napkins in the first two days. The discharge then
usually stops, and the tampon ceases to be of use ex-
cept as a moderate support. The fact that it is of
some value as a support is a second respect in which
it is of more advantage than the hot-water douche.

The third day I repeat it, and each third or fourth
day until the sensitiveness is diminished enough to
admit of the second step in the treatment.

Painting the vault of the vagina with Churcbiirs
iodine is of considerable value as a secondary means
of relieving pain and congestion. I have, however,
. found ichthyol much more effective as an analgesiac,
and it can be very conveniently combined with the
glycerine treatment. A small wool tampon soaked
with a mixture of ichthyol and glycerine, one part to
eight, is first placed against the cervix, and the larger
tampon inserted after it. I cannot say that I have ob-
served the melting away of inflammatory products
under the use of ichthyol which have been reported by
some writers, but its effect on pain has been very
marked.

The second indication for treatment is to restore the
mobility of the uterus, and to stretch or break up the
adhesions. This can only be attempted after the sen-
sitiveness has been materially lessened. The method
may be conveniently described as consisting of two
steps : first, putting the adhesions on the stretch, and
second, keeping them so. In the first place, I would

warn against the use of the sound or any repositor to
replace the uterus. Such an instrument used for soch
a purpose is uncertain and dangerous. There is do
better or safer repositor than the finger. In order to
bring the adhesions on the stretch, the anterior lip of
the uterus is seized with the double tenacnlum and
moderate traction made on it, while one or two fingers
of the left hand, inserted into the posterior cal^le-sac,
gently lift the uterus and carry it forward. Id this
way the adhesions can usually be felt or the ioflamma-
tory swellings palpated. A very e£Eective massage
may now be practised, of short duration, bat with
graidually increasing force, gently patting the tight
bands on the stretch, or rubbing the hard masses with
the tips of the fingers. I lay great stress in the treat-
ment of these conditions on this lifting and massage of
the uterus, and the inflammatory products in its imme-
diate neighborhood. I am confident that I can get
good results in much less dme than I could formerly
by packing alone.

When the uterus has been raised as much as is safe,
the vagina is then thoroughly packed, just as firmly ss
the patient can bear, and the tampon left three, or at
the most, four days. I usually pack a second time
before repeating the lifting and massage, as it is apt
to cause sensitiveness if it is repeated at too short Id-
tervals.

There will come a time in the treatment of some of
these cases when farther attempts at restoring the
uterus to its normal position seem useless. The adhe-
sions are too firm to be separated, and though there is
some improvement, yet the pelvic conditions are not
yet normal. Sometimes the uterus is still retroverted
and the inflammatory thickenings still prominent. To
suspend treatment here is to lose all we have gained,
and the most satisfactory way to prevent a return to
the former condition is the use of a pessary.

Two or three years ago my attention was called to
an article in the American Journal of Obttelria for
1891, by Dr. Sarah £. Post, on the use of the inflated
ring-pessaries, and as their principle seemed to me to
be a good one for the class of cases which I am nov
describing, I determined to adopt iu I came to the
conclusion, however, after a short trial, that the solid
elastic rings of large calibre, did better than the in-
flated pessaries, as giving more efficient support, and
not causing trouble by gradually collapsing. These
rings come of several sizes. There are two varieties,
the solid rubber ones, and those composed of a spiral
spring covered with rubber. The former are very
much to be preferred, as after having been used
a while the latter become wrinkled, and are apt to
cause irritation.

I have found this pessary of great value in these cases.
In the first place, it supports and elevates the uterns.
This it does without causing as much pressure on any
particular part of the vaginal vault as do the pessaries
constructed on the Hodge model, which are very apt
to press on jast the most sensitive points; nor does it
push the uterus up quite so high as the others, which
in an adherent uterus is an advantage. It also relieves
pain by immobilizing the organ to a certain extent,
and yet allowing more freedom of motion than a
Hodge. It encircles the cervix with a firm, elastic
pressure, and while yielding perfectly to the natural
movements of the uterus, it prevents any sudden jar
from dislocating the organ too much. A second factor
iu relieving the pain has to do with the circulation of

Digitized by

Google

YOL. CXXX, No. 17.] BOSTON MEDIO AL AND 8UBOIOAL JOURNAL.

409

the ntenu. The even pressure around the cerriz and
upwards must to a certain extent equalise and regulate
the blood-snpply, and so favor the relief of the conges-
tion. This will in turn diminish the sensitiveness of
the nerves.

Not the least beneficial effect of this pessary is seen
in the changes which gradually take place in the pelvic
tissues themselves. Wearing it has resulted in, to a
degree, restoring the mobility of the uterus, improving
its position by thinning and stretching bands of adhe-
sions, rendering sensitive swellings smaller and less
sensitive, and reducing the size of the womb itself.
This result had followed too often to be a chance coin-
cidence, and I now confidently expect these results to a
greater or less degree in all suitable cases. Examina-
tion from month to month will show a gradual im-
provement in the condition of the pelvic organs, which
goes hand-in-hand with such an amelioration of the
patients' general health that they call themselves prac-
tically well.

This ritumi of my method of procedure in this class
of cases, the wool-glycerine tampon, ichthyol, massage
and packing, and finally, the cnshion-pessary, does not,
I confess, compare in brilliancy with the well-known
surgical procedures which are advocated for this type
of gynaecological cases, but I claim, first, that where
doubt exists as to the true condition of the pelvic
organs, this method clears up the diagnosis, and in a
majority of cases, and 1 speak advisedly, renders an
operation unnecessary ; and second, that the results
obtained are sufficiently gratifying to render the prog-
nosis less grave than is often supposed.

By way of illustration, I propose to give briefly the
histories of a few cases in which this line of treatment
has been carried out either in part or wholly.

Case I. Mrs. B., thirty-five years old, was brought
to me in December, 1891, by her physician, who bad
treated her for an obstinate retrofiexion for c long
time. She bad had one child six years ago. Her
principal complaints were great pain and soreness in
the lower abdomen and back, especially the coccyx,
dysmenorrbflea, irritable stomach, severe headaches
and inability to take much exercise. Her physician
had tried to relieve her symptoms, and to replace the
uterus by applications and tampons, but without suc-
cess. I found a heavy, retroflexed uterus only mod-
erately movable, a slightly-lacerated cervix and a sun-
dered perineum. Behind the uterus were several round
bodies, about the size of a filbert, which- were exqui-
sitely sensitive to the touch, and which I took to be
swollen glands. Any attempt to raise the uterus bi-
manually was accompanied by so much pain from
pressure on these bodies that it had to be abandoned.
So, too, the wearing of a retroversion or flexion pes-
sary was impossible.

After a little preliminary packing I adjusted a
cnshion-pessary, which gave her more relief than any-
thing else. She has now worn that for about six
months, and lately has been able to take care of it her-
self. The last time I saw her there, was a most
marked improvement in the condition of the pelvic
organs. The uterus was much more movable, and
could be raised nearly to its normal position, the seu-
sitive bodies behind in Douglas's cul-de-sac had nearly
disappeared, and she is now ready to have the cervix
and perineum repaired.

Cask II. Mrs. B., twenty-seven years old, con-
sulted me in July, 1891, for menorrhagia aud dysmen-

orrhoea. Six years previous to my seeing her she had
jumped from the box of a stage-coach to the ground,
which was followed by an attack of pelvic peritonitis
which confined her to bed for six weeks. After her
recovery from the acute attack she suffered from
severe pain at her monthly periods and profuse haemor-
rhages. Her general health, especially as regards her
nervous strength, had begun to suffer. She had never
had any local treatment. Examination showed a
firmly adherent, retroverted uterus, cul-de-sac partly
obliterated by thickened tissue, and yielding very little
to pressure by the finger. As she expected to be mar-
ried in a month or two, no treatment was begun for about
six months. Then tampons, packing and iodine were
used for some time, and a Meigs ring was finally in-
serted. The improvement was most marked, both as
regards her symptoms and the condition of the pelvic
organs. The uterus, while still in the first degree of
retroversion, was smaller and the adhesions less firm,
allowing considerable mobility. Two years after mar-
riage she miscarried at two mouths. A second preg-
nancy has resulted happily in the birth of a child last
December.

Cask III. Miss C. first consulted me in 1888.
Was twenty-one years old. Had a fall when eleven
years old, since which time has suffered from a lame
back, pain iu back and right groin, headaches, delayed
menstruation, usually five weeks, but occasionally
going from three to six months, dysmenorrhoea lasting
from half a day to a day, leucorrhoea and depression of
spirits. She was wearing a pessary when she came to
me, but I found the uterus retroflexed over the top of
it, and apparently adherent. The right ovary was en-
larged and sensitive aud prolapsed. She had consulted
one of the most eminent gynaecologists in New York,
who had advised removal of the tubes and ovaries.
After packing firmly for a month, although the uterus
was not thoroughly forward, a bulb pessary was intro-
duced, to be worn dnring the catamenia. This proved
so comfortable that she wore it all summer. In Sep-
tember the uterus was in a position of right lateral
flexion, a position that I have often observed an ad-
herent uterus assume as it changes from a backward
position to the normal. Sometimes, as in this case, it
remains drawn to one side. In March, 1889, she mar-
ried, became pregnant in June, and is now the mother
of three children.

Cask IV. Miss M., thirty-three years old, had
been well until two years ago, when, after running a
heavy machine, she began to suffer with a feeling of
pressure and darting pains in the rectum, and a feeling
of heat in the lower part of the back. She also suf-
fered from leucorrhoea. She was unable to work on
account of the pain in her back. I first saw her Octo-
ber 18, 1892, and found the uterus retroverted and
tightly bound down by adhesions, some of which,
especially on the right side, could be felt as strong
bands. Three weeks' treatment by firm packing and
raising the uterus manually brought the uterus into
fair position, though one strong band of adhesion on
the right failed to give way. A cushion-pessary was
introduced, and by January she was able to resume
work. She still is wearing the support, aud there is
steady improvement in the mobility of the fundus, and
the adhesions grow more defined and thinner.

These cases may, perhaps, be considered typical of
the class in which I have foopd the treatment I have
outlined of benefit. As I said at the outset, there is

Digitized by

Google

410

BOSTON MEDICAL AND 8UBOIOAL JOURNAL.

[Apbil 26, 1894.

DO new principle iuTolved, bat poasibly the particalar
application of these varioas remedial aeents may be
suggestive. It will, at any rate, emphasize what may
be called the conservative way of looking at the treat-
ment of pelvic infiammatioDS and their results.

THREE CASES OF OCCLUSION OF THE SUPE-
RIOR MESENTERIC ARTERY.*

BT W, T. COCHOILMAIf , K.D.,

Shattuck Prqfator of Pathologieal Anatomy, Hareard Dnivertity ;
PathoiogiMt to the Boston CUy BotpUcU.

The cases which I present to>nieht are not only in-
teresting in themselves, bat show Ae tendency of rare
pathological conditions to occur in groups. All of the
autopsies were made within the last two weeks, and
they are the first specimens of the sort which I have
seen for a number of years.

Case I. The first specimen which I shall show
comes from an autopsy made for Dr. J. L. HUdreth.
The clinical history of the case is as follows :

Mrs. X., aged eighty-five. Although feeble for a
number of years, the general health was fairly good
with the exception of attacks of bronchitis at intervals.
Twelve days before death she had not been feeling
well, and went to bed somewhat earlier than the usual
hour. She was not able to sleep, and called an at-
tendant at ten complaining of pain in the bowels. The
pain became more intense, and Dr. Hildreth first saw
her at 2 A. H. At that time she was restless, com-
plained of intense pain in the bowels ; pulse 70. No
physical signs could be made out either in chest or ab-
domen. The pain was referred vaguely to the right
iliac fossa. An opiate was administered, and repeated
until pain was allayed. In the morning the pain re-
turned in the same place. A large enema was given,
which produced no results. There was no passage of
flatus from the bowels. The abdomen became more
distended, and the pain seemed localised in the right
iliac fossa. At the end of the third day the condition
continued the same. No vomiting. The temperature
1° subnormal. Dr. Marcy, of Cambridge, saw patient
in consultation on the fourth day. Diagnosis niade of
complete obstruction of bowels. An operation was
suggested, but not urged. All of the symptoms con-
tinued until the seventh day when the temperature
was 2^° sub-normal. From this point the temperature
gradually arose, and before death reached 2" above
normal. Vomiting commenced on the fourth day be-
fore death, fiually becoming fecal. The pulse became
quicker and weaker, and death took place twelve
days after the first attack.

At the autopsy the abdomen was greatly distended.
The intestines were enormously distended and some-
what congested. lu the lower lobes of both lungs and
in the posterior portions of the upper lobes there were
numerous areas of consolidation. The pleura over
these portions of lung was covered with a fine fibrinous
exudation. The consolidation in the upper lobes had
a distinctly lobular distribution. In the lower lobe of
the left lung the consolidation was more extensive, but
here, aleo, was apparently produced by the confluence
of smaller foci. There was extreme fatty degenera-
tion and atrophy of the heart and extensive atheroma-
tous degeneration of the aorta. The heart was per-
fectly flaccid and so soft that the finger could be thrust

> SpwlmeDa of theae saw* w«rB shown at a meeting of the Boston
JMClet; for Medical ImproTement.

through the ventricle at any point. The entire ab-
dominal aorta was covered with flakes of calcification.
On these rough, calcified plates there were nnmeroaa
thrombi. The most extensive thrombus was on the
anterior surface of the aorta just above the origin of
the superior mesenteric, and almost completely oo-
daded the opening of the artery. The thrombus ex-
tended for a very short distance into the artery, hot
the artery itself was free from both emboli and
thrombi. The small intestine was greatly distended,
and in places there were a few small ecchymoses ; bat
there was neither intense congestion nor at any point
complete infarction.

In this case it seems probable thai the partial occlu-
sion of the artery by the thrombus in the aorta was, in
the weakened condition of her circulation, sufficient to
cause entire paralysis of the bowel and obstruction
from this reason.

Cultures made from the tissues gave pneumocooci in
the consolidated portions of the lung,' in the spleen
and in the liver. Id all of the organs colon bacilli
were fonnd.

Case II. The clinical history of this case, of which
the heart, aorta and mesentery were shown, is this :

R. T., aged sixty-one. Entered hospital January
I9th. Complained of pain in left foot and ankle. The
parts were much swollen, cold and blue. Three days
afterwards the right foot showed the same process.
Two days before death complained of pain in abdomen,
pulse gradually sank and death took place.

At the auto'psy the intestines were found enormously
distended. The peritoneum was covered with a fi-
brino-purulent exudation, which in places produced a
slight adhesion of the loops of the intestine. Pockets
of pus were here and there found between the adhe-
rent loops of intestine. The entire small intestine iras
deeply injected and in the jejunum for a distance of
about sixty centimetres the wall was greatly thickened
and haamorrhagic. In endeavoring to discover the
CMise of the peritonitis all the ordinary sources could
be excluded. There was no evidence at any point of
intestinal perforation. The mesenteric artery, how-
ever, was seen to be completely occluded by a throm-
bus about half-way between its origin and the intes-
tine. This thrombus was firmly adherent to the wall
and was totally occlusive.. Beyond the thrombus there
was a short space in the artery which was filled with
a soft, dark coagulum, and further up, just opposite
the area of intestine which shows the hsemorrhagic in-
farction and at a point in the artery where three
branches are given off together, there was another
thrombus which was also firmly adherent. On opening
the intestine it was seen that on the mncous surface, in
addition to the infarction, there were areas of distinct
necrosis — some of these areas passing through the in-
testine. The source of the thrombus masses in the artery
was evident from an examination of the aorta just above
the heart. Here a ronghened, calcified plate on the
intima of the artery was seen, and adherent to this was a
large thrombus. The thrombus in the aorta was evi-
dently of a rather old date. In the kidney and in the
spleen there were numerous infarctions produced by
emboli. Some of these infarctions were ansemic, others
hssmorrhagic. In some of them there was organiza-
tion of the anaemic territory with cicatrization.

In both lower extremities, more marked on the right
side, there was gangrene extending nearly np the knee.
No line of demarcation as yet produced. The parts

Digitized by

Google

ox.. CXXX, No. 17.J BOSTON MBDJOAL AND SURGICAL JOURNAL.

411

ere swoUen, red, infiltrated with bloody fluid, large
eaiclea beneath the epidermis, and in places on the
alf of leg the epidermis had desquamated. The arte-
ies of both extremities occluded by thrombi. On the
ight side the thrombus extended up to the middle of
he femoral artery ; on the left side up to the popli
e»l. The occluded arteries were smooth, the thrombi
ightly adherent.

On microscopic examination of the peritoneal exu-
latioD, colon bacilli were found in large numbers, and
snlttirea from the peritoneum' and from the other or-
g&na showed a general infection with colon bacilli. No
other organisms were present in the cultures.

Xhia case is of interest from the extent of the em-
bolism, and also as showing peritonitis certainly pro-
claced by the colon bacilli, with a general infection of
Ihe other organs. From the examination of the intes-
tine and the superior mesenteric artery, it would seem
probable that there were here two emboli of different
dates. The embolus towards the end of the artery,
corresponding to the area of beginning hsemorrhagio
infarction and necrosis, is evidently of older date than
the one occluding the artery nearer its origin.

Ca.se III was from an autopsy in the Massachu-
setts Hospital for which I am indebted to Dr. W. F.
Whitney. The clinical history is as follows :

A. B., seaman, aged sixty-two. At age of twenty,
in bed for six months with general muscular tender-
ness and inability to use arms and legs. During this
time there was some dyspnoea and slight palpitation.
Since then he has had many similar painful attacks,
bat nu cardiac symptoms until six months ago, when
there was a sense of constricdon in the region of the
heart and marked shortness of breath. This condition
increased constantly, and finally compelled him to
cease work. Orthopnoea and anasarca then appeared,
and have existed for the last month. When he entered
the hospital the skin was somewhat jaundiced, and the
respiration had at times the general Cheyne-Stokes
characteristics. Four days later the abdomen became
quite tender. On the following day the tenderness
increased, and frequent loose stools occurred. There
was bseffloptysis with ' physical signs of consolidation,
and the pulse became very rapid and irregular. Four
days later death took place. The abdominal pain and
diarrlioea, with some elevation of temperature, persist-
ing until the end.

I showed the mesenteric artery, with a portion of the
ioteitine, from this case. Almost the entire small
intestine was in a condition of hsemorrhagic infarction.
The bowel contained a thin hsemorrhagic fluid; the
walls of the intestine were greatly thickened from hsem-
orrhsge. On the peritoneal surface of the intestine
everywhere there was a very slight fibrinous exudation.
The mesenteric artery from its beginning was entirely
occladed by a thrombus. The source of the thrombus
was DOt definitely made out. The heart was greatly
enlarged. The aorta dilated, roughened, and the aor-
tic vslres relatively insufficient. It is probable that
the thrombus in the mesenteric artery was of embolic
origin, and came from a thrombus which had formed
in the roughened aorta.

These cases are all of interest. In the first the
dinicsl picture was that of obstruction without perito-
nitii. In the second there was a marked peritonitis
tod is the third only a slight beginning peritonitis.
The nose of the peritonitis in the second case was
evidently due to the colon bacillus. It is not necessary

to have an olceraUon of the intestine or perforation in
order for this organism to enter into the peritoneal
cavity or into the tissues. There is no organism so
commonly found in cultures from the various organs
as is the colon bacillus. It is found in disturbances of
the circulation of the intestine, such as is given in ex-
treme chronic passive congestion. The resistance of
the tissue in these cases is apparently so lowered that
the organism finds entrance into the tissues. In all
cases in which there are lesions of the mucous mem-
brane of the intestine, it matters not how slight in char-
acter, the tissues will be invaded by this organism.
In the second case in which there was marked perito-
nitis, the bacillus apparently found suitable conditions
for growth in the necrotic tissue of the intestine, and
it evidently passed through, or grew through, the in-
testinal wall into the peritoneal cavity. In a case
which I autopsied at the City HospitaJ lately, there
was a general fibrino-purulent peritonitis of slight de-
gree in which the colon bacillus was found to be the
only organism both in the peritoneal cavity and in the
cultures. The source of the peritonitis in this case
was in a small area of the intestine which had been in-
carcerated in a hernia. In the incarcerated portion of
the intestine there was intense congestion with slight
necrosis of the mucous membrane.

Hsemorrhagic infarction of the intestine resulting
from obstruction of the mesenteric artery is an ex-
tremely interesting condition. In spite of the size of
the mesenteric artery and in spite of the angle in which
it leaves the aorta, which would appear to favor the
entry of emboli into it, large emboli appear to be ex-
tremely rare. It is probable that small emboli fre-
quently do enter the artery, but from the character of
the circulation of the intestine and the abundant anas-
tomosis which are found between the small branches
of the artery, these small emboli produce no barm.
The superior mesenteric artery is in no way a terminal
artery in the sense of Cohnheim. There are numerous
anastomoses, not only between the very small branches,
but with the gastro-dnodenal and inferior mesenteric
The area of tissue supplied by the artery, and the ex-
treme length of the intestine are unfavorable for the
development of a sufiicient collateral circulation. In
the dog, tying of the superior n^senterio near its
origin always produced complete hemorrhagic infarc-
tion of the intestine. The infarction is due to the
entry of blood into the ansemic territory from the anas-
tomoses above and below. It is remarkable that in
the three cases which I show, the hsemorrhagic infarc-
tion should have been so slightly developed. In only
one case, that from the Massachusetts Hospital, was it
at all extensive. In the second case, although the
entire artery was obstructed, there was only a begin-
ning infarction in a small area of the intestine corre-
sponding to the first embolus. In the first case it is
probable that the thrombus of the aorta extending into
the artery was not a totally occluding one. Only in
this case was obstruction of the intestine a prominent
clinical feature. It is probable that suificieot blood
entered through the obstructed artery and through the
anastomosis to preserve the integrity of the vessels
sufficiently to prevent diapedesis and infarction, but
not sufficient to provide the necessary enervation. It
is important to know that obstruction of the superior
mesenteric artery may give rise to paralysis of the in-
testine, obstruction and to peritonitis, and it is a condi-
tion which is beyond surgical interference.

Digitized by

Google

412

BOSTON MEDICAL AND SUROIOAL JOURNAL.

[Apkil 26, 1894.

LAMINECTOMY ELEVEN MONTHS AFTER IN-
JURY TO THE SPINE.'

BT WALTCB B. PLATT F.B.C.S, (BKO.), BALTIKOBB, MD.

MoBB than twelve hundred years ago Pan) of iBgina,
that famous Greek physician, definitely proposed the
operation of laminectomy after injury to the spine, in
these words : " Wherefore, having first given warning
of the danger, we must if possible attempt to extract
by an incision the compressing bone, or if not, we must
soothe the part by the anti-inflammatory treatment.
But if any of the processes of the vertebras of which
the spine as it is called consists, be broken off, it will
readily be felt upon examination with the finger ; the
broken piece yielding and returning again to its posi-
tion, and therefore we must make an incision of the
skin externally and extract it, and having united the
wound with sutures, pursue the treatment for recent
wounds."

Later, Albucasis also recommends that, when a piece
of the spine is broken off and causing great irritation,
an incision be made and the piece removed.

So great a period between the conception of an oper-
ation and its successful practical execution as exists in
the cttse of laminectomy can scarcely be paralleled in
the history of surgery.

We must not forget that eminent men have per-
formed this operation again and again between that
time and this, and that it was again and again advised
as the right thing to do, while nearly always the resnlt
was fatal, apart from the mortality of the injury preced-
ing the operation, in which other important structures
and organs, notably the kidney, were damaged. Why
the result was so fatal, we now know. It is an oper-
ation that can oply succeed with the most perfect
aseptic or antiseptic precantions.

Laurence Heister, Professor of Surgery in the
German University of Helmstadt, writing in 1739,
advises : " If in any case the spinal marrow should be
divided. Death will generally be an inevitable Ck>n-
sequence. But to offer the patient no Assistance be-
cause we despair, would seem cruel and uncharitable ;
therefore we must try our Skill, though our Attempt
should be in vain. In order to which, the Surgeon
must lay bare the fractured Vertebrse with a Scalpel,
and replace or else remove, such Fragments as injured
the spinal-marrow. The Wound is afterward gently
cleansed as usual, and dressed with the balsams . . .
to be held on with the Napkin and Scapulary, till the
wound Shall terminate either in a perfect Cure or
Death."

In 1762 Louis removed fragments of the laminae
through a gunshot wound, and the man recovered with
partial paralysis. This is, however, a very different
matter from making an incision where no wound exists.

It is probable that Henry Cline, in the year 1814,
was the first to do this (in other words, to do a laminect-
omy), and his patient died. For doing the operation
he was severely condemned by his colleagues. Then
comes a long list of laminectomies every one of which
was fatal, each operator thinking that perhaps his
method or the conditions in his case might admit of a
good result.

There is a rather indefinite report of a case done by
Dr. H. A. Potter, of Geneva, K. Y., where the patient
survived. Hamilton (" Dislocation and Fractures ")

> Read at the ■aml-aiuioal meeting of the Medloal Ohlnirgleal
nMolt; of MujlaBd, MoTember ill, ISSS.

gives a list of 14 operations by various surgeons all of
which were attended by fatal results. Sir Astley
Cooper ("Manual of Surgery," 1837) recommends the
operation, but advises against it in the same breath.
Hamilton, as late as 1875, tell us that "we are reloo-
tantly compelled to declare that the expedient is scarcely
worthy of a trial " (" Fractures and Dislocations ").

Samuel Cooper ("Practice of Surgery," London,
1820), writes : " We read of incisions being made, and
of the fragments of bone causing pressure od the spinal
marrow being elevated" or extracted ; but what con-
siderate surgeon would venture to imitate such prac-
tice." Bransby Cooper (" Surgical Essays," etc., Lon-
don, 1843), in speaking of removing fragments of
broken laminae after an injury, by making an incision,
says : " 1 believe there are cases which may warrant
the importance of this operation, although at the tame
time I believe there are but few cases in which socceK
is to be expected." Sir Benjamin Brodie (" Injnries
of the Spinal Cord " in " Med. Chirorg. Transactions,"
London, 1837), says : " I am not aware that in any of
the cases in which it has hitherto been performed the
operation has been the means of preserving the patient's
life or even of relieving any of the more important
symptoms." Liston (" Practical Surgery," London,
1840), writes : " It has been proposed to make incisions
on the broken bone to examine the extent of the fract-
ure and displacement, and to attempt the removal of
the pressure on the chord by trephining. . . . By these
means, now generally and very properly looked apon
as unwarrantable, effused blood could not be removed
nor lacerations repaired, while the chance of inflamma-
tory action would be much increased."

Gross, as late as 1862 ("System of Surgery"),
writes ; " Trephining will not be likely to be of any
service ; the operation has been tried in a number of
cases of depressed fracture of the vertebrae, bnt in none
has it ever been productive of any benefit."

Eriohsen (" System of Surgery," " Science and Art
of Surgery," 1872), in speaking of the removal of
broken laminae after spinal injury, writes : " But though
so far the resnlt has been but little satisfactory, ought
Hurgeons to discard the operation ? I think not."

Bryant (" Practice of Surgery," 1872,) mentions a
successful instance of trephining by Gordon of Dublin,
and adds one of his own where he removed the spinous
process and laminie of the fourth cervical vertebra, with
recovery from the operation and decided improvement
in motor power. The doodern surgery of the spine is
of but ten short years' duration, and most of the soo-
cessful cases are within the last five years. Macewen,
in 1883, did a laminectomy of three dorsal verte-
brte, for complete paraplegia of two years' duration
caused by angular deformity of the spine. The patient
is said to have completely recovered (Treves, " Oper-
ative Surgery "). In June, 1888, Gowers and Horsley
reported a case of the successful removal by laminect-
omy of a tumor from the spinal cord. Since then
there have been a number of laminectomies reported,
among them those of DeForest Willard, William White,
Abbe, Burrell, Deaver, Dawbam, and Richardson in
this country, as well as Macewen, Lane, Wright and
Duncan in Great Britain.

Dr. J. William White of Philadelphia and Dr. H. L.
Burrell of Boston have made admirable reviews of the
cases and results up to three years ago, when it is fair
to believe that the technique of the operation was
pretty well understood.

Digitized by

Google

Vol. CXXX, No. 17.] BOSTOST MEDIOAL AND SURGICAL JOURNAL.

413

The resnlto io laminectomy, vary of coane as to
whether it is done immediately after the injury or
gome time afterward. Again, whether it is done for
Pott's disease or for the removal of a tumor within the
cord. Dr. William White has shown that oat of 37 op-
erations recently performed with antiseptic precantions,
after fracture of the vertebree, there were 6 complete
recoveries ; 6 were benefited, and recovered from the
operation ; 11 recovered, unimproved ; and 14 died
("American Text-Book of Surgery "), a mortality of
38 per cent.

Careful observations show a very large per cent, of
fractured laminse in all cases of fractured spine. The
pressure of the broken portions is often the exciting
cause of secondary changes in the cord. This was
probably true in the case now reported by me where
the paralysis came on some three weeks after the injury.
It is likely that the laminae fractured at the time of
the accident became displaced later and pressed upon
the cord. It will be seen that operation was delayed
until eleven months after the accident, and at least
ten months after total paralysis, making the case a
most unpromising one at the outset, both from the
total long-existing paraplegia, and the extremely poor
general condition. The operation was the only hope
for the least benefit

In the operations undertaken to relieve paralysis
due to Pott's disease, the results have been brilliant.
In one case where the paralysis of motion and sensation
bad existed for two years with paralysis of rectal and
vesical sphincters, the boy was able (after five years)
to play football. Laminectomy should never be done
to relieve the paralysis of Pott's disease until the
failure of all other approved methods of treatment,
and the patient is steaidily growing worse. Statistics
show that over 80 per cent, of such cases recover with-
out operation.

The mortality of laminectomies in traumatic cases,
as stated by Chipanlt {Rtvu» de CMrurgie, March,
1893), out of 160 cases, was 65, with 15 unknown re-
sults. He further states that in delayed operations
after injury, myelitis sets in after two or three days,
and after some weeks sclerosis of the cord ; that de-
layed operations have never given satisfactory results,
while early ones have nearly always had the contrary
result.

We see then that in cases of broken back, instead of
allowing the patient to die a miserable death, he should
be operated on at an early date, and the compression
removed, as is often possible by a laminectomy, when
there is a good chance of, at least partially, restoring
the patient to good health.

The patient J. L., white, thirteen years old, was
admitted to the Garrett Hospital for Children, August
23, 1893, with the following history : In October,
1892, in coming down stairs the patient slipped, and
in trying to recover his balance the back was bent
sharply backward. In consequence of this, he suffered
pain in the spinal column, which pain persisted. Two
weeks later he fell from a car, striking his side upon a
curbstone. One, week later, while walking along the
street the patient was suddenly seized with peculiar
•ensations in his legs and abdomen — tingling and
numbness. This was accompanied by weakness of the
lower extremities, whereupon he went to bed. lu
three days there was complete paralysis of motion and
sensation as high as the margin of the ribs. Four days
later loss of control of the bladder and rectum was

noted. One month after taking to bed, that is, about
seven weeks after injury, a long, round curvature ap-
peared in the dorsal region. The first bed-sore was
over the sacrnm, and this occurred about the end of
December, 1892.

On entrance to the hospital, August 23, 1893, the
patient exhibited the following physical signs : Aneemic,
emaciated. Had a tight cough, no expectoration.
Night-sweats present. Afternoon temperature 102.2° ;
pulse 128 ; respiration 32. Marked anterior posterior
curvature of spine, from sixth to tenth dorsal vertebrae.
The vertebra spines in question could not be felt by
reason of the general thickening over the whole region.
There was considerable swelling laterally, marked on
the right side, where there was also some rise of tem-
perature superficially. Tenderness and cedema, but
no fluctuation. The swelling occupied the entire in-
terscapular region. Scapulae stood out prominently.
There was dulneas on percnsaion on the right side of
the chest below the nipple in front, extending into the
axillary region, and nearly all over the back. Loud
pleuritic friction-sounds could be felt and heard over
the right back posteriorly, below the scapula. The
skin over the paralyzed region was dry, shiny and
desquamating. Small, round, faecal masses could be
plainly felt along the tract of the ascending colon.
There was complete paraplegia, both motor and sen-
sory. There was great wasting of all the muscles in
the paralyzed area. The paralysis extended as high
as the line of the tenth rib behind, and one inch from
the costal margin in front. There was a wide zone of
hyperaesthesia immediately above the line of paralysis.
There was a line about one inch wide below the hyper-
eesthetic zone, where sensation was dulled, but not
absent. Below this paralysis was complete. Entire
\0M of control over sphincters of bladder and rectum.
There were seven or eight bed-sores, some large, some
much smaller. They were situated over the sacrum,
trochanters, heels, and over the right fibula below, etc.
The pleuritic friction-sound rapidly diminished, and
finally disappeared after four or five days. There was
never any pus or discharge from the back, except such
as arose from the bed-sores.

OPERATION, SEPTEMBER 6, 1893.

The patient being etherized, two longitudinal parallel
incisions were made, one on each side of the dorsal
spine, five inches long, extending from the fourth to
the ninth vertebral spines. These were connected at
the top by a transverse incision after the completion
of the others, and after the bcemorrbage had been
checked. The latter was abundant and of very dark
blood.

The longitudinal incisions were made just to the
inner side of the transverse processes, which were with
difficulty made out, with the patient in the semi-prone
position ; the planes of the incision were directed to-
ward the median line as well as downward. The
haemorrhage was checked by pressure with pads of
sterilized gauze, thrust into the wounds. The inter-
spinous ligament was now divided at the bottom of the
transverse incision, and the laminae of three vertebrse,
the fifth, sixth and seventh, divided close to the trans-
verse processes by oblique-cutting forceps. A number
of loose fragments of laminae were felt and removed
when the longitudinal incisions were first made. The
flap, consisting of skin, muscle, ligaments and bone,
was turned downward, exposing the dura mater of the

Digitized by

Google

414

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Afbil 86, 1894.

cord. All pieces of bone which coold be felt in the
reversed flap were now detached from their counections.
The pieces were irregular in outline, and evidently
remnants of partially absorbed lamintB and spines.
The dura was exposed for a distance of four inches.
It appeared to be perfectly healthy, and was not there-
fore opened. The spinal canal above and below the
seat of operation was smooth, and of normal calibre.
The dara was pale blae in color, not thickened exter-
nally, neither was there any pus or exudation seen
anywhere in the course of the operation.

The flap was now replaced, and stitched in place by
a number of silkworm-gut and a few silk sutures.
These were for the most part inserted as deeply as
possible. No arteries required ligature. A rubber
drainage-tube was inserted at each outer, upper angle
of the wound. Iodoform ganze, sterilized gaoze, and
absorbent cotton were applied, and the whole kept in
place by a gauze bandage.

The operation lasted one hour and twenty minutes.
During the night the patient seemed very weak, but
reacted well considering his exceedingly feeble state ;
and the day following be seemed but little weaker than
before the operation.

September 11th. Patient has some cough, but is
steadily gaining in strength each day.

September 12th. Yesterday patient complained of
his toes feeling cold and as if electricity were passing
through them. Nine centimetres above umbilicus he
has skin sensation. Deep pressure cau be felt much
lower down. Touching skin just above the totally
paralyzed area excites reflex movements of opposite
left (right) hand. Pressure in right hypochondrium
excites immediate pain in the left. Bed-sores looking
better. There is occasionally a faint, dry cough.

September ISih. Said he felt the catheter when it
was passed.

September 14th. Seven sutnres removed, some pus
about stitches.

At the present date (November 21) the patient is
aa emaciated as before. The bed-sores have nearly all
healed a great deal since the operation. Some are
entirely well. The patient, as a rule, eats with an ex-
cellent appetite. He can now lie on either side with
comfort, something impossible before the operation.
There is no perceptible gain in skin sensation. The
ansssihesia (to touch) is as marked as before the opera-
tion. The patient is, however, considerably more sen-
sative to abdominal pressure, and mach more so to the
stimulation of the faradic cnrreut. He now feels the
faradic current iu both thighs, legs and feet, when ap-
plied over the tracts of the large nerves with firm
pressure. Application of the current to one limb will
often cause decided sensation in the opposite limb.
Wherever the current is applied, whether to thigh or
leg, patient complains of feeling the current in the
feet. There is absolutely no contraction of any muscle
below the paralyzed area to any amount of faradic
stimulation. The lines of operation are entirely healed,
with the exception of a small graunlaiing surface at
one upper angle one-quarter of an inch in diameter.
There are no sinuses left after the operation. Patient
sits propped up in bed a few minutes at a time without
undue fatigue.

The net result of the operation at the time of writ-
ing this paper, may be stated to be: No improvement
whatever in motion since operation, some decided in-
crease in sensitiveness to faradic stimulation, healing

of bed-sores to a considerable extent. The patient is
able to lie on either side for a time without fatigue,
something impossible before, although he was in the
hospital two weeks before operation. He has appar-
ently reached a standstill in improvement in his general
condition. He no longer has night-sweats.

I was never able to convince myself of the existence
of tuberculosis of the lungs. He has had the most
careful nursing, and the most generous diet that he could
take, wine and whiskey being allowed with his meals.
When his temperature rose be was immediately put
upon a suitable diet One four-hundredth of a grain of
atropia at night will control the sweats perfectly, as
we repeatedly determined. He has always been cathe-
terized twice daily, and the bladder washed out when
urine became turbid or ammoniacal.

In performing the operation the following points
were noted :

The copious venous hsemorrhage, controlled by
pressure with pads of sterilized gauze wrung out of
hot boiled water.

The unusual retraction of the skin, which rather
assisted than acted as an obstacle in carrying out the
operation.

The difficulty in dividing the laminte, and the ntre
that had to be used iu keeping within the transverse
processes so as not to go wide of the objective point.

The operation is considerably easier on the living
than on the cadaver, on account of the bowing of the
back nsaally present in the patient, and the compara-
tive wasting of the muscular substance.

With ordinary care there is little danger of wound-
ing the spinal cord.

The cutting bone-forceps should be directed well
inwards, so as to divide the lamiuss at a right angle to
their axes.

We are not only justified in considering, but we are
bound to regard laminectomy of the spine iu the same
way as we do trephining of the skull, that is to say,
the mortality of the operation after an injury is to be
attributed in large part to the injury which is the occa-
sion of the operation, and not to the operation itself.

As in trephining the skull, the mortality should be
reckoned by the number of deaths occurring when
performed for disease. The mortality should, more-
over, be distributed according to groups ; for example,
the number of deaths after an operation to remove
broken or displaced laminae might be widely different
from a laminectomy to relieve pressure of an exudation
between the laiuinn and the bone, or for hsemorrhage
without or within the dura, etc. No useful purpose
or rules for guidance can be formed by grouping unlike
cases together. As in skull-trephining after accident,
the bad results after spine trepiuing are largely due to
the laceration of the nervous subetanoe which may be
injured, beyond any possibility of repair, by the force
of the blow constituting the accident — not due to the
surgical operation, but in spite of it.

A large portion of the back of a cadaver was here
exhibited, showing the facility with which a sufficiently
large section of the cord may be exposed without loss
of substance ; the ease of replacing the flap which was
turned down ; the depth below the surface of the latter,
reminding one strongly of the railroad at the bottom
of a " cut." The disadvantages of this operation were
also shown, there being two long incisions instead of
one to heal, twice as many vessels divided, and the
mnacles close to the median line cut transversely above.

Digitized by

Google

Vol. CXXX, No. 17.] BOSTON MEDICAL AND SOSOIOAL JOURNAL.

416

Practically I do not believe these objections in any
degree important.

FDHTHBH HI8TORT.

The patient seemed to be gradaally losing strength
the first week in December. He was taken home
(fire hoars by rail) against adrice, by his father,
December 24th, and died DecemberSl, 18il3, 116day8
after the operation. This was one of those cases
where -there was reason to fear a total transverse lesion
of the cord ; bat as the operation ofEered the only hope
of relief, it was performed. Mo autopsy was obtained.

Cltnical Z>e)iactmetit.

CLINICAL NOTE-TAKING, WITH A LIST OF
FOUR HUNDRED AND NINETY-ONE MEDI-
CAL CASES SHOWN TO THE THIRD CLASS
OF THE HARVARD MEDICAL SCHOOL.'

BT BLUOTT P. J08LIN, A.B., PH.B.,

Oarvard Mtdieal aehool.

Mant advantages accrue from note-taking at a clinic,
but for these notes to be of permanent value to the
stadent they mast be accessible. With this end in
view the following method has been adopted by the
writer.

The record of each patient was taken on a separate
sheet of paper. At the head of the sheet was printed

Dtagnoits

Duration Sex

Nune
BMldenoe

Married Single Age
Ooeapatlon

If the case required more than one sheet, blank slips
of the same size were used, and the pages numbered.
This allowed easy insertion of subsequent reports of
the progress of the individual. The same plan allowed
a ready classification, since all the notes were turned
into a card catalogue by a simple grouping of cases.
These were arranged in a box with index cards of ap-
propriate size denoting the various diseases. As a re-
solt, a student can have at the end of his course a very
serviceable text-book of medicine, containing the teach-
ings of several clinicians emphasized by and based on
what he has himself seen. How valuable this " text-
hook of notes" may be, can be judged from the follow-
ing list of cases which were shown by Drs. R. H. Fitz,
F. C. Shattuck, A. L. Mason and H. F. Vickery at
the Massachusetts General and City Hospitals. The
list covers a period of about twelve school-year months,
and represents the cases seen by one member of the
present third class of the Harvard Medical School.

Specifio IxracTiODR Dibbabu.

TntuMterar 21, raeslnatlon 1, mnmpa I, Inflaenia 8, lequela o(
dlphtlieria 2, malaria 7, ■jphllta 7, tuberoaloela of l;mph glands 3,
toberealoela of Inngi 19, tuberonloBia of peritoneum S, tnbercnloela
of meninga* 1, general tnbercuioeU 3. Total, 71.

ComriTirrioHAL Disbabbs.

Bbeomatle fever 2, ebronle rhenmatlam 6, paeado-rhenmatto affec-
tiona 4, moaoolar rheumatiim 2, artbrltia deformana 3, gout 2, dia-
bete* mellUoa 12, rlokets 4. ToUl, S4.

Disbabbs of thb Diokbtivb Stbteh.

Stomatitis I, chronic tonsiUitia 2, cancer of the aaophagas 1, gaa-
trie catarrh 1, dyspepsia 2, nerroas Tomitlng 1, dilatation of stomach
8, gastric nloer 2, gastric cancer 11, diarrhoea 1, appendicitis 11, in-
testinal obstmctlOD I, constipation 1, catarrhal jaundice 4, gall
stones 7, oirrhcela of lirer 18, aDsceas of liver 2, neoplasm of liver 2,
dislocation of liver 2, hypertrophy of spleen 1. Total, 74.

' Bead at a meeting of the Boylston Medical Society, April 18, ISM.

DISBASBS or THB Rbspibatokt Ststbh.

Aoate bronchitis 1, chronic bronchitis 4, bronchitis and emphysema
3, bronchial asthma S, partial ocoluKion of bronchos 1, oeilema of lung
X, aoate ttbrinoas pneumonia 18, chronic interstitial pneamonia 2,
emphysema t, gangrene of lung 1, abscess of lung 1, acute pleurisy
IS, chronic pleurisy s, cancer of pleura 1. Total, w.

Disbabbs or thb Circdlatobt Ststbm.

Pericarditis 4, endocarditis 2, ehronio valvular disease 34, hyper-
trophy and dilatation 4, myoearditis 4, neuroses of heart 4, arierio-
seleroalsS, aneurism 6, phlebitis 2, abnormal position of pulse 1.
Total, iB.

Disbasbs or TBB Blood asd Ductless Olanim.

Secondary antemla 6, chlorosis 4, progressive pernicious ansmia 2,
leukeemla g, pseudo-leuk«mla 8, goitre 2, exophthalmic goitre 7,
myxcBdama 2. Total, X.

Disbasbs or thb Kidhbts.

Hyperamla 1, floating kidney 6, paroxysmal hssmagloblnotla 1,
ebyliurial, acute nephritis 7, chronic nephritis 16, renal oalcaiosj,
tumors 2, perlnephrltic abaecas 1, incontinence of urine 1, cystitis 1.
Total 41.

Disbabbs or thb Nbbtoos Ststbm.

Neuritis 11, Meaiire's disease 1, solatloa 3, diffuse myellUs I,
ascending lateral degeneration 1, descending lateral degeneration 1,
locomotor ataxia 7, compression of spinal oord I, cerebral meningitis
2,apha8lal, hemiplegia IS, Insular solaroels 1, general paralysis of
the Insane 2, brain tumors 3, chorea 6, epilepsy 5, migraine 1, occu-
patlon neurosis I, hysteria 2, neurasthenia 4, heimanieathesia I,
acromegalia 1, scleroderma 1, melancholia after delivery 1. Total, 73.

Dboo PoiBOBna.

Alcoholism 4, opium 2, lead ,10, aisentc 2, tobaooo 3, lllnmlnatlng
gas 2, aconite I.eopalbftl. Total 24,

HISCBLLAXBOCS.

Tumors 8, sexual Impotence 1, debility 2, elephantiasis 1. " chronic
unemployed " 1. Total IS. Total number of oases shown, 491.

RECENT FEOGBESS IN SURGERY.

0T H. L. BOBBBf.!,, V.D., AHD H. W. CCSHIKO, K.D.

Concluded from Mo. 16, p. 387.

TBAUMATIO ANBDSISM OP THB YKRTBBRAL ARTBRT.

Matas " records a case of aneurism of the vertebral
artery, which was cared by extirpation of the sao. The
author concludes : " That in certain favorable cases of
traumatic aneurism in the upper and more superficial
part of the vertebral artery, recovery without operative
interference is possible. In every case when the dan-
ger of rupture of the sac is not immediate, good results
may be expected, if only as adjuvants to future radical
treatment, from the systematic application of cold and
pressure to the sac, or digital pressure over the artery
below the carotid tubercle. In most cases there is a
tendency in the aneurism to progress rapidly to rupt-
ure, such tendency being often favored by the increased
tension caused by ligature of the carotid trunks under
mistaken diagnosis. This error may always be avoided
by carefully observing the effects of temporary com-
pression of the carotid on the circulation in the tumor.
Free exposure of the bleeding region and temporary
plugging have hitherto given the most satisfactory re-
sults. The use of coagulant injections is especially to
be condemned. In the extremely rare cases of idio-
pathic cervical aneurism, and in circumscribed traumatic
aneurisms situated high up in the posterior triangle,
proximal ligature might be attempted with some pros-
pect of success, especially if cold pressure and rest be
resorted to as adjuvants in the treatment. In aneu-
risms situated low down in the posterior angle, the
Hunterian operation will almost certainly fail, as it
will be found impossible to reach the trunk of the

>' Annals of Surgery, Hovember, 1893
Deownber 9, 1893.

British Medical Joornal,

Digitized by

Google

416

BOSTOS MEDICAL AUD 8VRQI0AL JOVRSAL.

[Apbil 26, 1894.

artery without involving the sac in the incision. When
in a case of an aaeariBm well circumscribed and situ-
ated high up in the neck, the ordinary local treatment
has failed and it has been decided to open the sac, it is
justifiable to expose the vertebral artery below the
anterior tubercle of the sixth cervical process, and to
compress the vessel until its wounded part has been
definitely secured at the bottom of the aneurismal cav-
ity. In the management of non-aneurismal wounds of
the vertebral artery, the surgeon should apply the
same treatment as in cases of traumatic aneurisms in
this vessel. In some rare cases, however, and espe-
cially in gunshot injuries through the mouth, in which
more than one vessel may be injured, a direct attack
on the bleeding point is impossible. As plugging
through the mouth is impossible, the only hope for the
patient lies in the immediate bnt provisional control of
both the common carotid and vertebral arteries of the
same side, with a view of cutting o£E the entire arterial
supply from the injured region. After the predse seat
of the hssmorrhage has been deliberately made out,
the definitive ligature may then be applied to either of
the exposed arteries, or to both, if necessary. In the
more common cases the diffieultie; in applying direct
pressure to the bleeding point are less in the upper
part of the neck than in the lower part where the
artery is surrounded by vital structures."

A MODE or OONTBOLLIMa THE OIRCCLATION
THBOUOH THE ABDOMINAL AOBTA.

William McEwen ^' suggests a method which he has
used for the last fifteen years for controlling the ab-
dominal aorta. It is as follows :

" As the patient lies on his back on the table, the
assistant, facing patient's feet, stands on the left side
of the table in a line with the patient's umbilicus. He
then places his closed right hand npon the patient's
abdomen, a little to the left of the middle line, the
knuckles of the index finger touching the upper border
of the umbilicus, so that the whole hand will embrace
about three inches of the distal extremity of the aorta
above its bifurcation. The assistant, then standing
npon his left foot, his right foot crossing his left and
resting upon the toes of the right — an attitude com-
monly assumed by public speakers — leans upon his
right hand, and thereby exercises the necessary amount
of pressure. With the index finger of the assistant's
left hand, the weight necessary for the purpose can
easily be estimated by the effect produced upon the
flow of blood through the common femoral at the brim
of the pelvis. Whenever the flow of blood through
the femorals is absolutely arrested the abdominal aorta
is sufficiently controlled, and no further weight ought
to be applied.

" The weight exercised can be varied at will by in-
creasing or decreasing the angle which the assistant's
body makes with the floor. The position which the
assistant assumes relatively to the patient is represented
in the accompanying photographs.

"As the abdominal aorta sometimes bifurcates higher
than usual, before the operation is commenced a trial
of the effect of the pressure at the part selected ought
to be made, testing the result of pressure on both
femorals. When both are equally controlled, the bi-
furcation occurs below the point pressed on ; when
only one is controlled the hand requires to be. placed
on a more proximal part.

" Annals of Surgery, Jannary, UM.

" Aa there is do direct muscular effort reqaired in
maintaining the pressure further than the preBervation
of the equilibrium, the position can be maintained by
the assistant without undue strain on his part, and
without shifting his hand for at least half an hour, a
time amply sufficient for the performance of most oper-
ations requiring the control of the circulation through
the abdominal aorta."

SCTCBB OF NEBVES.

Gneiss" reports eleven cases of nerve-sutare at
Brnn's clinic. Four were cases of primary operations,
and seven secondary. The following nerves were
sutured: the median, five times; the ulnar, three
times ; the radial, four times ; the perineal nerves
once. All but one operation was successful. An in-
teresting point of the report is the description of
Brun's technique. In the cases of primary operation
the ends were united at once ; iu the secondary cases
the ends were usually refreshed and the cicatricial
mass removed. One case, as shown by illustration,
was treated by making a slit in the nerve trunk,
which split the cicatrix and extended into sound nerve
tissue ; the ends of the cut were then approximated so
that the sides were brought in contact, and the line of
incision at right angles to the long axis of the nerve
trunk. Sutures passed through these lateral projec-
tions secured the nerve in its new position. Catgut
was the material used for suture. In four cases the
nerve was protected from pressure during healing by
a decalcified bone tube. The article is a valuable one,
and contains many interesting details.

SUPPDBATIYE TENO-8TNOVITI8.

Tollemer and Macaigne ** relate a case in a mao
aged nineteen. On the fifth day of the gonorrhoea he
had pain and swelling in the small joints of the left
hand. On the fourteenth day the right hand, and
chiefly the tendon of the index finger, were affected.
Here a lymphangitis also appeared. The pus was let
out, and movement was eventually completely restored.
The tendon of the left little finger also became in-
volved. The inflammation was here adhesive only,
and the tendon remained adherent to the sheath with
limitation of movement. In the above-named pus, a
micro-organism — proved to be the gonococcus (1) by
its form, (2) by its presence in the cells, and (3) by
its decolorization by Gram's method — was found in
pure culture. Cultivation experiments were also made.
There is now no doubt that gonorrhoea may assume
the character of a general disease. The micro-organ-
ism has rarely been found in the articular serous effu-
sions, but the negative results may be due to its rapid
disappearance. There was practically no fever during
the whole of the illness. Owing to the limited vitality
of the gonocoocas, the suppuration seems to end as
soon as the pus is let out.

MALLET FINQBB.

Robert T. Morris *' describes a condition which he
states is not uncommon among men engaged in athletic
sports. The injury consists, not in a bodily separa-
tion of the tendon from its points of attachment, but
rather in a thinning of the tendon cephalad from the
principal point of attachment to the phalanx, and from

w Brltritge znr Kiln. Cbir., 1893, Bd. x, Heft it. . „

M BoT. de MM., November, I8SS; Britlsli Medioal Joumal, D«-
oember 16tb.
•> Madloal Neva. Swtembw •, 1893.

Digitized by

Google

Vol. CXXX, No. 17.] BOSTON MBDIOAL AND SVBGIOAL JOURNAL.

417

the fibres that form the posterior ligament of the last
phalangeal articulation. A few fibres of the tendon
are andoabtedly raptured, but most of them slide
awaj from each other very much as the threads of a
textile fabric separate when the fabric is violently
stretched, bat not torn, the structure retaining its
original general appearance.

Immediately after the occurrence of the injury to
the tendon, the last phalanx of the finger assumes a
semi-flexed position, and the deformity is usually per-
manent, the extensor tendon then having little or no
influence upon the freed phalanx. Aside from the un-
canny appearance of such a finger, the deformity is a
source of annoyance to the patient.

The tendon is repaired without much difficulty by
making a longitudinal incision two centimetres in
length over the site of the injury, dividing the thinned
tendon longitudinally into the two principal fasciculi
into which it naturally separates, dividing the tendon
cephalad transversely from the thinnest point, and ad-
vancing each fasciculus to a point upon its own side of
the finger, near the base of the finger-nail. At this
point the fasciculus is sutured to the under surface of
the skin rather than to the periosteum and tendinous
remains, because the former structure affords a firmer
hold ; and the cut end of the tendon makes as good a
union with the phalanx as it would if sutured directly
to the periosteum.

THBATXENT OF TDBEBCULAB COXITIS BT lODOrOBU
INJBOTION8.

G. Banger" considers this method advantageous,
and recommends Keuster's technique. He injects into
the hip-joint through a puncture made at a point (the
inner border of the sartorius) in a horizontal line
drawn from the femoral artery where it crosses the
pubic bone to the trochanter. The injection is made
with a hypodermic syringe having a needle five to
seven centimetres long. Two and one-half grammes
of a twenty-per-ceut mixture of iodoform and glycerine
are injected every eighth to fourteenth day.

OSSIFTINO HEMATOMA.

Arsdale ^ has reported a case occurring in a man
twenty-two years of age, who had a severe contusion
on the right arm, just below the insertion of the del-
toid. When first seen a fluctuating tumor was there.
At the end of six weeks a tumor of bony hardness was
present. Aspiration having failed, it was decided to
remove the tumor. This was done, and the patient
was discharged cured. The function of the arm at
the end of two years was perfect. The points of in-
terest in this case are that an ossifying heematoma may
be readily confounded with an osteoma, periostitis,
myositis ossificans and osteosarcoma.

80MB POIICTS OF PBACTIOAL IHPOBTANOB IN THE D8E
OF OCBTBD SKIM INCISIONS.

In an interesting article, Peyton T. B. Beale ^ has
summarized the advantages of curved over straight in-
cisions wherever the former is practicable.

" (1) It heals more rapidly, and for these reasons :
there is really only one edge of the wound, that be-
longing to the flap, that is movable, the other edge
being still adherent to the subjacent tissue ; moreover,
the flap having been stitched to the neighboring skin

« Centnlblmtt (Ur Chir., 1893, No. 51.

M AniuUi of Snnerr, toi. xTiil, No. 1, July, 1893.

>• LaiiMt, July 8, 189S.

or held well away from the seat of operation, both
edges of the wound are quite uninjured by the time
the sutures are inserted. (2) The resulting scar is
smaller, though this is only of importance in certain
parts, for the skin may be incised obliquely in making
a curved incision, so that the epidermis on the edge of
the flap is slightly in advance of the true skin. (3) It
fully exposes the part to be> operated upon, assuming
that the base of the flap is twice or three times its
length, and gives the operator plenty of room in
which to work. (4) Suturing the edges is easier than
in the case of a straight incision, especially if the skin
be pricked in one or two situations exactly opposite to
one another before the incision is made, and more often
the curved wound is adapted to the shape of the part
than a straight one. (5) The resulting cicatrix is not
over the seat of operation. (6) Drainage is often
most perfect by inserting a tube through an incision in
the base, or some part of the flap, thus giving no hin-
derance to the primary union of the incision, and pre-
venting any possible discharge from infecting the
edges. (7) Incision through inflamed or diseased
skin may be avoided, and yet the disease is easily
reached. (8) There need be no tension on the edges
of the wound, as the flap of skin is, so to speak, loose,
and if there is fear of tension, a silk suture can be
passed through the base or some part of the flap and oat
again, and then through the skin on the other side of
the incision, and there fixed, thus avoiding a long suture
beneath either edge of the wound. I think that the form
of skin incision, its subsequent result to the patient,
and its immediate results to the surgeon during the
progress of an operation, are matters often neglected,
and not sufficiently considered before the operation is
undertaken, and I feel sure that there are many points
of interest connected with the subject."

BLOODLESS AMPUTATION AT THE HIP-JOINT.

Dr. John A. Wyeth^ reports 40 cases operated
upon by his method. This is undoubtedly one of the
best methods we have for controlling haemorrhage in
this formidable operation. He says: "Without dis-
cussing statistics, I claim it safe to conclude that by
the method given bleeding after hip-joint amputation
is as safely and surely controlled as for an amputation
of the thigh lower down. In no single case has it
failed, and it has been employed by operators of all
grades of experience. The 40 cases are divided as
follows: sarcoma, 17 (mortality, 11.76 per cent.); in-
flammatory bone disease, 18 (mortality, 1 6.6 per cent.) ;
violence, 4 (mortality, 100 per cent.) ; nerve injury, 1

(mortality, )\ for disease, 36 (mortality, 13.88

per cent.) ; for injury, 4 (mortality, 100 per cent.) ;
giving a total death-race of 22.5.

SACBAL OSTKO-PLA8TIO OPEBATIONS.

Czerny's " report at the last meeting of the German
Surgical Congress, in which he describes the removal
of intra-pelvic tamors by the sacral route, is a very in-
teresting one. It describes in detail numerous opera-
tions performed for the removal of such neoplasms,
and is too long to give more than the writer's conclu-
sions. An excellent abstract has been published,
however, by Warbasse." Czerny thinks that the
sacral method of 0{>erating on intra-pelvic tumors will

" Hedleal Mews, Deounber 9, 1893.

•• Tarbandliuig der dantsohen Gesellsoluift tUr Obtr., xxli Kon-
greo, 1893.
•> Annali of Sorgary, 1891, vol. xvUi, HI.

Digitized by

Google

418

BOSTON MBBWAL AND SVSGJCJL JOURNAL.

[April 26, 1894.

pass through the same stages as the sacral extirpation
of the rectum, it was at first received with iudiSer-
ence or reserve, then practised too enthusiastically,
but gradually has taken its proper and legitimate
place, and is considered an operation of value in se-
lected cases. He also thinks the sacral route is the
shortest to the parametria! region for the enucleation
of paracervical myomata, or similarly situated growths.

ON THE ADVANTAGES OF THE STEEL 8CSBW IN THE
TBEATIIENT OF UHDHITBD FBACTCBE8.

W. Arbuthnot Lane** suggests the use of steel
screws in immobilizing ununited fractures. He speaks
of the ditBculty of retaining the sawn surfaces in posi-
tion by means of silver wire, and believes that the two
following conditions must be complied with to ensure
success :

"(1) The surgeon must not be satisfied with remov-
ing a thin surface of bone on each side of the fibrous
ankylosis, but a good, thick slice must be taken o£E the
end of either fragment, so as to expose the normal
structure of the shaft. It would seem that the bone in
the immediate vicinity of the acquired amphiarthrodial
joint undergoes such vascular changes as interfere
with its taking an active share in the formation of cal-
lus and bony ankylosis of the fragments. If a thick
slice of bone, which has been sawn off one of the frag-
ments in such an operation, is divided vertically, the
bone in immediate relation with the false joint will be
foand to be dense and comparatively evascular, and
this condition will be found to extend for an unex-
pected distance into the shaft. Therefore, in order to
obtain bony union with any certainty, it is necessary
to sacrifice a considerable portion of the length of the
limb, and the amount of bone removed from each frag-
ment must bear a direct relationship to the duration ot
the interval that has elapsed since the injury. Such
operations are sometimes the most difficult in surgery,
especially when performed for ununited fracture of
the tibia in its upper third. The difficulty is some-
times greatly increased by the necessary removal of a
portion of the fibula, this bone not having been broken
at the same time as the tibia, or, if it had been, union
had ensued in it. Such conditions of non-union of
fractures in the leg are, in my experience, always the
result of the application of the principle of the vertical
foot-piece, and 1 trust that, since the fallacy of that
treatment has been satisfactorily exploded, surgeons
will not have to deal with such diiBcult cases in the
future.

*' (2) The recently sawn surfaces of bone must be
retained immovably in accurate apposition. 1 have
frequently found the greatest difficulty in retaining the
freshly sawn surfaces of bone in accurate and firm ap-
position by means of the silver wire, for the reason
that the obliqae sectional planes presented by the
fragments are in different vertical levels, and tend,
when fastened together with wire, to separate verti-
cally, however firmly they may be clamped together
during the boring of the holes, and however great the
strain exerted un the wire during its fixation in posi-
tion. Again, the circumstances are quite different
from those present in a recent fracture, where, as is
well known, if sufficient care and trouble are taken,
the broken surfaces will correspond exactly. In the
case of the ununited fracture, the plane of the fracture
is often only to be guessed at, since it has been much

*• LaoMt, DMemtwr IS, 18S3.

modified by the formation of callus, etc. I have beeo
much disappointed on several occasions, on cutting
down on cases of ununited fracture in which an opera-
tion had been performed without success, to find ths
loop of wire lying comparatively loose in the bones.
I therefore determined to try what I could do by using
screws instead of wire, and then found that 1 was able
to bring and to retain the opposing surfaces of bone
into most accurate and forcible apposition by means of
this powerful instrument. The use of two screws is
much more advantageous than one alone, for the
reason that any rotation of the bony surfaces around
the screw as an axis is completely obviated. The
screws produce no irritation whatever, and do not re-
qoire to be removed. I should have found some of
these operations impracticable but for Gowan's osteo-
tome, which is an invaluable instrument under the dr-
cumstaoces. With it, one is enabled to ensure acca-
racy of parallelism in the sectional planes with a
minimum of damage to adjacent vessels (a matter oc-
casionally of no little importance), and by using the
clamp portion of the instrument without the saw, the
cut surfaces can be held firmly and immovably in ap-
position during the boring of the holes and while the
screw is being driven in. It is well to remember that
it is by means of the final turns of the screw that firm-
ness and accuracy of apposition are obtained."

SEPARATION OF THE LOWEB FBHORAL EPIPHT8IS.

Mayo Robsou " directs attention to this accident,
which is usually the result of direct violence. Short-
ening the projection of the diaphysi* in the popliteal
space, and of the epiphysis anteriorly, combined with
the interference in the circalatioo, are the physical
signs present. If there is 'any difficulty in reduction
an anaesthetic should be used and the tendo-Achillis
divided. A weight and pulley are needed in the after-
treatment. If the large vessels are ruptured and gan-
grene supervenes, of course amputation is necessary.

TREATMENT OF OnNSHOT WOUNDS OF THE ABDOMEN.

Von Bramau "^ has reported eight cases of gunshot
wound of the abdomen, and has been led to form the
following conclusions: (1) In all cases of gunshot
wounds of the abdomen in which signs of injury of
stomach or intestine, or of profuse internal bleeding,
are presented immediately after the injury, prompt
laparotomy is imperatively indicated. (2) The opera-
tion is especially indicated in every case in which the
direction taken by the bullet leads not only to a proba-
bility, but even to a possibility, of the existence of a
wound of the stomach. In 90 per cent, of cases of
such injury to the stomach, death is inevitable under
any plan of expectant treatment. (3) When unde-
tected, laparotomy should be performed as soon as pos-
sible in cases of gunshot wound of the abdomen, as the
prognosis becomes more and more unfavorable after
every hour, and — particularly as a result of septic
perforation — peritonitis is very bad indeed after an
interval of twenty-four hours. (4) The indications
for laparotomy thus furnished by the results of ab-
dominal gunshot wounds in civil practice are still more
imperative in the practice of military surgery. (Si)
Haemorrhage caused by gunshot wounds of the liver
and spleen shonid be assisted by plugging after lapa-
rotomy. (6) Operative interference and extirpatioB

» AnnaU of Snisarj, rol. XTiit, Mo. 1, Jaly, ISSS.
«> C«iit»lbL f . OMi. Bailee, Mo. SO, IStt,

Digitized by

Google

Vol. CXXX, No. 17.] BOSTON MEDIO AL AND SURGICAL JOURNAL.

419

in cases of ^anshot woand of the kidney are indicated
only by profase and persistent bleeding. (7) Lateral
wound of the ureter may heal apontaneousiy ; com-
plete division, however, indicates stitching, and in
case of failure of this plan, nephrectomy. (8) Gun-
shot wound of the bladder should invariably indicate
suprapubic section and closure of the wound by sutures,
and the retention during the healing of a urethral
catheter.

BIBLIOORAPHY.

H. A. Hare and E. Q. Thornton. A study of the inflaence of

chloroform apoo respiration and ciroalation. Liancet, October

21, 1893.

, Leopold Hudson. Sea voyaKes for sargical convalescents (with

statistical Ubles). Lancet, October 21, 1893.

Lesi. Tetanos cured by aernm of an immunized horse. British

Medical Journal, October 7, 1893.
Boswell Park. The importance to the surgeon of familiarity
with the bacillus coli communis. Annals of Surgery, Septem-
ber, 1893.
Major. An improved method of draining the antmm of High

more. New York Medical Journal, August, 1893.
Krause. Priority of operation for intra-cranial neurectomy of
the fifth nerve (bibliography). Annals of Surgery, 1893, vol.
zviii, 362.
Nasse. Tumors of the salivary glands. Arch. f. Klin. Chir.,

vol. xliv.
G. J. Bond. On the ultimate condition of cleft palate cases

after operation. Lancet, September 9, 1893, p. 627.
William Pepper. Spasmodic and organic stricture of the oesoph-
agns : a report of two oases. Medical News, November 2S,
1893.
Rudolph Matas. Notes on some congenital anomalies connected
with the branchial apparatus. Medical News, December 2,
1893.
Delorme. A new method of opening the thoracic cavity. Tem-
porary resection of several ribs, modification of " Eslander.'*
Annals of Surgery, 189.1, vol. xviii, p. 77.
Barling. Surgical treatment of perforating gastric ulcer.

Birmingham Medical Review, September, 1893.
Editorial. Successful celiotomy for perforating gastric nicer.

Medical News, November 11, 1893.
Ederbobls. TecJiniqne of total extirpation of the uterus for

fibromata. Annals of Surgery, 18U3, vol. zviii, 398.
Harrington. Intra-peritoneal cystotomy. Annals of Surgery,

vol. xviii, No. 4, October, 1893.
Berger. Operative treatment of congenital umbilical hernia.

Rev. der Chimrgie, October, 1893.
Zeidler. Gangrene in strangulated hernia; resection vertut
anus pneternaturslis ; conclusions from 676 cases. Annala
of Surgery, 18H3, vol. zviii, 351.
Howard A. Kelly. Uretero-ureteral anastomosis — uretero-
ureterostomy. Annals of Surgery, January, 1894.
Bacon. Stricinre of the rectum. Annals of Surgery, May,

1893.
Kotdma. Tuberculous disease of the elbow-joint, statistical.

Annals of Surgery, vol. zviii, 108.
J. Colling Warren. Hypertrophies and degenerations of cica-
trices and cicatricial tissue. Annals of Surgery, September,
18rf3, p. 2S3.
Lipps. Ligature of eztemal carotid. Arch. f. Klin. Chir., Bd.

U. Bit. 1.
y. Ziemssen. Diagnostic and therapeutic value of puncture of

the spinal cord. Annals of Surgery, I8f3, vol. zviil, 235.
Coley. Treatment of malignant tnmors by repeated inocula-
tions of erysipelas. American Journal of Medical Sciences,
18!I3.
Herbert Snow. The so-called " parasitic protozoa " of mammary

carcinoma. Lancet, November 11, 1(S93.
Krause. Transplantation of large skin-flaps without a pedicle.

Annals of Surgery, V\>93, vol. zviii, 4S0.
Lanenstein, Carl. A method for obtaining double skin-flaps for

plastic operations. Annals of Surgery, 1893, vol. zviii, 674.
Bier. Plastic improvement of amputation stump of the leg.

Annals of Surgeiy, 1893, vol. zviii, 68t.
Stephen Smith. Some facts bearing on the condition and
■erviceabieness of the stump after amputations in the lower
eztremity at different points and by various methods. Medi-
cal News, September 9, 1893.
N. Seon. A new method of direct fization of the fragments in
compound and ununited fractures. Annals of Surgery, August,
1893.
B. Henry Anglin Whitelocke. The detachmentof tbeepiphyses
for the anterior inferior spinons process of the ilium through
enforced muscular action. Lancet, November 2fi, 1893.
J<riio B. Koberts. Simplicity in the treatment of fractures.

Medical News, July 8, 1893.
A. H. Tnbbey. Traumatic separation of the epiphyses of the
lower eztremity. Annals of Surgery, March, 1894, p. 289.

Arbnthnot Lane. Applicability of the Fartney tool or angular
snge to the surgery of the skull. British Medical Journal,
ovember 11, 1893.

gOD

Noi

lElepoct^ of j&ocietie^.

THE OBSTETRICAL SOCIETY OF BOSTON.
cnkxuwt w. TOWHSKSD, H.n., sKcasTAav.

Meetimo February 10, 1894, the President, Dr.
Charles M. Green, in the chair.
Dk. F. Mimot read a paper entitled

observations on cases of fibroid tdmor of the

WOMB.'

Dr. J. B. Atbr spoke of a case that had formerly
serious haemorrhages. She is now forty-eight years
old and the bsemorrhages have practically ceased, al-
though he was called to see her about a year ago for
retention of urine. He could recall other cases where
the symptoms improved but the tumor remained of the
same size.

Dr. W. H. Baker said he was much interested in
the paper and thought it was very unusual for nearly
one third of the cases to be between twenty and thirty
years of age. The youngest case he could recall was
twenty-three years old. Retention of urine he had ,
found to be rather rare, as the bladder can usually ac-
commodate itself to the growing tumor. As regards
pregnancy, he had found that the fibroids increase
very rapidly in size during the pregnant state, while
after delivery they diminished very rapidly and some-
times disappeared, the process ot involation extending
to the tumors.

Dr. F. MiNOT mentioned a case of spontaneous
expulsion of a fibroid tumor without any immediate
unpleasant e£fect. In a few weeks the patient be-
"an to cough, became tuberculous and died in a few
months. In another case, after a severe haemorrhage,
spontaneous expulsion of a large fibroid tumor took
place.

Dr. W. L. Burraob said that in his experience
these tumors, as a rule, cause comparatively little in-
terference with micturition. They occasionally cause
iuflammation in the pelvis which clears up ; as regards
their effect on the rectum, chronic and obstinate
constipation often occurred. The cases Dr. Miuot re-
ported of absence of htemorrhage for a long period
were particularly interesting.

Dr. F. U. Davenport had seen but few patients
with vesicle trouble due to fibroids. One was a case
of multiple fibroid tumor he had seen to-day who has
occasionally had retention of urine needing the catheter.
In another case there was slight heemorrhage from the
bladder. He found here a small fibroid projecting
from the anterior wall of the uterus and pressing
against the bladder. On raising the uterus the heem-
orrhage ceased.

Dr. a. Worcester said be had heard a good deal
said on the necessity of operating on every case of
fibroid of the uterus. He wished he could feel that
the operation was a safe one. He had watched pa-
tients who have carried fibroids for years, cases that
had been handed down to him from other physicians.
One is a lady of fifty years who has been cognizant of
the tumor for twenty-five years. Tlie tumor is so
large it rises above the umbilicus and seems like preg-
> Sae page 106 of the Journal.

Digitized by

Google

420

BOSTON MEDICAL AND SUSGIVAL JOURNAL.

[Apbil 26, 1894.

naocy at full term. She meDstraates regularly, and
has never suffered from menorrhagia or dysmenorrhoea ;
in fact, she is perfectly well and is able to do an
immense amount of work. Another case, which had
also been handed down to him, was supposed to have
a fibroid tumor before 1855. She has never been ill
with it, but a short time ago it began to increase in
size. Dr. Homans saw it, and found it to be not a
fibroid but an ovarian tumor, and removed it. Another
case had a fibroid as large as an orange on the right
side of the uterus, very prominent during pregnancy.
After delivery she made a poor recovery, complaining
of pains in the pelvis, an enlarged ovary being found.
The ovary was removed by laparotomy, and the fibroid
was found to have nearly disappeared, having decreased
to the size of the thumb.

Dr. Grben recalled one case in which a large
fibroid was Rpontaneously expelled : the tumor was
about as large as a foetal head. The patient had pre-
viously declined operative treatment, and was given
ergot, tampons being occasionally used to control
hsemorrhage. He had seen five or six cases in which
labor was complicated by the presence of a fibroid
tumor : where the tumor is seated low, perhaps filling
the pelvic cavity, it may obstruct labor and necessitate
abdominal delivery of the child or embryotomy ; bat
iu each of the cases he had seen the tumor recede, as
labor advanced, and the child was delivered either
spontanoously or by the aid of forceps. When the
tumor is seated somewhat higher, it may interfere with
the ordinary mechanism of labor; or, what is more
serious, it may interfere with the retraction of the
uterus. If, by chance, the placenta is attached wholly
or in part over the tumor, serious and even fatal htem-
orrhage may result. In regard to the subsequent
shrinkage in fibroid tumors after pregnancy, he thought
that usually the tumor involuted with the uterus : such
was the case in two patients he had seen within a year.
In one of these cases, which was in the Boston Lying-
in Hospital, at the beginning of labor the tumor entirely
filled the pelvis ; but it receded, and the child, which
presented the breech, was extracted alive without es-
pecial difficulty. The uterus and tumor both involuted,
and at the conclusion of convalescence the tumor had
shrunk to such a degree that it would scarcely have
been detected without careful examination. Dr. Green
thought that it was well to remember in these days of
operative zeal that fibroid tumors very often not only
do not grow rapidly but even remain stationary for
years. He had seen a case the day before which he
had observed for four or five years : the tumor, which
was sub-peritoneal, reached nearly to the umbilicus ;
but he had been able to detect no change in size dur-
ing the time mentioned. The patient was forty-seven
years of age, and there was reason to hope that with
the menopause so near at hand there might be no
further increase in the tumor. At present, certainly,
there was no indication for operative treatment, as
there was neither pain nor haemorrhage, and the pa-
tient was inconvenienced only by the weight of the
tumor.

Dr. Edw. Retnolds said he had watched a fibroid
grow to the size of a mandarin orange in the second
pregnancy and then dwindle to the size of the little
finger. In the third pregnancy it grew to the size of
two clenched fists, and is now, six weeks after delivery,
growing small again. He bad observed this same
thing in another case.

He bad seen six cases of labor complicated with
fibroids, all of which did well eventually. One had
severe post-partem haemorrhage ; one had a very diffi-
cult face presentation, owing to the fibroid ; bnt these
were the only cases in which there was any difficulty.

Dr. a. D. Sinclair mentioned a case where a
fibroid the size of a fist disappeared after confinement.

Dr. F. H. Davenport read a paper on

THE NON-SDRQICAL TREATMENT OF CBEONIO PELVIC
INFLAMMATIONS AND THEIR SEQUEL^.'

Db. W. H. Baker said he would rather be asked
to apeak on the surgical side, but as that was ruled
out by the paper he would quite agree with the method
of Dr. Davenport, which pnts the matter within the
hands of the general practitioner and enables them to
do good work.

Dr. G. Hayen said he would fully agree with Dr.
Davenport in the value of the treatment by massage.

Dr. a. D. Sinclair said that glycerine, ichthyol,
and massage were three very important things. Their
proper application took time, but the results were good.

Dr. a. Worcester would emphatically endorse
massage.

Dr. Edw. Reynolds reported a

case of extra-uterine PREONAMCr

and showed specimen.

Vitttnt Xtteratuce.

Wimmer't Table and Note* on Buman Oiteology.
For the Use of Students of Medicine. By Sebas-
tian J. WiMMER, M.A., M.D. With a preface by
Prof. William F. Wauoh. Philadelphia: The
Medical Publishing C!ompany. 1894.
Our opposition to anything of the nature of an anar
tomical compend baa been so persistent and (in oar
own opinion) so well founded, that we find it difficult
to give the praise to this little work which is no more
than its due. None the less it states the main facts of
osteology so clearly, simply and correctly that we mast
say that if used, and not abused by being taken as a
substitute for a text-book, it is distinctly a valuable
help to the student.

Sjftlabut of ike ObtUlrical Lecturet in the J/edieal D»-
partmml of the University of Penntylvania. By
Richard C. Norris, A.M., M.D., Demonstrator of
Obstetrics, University of Pennsylvania; Assistant
Obstetrician, University Maternity ; Physician to
the Methodist Episcopal Hospital ; Obstetrical Reg-
istrar, Philadelphia Hospital ; Consulting Obstetri-
cian and attending Gynoecologtst, South Eastern
Dispensary and Hospital for Women and Children.
Third edition. Philadelphia: W. B. Saunders.
1894.

The primary and chief value of this work is, of
course, to the students of the University of Pennsyl-
vania, for whose use it was written. It is secondarily
of interest to the specialist as offering an easy method
of judging of the obstetrical instruction given in so
prominent a school. The book is exactly what its
title implies — a syllabus of Dr. Hirst's lectures —
and little can be added to its title-page by a review ex-
cept to say that it seems to be a good syllabus.
> See imge 407 of the Journal.

Digitized by

Google

Vol. CXXX, No. 17.] BOSTON MEDICAL AND SURGICAL JOURNAL.

421

THE BOSTON

iSteUfcal atiD Surgical 3Iournal*

THURSDAY, APRIL 26, 1894.

A Jomal o/Mtdieine, Surgery, and Allied SeietteeM.publithed <U
BotUm, weetl]i, by the tmidenigned.

SVBSCKIFTIOK TSBMI : 9B.00 per year, in advance, poetage paid,
far tkt United Statu, Camada and Mexico ; $6.B« per year for all for-
tign eoHKlriM beUmginf to the Pottal Union.

All eonMmmieoMoM far the Editor, and all iooke for review, ehould
teaddrentdtothe Bdilorof the BoeUm Medieal and Surgical Journal,
28S Waahington Street, Boeton.

All letter* eomoiiiiii; bueineee eommunicationt, or referring to the
fuMieation, tubteription, or advertiting department qf this Journal,
ehould be addreued to the undereigned.

Xemitlaneee ehould be made by money-order, draft or regiitered
letter, payable to

DAMKELL ft UPHAM,
28S Washucotoic Stskbt, Bostoh, Mass.

IDIOPATHIC HYPERTROPHY OF THE HEART.

It was formerly taught that hypertrophy of the
heart is always consecutive to some valvular lesion
or some other more or less distant impediment to the
free circulation of the blood ; the heart enlarges to
overcome the obstraction, whether this exists in the
valves or in the blood-vessels. It is only thirty years
ago that Boar, in a thesis published in Giessen, de-
scribed eighteen cases of hypertrophy of the heart
without any discoverable valvular or arterial altera-
tions.

Since this time, many memoirs have appeared in
various parts of the world, especially in Germany,
substantiating the existence of an idiopathic hypertro-
phy of the heart. Many of the cases reported were
typical instances of the bovine heart. There is a
groap of cases of dilatation and hypertrophy conse-
quent on prolonged overexertion, and treated of by the
French writers under the head of /« eceur surmeni
(the overworked heart). This affection was first no-
ticed by Peacock among the Cornwall miners; was
next described by Clifford Albutt, and was afterwards
observed and studied by Da Costa and others, in sol-
diers who had, during the late American war, been
disabled by foroed marches and other hardships.

Osier writes of patients who frequently come under
the observation of the physician : " They are able-
bodied men, at the middle period of life, and complain
first of palpitation or irregularity of the action of the
heart, shortness of breath, and subsequently the usual
symptoms of cardiac insufficiency develop. On in-
quiring into the history of those patients, none of the
usual etiological factors causing valve disease are pres-
ent, but they have always been engaged in laborious
occupations, and have usually been in the habit of
taking stimulants freely."

. Schott, of Nauheim, says that the existence of such
a condition following overstrain can no longer be
doubted. He has made experiments with the view of
producing acute overstrain of the heart in healthy and
vigorous men by making them struggle till dyspnraa

came on. In a recent series of experiments the body
of the struggling person was compressed by a girdle
applied below the arch of the ribs, thus increasing the
intracardiac pressure and making the action of the
heart extraordinarily difficult. AH the symptoms char-
acteristic of acute overstrain of the heart were thus
produced, namely, dyspnoea, arythmia of the pulse,
tachycardia, etc., and above all dilatation of the heart,
including auricles and ventricles. In the second series
of experiments the heart sometimes assumed quite
considerable dimensions. Cases were also mentioned
in which symptoms of acute overstrain of the heart
were produced by lifting heavy objects, climbing
mountains, dancing, and particularly tight-lacing and
velocipede-riding.^ Such cases are reported by Jack-
son in a paper recently published in the Jodkmal.*
And in connection with this subject it is well to be
acquainted with the class of cases described by Da
Costa, under the head of " Cardiac Asthenia, or Heart
Exhaustion." *

At the recent meeting of the International Medical
Congress held in Rome (March 29 to April 6, 1894)
Laache, of Cbristiania, Norway, spoke of the subject
of idiopathic hypertrophy in connection especially with
alcoholism and overexertion. Alcohol is a prominent
etiological factor, and in particular, beer-drinking.
Here he is in accord with Bollinger who has published
some interesting researches on idiopathic hypertrophy
of the heart, and assigns to beer-drinking an important
etiological part. According to these writers, the
plethora provoked by the immoderate ingestion of beer,
and the augmentation in the blood-pressure therefrom
resulting, joined to a direct noxious action on the heart-
muscle explains the hypertrophy and other heart
troubles which are becoming increasingly frequent in
certain cities of the Empire, " resulting in a mortality
scarcely less than that caused by tuberculosis." The
condition of the heart thereby caused is spoken of in
Bavarian parlance as the beer-heart. This beer-hearl
is very prone to fatty degeneration ; secondary valve-
disease due to consecutive endocarditis is not rare.
Striimpell affirms that this condition is very common
in the draymen and workers in the breweries of Erlan-
gen, very few of whom pass the forty-fifth year with-
out indications of dilatation and hypertrophy of the
heart (Osier). At the post-mortem examination the
valves may be quite healthy, the aorta smooth, and no
extensive arterio-sclerosis, or renal disease be found.
The heart weighs from eighteen to twenty-five ounces.

Laache admits the frequent occurrence of cardiac
hypertrophy among the Scandinavian nations from
overstrain, especially in conjunction with heredity and
habits of alcoholism. The Norwegians are very fond
of gymnastic exercises, and these when indulged in
immoderately cause overstrain of the heart. A medi-
cal confrere of his lost his life by heart-rupture after a
long tramp on the Norwegian " ski " or skates. Sud-
den death is, in fact, according to the writer, a very

> Quoted from Saioiu' Annual, 1891.

> Februar; 1, 1894, p. 112.

' Amerioan JoorniU o{ the Medical Solanoes, April, 16M.

Digitized by

Google

422

BOSTON MEDIO AL AND SVBGJCAL JOUBNAL.

[Aphil 26, 1894.

frequent terminatioD of idiopathic cardiac hypertrophy
with degeneration. So frequent, in fact, is this form
of death in Scandinavia, that (in the words of this
writer) "one can hardly open a newspaper without
meeting with an account of a case of the kind, brought
on by heart-failure or heart-paralysis." But, he does
not overlook the wonderful recuperative power some-
times displayed by the heart, and which led Haller in
his day to apply to it the epithet ultimum morient.

With regard to the word idiopathic as applied to the
cardiac enlargement resnltiug from the causes above
mentioned, the word is quite correct. An idiopathic
disease is a disease which exists by itself, and is not
dependent on another (Robin). Some writers have
spoken of an idiopathic hypertrophy of the heart as au
affection occarriug without discoverable cause. There
is no sufficient evidence that any such affection has
ever existed. The mechanism of idiopathic hypertrophy
is not essentially different from that of hypertrophy
secoodary to valvular disease or renal sclerosis, and
may be summed up in these words : augmentation of
blood-pretsure.

THE ELEVENTH INTERNATIONAL MEDICAL
CONGRESS.

All accounts of the Eleventh InterDational Con-
gress— those directly from Italian sources, those sent
to the English, to the German and to our own jour-
nals, and those which we get directly from returning
delegates — concur in indicating that it was at once
the largest and the least well-organized of these inter-
national medical gatherings. There was no lack of
good-will or of hospitable intention on the part of the
hosts ; but there unquestionably was an evident lack
of previous appreciation of the inherent difficulties, of
the great numbers, of the necessary conveniences, as
well as a lack of executive capacity.

The truth is, the very success of these meetings
threatens to be their ruin. It is next to impossible to
provide properly for thousands of men speaking differ-
ent languages who come together for five or six days,
and it is quite impossible to do any sort of justice even
to a small part of four thousand papers in three or
four different languages.

The picnic side of these gatherings is the one which
has developed the most strikingly, and which threatens
to overshadow the rest. For those who can afford the
time and the expense, the outing is excellent, more-
over, they may make interesting professional acquaint-
ances. Those who stay at home may console them-
selves with the reflection that they get the scientific
results — a little later, perhaps, but always more fully
and more satisfactorily — without the fuss and the
scrabble which are getting to be inevitable accompani-
ments of the Congress. It seems a fair question
whether the unrestrained acceptance of many thousand
papers is to be approved. It offers a golden opportu-
nity, to be sure, for many to obtain the happiness of
capitalized print ; but a judicious selection would add
much to the merit of the meetings.

MEDICAL NOTES.

Charcot's Sdccessob. — Dr. Raymond of the
Salpetriere has been chosen by the Facnlte de M^de-
cine as Charcot's successor by a vote of thirty io thirty-
one.

Ykllow Feter at Rio Janeibo. — The yellow
fever still continues to increase at Rio Janeiro, the
deaths now numbering nearly a hundred every day,
while there are between four and five hundred nev
cases every week.

A Case op Small-Pox at Sussex, N. B. — A
case of small-poz has occurred in Sussex, N. B., the
patient being a physician just returned from New
York where he had attended a case of small-pox the
week before in connection with his hospital work.

Samoel Wabhen, D.C.L. — For the benefit of
those of our readers who were misled by a statemeDt
in our editorial of last week on " The Doctor in Fic-
tion," we call attention to the fact that Samuel War-
ren was not a physician, though he might have been.
He studied medicine at Edinburgh, bat lapsed into the
law, which profession he followed with some disdnc-
tion.

The Reappearance of Cholera. — The cholera
has made its appearance again for the summer of this
year. Throughout the winter there have been smoul-
dering centres of the disease in Russia and in some
Turkish districts, though not acknowledged by the
governments of those countries. Since the first of
April so many cases have occurred in Czenstochov, in
Poland, that the town has been quarantined. The
disease is now admitted to be epidemic in Kovno,
Kaliss, Plock and Warsaw. In Constantinople, there
are officially no cases, but the disease has been spread-
ing rapidly throughout the city, no longer being con-
fined to the poorer classes. Several of the foreign
legations have left the city for more healthy quarters.
On April 23d, 65 cases of " cholerine " were reported
to the health authorities of Lisbon, and on the follow-
ing day 104. The disease is reported to be present in
many villages in the interior.

The D. Hates Agnkw Memorial. — The D.
Hayes Agnew Memorial Committee, organized a year
ago to secure a lasting memorial of Dr. Agnew in
connection with the University Hospital, Philadelphia,
report that subscriptions have been promised of suffi-
cient amount to give reasonable assurance of the suc-
cessful carrying out of this plan which includes not
only a children's ward, but also an amphitheatre and
ward class-rooms, with wards for men and for women,
— the whole to be a model in perfection of details and
completeness of appliances, and thus a fitting represen-
tation of the work of Dr. Agnew. The Sute Legis-
lature, at its last session, made an appropriation of
$80,000 to the University Hospital for building par-
poses, provided that an equal sum of $80,000 be
raised by the friends of the Hospital. Of this sum
about $60,000 has already been raised, leaving only
about $20,000 more to be secured by May I, 1894^

Digitized by

Google

Vol. CXXX. No. 17.] BOSTON MEDICAL AND SURGICAL JOURNAL.

428

It is hoped to secure, in addition to this sum, a nucleus
for ao endowment fund for the new wing, which is to
be given the name of D. Hayes Agnew.

Shall-Pox in Chicago. — The small-poz epi-
demic in Chicago is at present assuming most threat-
ening proportions. Throughout the early winter scat-
tered cases were reported and cared for in the hospital,
but daring the last two months the cases have increased
ao rapidly that the health department has been entirely
unable to control the spread of the disease. During
March there were 308 cases, and at present there are
200 patients in the small-pox hospital, which is so
crowded that many of the sick are sleeping on mat-
tresses on the floor. Ten small-pox patients have
been taken into the County Hospital, which is now
quarantined with its 800 other patients, who cannot
be discharged. Sixty patients are already quarantined
in forty-eight private houses throughout the city for
want of any kind of hospital to send them to. The
bonse-to-house canvass shows a wide dissemination
throughout the city, and the increase of cases during
the last week was 126. The most seriously affected
portion of the city is the southwestern section. In
many cases the disease has not been reported until
after death, the inspectors finding three bodies in one
house last week.

ECBOK8 op the CONGRESS AT ROME.

Ahong other interesting facts gleaned from an
Italian source we learn that there were consumed at
the luncheon given at the Baths of Caracalla, six thou-
sand bottles of wine, of which three thousand were
champagne; eighty lambs; five hundred fillets of beef
one thousand chickens ; twenty-two thousand sweet-
cakes; twelve barrels (caratelli) of beer; and forty
thousand rolls (paynoteUe). This was accomplished by
about ten thousand participants. The Italian accounts
of the scene around the buffet at the reception given
in the great Capitoline Hall read more like an epic
rendering of an Irish wake than the story of a public
official reception of the world's representatives of med-
ical science in one of the oldest European capitals
But the reminiscences of that famous Berlin banquet
at the last Congress should have prepared us for the
possibility of these things. " Congressists " who have
discussed and listened to many papers require much
food and drink ; and after all what is a pasta dole* and
a bicchierino di martala among one — especially after
he has fought for it !

A CORBBSPOHDENT writes us of the absolute failure
of the attempt made to organize a bureau of information
for the members from the United States and Canada,
where those who knew no Italian (the large major-
ity) might be directed in their need. As none of the
Italians even seemed able to give any information or
to know anything about it at all, the attempt naturally
came to an undeserved and lamentable end. As the
Medical Record says, " A more go-as-you-please and
never-get-there Congress was probably never held."

Mr. Roskin has called opera as sung in Italy " the

vomiting np of hopelessly damned souls out of still
carnal throats," but a theatre full of Congressists paid
six dollars a seat to hear Verdi's " Traviata " poorly
sung.

The site of the Policlinico was not chosen for con-
venient reaching by the members of the Congress. It
was well enough in Rome to take a cab out, but they
did not wait during the meetings. Ooe could readily
ride out, *ed relrogrere gradum hie labor est, along a
newly-built and dusty Roman road — when there is no
luncheon in one's stomach and no idea of what has
really been said is within one's mind.

It was a serious grievance to many of the wives of
the members that they were not received by the Queen.
They could not appreciate the etiquette which excluded
them as not having been previously presented at Court.

An International Honor to Dr. Mdrpht. —
The International Medical Congress, in appointing its
honorary presidents for the year, made Dr. J. B.
Murphy, of Chicago, president for the United States.

A Proposed International Pediatric Associ-
ation.— During the International Medical Congress
at Rome a meeting was held at the bouse of Dr. Blasi,
President of the Section of Pediatrics, to arrange the
preliminaries for the organization of an international
Pediatric Association, one of the chief objects of which
will be to improve the present methods and facilities
for giving instruction in diseases of childhood.

•

boston AN1> new ENGLAND,

Acute Infectious Diseases in Boston. — Dnr<
ing the eight days ending at noon, April 25, 1894,
there were reported to the Board of Health of Boston
the following numbers of cases of acute infectious dis*
ease : diphtheria 36, scarlet fever 60, measles 22, ty-
phoid fever 16, small-pox 3 (and 1 death). There are
now seven cases of small-pox in the hospital. For the
six days ending April 25th, 24 cases of small-pox were
reported to the State Board of Health, 23 from Chico-
pee and 1 from Holyoke.

A Warning to Physicians in Boston. — Physi-
cians in Boston and vicinity are warned against a
swindler who calls in the doctor's absence with a pre-
tended order to repair the rubber sthmps.

An Outbreak op Diphtheria in Williams-
town. — The Board of Health has closed the Centre
school of Williamstown on account of the prevalence
of diphtheria. This school includes high, grammar
and primary grades.

One Hundred and One Years Old. — Mrs.
Betsey Davis, of Mansfield, Mass., celebrated her one
hundred and first birthday on April 18th. She was
the daughter of an early French settler named Dansance,
and the bouse in which she was born is still standing
in Whiteville, a part of East Foxboro.

The First Conviction Under the Connecti-
cut Medical Practice Act. — The first case
brought to trial under the new Medical Practice Act
of Connecticut occurred last week at Waterbury, in

Digitized by

Google

424

BOSTON MMDIOAL AND SURGICAL JOURNAL.

[Aphil 26, 1894.

that State, when a " Dr." Helen Ashley Keene was
fined one hundred dollars and costs for practinng
withoat a license. She has appealed to the District
Court under bonds.

The New England Crbkation Society. — A
meeting of the New England Cremation Society,
which was made open to the public, was held in
Boston on April 17tb. The report of the Society
shows a membership of nearly two hundred, among
whom are sixteen physicians and five clergymen.

Typhoid Feyeb at Windsob, Vt. — A most seri-
ous epidemic of typhoid fever exists at Windsor, Vt.,
there being at present 130 cases. There have been
eight deaths already. The serious nature of the situa-
tion can be appreciated when it is realized that the
ratio of sick to the total population is about one to five
or six. The investigation of the outbreak has given a
most convincing, and it is to be hoped useful, lesson
upon the danger of contaminated water-supply. In
January last, a case of typhoid of doubtful origin oc-
curred in a farm-house about 200 feet from the spring
and brook which supply the town reservoir. The
house stood about SO feet above the level of the brook,
and there was a natural surface drain from the house
and out-buildings to the valley beiow. There is no
evidence of any especial precautions having been taken
during the illness of the patient to prevent the dis-
charges being mingled with the usual drainage. Dur-
ing the spring thaws all these infected excreta found
their way into the brook and the town reservoir. In
March, several cases broke out in the village; and
within a few days the disease was general and wide-
spread. Since the undoubted pollution of the regular
water-supply has been proved, the local Board of
Health has issued a warning against the use of water
from the town reservoir, and has supplied water from
springs in other localities to families who have no wells
of their own. Several cases of typhoid fever have
occurred in neighboring towns, it is said, among those
who derive their water in part from Windsor. Busi-
ness and all social life are at a complete standstill, and
the labor devolving upon the physicians and those not
yet ill, has become most taxing. It is to be hoped
that BO plain a lesson will be remembered, and that in
each of the hundred houses now visited care is taken
that all the wells and other springs in the town are
not further infected.

HBW YOBK.

Vaccinating cndbb Poliob Pbotection. —
On the night of April 18th a corps of fifty vaccinators
from the Health Department, escorted by one hundred
policemen, made a descent upon what is known as
Bed Hook, a thickly populated tenement-house district
of Brooklyn, and vaccinated five thousand people.
The territory covered includes eight blocks, and two
weeks ago the health officers attempted to carry out
a similar crusade ; but, as they were then unaccom-
panied by the police, the inhabitants resisted and drove
them ofi the field with clubs and broomsticks.

William A. Conway, M.D. — Dr, William' A.
Conway, Coroner's Physician, died at his residence, 270
East Broadway, on April 17tb, after a month's illneis.
He was born in New York City in 1840. He received
his collegiate education at St. Francis Xavier College,
and in 1866 was graduated from the College of Physi-
cians and Surgeons, New York. He was connectsd
with the coroner's oiflce for nine years, and bad jast
entered his fourth term of office as deputy coroner.
Dr. Conway had always practised in his native city,
and was especially identified with the east side of New
York, where be had grown up and where he was held
in high esteem by a large circle of friends.

philadelphia.

Pbiladblpbia Codnty Medical Society and
the Code. — At a meeting of the Philadelphia Connty
Medical Society, held April 18th, the following reso-
lutions were adopted :

Whereat, The Code of Ethics of the American Medicil
Association declares it derogatory to professional character
for a physician to dispense or in any way promote the use
of a secret nostrum ; and the American Medical Associa-
tion, by a resolution unanimously adopted at its meeUng in
1892, forbade the advertising of such nostrums in it>
journal; and

Whereas, The Journal of the Association has continned
to advertise such nostrums, and, in defence of its coarse in
this particular, has published an anonymous personal attack
on a member of the American Association and of this
Society ;

Resolved, That the Philadelphia County Medical Society
respectfully demands that the Trustees of the Journal shall
in their public official acts respect the spirit and letter of
its Code of Ethics, and that the columns of its Journal
shall not be used for the anonymous personal abuse of
members in good standing.

Resolved, That a copy of these resolutions be tnuu-
mitted to the Medical Society of the State of Pennsylvania,
and to the American Medical Association and to the
weekly medical journals.

DR. WILLIAM PEPPER'S RESIGNATION AS
PROVOST OP THE UNIVERSITY OF PENN-
SYLVANIA.

Db. William Pepper has presented his resigna-
tion of the office of Provost in the following communi-
cation to the Trustees of the University of Fennsylvap
nia:

With deep thankfulness I recognize that the Universi^
has reached a stage of development and prosperity which
justi&es me in laying down the high office you intrusted to
me more than thirteen years ago, and which I liave held as
long as it was possible to combine the administrative labors
of Provost with the demands of medical teaching and prao-
dee. This time has now passed, and I beg therefore to
tender my resignation to take effect after the coming Com-
mencement.

The close of the current session will witness the comple-
tion of the formative period of the University. From a
group of disconnected schools there has been gradually or-
ganized a great academic body, complete in its nnitv and
instinct with varied yet harmonious activities. Mutual

Digitized by

Google

Vol. CXXX, No. 17.1 BOSTON MEDICAL AND SUEGIOAL JOURNAL.

426

confidence and co-operation have developed a sygtem strong
enough for effective central control, yet so flexible as to
admit affiliation with many separate organizations.

To our University is doe the credit of establishing uni-
versity extension in America, yet the important and success-
fol society which controls this movement has no organic re-
lations with the University, save that the Provost is ex
officio the Honorary President. The Wistar Institute of
Anatomy and Biology, a magnificent memorial of the
founder of American Anatomy, lias a separate charter and
is not owned by the University, yet is governed by a Board
the majority of whose members are appointed by yourselves.
The University Hospital, which has grown so prosperously,
is a special trust administered by a Board of twenty-two
members, only four of whom are appointed by the Trustees
of the University.

The Department of Arcliieology and Paleontology, under
whose energetic operations there is developing rapidly a
Museum of high rank, is governed by a Board of not less
than thirty-six members, of whom only six are appointed by
the Trustees of the University. Reference is made to
these familiar instances to illustrate the admirable results
which may develop under a system which excludes rigid
coolrol, and rests upon mutual confidence and a common
devotion to a great cause.

It has been a chief aim of your Board to demonstrate to
the people of this great Commonwealth that the University
is truly the voluntary association of all persons and of all
agencies who wish to unite in work for the elevation of so-
ciety by the pursuit and diffusion of knowledge and truth.
No less important has been the establishment of the prin-
ciple that the University, so far from being a private and
exclusive corporation, is essentially and organically a part
of the municipality. The large future of the University
was secured when, in X872 and in 1883, City Councils
voted, without a dissenting voice, the transfer to the Uni-
versity of splendid tracts of ground in consideration of the
estabUsbment in perpetuity of fifty free beds in the flospi-
tal for the poor of Philadelphia, and of fifty prize scholar-
ships in the College, to be awarded to graduates of the
public schools of Philadelphia. The subsequent accessions
of territory which have brought the domain of the Univer-
sity up to fifty-two acres, in a compact body in the centre
of the city, have been the logical consequences of these
great steps ; and so faithfully have ail the trusts and condi-
tions been executed, that it has come to be recognized by
the municipal authorities that it is more profitable to the
city to give freely to the University anything in its power
to bestow which is needed for the development of that in-
stitution than to dispose of it eUewhere even at a great
price. It needs only the resolute continuance of this wise
policy to secure for the University full recognition as a
branch of the City Government with a duly accredited rep-
resentative of its great constituency in her Councils.

Progress has also been made toward the establisliment of
the essential principle that the University is in right, and
should be in fact, the head of the educational system of the
entire Commonwealth. We may fairly claim to have done
much toward securing a recognition of the view that the
encoarai^ement of higher education, by the municipality and
the legislature,, is as proper and important in the older
communities of America as it has been decided to be in the
newer States.

While the unification of the University and the establish-
Dient of broad lines of policy may seem to be the most im-
portant work of the past thirteen years, it will be found
that the resources of the University and the educational
work in each department have been successfully promoted.
In 1881 its property was fifteen acres, while at present
there are owned or controlled by the University, in a con-
tinuous tract and solely for educational purposes, not less
than fifty-two acres. The value of the lands, buildings
and endowment in 1881 may be estimated at $1,600,000;
it is now over $5,000,000. Prior to the date of the late
.I"hn Henry Towne's great bequest, the University had
never received a single large gift or legacy. During the
current year ending September 1, 1884, there will l^ ac-

quired in lands, buildings, money and subscriptions not less
than SI ,000,000. The members of the teaching force in
1881 numbered 88, and the students in all departments
981 ; at this time the former are 268, and the attendance
has reached 2,180, representing every State of the Union
and no less than thirty-eight foreign countries. The Col-
lege Department has attained a national distinction, and
its complete reorganization, which has now been accom-
piiiihed successfully, gives sure promise of sound and rapid
progress. The Medical School has been advanced to pre-
eminence in equipment and prosperity, while plans now
maturing will place it abreast of the great schools of
Europe. The Law School has effected the prolongation
and elevation of its curriculum, and has deservedly won
national repute. Encouraging progress has been made
toward providing an admirable building on an approved
site, so that the future eminence of the school is assured.
Gratifving reports may be made of the position of the
Dentai and Veterinary Departments; and well-considered
plans for their still further development need only time for
their fulfilment. Upon this vigorous basis rests the De-
partment of Philosophy, which, although organized as late
as 1884, and still without special endowment, has already
one hundred and fifty-four students. It represents the
University in its highest and best intellectual life; it
affords inspiration to teachers and students ; it has enabled
us to extend the richest privileges of the University to
women on equal terms with men ; it points the way to
large endowment of rich research and advanced scholar-
ship.

The necessity of dormitories to the development of the
best university life has come to be clearly recognized by
your Board, and generous friends stand ready to supply
this important need.

It is pleasant, in these days of strength and prosperity,
to reflect upon those of doubt and struggle, when ridicule
met the assertion, the truth of which is now freely con-
ceded, that nowhere can a great university be developed
so favorably as in a great city.

In closing my term of service as provost, I may be per-
mitted to allude to the motives which impel me to this step.
The labor of these thirteen years has been so severe, in
connection with my professional duties in the Medical
School, and with the extensive medical practice necessary
to provide the funds which have enabled me to initiate
nearly all of the large movements undertaken during this
time, that I have often felt that my life was specially pre-
served for the work. It has, however, been growing
evident, for several years past, that the time was approach-
ing when the immense extent of the Univers-ity interests
would demand the undivided activity of the most energetic
man. It has now become necessary for me to choose be-
tween administrative work and medical science. My devo-
tion to the latter has determined the choice.

No official has ever been associated with more affection-
ate and indulgent colleagues, or has enjoyed more loyal co-
operation than has been extended to me. I am confident
that the choice of my successor will be wisely and promptly
made. I do not leave the service of the University, but
will remain, with more free hands, ready to serve her
every interest with utmost devotion.

I invoke upon your continued la1x>rs in the government
of this grand institution the richest blessings of Almighty
God, who has in the past so signally guarded it.

THE SEWAGE SYSTEM IN PITCHBURG.

The sanitary relations of one community to another
are in no wise different from those of individual per-
sons. A man is safe from filth disease if he himself,
his house, and his surroundings are clean ; but, it is
little security for him to know that his own house is
properly plumbed, if his sewage enters a sewer without
any outlet, or his next-door neighbor enters all his

Digitized by

Google

426

BOSTOS MEDICAL ASD SVBGJCAL JOVSHAL.

[April 26, 1894.

waste sewage into a glaggish-flowiog brook which fudb
by bis premises. With cities it is the same. The
increasing intercommnnicatioD of our cities and towns
— in the way of bnsioess, especially in supplying food
or milk, the one to the other — makes the sanitary
arrangements which shall prevent ao outbreak of
typhoid or other commaoicable disease in any town a
matter of no small interest to a wide circle of settle-
ments. A recent address of Dr. C. W. Spring, the
city physician of Fitchbnrg, Mass., calls attention to a
state of matters which might well be seriously con-
sidered. He says :

"The system of sewage disposal in Fitchburg, if
sach a process can be called a system, is to discharge
the sewage, and almost everything else that is not
needed, into the Nashua River. The river entering
th% town at its south-westerly corner, is a small stream,
which is soon increased in size by the junction of two
brooks. From a point above these tributaries, at the
extreme upper end of the city, to South Fitchburg, a
distance of about 6.S miles, the river has a fall of
about 275 feet. The valley through which the river
flows is quite narrow, and along its banks is located
the greater part of the population of the city. Within
this distance the river receives the sewage of some 20
miles of sewers from 21 separate openings, and the
refuse, in whole or in part, of 18 paper mills. S worsted
mills, 8 yarn mills, 1 cotton-batting mill. 5 gingham
mills, a gas works, various machine shops, and many
other establishments of various kinds — to say nothing
of the large amount of rubbish which is thrown directly
into its waters. Below (he city the valley widens, and
the river is joined by Baker's Brook, which though it
drains an area about one-fourth as large as that drained
by the main stream, is almost free from sewage pollu-
tion."

The pollution of the river is well shown by the sum-
mary of analyses made at different points along its
course. Shortly after reaching the city the river water
begins to assnme its characteristic milky appearance.
The total solid matter, both dissolved and suspended,
is 8 parts in 100,000, and the number of bacteria for
each cubic centimetre is 496. Shortly after being
joined by the first brook the water contains 16 parts
of solids and 7,600 bacteria. For a short distance
there is slight improvement, but the pollution rapidly
increases, lower in the city, to 17 parts of solids and
45,600 bacteria, to 21 parts of solids with 56,400
bacteria, until half a mile below the last paper mill
the maximum pollution is reached — the water being
thick, muddy and offensive to the smell, the solids
reaching /i8 parts and the number of bacteria 111,600.
The increase in pollution in the fifteen years from 1876
to 1891 was nearly 300 per cent. ; the figures show-
ing in 1876 an increase between the most northern
and sonthero points in the river from 2.64 to 7.46,
and in 1891 from 7.50 to 20.50.

" The Nashua River is not, however, the only stream
in the city which is made a public sewer. Punch
Brook has long been, and now is, a public nuisance.
It receives a large amount of sewage, either directly
or indirectly, and ruaning as it does often concealed
from view, and underneath houses, its danger is all the
greater. If it was open its whole distance its waters
might become a little less foul from the natural oxida-
tion which would take place by contact with fresh air.
It is hardly necessary to say that such a nuisance should
be abated."

A BILL TO PROVIDE FOR THE REGISTRA-
TION OF PHYSICIANS AND SURGEONS IN
THE STATE OF MASSACHUSETTS.

The following bill has been
chusetts Senate :

passed by the Masea-

Section 1. The goTemor, with the advice and consent of
the council, shall appoint seven persons, resident in this Com-
monwealth, who shall be {graduates of a legally chartered medi-
cal college or QDlversity hHTing the poiver to confer def^reesls
mediclDe, and who shall have been actively employed in the
practice of their profession for a period of ten years, who Bball
constitate a lioard of registration in medicine. Such peraons
shall be appointed and hold office for terms of one, two. three,
foar, five, six and seven years, respectively, beeinning with the
first day of July in the present year, and until their respective
successors are appointed, and thereafter the governor, with the
advice and consent of the council, shall appoint before the firat
day of July in each year one person qiuuified as aforesaid lo
hold office for seven years from the flist day of July next en-
suing. No member of said board shall belong to the faculty of
any medical college or university. Vacancies in said bosid
shall be filled in accordance with the provisions of this act for
the establisbment of the origtoal board, and the person appointed
to fill a vacancy shall hold office during the unexpired term of
the member whose place he fills. Any member of said board
may be removed from office for cause by the governor with the
advice and consent of the executive council, and not more than
three members of said lioard shall at one time be merabeis of
any one chartered State medical society.

SiCT. 2. The members of said board shall meet on the second
Tuesday of July next, at such time and place as they m«y de-
termine, and shall immediately proceed to organize by electing
a chairman and secretary, who shall hold their respective offices
for the term of one year. The secretary shall give to ths treas-
urer and receiver-general of the Commonwealth a bond in the
penal sum ot five thousand dollars, wiib sufficient nureties to
t>e approved by the governor and council for the faithful dis-
charge of the duties of bis office. The said board shall bold
three regular meetings in each year, one on the second Tnesdsy
of March, one on the second Tuesday of July and one on the
second Tuesday of November, and such additional meetings St
such times and places as it may determine.

Sect. 3. It shall be the duty of said board Immediately npon
its organization to notify all persons practising medicine in this
Commonwealth of the provisions of this act by publication in
one or more newf^apers in each county, and every snch person
who is a graduate of a legally chartered medical college or uni-
versity having power to confer degrees in medicine, and every
person who has been a practitioner of medicine in this Cnmmon-
wealth continuously for a period of three years next priorto the
passage hereof, shall upon the payment of a fee ot one dollar be
entitled to registration, and said board shall issue to him a
certificate thereof signed by the chairman and secretary.

Sect. 4. Any person not entitled to registration as aforesaid
shall, npon payment of a fee of ten dollars, be entitled to ex-
amination, and if found qualified by four or more members of
said board shall be registered as a qualified physician and shall
receive a certificate thereof as provided in section three. Any
person refused registrHtion may be re-examined at any regular
meeting of said board within two years of the time of such
refusal, without additional fee, and thereafter be may be ex-
amined as often as he may desire npon the payment of thefee
of ten dollars for each examination. Said board, for criminal
cause shown and after hearing, may by unanimous vote revoke
any certificate ixsued by them and cancel the registration of the
person to whom the same was issued. AH fees received by the
board under this act shall be paid by the secretary thereof into
the treasury of the Commonwealth once in each month.

Sect. 6. The compensation, incidental and travelling ex-
penses of the board shall be paid from the trensury of the Com-
monwealth. The compensation of the board shall be ten dollan
each for every day actually spent in the discharge of their
duties, and three cents per mile each way for necessary travel-
ling expenses in attending the meetings of the board, but in no
case shall any more be paid than was actually expended. Such
compeneation and the incidental and travelling expenses shall
be approved by the board and sent to the auditor of the Com-
monwealth, who shall certify to the srovernor and council the
amounts due as in case of all other bills and aeconots approved
by him under the provisions of law : provided, that the amounts
so paid shall not exceed the amount received by the treasnrer
and receivei^general of the Commonwealth from the board in
fees as herein specified, and so much of said receipts as may be
necessary is hereby appropriated for tiie compensation and ex-
penses of the Imard as aforesaid.

Sect. 6. The board shall keep a record of the names of all
persons registered hereunder, and a record of all moneys re-
ceived and disbursed by said board, and said records or dupli-
cates thereof shall always be open to inspection in the oCBce of
the secretary of the Commonwealth, Said board shall aouoally

Digitized by

Google

Vot. CXXX, No. 17.1 BOSTON MBDIOAL AND SUBOWAL JOURNAL.

427

report to the gOTerDor, on or before the first da; of Jantiary In
each year, the condition of medicine and sar|!ery in this dom-
monwealth, which report shall contain a fall and complete
record of all its official acta during the year, and shall also con-
tain a statement of the receipts and disbursements of the board.
Sect. 7. It shall be the duty of the board to investif;Hte all
complaints of disregard, non-compliance or violation of the pro-
TisJons of this act, and to bring all such cases to the notice of
the proper prosecuting officers.

Sbct. H. On and after the first day of January, in the year
eighteen hundred and ninety fitre, the board shall examine all
applicants for registration as licensed physicians or surgeons in
this Commonwealth. Applicants must give satisfactory proof
of being twenty-one years of age and of good moral character;
and every applicant who is a graduate of and has received a
degree of M.D. from a legally cuartered medical college or uni-
versity having power to confer degrees in medicine in this
Commonwealth, shall be entitled prima facie to be registered
nnder this act upon payment of the fees herein provided.

Skct. 9. Ktaminations shall be, in whole or in part, in writ-
ing, and shall be of an elementary and practical character.
They shall embrace the general snbjects of sargery, physiology,
pathology, obstetrics and practice of medicine, and shall be
sufficiently strict to test the qualifications of the candidate as a
practitioner of medicine.

Scot. 10. 'Whoever not being registered as aforesaid, shall
advertise or hold himself out to the public as a physician or
snrgeon in this Commonwealth, by appending to his name the
letters " M.D.," or using the title of doctor, meaning thereby a
doctor of medicine, shall be punished by a fine of not less than
one hundred nor more than five hnndred dollars for each
offence, or by imprisonment in jail for three months, or both.

Sect. 1). This act shall not apply to commissioned officers
of the United States Army, Navy or Marine-Hospital Service,
or to a physician or surgeon who is called from another State to
treat a particular case, and who does not otherwise practise in
this State, or to prohibit gratuitous services; nor to clairvoy-
ants, or to persons practising hypnotism, magnetic healing,
mind cure, massage methods. Christian science, cosmopatbic or
any other method of healing: provided, such persons do not
violate any of the provisions of Section ten of this act.

Sect. 12. For the purposes of the appointment of said board,
and of registration of persons by it hereunder, this art shall take
effect upon its passage, and shall take full effect on the first day
of January in the year eighteen hundred and ninety-five.

worthier kind of tact ; indeed, the best reward of the
Qtterer of a small witticism, or play upon words, iu his
presence, was the blank, if benevolent, perplexity with
which be received it. And I suppose that the charac-
ter-sketch would be incomplete, without an explanation
of its peculiarities by a reference to the mixture of two
sets of hereditary tendencies, the one eminently Hiber-
nian, the other derived from the stock of the English
Bible translator and Reformer."

PROFESSOR TYNDALL.

Pbofbssor Hdxlet* draws the following clear
picture of Tyndall's character, at the time when he
first became acquainted with him:

" My elder by some five years, Tyndall's very
marked and vigorous personality must have long taken
its final set when we foregathered in 1851. But 1
found my new friend a difficult subject — incertee sedis,
as the naturalists say ; in other words, hard to get into
any of my pigeon-holes. Before one knew him well,
it seemed possible to give an exhaustive definition of
him in a string of epigrammatic antitheses, such as
those in which the older historians delight to sum up
the character of a king or leading statesman. Impul-
sive vehemence was associated with a singular power
of self-control and a deep-seated reserve, not easily
penetrated. Free-handed generosity lay side by side
with much tenacity of insistence on any right, small or
great; intense self-respect and a somewhat stern inde-
pendence, with a sympathetic geniality of manner,
especially toward children, with whom Tyndall was
always a great favorite. Flights of imaginative rheto-
ric, which amused (and sometimes amazed) more phleg-
matic people, proceeded from a singularly clear and
hard-beaded reasoner, overscrupulous, if that may be,
aboal keeping within the strictest limits of logical
demonstration ; and sincere to the core. A bright
sod even playfal companion, Tyndall had little of that
qnick appreciation of the humorous side of things iu
general, and of one's self in particular, which is as oil
to (he wares of life, and is a chief component of the

> Popnlar Seienoa Monthly, Haroh, I8t4.

MEASLES AND THEOLOGY.

Aboct two years ago a curious incident was re-
ported from a Swiss village, regarding an epidemic of
measles which attacked the children only of Catholic
parents. A repetition of this doctrinal distribution of
disease is now reported by Dr. Gryglewicz, of Jutro-
schin.'

Under the date of January 11th, he writes that for
three weeks there had been a sharp epidemic of measles,
and in all that time be had found the disease only
among Catholic children. Some grades of the Catho-
lic schools were closed as over eighty per cent, of the
pupils were ill. Upon inquiry among the evangelical
schools, it was found that not a child was absent. In
his practice, he had seen no Protestant children ill.
The 2,000 inhabitants of Jutroscbin are about evenly
divided between Catholics and Protestants ; and there
are about 150 Jews in the town, among whom there
was one case of measles. No explanation of this cu-
rious occurrence has yet been found. If in the future
the present difficulties of bacteriological etiology and
diagnosis are to be further involved by theological and
denominational difficulties, the path of the advancing
scientific physician will be no easy road to fact or fame.

THE HINDU SYSTEM OF MEDICINE AND THE
SECRET OF SUCCESS IN PRACTICE.

Thb eighth fascicle of the GharakaSamhita con-
tains a most interesting account of the basis of the
Hindu system of medicine as it includes a classifica-
tion of all illnesses. " Diseases that occur are of four
kinds: first, accidental, as wounds inflicted by nails,
or falls, incantations, curses, assanlts of evil spirits,
acts of violence, binding, cords, burns and lightning.
All other diseases are constitutional, and have three
classes due to disorders of wind, bile and phlegm. Ac-
cidental diseases arise at first with pain, and after-
wards cause disorders of wind, bile and phlegm. In
constitntional diseases, wind, bile and phlegm in the
first instance become disordered and afterwards lead
to pain.

" The respective divisions of the body that constitute
the seats of the three faults are as follows : The hypo-
gastric or pubic region, the place where the fssces
collect, the regions about the loins, the thighs, the
feet, and the bones, are the seats of wind. That por-
tion of the stomach, however, where digestion goes on,
among the seats of wind, is in particular the seat
thereof. Sweat, the thorax saliva, blood, and that
portion of the stomach where undigested food remains,
are the seats of bile. Amongst these all, the last is
especially the seat of bile. The thorax, the head, the
throat, and all the joints, that portion of the stomach

> Deutsoba Med. Zdtnng, 18M, No. 29.

Digitized by

Google —

428

BOSTON MEDICAL AND SURGICAL JOOBNAL.

[Apbil 26, 1894.

which holds the uudige«ted food, and the fat, are the
Beats of phlegm. Amongst these all, the thorax is
especiallj the seat of phlegm. Verily, wind, bile and
phlegm wander over everj part of the body. lu their
normal or unexcited state they produce beneficial re-
sults, such as growth, strength, good complexion and
clearness of senses. When not in their normal state,
they produce many evil consequences called disease."

There then follows a most extended nosology of the
diseases due to those three causes, from which it is
readily perceived that wind, bile and phlegm are used
as technical terms implying certain states of the phy-
sical constitution and not at all in the ordinary sense
of atmosphere, hepatic secretion or mucous exudations.
Having carefully enumerated each with its appropri-
ate treatment, the eighty diseases of wind, the forty
of bile, and the twenty most common of the innumer-
able diseases due to phlegm, the writer closes with the
following injunction to the reader :

" The diseases should first be carefully ascertained.
After this, the medicine to be applied should be care-
fully selected. Subsequent to this the physician should,
with full knowledge of consequences, commence the
treatmenL That physician who, without carefully
ascertaining the disease, commences the treatment,
seldom meets with success even if he be well conver-
sant with medicines and their application. That phy-
sician who is well conversant with the features of
disease, who has a tborongh acquaintance with all
medicine, and who has knowledge of the considera-
tions dependant upon time and place, achieves success
without doabu"

Corre^jpotmetice.

[Special Correspondence.]

LETTERS FROM ROME.

THE ELEVENTH INTERNATIONAL MEDICAL
CONGRESS.

RoMB, April 10, 1894.

Mr. Editor. — A few words relative to the Eleventh
International Medical Congress just closed in Rome may be
of some slight interest to your readers. In some respects
the Congress was as much of a success as can be expected
of such large and democratic medical assembliea. About
7,000 phvsicians were re^ixtered from all over the world
and about 1,500 guests, a larger number than was at Berlin
at the last meeting. American physicians were more con-
spicuous by their absence than by their presence, not quite
200 being on the list, while at Berlin there were over 600.
Those who suled from New York on March 1 7th, with the
expeclatinn of landing in Genoa on the 28th, among whom
was Dr. Jacobi, tbe chairman of the American delegation,
were doomed to dbappointment. Although the Kaiser
Wilhelm left her dock promptly at seven o'clock in the
morning, she as promptly ran on to the bar in the harbor,
and lay there seven or eighl hours, thus causing us to lose
a day. Over thirty of her passengers were physicians, and
they did not reach Home until Friday, too late for the
opening exercises, which took place on Thursday in the
presence of the King and Queen of Italy, and a large as-
semblage completely filling the Costanzi Theatre. Signer
Crispi made the address of welcome on the part of the king.
Dr. Baccelli followed in a Latin discourse, and Prince
Ruspoli greeted tbe members " in the name of the city of
Rome." Virchow gave an admirable paper on the growth
of medical science, laying especial emphasis upon " Mor-
gagni and his influence upon anatomical thought."

During the Congress notable addresses were made by

Nolhnagei of Austria, on " Modifications of the Organiun
in conseqaence of Pathological Alterations"; Bouchard,
" On Fevers " ; Professor Babes, of Bucharest, " The State
in its Relation to the Results of Modem Bacteriological
Researches " ; Stovis, on " Chemistry and Materia
Medica"; Kocher, on "Projectiles and their Effect upon
the Wounded." Dr. Murphy, of Chicago, created a very
favorable impression with his paper on " Choleeystenteros-
tomy. Twenty Successful Cases"; he also reported 145
laparotomies for appendicitis. Dr. Link, of Terre Haute,
Ind., presented a paper in which he claims to have proved
by experiments on dc^s, as well as by clinical experience,
that at least three inches of the tibia and fibula with the
periosteum may be removed, as in a compound and com-
minuted fracture, and new bone be formed loitAout thorten-
ing I The dressing consists of old linen and thin wooden
splints, which are not removed till the patient is welL He
lays great stress upon frequent and long-continued douch-
ing with water as hot as can be borne. Dr. Turck, of
Cmcago, read a paper upon die value of swabbing out tbe
stomach with a sponge. He demonstrated his method upon
a man said to have a dilated stomach. The apparatni
consists of a wire about three feet long with a sponjee look-
ing not unlike a sponge tent, about two and a naif inches
in length by three-fourths of an inch in diameter, fastened
to one end. The wire protected by rubber tubing is at-
tached to a rotary machine resembling an egg-beater, or s
hand-drill. On introducing the wire into the stomach and
turning the handle the sponge is made to revolve rapidly,
and can he felt externally in a thin person. Dr. Turck
claims that he can thoroughly cleanse not only the stomach
in this manner, but that he also pushes the sponge into the
duodenum. The patient bore the manipulation very well
indeed, often turning the crank himself I There was no
vomiting attending the demonstration. We were given to
understand that this method is in daily use in the doctor's
practice.

The scientific work of the Congress was done in sections,
there being seventeen or more of them. As over 4,000
papers were presented, it may be easily imagined that the
work of some of the sections was hurried and hence unsat-
isfactory. An idea may be formed of the work crowded
into some of the sections from the fact, that in the official
list 60 papers would be put down for one day in physiolog}',
26 in anatomy, 36 in pathology and pathological anatomy,
48 in obstetrics and gynecology, 93 in surgery, and 124 in
internal medicine. The papers were not repeated from
day to day in the list. I am told that some rather startling
jumps were made in some of the lists, in one instance going
from No. 4 to No. 92. The sections began work at eight
o'clock in the morning and the greneral sessions, held a mile
away, at four iu tbe afternoon.

Tbe exhibit of surgical instruments and appliances wss
not as extensive as at Berlin. One noticeable article in
the collection was an operating-table made by Stille, of
Stockholm, which was adjustable to many positions, and,
while being strong and firm, was yet simple and free from
complicate contrivances, so liable to get out of order or
to refuse to work at critical moments. The electrical ex-
hibit was quite good, a hand-light for the throat being
very noticeable.

The social part of the Congress was by no means
slighted. Perhaps the most satisfactory feature was the

farden-party given at the palace by their Majesties, the
Ling and Queen. At least, it was satisfactory to those
who were fortunate enough to receive invitations. The
ladies were handsome, the dresses were beautiful, the
music by two bands was fine, the weather was perfect,
their Majesties were gracious; and upon this occasion,
which was almost the only one of which that can be said,
the crowd was not too large. The reception given at the
Capitol by the city was a great success as regards numbers,
elegant toilets, etc. The climax, however, was reached on
the last day of the Congress, when a lunch was served at
the Baths of Caracalla. Tables were set for •ho<;^ *
thousand, while several thousand were present T^
struggle to get something to drink — or eat — which took

Digitized by

Google

Vol. CXXX, No. 17.1 BOSTOH MEDICAL AHJ) SURGICAL JOVKHAl.

420

place about those two tables may be imagined. The posi-
tion of the two waiters, who were pelted with hard rofls of
bread and an occasional plate, was not an enviable one.
The crowd was jolly, good-natured and noisy. It almost
seemed to be a fit occasion for a repetition of the miracle
of the loaves and fishes.

The festivities wound ap with a " Battle of Roses " upon
the " Corso " in the afternoon, and a torch-light procession
in the evening. To those not familiar with the famous
carnivals of Rome, it may be said that the " Battle of the
Roses " consists of crowds of people in carriages and on
foot, promenading up and down this, one of the principal
streets, and throwing flowers to whomsoever they choose.
When friends meet the scenes are often animated and ex-
citing. The windows are crowded, as well as the streets ;
everybody is happy, and to a stranger tbe scene is a
novel and interesting c)ne.

lite Italians seem highly pleased at the success of the
Congress, and certainly ereat efforts were made by them
to make it a success. There were rumors that the next
meeting would be held at St. Petersburg.
Very truly yours,

Georgk W. Gat, M.D.

A FEW NOTES ON ROME AND THE LATE
INTERNATIONAL MEDICAL CONGRESS.

Rome, April 6, 1894.

Mb. Editor : — A little more than two years ago, (Oct.
8, 1891), it was my privilege to have a short communica-
tion published in the columns of the veteran Boston Medi-
cal and Surgical Journal, on "Rome, Her Sanitation and
Her Facilities for Holding a Polyglot Medical Congress,"
in which I ventured to predict, from what I could then
learn from a tour through the Eternal City and her
saburbs, that though the medical brethren might mobilize
from every point of the compass, over all those roads
which lead to Rome, yet the old city could abundantly
and comfortably provide for all; that the city was well
drained, healthy and delightful at every season of the year,
though she was at her best in tbe early spring.

1^11 1 the weary pilgrims came ; they have held their
Congress, and again scattered, over land and water, to
their own countries. All were well-fed and housed, at
moderate rates. All were received with a royal welcome,
in which the King himself and his beautiful Queen actively
participated; luncheon parties and banquets were held on
a munificent scale; transportation of every kind was
accessible and moderate ; and more than five thousand
visiting medical practitioners and their friends have left
for home without any serious cases of illness developing
which could be ascribed to local causes.

Never before did the medical profession, to a greater
extent or in a more substantial manner, demonstrate to the
world its cosmopolitan character and its integral common
brotherhood.

Here, they massed, many of the most eminent and dis-
tinguished members of their profession, to offer from a
common altar, the fruit of their life-long studies, observa-
tions and investigations, not for' the benefit of any sect,
nation or race, but for the alleviation of the sufferings, and
for the well-being of all humanity. The Policlinico, the
building in which the Congress convened, was well adapted
for the purpose. In it eighteen sections daily convened
and all the national committees assembled simultaneously.
It consisted of a series of eight large, two-storied, lofty
pavilions, with superb marble stair-ways, large windows
and porticos, and immense areas or courts for light and
ventilation. It is intended, as its designation intimates, to
be the principal Infirmary and centre for teaching for all
Italy. Its capacity when complete will be for about four-
teen hundred beds, which, with the extensive laboratories
and spacious operating-theatres and lecture-rooms, will be
one of the best-equipped institutions for teaching in all
Europe.

The only possible objection to it, as a visiting place, was
its distance from Piazza-Colonna, or tbe centre of the city —
about two miles — and because of its newness it was yet
rather damp and chilly.

Tbe language most generally spoken at the Congress
was French. All the Italian doctors seem to have a speak-
ing knowledge of this tongue, and even the Spaniards from
South America could make themselves readily understood,
through its employment. German came second, although
the Germans did not attend in very large numbers. English
came in a p^or third ; and he whose linguistic capacity
was limited to this language, was at a great disadvantage.
It might be stated, without fear of over-stating the
truth, that English-speaking readers were barely tolerated.
Essayists who read English or discussed contributions,
were restrained within the severest limits ; while the
French, Italians and Germans had carte blanche and
consumed as much time as they liked. Perhaps the
Romans were not so much to blame for this, as the French
element was there in great strength, and seemed to vastly
predominate in influence. Moreover, there seemed to be a
disposition on the side of both Italians and Freni-h to re-
establish the old entente cordiale so long interrupted.

The attendance from the United States was not large,
nor representative of the leading members of the profes-
sion. This, no doubt, was attributable to the season of
the year, when all the schools were in session, and many
famous teachers were unable to be present. In the com-
mittee rooms of the American delegation, however, one
hundred and seven registered ; the greater number of
them being from the West and South. But our army,
navy and marine-hospital services were amply represented
by medical officers of advanced rank, who attended the
sessions in full uniform.

The general sessions were held in the Eldorado on the
via Geneva, every afternoon during the five days of the.
Congressional sessions, at three in the afternoon. Here,
only on the last day, was America accorded the privilege of
entertaining the assembled multitude with a public address.
This was presented by Dr. Abram Jacobi of New York,
whose effort was well worthy of the distinguished speaker
and the country of his adoption.

As might be exfiected, the scientific portion of it dealt
chiefly with the maladies of children ; but, as he pro-
ceeded, he considered the present status of the healing art
in the United States, and dealt the over-specializing ten-
dencies of modern times some crushing blows. The reck-
less, useless mutilations so often practised, at present, as
current operations, he declared were little short of murder ;
and he anathematized I he performers of them as those
whose hands were so stained that no amount of sterilization
could purify ; and whose souls were so corrupted that no
chemical fluid could preserve or restore them. Modern
antipyretics he declared had killed more than they cured,
and the profession was responsible for the position which
proprietary medicines occupied.

One feature of the Congress, of interest to Americans,
and which did good service for our scattered delegates,
was the organization of the American Delegation, in Section
C of the Polyclinic. Here the delegates from the United
States and Canada organized a bureau for information,
with Dr. Abram Jacobi for President, Dr. Thomas H.
Manley, of New York, Dr. William Tobin, of Halifax, and
Dr. G.' A. Simmons, of Sacramento, Cal., as an Executive
Committee, and Dr. Douglas H. Stewart, of New York, as
Secretary.

During their second day's session the delegation was
visited by the American Ambassador to Italy, the Hon.
Wayne McVeagh, who made a short address, in which he
declared that it afforded him great pleasure to meet the
American contingent. He bespoke tor them a hospitable
reception from tneir Italian con/rires, and reminded the
delegates that he would be ready to serve them at any
time during their stay, by every possible means within his
power.

In conclusion it may be said that while the late Con-
gress did not in every particular fulfil all that was expected

Digitized by

Google

430

BOSTON MSDIOAL AND SUROIOAL JOORSAL.

[April 26, 1894.

of it, yet, considering the many difficultiei in the war, the
anticipations of the majority were more than realized. At
all events, when it is remembered that the English, French
and Italian railways reduced their travelling rates for pas-
sengers fifty per cent., and that an opportunity was per-
mitted to visit the principal cities and nospitals of Europe
° en route, the time consumed by the Americans was not
misspent, and they will return to their homes with renewed
energy after their short holiday, and all the better equipped
for the duties which await them on their arrival.

Un Votaobdr.

THE PROPOSED REDUCTION IN THE ARMY
MEDICAL SERVICE.

Grotelakd, Mass., April 10, 1894.

Mr. Editor : — I noticed your correspondent's anony-
mous communication (April 5, 1894), signed "Medicus,"
concerning the " Proposed Reduction of the Army Medical
Corps," with a secondary title, "An Attempted Legislative
Outrage I " I do not like (o reply to, or even notice, any
communication in which the author, for certun reasons
best known to himself, conceals his name.

The statement concerning acting assistant-surgeons,
which title pleases not your grumbling incog, (who is prob-
ably a member of the Medical Corps) that " there is no
provision of law whereby they (acting assistant-surgeons)
can be placed in charge of the medical department at a
military post," is either a malicious lie or an ignorant as-
sertion of erroneous views. In either case it is untme.
There are some younglings, bursting with importance, who
know little of military medical history in this country, par-
ticularly during the late Civil War, who pretend to imagine
that by scorning acting assistant-surgeons as "contract-
doctors " they in some measure increase their own promi-
nence. It would take too much of your time to name hun-
dreds of prominent medical men who were once acting
assistant-surgeons to the United States Army. These and
their associates have all " been placed in charge of the
medical department at a military post" time and again.
Some have served as acting medical directors of a depart-
ment, some in charge of large hospitals, camps, transports,
etc. Some preferred capture in battle rather than to
desert their wounded. If " Medicus " will read the records
of the Association of Acting Assistant-Surgeons, United
States Army, be will learn the history of many medical
men who have become eminent in medical history, and
whose position socially and professionally is ejuo/^ec^ by fete
of the so-called regular officers of the medical department,
who are so well paid and yet have so little to do.

Prominent generals of the army and prominent members
of the army medical department have gladly offered their
testimony in favor of the bill for the acting assistant-sur-
geons which has been lately presented to Congress. Your
own kindly notice of the Association of Acting Assistant-
Surgeons in a recent number of the Journal reflects the
best professional opinion concerning them.

For some years an influence has been exerted by a selfish
clique, under the leadership of the Surgeon-General's
Office, to make the way of the acting assistant-surgeon a
hard road to traveL Any one acquainted with the true
facts must have seen how pernicious and unmanly this in-
fluence has been. The acting assistantrsurgeon has invari-
ably accepted the duties of military medical life with the
miserable pay offered, and he has also known the perilous
detail, when the more favored surgeon remained comfort-
ably at home and received the extra fees from outside
practice.

In my opinion, the sneers and misinformation contained
in the communication of " Medicus " are unwarranted, un-
kind and ungentlemanly, and deserve to be disapproved of
by all medical men. I have known the acting assistant-
surgeons for over a quarter of a century, and I have
always found them faithful, competent and honorable, de-
serving a much better status. It is very remarkable that
members of a medical corps so well paid (much better paid

than the medical officers of any other army) should attempt
to persecute reputable medical officers who perforin the
same duties, and with exactly as much skill as the more
favored members of the so-called Medical Corps.

Little can be hoped for, so far as justice is concerned.
Acting assistant-surgeons who have faced the perils of
Indian warfare are just as much heroes as those who
served in the war of the Rebellion. An acting assistant-
surgeon is peer of any medical officer, and from real men
and true gentlemen receives every courtesy.

Yours truly, W. Thornton Parker, M.D.

New York, April 15, 1894.

Mr. Editor : — In a recent number of the Journal I
called attention to the legislative outrage now being at-
tempted in Congress of cutting off from the Medical Corps
of the Army thirty-five of its members, on the buncombe
plea of economy, and in spite of the strenuous objections
of the Surseon-General, Dr. Sternberg, and the com-
mander-in-chief of the United States Army, Gen. J. M.
Schofield, both of whom have clearly shown that these men
are really needed. As General Schofield put it in a letter
to the Secretary of War, dated March IS, 1894, this pend-
ing bill would be " seriously injurious to the military ser-
vice"; also, "the Medical Corps of the Army is none too
laree for the necessities of the service."

lam therefore surprised that any self-respecting doctor
could write in defence of this measure, so utterly unworthy
of support. Indeed, not alone the Boston Medical and
Surgical Journal, but following it, the New York Medical
Journal, the Philadelphia Medical News, the New York
Medical Record, and many more of the most influential
and able medical publications of this country, have re-
cently published vigorous editorial denunciations of this in-
sult to our profession : a measure which, if successful, will
result at once in stopping the working of the new Army
Medical School, which, under General Sternberg's able
lead, is doing such scientific work among the younger sur-
geons in the army, educating them in sanitation of military
hospitals and troops, commissary knowledge, bacteriology,
military surgery, etc.

The tone, the evident animus, of the gentleman who has
seen fit to honor me with his attack deprives his letter of
weight, even aside from its misstatements. Nevertheless,
let me point out to your readers, Mr. Editor, the fact that
he seems to regard this bill as one which, if it passes, drop-
ping thereby thirty-five regular medical officers, will enable
contract-doctors to take uieir places ; and he looks upon
my letter as an onslaught against contract-doctors in
general, whom he proceeds to defend-
There is not a line, not a word, in my letter to justify
this excited rhetoric.

What I said in this context is as follows: "There is
now no appropriation made for contract-doctors, thougb
formerly this was the case ; and even if there were, there
is no provision of law whereby they can he placed in charge
of the medical department at a military post. Therefore,
they cannot take charge of the discipline and field-drill of
the Hospital Corps detachment, nor be responsible for the
post-hospital with its supplies. To effect economy as far
as practicable, the Surgeon-General has long employed
only private physicians at all the arsenal-posts in the
country, these being small ones."

The doctor attacking my letter denies the truth of the
statement which I have put in italics, and becomes vi-
tuperative thereupon regarding my ignorance.

Let me reply that this statement was made by me upon
authority of the words of the Surgeon-General himself.
Indeed, every figure, every assertion in my letter was ab-
solutely accurate, having been furnished me by one of the
medical officers of highest rank in the army, and with a
view to publication.

Whatever powers the contract-surgeons had during war
times, the fact as to the law to-day is precisely as stated in
my letter. If this gentleman who went off at half-cock,
and loaded only wiu blank cartridge, will apply to Snr-

Digitized by

Google

Vol. CXXX, No. 17.] BOSTOS MEDICAL AND SURGICAL JOURNAL.

481

geon-G«neraI Sternberg for much-needed information, every
word that I have stated will be corroborated.

In conclnsion, Mr. Editor, allow me to say with refer-
ence to the remarks on anonymous contributions, that you
were furnished with my name, and, had yon seen fit, could
have signed it to my letter. Very properly, you did not
regard my own personality as one that had anything to do
with the question at issue, which is not a personal matter,
bat one affecting the well-being of forty-three thousand
soldiers and civilians in the army, with their wives and
children, and also involving the self-respect and dignity of
the noblest of professions.

Very respectfully,

RoBKRT H. M. Dawbarn, M.D.,

106 West 74th Street.

RECORD OF MORTALITT
Fob TBI Wbbk imdino Saturdat, April U, 1894.

PERFORATING WOUND OF THE HEART.
Baltimore, Md., April 20, 1894.

Mr. Editor : — Seeing a case reported in the Journal
from California, where a pistol-ball went through the heart
and the man lived thirteen hours after the injury, reminds
me of a case which I reported to the Baltimore Clinical
Society in the year 1889.

It was that of a woman, age about twenty-two years,
who was stabbed and thrown from her husband's knee to
the floor. She died six days and fifteen hours after receiv-
ing the wound and the blow. It was shown post-mortem,
ten hours after death, that a wound in left breast to the
right of left nipple, between the third and fourth ribs,

{tasaed through the pericardium, making a slit one inch in
ength. In the pericardium, two tablespoonf uls of partly-
clotted blood were found. The wound then entered the
right ventricle a little to the right of the ventricular sep-
tum, passing entirely through the anterior portion of the
ventricle, being about a half-inch long on its outer aspect
and about one-quarter of an inch on the inner side. On
the outer side of the heart there was a thin layer of lymph,
and through tlie opening made in the heart there was a
solid plug of lymph extending somewhat into the heart.
A very small quantity of fluid blood was found in the
heart. The blow bronght on an abortion, as she was be-
tween two and three months pregnant, and she eventually
died of septicsemia. She was jaundiced, liver was fatty,
mesentery and serous coats of tlie bowels were of a golden
hue, and there was peritonitis. The point that I made in
my paper was that, bad it not been that the woman was
pregnant, she would have undoubtedly recovered from the
rtab-wound through the heart, as nature was making every
effort to heal the breach. Hence I say that stab or pistol
wounds into the heart are not necessarily fatal, as the
records from the history of the late war will show.

Yours truly, R. M. Hall, M.D.

HETGOROLOGICAL RECORD,

For the week ending April 14tb, in Boston, acoordiUK to ob-
serrations fnmisfaed by Sergeant J. W. Smith, of the United

State-i Si)(na] Corps:—

Baro- Tbennoin-, Belatira | Dlraotion

Velocity ;w»'th'r.

B

i
1

meter
Oata.l 1

eter. IhonlditT.

Of wind.

of wind.

•

iiii'

i.

1

a

i

i

a

a a

! K K 1 -^ i 9 ! -4

«•

K

4

>•

■i

«.

■i i

I

S

1

i

i

S

00

8.00
8.00

1

8.. »

ao.iw

32 '31

31

100

96

98

N.E.

N.

26

29

N. IN.

1.18

M.. 9

30.16

34139

30

m

83

78

N.W.

N.

18

9

N. 1 0.

fl.U

T..IO

311.17

38 VI

35

DO

6S

6*

N.E.

N.E.

13

12

F. . F.

W.lt

28.92

34136

33

Ti

9S

84

N.E.

N.E.

2R

44

0. 1 N.

T..12

29.81

81,37

32

100

86

9M

N.K.

N.E.

26

36

N. , K.

:.4<

F..13

.9.M

38 '39

31

87

84

86

N.

N.

2A

28

N. 1 R.

0.1(1

S..14

2)>.92

39I44

31

86

79

82

N.

U.K.

18

20

0. , R.

nr

1 !

1

Estimated popu-
lation for 1893.

1

SB
1

r

Percentage of deaths from

UHlea.

m 8

1'

ifllll

5^1

a> o

Si;

-P

New York . .

1,891,306

333

333

16.92 19.32

2.52

6.24;

2.40

Chicago . . .
Philadelphia .

1,438,000

—

— — 1 —

—

1,115,062

408

139 12.76 1 16.00

.80 6.60 1 .CO

Brooklyn . .
St. Louis. . .

978,384

347

141 20.59 , 20.30

.68 10.44 1 2.81

560,000

,

Boston . . .

487,897

208

69 j 10.66 ' 15.86

1.20 1 _

Baltimore . .

500,000

—

— , — ,

—

1 —

Wafhington

308,431

106

32 3.76 1 19.74

vje»

— 1 _-

Cincinnati . .

305,U00

108

30 6.36 20.24

—

2.76

Cleveland . .

290.000

VI

— 1 14.42 12.38

3.09

3.09

3.09

Pltuburg . .

263,709

—

_ 1 _ _

—

—

Milwaukee . .

250,0110

88

28 1 4.66 \lJk2

2.28

2.28

_

NaahTllle . .

87,764

25

11 ( 12.00 : 12.00

—

4.00

4.00

Oharleston . .

65,165

30

12 ; - 1 -

—

—

Portland . . .

40,000

—

—

—

Worce«ter . .

96,217

SO

13 1 C.66 1 20.00

—

3.33

Fall River . .

87,411

—

— . — 1 —

—

_

Lowell . . .

87,191

30

11 , 6.66 ; 33.33

3.33

—

_

Cambridge . .

77,100

21

12 1 UM 23.80

—

—

19.M

Lynn ....

62,656

14

4 , 11.28 14.28

—

_

7.14

Springfield . .

48,684

16

3 1 13.33 13.33

6.66

»M

Lawrence . .

48,365

—

1 — t ~* ~-

—

—

New Bedford .

45,886

17

6 6.88

17.64

6.88

—

_

Uolyoke . . .

41,278

—

—

—

—

Salem ....

32,233

16

4 ' -

MM

—

—

Brockton . .

32,140

11

6 ' —

8.09

—

HaverhlU . .

31,386

13

! 1 1 7.69

30.76

—

—

Chelsea . . .

30,261

12

4 IC.M

8.33

8.33

6.33

_

Maiden . . .

29,394

10

6 10.00

20.00

—

—

10.00

Newton . . .

27,666

10

1 1 1 - : 1:0.00

._

—

—

Fltchbarg . .

27,146

«

1 2 1 — _

—

_.

Taunton . . .

26,972

18

7 6.66 11.11

0.fi5

—

_-

Gloucester . .

26,688

6

1 — ' —

-

—

—

Wallham . .

22,06l>

5

3 — , 40.00

—

—

Qnlncy . . .

19,642

—

— — 1 —

—

— I —

PitUfield . .

18,802

5

0 40.00 , 20.00

- ' — 1 20.W>

Everett . . .

16,686

5

1 3 60.00 40.00 1 20.00 2C.00 1 _

Northampton .

16,331

6

' 3 20.00 ' 2U.0O

— • — 1 —

Newburyport .

14,073

8

, ' "l -

— — 1 —

Amesbnry . .

10,920

1

: », -1 -

— 1 ~ i ~

* 0.,elo«i(tT: C . elfsn F., f.irt O., foci H.. hujt 8..«mokyi R., mm T.,thr««t-
alD(tII.,ainr. t IndlnWi tnw of nialmll. ay Mntt <brwt.k.

Deaths reported 2,636: nnder five years of afte 888 ; principal
infectious diseases (small-poz, measles, diphtheria and croup,
diarrhceal diseases, whooping-cough, erysipelas aiid fever) 340,
acute lung diseases 463, consumption 2iM, diphtheria and croup
142, scarlet fever 12, diarrboaai diseases 38, measles 37, wboop-
ing-cou^h 30, typhoid fever 17, small-pox 16, cerebro-spinal
meningitis 14, erysipelas 4.

From small-poz Mew York 7, Brooklyn 6, Boston 3. From
measles Mew York 16, Brooklyn 10, Philadelphia and Cleveland
6 each, Northampton 1. From whooping-cough Mew York 10,
Philadelphia and Brooklyn 6 each, boston 3, Cincinnati, Mash-
ville, Lowell, Everett and Hyde Park 1 each. From typhoid
fever Mew York and Pbiladelrhia 6 each, Cincinnati 3, Brook-
lyn, Waabingtciu, Lynn and Haverhill 1 each. From cerebro-
spinal meningitis Mew Yoik H, Boston, Washington, Worcester,
Somerville and Pittsfield 1 each.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,468,442, for the week ending
April 7th, the death-rate wa^ 19.b. Deaths reported 3,9J3:
acute diseases of the respiratory organs (London) 314, measles
210, whooping-cough 148, diphtheria 80, scarlet fever 39, diar-
rhoea 29, fever 28, small-poz (Birmingham 4, London and West
Ham 2 each, Bradford 1) 9.

The death-rates ranged from 12.7 in Brighton to 27.4 in Sal-
ford; Birmingham 23.0, Bradford 15.1, Bristol 18.9, Croydon
16.8, Hull 17.9, Leeds 20.6, Leicester 14.9, Liverpool 26.3, London
19.0, Manchester 21.6, Mewcastle-on-Tyne 22.2, Nottingham 18.4,
Portsmouth 16.6, Sheffield 18JS.

OFFICIAL LIST OF CHAMQES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. 8. ARMY, FROM APRIL 14, 1891, TO
APRIL 20, 1891.

First-Liedt. Allbn H. Smtth, assistant surgeon, will be
relieved from dnty at Fort Caster, Montana, at the expiration
of his present leave of absence and will report in persou to the
commanding officer, Fort Reno, Oklahoma Territory, for duty
at that post.

FiRST-LuDT. Jamrs H. Kbnnbdy, assistant surgeon, is re-
lieved from duty at Fort Riley, Kansas, and ordered to Fort
Custer, Montana, for dnty.

By direction of the President, Caftain Alonzo R. Cuapin,

Digitized by

Google

482

BOSTOJH MEDICAL AJfD SURGICAL JOORSAL.

[April 26, 1894.

■asistant (nrgeon, will report in person to the president of the
Army retiring board at Fort Bliss, Texas, for ezaminatioo by
the board.

The leave of absence K^anted Captain Oodbh Raitkbty,
assistant sargeon, is extended eighteen days.

FiHST-LiBCT. Charles Willcoz, assistant sargeon, is re-
lieved from temporary duty at Angel Island, Cal., and will
rejoin his proper station, the Presidio of San Frandsoo, Cal.

Par. 2, S. O. No. 68, A. G. O., is so amended as to direct Fibst-
LiKUT. UarlanE. McVAY,a8si8tant8argeon, on being relieved
from duty at San Carlos, Arizona Territory, by Fibst-Libdt
Stradb, assistant surgeon, to report for duty at Angel Island,
Cal., instead of Fort Huacbuca, Arizona Territory.

So much of Par. 13, S. O. No. 79, A. G. O. as relates to Major
Petbr 3. A. Clbaut, surgeon, is so amended as to direct him
on being relieved from duty at Fort HcPberson, Georgia, to re-
port for duty at Fort Wingate, New Mexico, instead of Fort
Custer, Montana, for duty at that post, to relieve Uajob
Washington Hattebws, surgeon

Major Hatthbws, on being so relieved, will repair to Wash-
ington City and report in person to the surgeon-general for
temporary duty In bis office.

pbokotion.

Captain Jambs C. Mbbbill, assistant surgeon, to be surgeon
with the rank of Major, March 13, 1894, vice Babtrolt renred
from active service.

SOCIETY NOTICES.

Thb SirrFOLK District Mbdical Socibty, Suboical Sec-
tion. — The Surgical bection of the Suffolk District Medical
Society will bold its regular monthly meeting on Wednesday
evening, May 2d, at 19 Boylston Place, at 8 o'clock.

Dr. M. H. Richardson will make a report of " Cases of Intes-
tinal Resection with Snbseqnent Snture of the Bowel."

Chablbs L. Scvddbb, M.D., Hecretaiy.

Suffolk District Medical Socibty. — The annoal meet-
ing will be held at 19 Boylston Place, on Saturday, April 28,
1894, at 8 P. M.

Papers. Dr. F. S. Watson, " Some of the Clinical Features
and the Surgical Treatment of Primary Tnbercnlosis of tbe
Urinary Organs." Discussion by Dr. P. Thomdike and others.
Dr. F. H. Williams, "Diphtheria." Dr. W. A. Morribon,
" The Value of tbe Stomach-Tube in Feeding after Intubation "
— based upon twenty-eight cases. Discussion by Dr. F. B.
HarriugtoD, Dr. Gannett, Dr. C. M. Whitney and Dr. Prescott.

Suiineu. Report of tbe treasurer and the librarian. Elec-
tion of officers. Appointment of delegates to tbe American
Medical Association.

Sapper after the meeting.

A. L. Mason, M.D., Prttident.
James J. Minot, M.D., becretary.

American Pediatric Society. — Tbe American Pediatric
Society will bold its sixth annual meeting at Washington, D.C.,
May 29, 'M, 31 and June 1, 18M. Tbe sessionB will be held at
the Arlington.

American Dkrmatolo<iical Association.— The eighteenth
annual meeting of the American Dermatological Association
will be held at the Arlington Hotel, Washington, D. C, May 29,
30, 31 and June 1, 18ii4.

The general session of the Congress will be held at 3.30 p. M.
on May SOth, tbe subject for discussion being " The Distribution
and Control of Leprosy in North America."

R. B. MoRisoN, M.D., Pretident, Baltimore.
C. W. Allen. M.D., Secretary, New York.

Association or American Anatomists.— The sixth annual
meeting of the Association of American Anatomists will be held
in connection with tbe Congrefs of American Pbysiciaus and
Surgeons, May 29 to Jnne 1, ISM, in the city of Washington,
D. C. This will be tbe first meeting since that of December 27
to 29, 1892, at Princeton, N. J. The sessions will be held in tbe
Preparatory Department of the Colnmbian University.

HARVARD MEDICAL SCHOOL.

EVENINO LECTDBBS.

The next lecture will be given on Wednesday evening, Hay
2d, at 8 o'clock, by Assistant Professor T. M. Rotch. Subject,
" Infant Feeding." Physicians are cordially invited.

RESIGNATION.

Dk. Juun Luvett Morsb, has resigned the positiou of
Registrar at the Carney Hospital.

THE MIDDLETON GOLDSMITH LECTURE.

Tbe Middleton Goldsmith Lecture of tbe New York Patholog-
ical Society for 1694, will be delivered at tbe New York Acad-
emy of Medicine on Saturday, April 28th, at 8.30 p. u., by Prof.
William H. Welch, of Johns Hopkins University. Subject:
" Mixed and Secondary Infections."

RECENT DEATHS.

William V . Keating, M.D., died in Philadelphia, April liKh,
aged seventy years.

David Crary, Sr., M.D.,died in Hartford, Conn., April 16th,
aged eighty-eight years. He graduated from tbe Medical
College at Castleton, Vt., in 1834, and bad practised in Hartford
since 1838. He was present at tbe first administration of ether
by Dr. Wells and had attended over three thousand cases of
childbirth. He was a member of tbe Connecticut Medical So-
ciety.

Dr. Fritschi, Privat.docent in the University of Freiburg,
and the oldest privat-doceut in Germany, died recently, aged
eighty-two years.

F. W. Weber, M.D , Ph.D., died at Nieheim, Westphalia,
April 5th, aged eighty-one years. Besides his reputation as a
physician in his own province he was one of tbe best-kDOvn
poets of tbe present time in Germany, and for thirty-two yean
represented his district in the Prussian Landtag.

Jban Edouabd Juhbl-Rbnoy, M.D., one of the ablest of tbe
younger physicians of Paris, died in that city, March IMtb, aged
thirty-nine yean. He was physician to tbe Hopital Cochin sod
bad contributed many articles to medical literature, especially
in the " Dictionnaire de Medicine et de Chirargle" and the
" Dictionnaire Encyclopediqne des Sciences He'dicales." Byi
curious fatality be died of typhoid fever contracted from a pa-
tient while preparing a paper on tbe treatment of that disease
to be read at the International Medical Congress in Rome.

Henry Smith, F.R.C.S., England, Emeritus Professor of
Surgery at Kings College, London, died at Summerbill, Horsell,
Surrey, March 26tb, aged seventy years. He was, in his earlier
days, assistant to Sir William Ferguson, and was conbulting
surgeon to Kings College Hospital and at one time President of
the Medical Society of Loudon. Following Ferguson's lead be
gave great attention to advocating a more conservative treat-
ment of bone and joint disease than the then too common am-
putation. His chief surgical reputation, however, was made io
the department of diseases of tue rectum and be will be long
remembered as tbe introducer of tbe clamp and cautery treat-
ment of basmorrhoids. He was Lettsomian Levtarer in 1865 and
chose as his subject " The Surgery of the Rectum." He was an
ardent lover of natural history and a most enthusiastic fisher-
man, his clinical and didactic lectures on surgery being con-
stantly interspersed with anecdotes and illustrations from his
favorite sport.

BOOKS AND PAMPHLETS RECEIVED.

A Modern Wizard. By Eodrigues Ottolengui. New York:
G. P. Putnam's Sons. 1894.

Report of the Jeffeison Medical College and Hospital for tbe
Year ending September 30, 1893.

Laparo-Hysterotomy: Its Indications and Technique. ByN.
Senn, M.D., Ph.D., LL.D. Reprint. 1893.

The Annual Report of the Health of the Imperial Navy for
the Twenty-fifth Year of Meiji (1892) Tokyo.

Remarks upon Appendicitis based upon a Personal Experience
of 181 Cases. By Maurice H. Richardson, H.D., of Boston.
Reprint. 1894.

Clinical Diagnosis. By Albert Abrams, M.D. (Heidelberg).
Third edition, revised and enlarged. Illustrated. New Yors:
E. B. Treat. 1894.

Some Considerations Bearing Upon Practice with Dynamic
Autagoniste in Cases of Drug-Poisoning. By Chas. 8. Uack,
M.D. Reprint. 1894.

The International Medical Annual and Practitioners' Index;
A Work of Reference for Medical Practitioners. Twelfth year.
New York : E. B. Treat. 1894.

The Diagnosis of Mitral Valvulitis, with a Report of Three
Cases. In Memorism, John M. Keating, M.U., LLD. By
Judson Daland, MD., Philadelphia. Reprints. 1894.

Station-List of Officers of the Medical Department and Hcni-
tal Stewards of the Hospital Corps, United States Army^pn>
1, 1894, or at date of last report received at this office. Wssn-
ington. 1894.

Sixteenth Annual Report of the SUte Board of Health of the
State of Connecticut for the Year ending June 30, 1893, with the
Registration Report for 1892 Relating to Births, Marn»ge»i
Deaths and Divorces. New HaTen. 1894.

Digitized by

Google

▼OL. CXXX, No. 18.] BOSTON MBDIOAL ASB SUSOIOAL JOVBBAL.

433

THE AFTER-TREATMENT OF OPERATIONS
FOR APPENDICITIS.*

BT EEKBBKT L. BURSBLL, H.C,

iMlmeftir in CHntcoi Surgtry, Harvard Medical School; Surgeon,
Botton aty Botpital.

The following details and qaestions have presented
themselves to me in the after-treatmeot of operations
for appendicitis :

(1) The method and material to be used in securing
the stump of the appendix. While, strictly speaking,
the treatment of the stump of the appendix is a part
of the operation, yet I shall speak of the method and
material to be used as I believe it influences the treat-
ment. I have been in the habit of using silk, and in
the majority of instances it has been satisfactory ; but
it is occasionally open to the objection that it becomes
a foreign body in the wonnd and may be cast oS after
a time, varying from weeks to months, and has made
a troublesome sinus and required (in one or two in-
stances) curetting under ether in order to remove it.
While we may use silk which is perfectly aseptic it is,
of course, immediately contaminated by foul septic
fluids, and hence does not become organized. Ca^ut
of sufficient size has seemed to me to be equally effi-
cient in holding the stump of the appendix, and only
occasionally have I found it necessary to nse inter-
rupted Lembert sutures to invert the peritoneal sur-
faces covering the stump of the divided appendix. In
fact, wherever time has been of great importance I
have simply thrown a ligature around the end of the
appendix dose to its origin, and have cut away the re-
maining end. In operations where there is but little
pus I see no objection to using silk, but where there is
a good deal of pus until 1 see some reason to change
my method I shall use catgut in securing the stump of
an appendix.

(2) Closure of the wound. I think that all surgeons
would agree that the best time to operate upon an
appendix is between the attacks. At this time we
have a wound free from pus, and while the appendix
is difficult at times to isolate, yet having once secured
and removed it a clean wound is left, which can be
sewed up and the patient left with but little anxiety.
In several instances where I have operated between
the attacks I have been surprised to find a few drops
of pus, and in one instance I found while operating be-
tween the attacks, the patient having been about for
some time after the previous attack, a fsecal concretion
the size of a cranberry bean, which was loose in the
peritoneal cavity. There was also a minute perfora-
tion of the appendix. These conditions would con-
taminate the wound unless the septic material were re-
moved mechanically, and the cavity rendered relatively
sterile. Where time is an object I have used sutures
transfixing the abdominal walls. Where the wound
could be closed at leisure I have used three lines of
sutures, one in the peritoneum, one in the transversalis
fascia and muscles, and the third in the skin. These
have usually been of silk of small size, although I pre-
fer silkworm-gut.

(8) The treatment of shock following operation.
In addition to alcoholic stimulants, brandy, whiskey,
etc, heaters and rectal enemata of brandy, atropia

> Head Iwfora the Boeton Sooietj tor Medical ImprOTement, Ttlb-
narf I3, I8S3.

(.^hs gr-)» 8trychnia (^ gr.) and digitalin (yj, gr.)
have been used subcutaneously to much advantage in
the critical cases.

(4) The feeding of patients. I have given patients
only cracked ice, beef tea, and a little milk for the
first twenty-four to forty-eight hours. Opiates are
used freely, for I believe that the patient loses more
from suffering pain than he gains by the free action of
the intestines from saline cathartics. I am sure that
in one instance by the use of saline cathartics I turned
the scale against the patient's recovery.

The vomiting which follows operations of this de-
scription I have treated by morphia, one-eighth to one-
quarter of a grain doses, combined with cracked ice,
siphon of soda and champagne. Mot infrequently I
have withheld all food by mouth, and have depended
entirely upon nutrient enemata for from twenty-four
to forty-eight hours where vomiting has been a promi-
nent symptom. Occasionally the white of an egg has
been retained where other substances have been re-
jected. In one instance at the end of three days where
the vomiting continued I washed out the stomach with
the result that the vomiting ceased. If, however, the
vomiting continues beyond the third or fourth day I
have usually regarded the case as hopeless.

(5) The indications and contra-iudications for the
use of saline cathartics. These I have used freely,
and whenever there has been any rise in temperature
after the first forty-eight hours, any increase in the
frequency of the pulse, or a glazing of the tongue, I
have U8^ a saturated solution of salts in teaspoonful
doses, or even in half-drachm doses, combined with
soda water from a siphon, the drink to be given very
cold. When there is any tendency to vomiting I have
used half-drachm doses of the saturated solution of
salts combined with a siphon of soda water, the drink
to be given very cold, every hour. Occasionally where
there has been vomiting I have used a saturated solu-
tion of salts by enema with excellent results, and at
times a glycerine suppository enenuk combined with
the saline enema has been efficient in establishing in-
testinal drainage, and I am convinced that while saline
cathartics are of great value in producing intestinal
drainage in septic peritonitis, yet the withholding of
morphia in order to attain the fall action of the salts
is at times unwise. I can see no reason why opiates
and saline cathartics should not be given at the same
time. Of course, we must recognize that they coun-
teract one another, but I have found that in using
them in conjunction with one another I have obtained
the benefits of each.

(G) The kind, amount and frequency of irrigating
fluids to be used. I feel safer in mechanically flush-
ing out with sterile water or boracio-acid solution a
cavity of an appendicitis operation than I do in using
solutions of corrosive sublimate, lu one instance
where there was a small amount of pus and a septic
condition of the surrounding tissues the wound was
cleansed thoroughly with hydrogen di-oxide (50 vol-
umes), and then the septic purulent surfaces were
touched with the actual cautery and the wound sewed
up ; but it had to be reopened on the fifth day in
order to evacuate pus. This case, however, recovered
very rapidly after the wound was dilated and irrigated,
and at the end of six weeks the wound was completely
healed and the patient up and about. It has seemed
to me that it was better to depend upon flushing with
sterile water than to rely upon the germicidal action

Digitized by

Google

434

SOSTOS MMDIOAL AUD SVSOIOAL JOURNAL.

[Hat 8, 1894.

of antiseptics in the removal of septic material from
an appendiceal woand.

The question of how frequently to irrigate a wound
depends upon what kind of material is used to drain it.
When (here is a temperature above 101° after the
third day I have nsaally irrigated frequently and
freely, sometimes every four or six hours during the
twenty-four.

(7) The next three questions may be discussed to-
gether. They are, when to dnun and not to drain ;
what material to use as a drain, whether tubes, gauze
or rubber dam ; and bow long to drain.

If there is no pus in the abdomen, of course the
wound is closed. I have found that when there is a
slight amount of pus in the wound, where the cavity
can be completely cleansed, one can safely close it.
However, it is safer to err on the side of drainage than
non-drainage.

Whether to use iodoform gauze, rubber-dam or rub-
ber tubing has been to me an important question.
Rubber tubes, I believe, are indicated where there is a
large pus cavity with walls which do not collapse;
rubber-dam or iodoform gauze are indicated where the
cavity is collapsable ; where the intestines fall into
the abscess cavity the gauze can be insinuated into
nooks and corners and crevices which a tube can never
reach. I am sure that it is wiser to use gauze than to
use tubing in those cases of early operation for appen-
dicitis where the appendiceal inflammation is not walled
oS. Where in doubt, and yet where I have closed
the wound, I have placed between the edges of the
wound a narrow strip of iodoform gauze or rubber-
dam, which I have removed on the third or fourth day
if it were not found necessary before. The cases
which I always feel demand iodoform gauze are those
where in operating within forty-eight hours from the
beginniHg of the attack a perforated appendix is found,
especially when it is a question whether the general
peritoneal cavity is invaded.

In these cases I have left iodoform wicks in for
weeks at a time, gradually withdrawing them until
every vestige of septic material was removed from the
wound by washing with boracic acid or sterile water.

How long to drain is a question that has never been
settled in my mind. When the temperature reaches
to normal, and when there ceases to be an evening rise
in temperature, I nsually remove a few of the iodo-
form wicks or the tube. The wound is, of course,
irrigated out daily, and if there is much discharge iodo-
form is dusted over the open wound. It has been my
practice where I removed an appendix, — and I never
feel satisfied that I have given the patient the best
chance unless I have removed the appendix, — to carry
the iodoform gauze down to the stump of the appendix,
believing that if this could be covered by granulation
tissue a firmer cicatrix would be gained, and less liabil-
ity to hernia would exist.

As a rule, I have been inclined to remove the drain-
age too early, judging alone from the wound, and in
my later cases have come to depend upon, not alone
the condition of the wound, but the patient's tempera-
ture, pulse, and the condition of the general peritoneal
cavity, whether showing evidence of inflammation or
not.

(8) The indications for reopening a closed wound
or for exploring an open wound following an appendix
operation. To reopen a closed wound offends one's
surgical sense, but to allow a patient to die from septic

absorption from defective drainage is, to put it mildly,
very unfortunate. On the other hand, to explore an
open wound following an appendicitis operation is a
thing that I have been led to do in a number of in-
stances. I always think of doing it whenever there it
a continued rise in temperature siter the fifth day or a
chill, where a wound tends to gape, or from which pat
flows, a drachm at a time, at indefinite intervals ; and
whenever there is associated with it evidences of infec-
tion of the general peritoneal cavity I believe that the
patient should be etherized, the wound carefully ex-
plored with the finger, and any pocket of pus or leptic
material that is loose should be washed out thoroughly.
I am sure that this is an important thing to do, and a
moment's thought must make it clear that a cavity
filled with coils of intestines is very difficult, and at
times almost impossible, to free from septic material
at the time of operation.

In three instances last summer, between the tenth
and twelfth days, after the temperature had been nor-
mal, I was obliged to reopen wounds on account of a
sudden and continued rise in temperature and chilli.
An abscess was suspected, but in none of these catei
was an abscess found. On opening up the wound, bow-
ever, and separating the coils of intestines, there et-
caped a large quantity of offensive gas. It was to
marked that in one case a bystander said, " Why, there
must be a perforation of the intestines." I suspect that
this gas had something to do with the continued high
temperature, for in each instance the wounds were re-
packed, the temperature fell to normal in a short time,
and convalescence was established.

In one case 1 explored a wound on the tenth day,
and found an abscess pointing toward the loin. A
counter-opening was made in the back, a drainage-tube
inserted and through-and-through irrigation established.
Where the appendix rests high up in the loin, and
where there is a large amount of pus, I am inclined to
believe that this through-and-through drainage would
at times be of great value.

In two instances I have had fsacal fistulse develop,
but by thoroughly cleansing (by irrigation) the woood
it has been possible to bring about a complete, al-
though delayed closure of the wound. *

I have presented these questions in the after-treat-
ment of this operation as they have occurred to my
mind. There is, of course, room for difference of
opinion, and it is impossible at present to lay down
principles in the after-treatment of this operation ; bat
I am sure of one principle, and that is, that when we
are in doubt the wound and abdomen should be freed
from all septic material.

THE PBODUCTION OF VACCINE VIRUS.'

BV D. D. OII.BBBT, M.D., OHtiailtW, DOaclUISTKB, MAla.

Tour committee have visited the two principal
depots from which the vaocine stock is supplied to thit
section, namely, the New England Vaccine Company's
operating-rooms in Chelsea, and the operating-roomt
of the late Henry A. Martin, M.D. We were wel-
comed with gentlemanly courtesy and attention at both
places, where the processes were freely shown and ex-
plained. We have also had freely given from Codman
& Shurtleff a description of the process pursaed by

> The report of a oommittM appoUted b; the Noifolk OUtriot
Madloal Society to iiiTeetlgate the production of Taoeine Tim-

Digitized by

Google

Yov. CXXX, No. 18.] BOSTON MEDWAL AND 8UR0I0AL JOURNAL.

435

them at their farm in Stoughtoo, which we were cordi-
ally invited to visit. Also, I will state that, at the
meeting of the Norfolk District Society where this
report was originally made, Dr. Francis C. Martin
made some remarks in regard to the course pursued
by him at his establishment.

At Chelsea we found buildings well adapted for the
purpose — a stable so built with cemented floors,
gutters and walls, that it could be thoroughly flushed ;
and it had evidently so been, for not a particle of stable
dihrit was present. Leading from this stable, sepa-
rated by an entry and double-doors, is the operating-
room proper. This room has a floor of artificial stone,
tiled walls, and is heated by steam. It is furnished
with sets of stanchions in which to securely and com-
fortably confine the cattle undergoing the operations,
and with a closet of fine-wire gauze, for the drying of
the freshly charged points, admitting the air but ex-
cluding the coarser particles of dust. This room can
also be thoroughly flushed, and it is claimed that it is
so treated with antiseptic solutions from time to time.
There is an evident intent to preserve the appearance,
at least, of asepsis, but one notices a carelessness of
the employes in handling the charged points, etc., with
hands which are certainly not surgically aseptic.
Whether this comes from ignorance of what science
has a right to demand in such a process, or whether it
is the carelessness which familiarity with routine work
almost necessarily begets, I do not know. In regard
to the results I will speak later.

The operating-room at the Martin establishment is
an ordinary room opening directly from the carriage-
house of the stable. This room has wooden floor and
walls, and has no conveniences whatever for producing
aseptic conditions other than such as accompany ordi-
nary cleanliness. Mr. Seed told us they made no
pretensions to do more.

The process of securing the lymph at the two estab-
ishmeuts differs in many ways. At the New England,
they use mature animals, about four years old. These
are vaccinated on the back of the buttocks, in about
a dozen large conflaent patches, three to four inches
sqoare. At the Martin establishment they use im-
mature animals, preferably under one year of age.
These are vaccinated on the back of one buttock and
on one side of the belly, in small patches about three-
fourths of an inch square, which do not materially en-
large in development. At the New England estab-
ishment the animal while undergoing operation remains
standing, confined by a set of . stanchions. At the
Martin establishment the work is done upon the ani-
mal lying on its side, and strapped to a table. At
Codman & Shnrtleff's, and at Dr. Francis C. Martin's,
the age of animals and the process are practically the
same as at the Martin stable in Brookline.

Dr. Perry, of our committee, has kindly prepared
some rongh diagrams which will give you a better idea
of how the animals are vaccinated than will any verbal
description.

Mr. Reed, of the Martin establishment, claimed
that the advantages of using young animals are the
lesser danger of their being diseased, and the greater
facility of handling them. At the New England in-
stitute there seems to be no difficulty of handling the
animals with the facilities which they have, and each
animal before it is taken into their stable has been ex-
amined by a veterinary surgeon, and a certificate of its
healthy condition issued to the company. This cer-

tificate is numbered, and the cow is tagged with a cor-
responding number which is recorded. By means of
this system of numbering the company are able to know
from what animal any issued points have been taken.
The same system of numbering, but not of veterinary
examination, is pnrsued at the Martin establishment.
Codman & Shurtleff have all their animals examined
by a regular physician, and a record of each animal is
kept.

At the first glance at the animal vaccinated and
ready for use, the sight is repulsive, and the broken-
down, suppurating crust seems a most disagreeable
thing to inoculate into the human organism. These
crusts and their accompanying debri$, you are told, are
ground up with glycerine and regularly dispensed as
vaccine stock in some foreign countries. Bere the
crust and all loose tissue are removed, thus exposing
the base of the vesicle. At the New England institute,
this, with the surrounding skin, is thoroughly washed
with a sponge and clean water, and after a few minutes
the serum exudes and, the animal standing in an up-
right position, trickles down to the lower edge of the
patch from which it is taken npon the points. The
first flow is a little discolored with blood, and is kept
to revaccinate new animals with. After a while the
flow of serum is obtained perfectly clear and of a slightly
yellowish shade. By this method, at the New Englan4
institute, the points are not bronght at all in contact
with the raw surface but receive the lymph as it trickles
down to the sound skin. The points are then laid
upon a nickel-plated metal tray, channelled and adapted
for the purpose. When the tray is filled, it is placed
inside the gauze closet to dry.

At the Martin establishment, as I have said, the
vesicles are individually smaller, and, after having
been freed from the crust, are not washed bnt are wiped
with a towel which seems to have done some service
in the same direction before. From these vesicles,
there being less tension of the tissues than where the
patches are larger, the lymph does not exude itself
but is squeezed out by compression of the base with
forceps, and the points are charged directly from the
denuded surface ; therefore all are more or less dis-
colored with blood. At the New England establish-
ment the points having been received from the factory
are sterilized before being charged — subjected for an
hour to a temperature of 212°. At the other place,
as I have said, no attempt at asepsis is made.

At Codman & ShurtlefTs establishment the process
is similar to that at the Martin, except that, instead of
dipping the points into the lymph exuding from the
raw base of the vesicle, the lymph is collected in little
glass cups, and any dibris present in it is allowed
to settle or is skimmed off, after which the points are
charged with the clear lymph.

Now, while neither of these processes approach what
we know as surgical asepsis, yet the fact remains that
we never hear of septic inflammation setting in within
a few hours after vaccination, which it surely would do
if septic matter were directly introduced into the sys-
tem ; so that we must believe that the charged points
are not septic even if the process of preparing them is
not ideal.

On the other hand, when suppuration does occur, it
sets in as a secondary result to the mature vesicle.
This it is claimed, and justly it would seem, is due to
atmospheric germs having found their way within the
ruptured capsule of a broken vesicle. . Therefore, when

Digitized by

Google

486

BOSTON MEDIO AL ASD 8UB6I0AL JOURSAL.

[Hat S, 1894.

this occurs in this secondary mander, it is after the
vaccinia has been produced, and it does not, as is some-
times claimed, interfere with the protective power of
the vaccination. The resulting sore should therefore
be treated antiseptically from that time on, and healed
as soon as possible.

Dr. Cutler, at the head of the New England estab-
lishment, maintains that a small vesicle should always
be obtained, and that, from the commencement, it
should be kept as dry as possible, no moist or oily
dressing ever being used. A email vesicle produces
less inflammation — and so less necrosis of subjacent
tissue, less areola, and so less constitutional disturbance.
Moreover, it is far less liable to crack and rupture.
He claims that the size and accompanying characteris-
tics of the vesicle may be absolutely determined by the
size of the original scarification, which had better be a
mere puncture, and never should exceed one-sixteenth
of an inch in diameter. There should be two or three
of these vesicles situated nearly two inches apart, so
that th^y may never become confluent with one an-
other. He exclaimed, "It was a bad day when we
were taught to scarify instead of the old-style punct-
ure." His explanation of this and of his theory that
a large scarification makes a confluent and highly in-
flamed vesicle is, that, while it is necessary to spread
the inert virus obtained from calves over a large scari-
fication, to get any result — uncertain at best — the
lymph obtained from mature animals is richer in germs
which become implanted all over the scarification and
start numerous colonies, each a nucleus of vesicles
which, as they grow, coalesce until they form the large
confluent vesicle.

When a large confluent vesicle is produced in the
human subject, the resulting cicatrix often fails to
present the minute pits which the older vaccinators
considered characteristic of successful vaccination, but
this is really of no importance. In the human subject
vaccinia produces a deeper inflammation than in the
cow, and this fact, taken in connection with the high
degree of inflammation produced by a large confluent
vesicle, accounts for the necrosis of tissue which de-
stroys the natural base of the vesicle with its char-
acteristic pits. The simple appearance of a cicatrix
affords no evidence as to the amount of protection. A
cicatrix is only presumptive evidence of previous vacci-
nation, and, if it is more than five years old, vaccina-
tion should be done in the presence of au epidemic.
The only real evidence of protection is the insusceptibil-
ity to vaccinia under the most favorable conditions.
Insusceptibility to vaccinia under such conditions is
insusceptibility to variola. In the early history of
vaccination some bold experiments were made at the
small-pox hospital established by the Boston Board of
Health at Noddle's Island. Massachusetts, by the way,
was the first colony to introduce small-pox inoculation,
and the first State to introduce kine-pox vaccination.
"On August 16, 1802, 19 boys were vaccinated, and
all passed through the regular stages of the cow-pox ;
and on November 9th following, 12 of them, together
with the son of Dr. Bartlett, who bad previously had
the cow-pox, were inoculated for the small-pox with
matter taken from a patient in the most infectious
stage of the disease ; and no trouble whatever followed."
These facts are given in a report signed by eleven
physicians, including Benj. Waterhouse and James
Lloyd. A full and official account of the affair is
found in the Coluinbian Centinel, December 18, 1802.

The formation of the areola is claimed to be the
only test of constitutional or protective vaccination. If
a person has been infected with small-pox, vaccination
will not modify the disease unless the areola forms
before the small-pox symptoms show. If, however,
the stage of areola is reached before the symptoms of
the graver disease appear, that disease will be aborted
or modified by the vaccination.

Distinct, probably, from the various postrvaccinal
eruptions which are sometimes called into activity by
the excitement of vaccination, is a more or less widely
distributed exanthem, or roseola, which is claimed to
be simply a distributed areola, and need give rise to do
anxiety, since it runs the same course as, and disap-
pears with, the areola.

In conclusion, your committee are inclined to believe,
from the limited observation which they have been
able to make, that the New England virus is the more
active and therefore the more dangerous virus to use ;
that the Martin virus is not as active and consequently
may be the safer for general use. In reference to this,
the New England people state that the danger of ex-
cessive result should not be laid at the door of active
virus, which is necessary to fight an epidemic with,
but is due to the ignorance of the proper technique of
vaccination among some members of the medical pro-
fession, and especially among laymen who often do not
hesitate to perform the operation. On the other hand,
the late Dr. H. A. Martin has maintained that the
serum from the large confluent vesicle on the cow, with
its higher degree of inflammation, is alone responsible
for the greater degree of irritation in the human sub-
ject. Your committee believe that these poiots can
only be settled by a more careful attention, on the part
of physicians, to the technique of the operaUon, and
an observation of subsequent results.

Further, your committee are led to the positive belief
that the whole subject of preparation of vaccine stock
should not be left in the hands of rival commercial
companies, but should be wholly ander the official con-
trol of either city or State.

WHAT MIGHT BE DONE BY THE OBSTETRI-
CAL SOCIETY TO ADVANCE THE TRAINING
OF NURSE8.»

BT A. WOBOBSTBB, XJ>., WALTEAM.

In the successful management of obstetric oases
much depends upon -the nursing service. Indeed, in
normal cases, more depends upon the nurse than upon
the physician. And in abnormal cases, especially
where surgical interference is exercised, after the oper-
ation or the delivery is over, then even more responsi-
bility falls upon the nurse for the happy uninterrupted
recovery of the patient. If, to this is added the re-
sponsibility of starting a baby on a prosperous career
of health and happiness, it would seem as if the
monthly nurse always ought to be at least an angel.
Sometimes she is one : sometimes she — isn't.

If obstetricians have poor or only tolerable nurses,
it is their own fault: if they submit their patients to
positively bad nursing service, then their fault is in-
excusable. In other words, the physician is not blame-
less if his patient suffers from faulty nursing.

This particular responsibility of the doctor is of
comparatively recent origin, and is due to the fact that
1 Bead before the Obstetrioal Soeiety o( Boston, llaroli 10, 18M.

Digitized by

Google

Vol. CJXXX, No. 18.] BOSTON MEDIOAL AND SUR6I0AL JOURNAL.

487

within the last few jean the profession of nursing has
been revolutionized.

Monthly nurseg used to be expected to know every-
thing about mothers and babies. They did just as
they pleased. They followed the suggestions of the
physicians, if they saw fit to do so. Among these old-
time nurses were many whose long experience, whose
sterling common-sense and unfailing devotion entitled
them to far greater rewards than they ever received.
Some few of these old nurses or of their legitimate
descendants may still be found in the old-fashioned
households. But their type is fast passing from the
stage.

In their place have come young women who have
Uudied nursing. How contemptuously would the real
old-timer have spoken of a student nurse ! And how
densely ignorant she wonld have seemed to the modern
training-school graduate ! Neither could understand
the other. The revolution in nursing is complete.

With the old nurse the doctor's responsibility for
the nursing service was very faint. She would brook
bat little criticism. Her unfailing defence lay in her
silence. She would report only what she chose to re-
port, and whatever happened she would never acknowl-
edge her ignorance. Indeed, had she done so, her
usefulness woald have been abridged, for her families
took comfort in her supposed infallibility. And much
of the uncouth traditionary household physiology and
pathology of to-day has its origin in the speculations
of the old monthly nurse.

With the modern nurse, on the other hand, the doc-
tor's responsibility as to the nursing service is like
that of the captain for the safety of his ship. Both
are alike responsible for the execution of their orders.
The modern nurse recognizes her position to be that
of an executive ofiBcer : and when she is working under
a physician who so recognizes her position, then all
goes well. Where the modern nurse fails to give satis-
factory service, the failure is generally due either to
her improper training or to the inexact and unintelligi-
ble orders under which she was working. In either
case the failure is primarily the physician's. For it is
his business to train his narses, or at least to secure
trained-nurses for his patients, as it is also his business
to give his directions in such exact intelligible fashion
as will effectually prevent any misunderstanding.

Of course, it is possible that the failure of satisfac-
tory service is doe to the nurse's personal unfitness for
her work ; bat, even so the physician is not free from
accountability, for he ought to know the characteristics
of his nurses and their fitness or unfitness for his dif-
ferent &mi]ies and patients. The physician must ap-
portion their service, just as a general must, by taking
into account his subordinates' special fitness for various
positions of responsibility. The personal equation
nowadays is of constantly increasing importance. This
is the age of specialists, and nurses equally good in all
kinds of work and under all sorts of conditions are not
to be found seeking employment.

If I am right in thus stating the responsibility now
resting upon the medical profession as regards the
nursing of their patients, it must be admitted that this
responsibility is not generally acknowledged. Many
physicians still scold about their nurses. Few take
any pains to improve them, or take any interest in the
methods of training. In short, the revolution in nurs-
ing has not yet penetrated the apprehension of such
physicians.

My object in asking the attention of this Society to
this subject is to enlist the coSperation of all who are
interested in advancing the new movement. It is high
time that concerted efforts should be made to secure,
first, more trained nurses; second, better trained
narses ; and, third, a more serviceable working rela-
tionship between doctors and nurses.

In this paper I purpose to consider especially the
subject of obstetric nursing. Let us then, first, inquire
how the supply of monthly nurses may be increased.

It is, of course, plain that the training schools of the
lying-in hospitals cannot more than begin to supply
the demand even of their immediate vicinity. When
the birth-rate of the community is considered in com-
parison with the possible number of such graduates, it
is only too apparent that not one out of every ten con-
finement cases can be so cared for.

Where the supply is so limited high wages rule, and
only the rich can afford to employ trained nurses ; ac-
cordingly physicians whose practice is mainly among the
wealthy do not appreciate the scarcity. But women
of moderate means, and of no means, need trained
nurses just as much, if not more, than do their wealthy
neighbors. Moreover, the physicians who attend such
women in their confinements need the assistance of
trained nurses.

The problem thus becomes one of economics at the
very start. Its solution is not impossible. For just as
is the case with physicians, so it should be with nurses :
the poor now receive their medical attention at the
hands of beginners or as a direct charity, and so they
must receive their needed nursing service. Families of
moderate means employ medical attendants who are
willing to work for moderate fees. As these physicians
and surgeons acquire greater reputation they take new
patients only for increased fees, and so it goes on until
only the very rich or those suffering from some patho-
logical rarity can enjoy the privileged service of the
very distinguished practitioners. So it must be with
nurses. In a properly adjusted system of training,
student nurses would practise, under the direction of
their teachers, among the poor and those of moderate
means. Immediately after graduation, instead of de-
manding at once the highest wages, they should expect
to work for moderate pay among those who cannot
afford more ; and only after several years of increas-
ing experience should trained nurses expect the highest
wages.

At present the nursing profession in matters of com-
pensation is too much like the clerical, where experi-
ence and proved usefulness count for little against
youth and " brilliant promise."

It is, therefore, in this solution of the economic
problem that we may discover how to increase the
ndmber of trained nurses. Not by increasing the ly-
ing-in hospitals, however desirable otherwise that may
be, but by utilizing the opportunities for training that
now surround us in the homes of the poor and of those
moderately circumstanced. Thus, too, may be secured
better narses, and also that final desideratum — a
more serviceable relationship between the two profes-
sions.

Until recently it has been held that nurses could be
trained only within hospital walls. Whereas the truth
is that narses so trained begin their private practice
under great disadvantages when compared with others,
whose training has been in part in the private practice
of their instructors. And iu recognition of this fact,

Digitized by

Google

438

BOSTON MEDIO AL AND SURGICAL JOURNAL.

[Mat 3, 1894.

many of the best training schooU have already arranged
to send oat their student nurses to private work for a
part of their training.

Meanwhile, the special problem before as is to ar-
range for the instraction in obstetric nursing of the
hundreds of student-nurses and training-school gradu-
ates in this vicinity who now have no chance to learn
the art. For, so long as our large training-schools
graduate nurses, whose only instruction in obstetrics
has been one or two lectures on the subject, we need
not expect any spontaneous improvement. The grad-
uates of these large schools may know how to manage
a typhoid-fever patient, but many of them do not
know a nipple-shield from a breast-pump ; they, of
course, do know how to arrange a room, and instruments
and dressings, and the patient for an aseptic surgical
operation, but they do not know how to prepare for
ordinary obstetric cases. And -yet, when they seek
for private work, they soon find that surgical cases are
not so common as confinemeDts. Their general train-
ing, of coarse, helps them greatly in obs'tetric work if
they bravely undertake it, but they have no opportuni-
ties hereabouts for instruction in this branch unless
they enter the lying-in hospital courses, which at
most could not accommodate one-tenth of those who
should receive instruction before receiving their di-
plomas.

Physicians have to study surgery and obstetrics,
even if they from the first intend to practise only as
specialists in other branches. And it is accepted as
axiomatic that some preliminary general practice is
necessary to highest development in any specialty.
Even more truly is this the case in the profession of
nursing. No training should be considered complete
that does not include obstetrics : nor should any obstet-
ric nurse be considered as well trained who has not
also been trained in the nursing of surgical and medi-
cal cases.

And yet the custom still prevails in Boston of train-
ing narses only in specialties. Obstetric nurses, and
nurses for infants, for lunatics, for neurasthenics, are
graduated annually from various institutions j but very
few nurses can be found who have received all of the
different diplomas, and this in spite of the possibilities
that neurasthenic women may have to be delivered
and may become insane. Consulting specialists may
so supplant the general practitioner that bis type shall
become extinct ; bat in the profession of nursing the
good, all-around nurse is what is wanted now, and will
be forever.

As a remedy for the present confusion, it might be
thought possible to secure some cooperation among
the different training-schools, such as has been secured
iu other cities ; but that hope need not be entertained
for Boston, for so jealously guarded are their doors,
that not even the graduates and superintendents of
other schools are allowed opportunity to study each
other's methods of training. In other cities, both in
this country and abroad, such opportunities are most
hospitably afforded. In Boston, it would be consid-
ered most impudent even to suggest to any one train-
ing-school the possibility of its being improved by
association with any others, and any appeal for a more
general distribution of its peculiar advantages is met
by the courteous announcement of its weekly lectures
and monthly conferences, which by the liberality of
the trustees are open to outsiders.

The means of improvement must, therefore, be

sought independently of present organizations. It
would be easy, for instance, for the Obstetrical Society
to inaugurate, or at least to matronize, a coarse of
post-graduate instruction in obstetric nursing which
should include a stiff coarse of lectures, recitations and
examinations, with practice under approved instracton
in the dispensary districts and in the homes where only
very moderate wages could be afforded. The diploma
granted to those who earned it would give a rating
like that of the London Obstetrical Society. Were
such a coarse of instruction offered, hundreds would
apply. There would be an immediate supply of nunes
for the poor, and for those who can pay at most only
a few dollars for their care during confinement. The
instructors in this post-graduate school, in return for
their teaching, would have an abundance of assistance,
and would be saved many hours of weary nursing ser-
vice which they now endure.

In the same way, other societies might inaugurate
special post-graduate courses of instruction in other
departments of nursing. Thus nurses might be taught
how to take care of infants, a department now most
sadly neglected.

But better far than separate and independent post-
graduate courses would be a central post-graduate
school which would have general management. Such
a school could do more for the advancement of the
nursing profession, and consequently, for the advance-
ment of the practice of medicine, than any agency
within the realm of things possible and practicable.

Such a school woald need no endowment. From
its inception it would be more than self-supporting.
Out of it would grow perfect systems for the registra-
tion and the distribution of nurses, in place of feeble
guilds and graduate clubs would grow a large, strong
association of all the members of the nursing profes-
sion. And finally, Boston might so regain her old-
time preeminence as an educational centre for narses.

One of the many advantages that would result from
such a central post-graduate school would be that of
uniformity in the matter of giving diplomas to nurses.
The coarse of instruction would have to be lengthened,
which by no means should be considered a disadvan-
tage. Graduates of the present schools might then
seek work, as they do now, or they might take the dif-
ferent courses and examinations of the post-graduate
school in the sarety that, having obtained the ad-
vanced diploma, their services would be in greater
demand.

This in time would naturally lessen the apparent
value of the diploma now given by the <Ufferent
schools ; bat if it led, as well it might lead, to a uniform
examination by the central licensing board, the great-
est benefit would result.

Thus, in the special department of instruction under
our present consideration, there is now no uniformity
in the different diploma-giving schools, and we have
no means of ascertaining what instruction has been
given to the narses who are engaged for oar obstetric
cases. For this we have only ourselves to blame, for if
we instituted even examinations for nurses in this depart-
ment, the different schools would at once try to con-
form their instraction in this branch in order that their
graduatex might with least difficulty obtain the ad-
vanced diploma.

As is true in every professional school where the
diploma carries with it any certificate of fitness to
practise, the diploma is open to suspicion if it be

Digitized by

Google

Voi» CXXX, No. 180 BOSTON MEDIOAL ASD SUBGIOAL JOURNAL.

489

granted solely bj the instractors of that particular
school. Thus, for iDstance, the possessor of such a
diploma may be better versed in the difEerent iostrao-
tors' whims than in real knowledge.

If, then, we cannot at once arrange for post-gradu-
ate instruction for nurses, let as at least arrange for
the examination of nurses, and so secure some sort
of uniformity in their training.

THE GASTRIC AND RESPIRATORY SYMPTOMS
CAUSED BY THE DUST OF CURLED HAIR.»

BV AKTBDB r. CH^DBOUBHE, H.D.,

/>Ajtnci<m to OtU-Patient*, Carney Hoipital; DetiMTUirator of Ex-
periwiental Pharmacology, Harvard Medical School.

CoNsiDKRiNO the great differences in the composi-
tion of the various kinds of " dust " that are known
to cause so-called " dust-disease," it is somewhat sur-
prising that it should have been possible to group
almost all the resulting symptoms under the single dis-
ease called "fibroid phthisis," or " pneumokoniosis." '
The list of indastries that are recognized as being dan-
gerous to the workmen on this account is already a
long one, and a single addition to the number would
be of little interest. The patient who is here to-night,
however, has no evident signs of a " fibroid " change
in the lungs, though his symptoms nndoubtedly arose
from continued exposure to dust in the factory where
he has worked for many years.

Before giving the history of the present case, let us
consider what this dust really is, and in what ways it
would be likely to act in producing disease. Though
there are hardly any two of the " dus^producing
trades " in which the composition of the dust is exactly
the same, yet in all the dust is alike made up of
minnte particles, so small as to float about for some
time and be easily drawn in with the air breathed by
the workmen. The action of these minnte particles
may be purely mechanical, and it is largely, if not en-
tirely, from this mechanical irritation that so-called
" fibroid phthisis " is commonly believed to arise. In
the second place, the great differences in the compoti-
Hon of the different kinds of dust might well be ex-
pected to influence its heed action, if nothing more.
Among the substances that make up these minnte par-
ticles are some that are known to have a marked
action on the human organism as a whole ; in others
the effects are more local, or confined to one or more
groups of organs ; some are accumulative, others active
poisons ; while still others are probably inert, at least
in the form in which they occur in the dust, and
finally, quite a number are used as medicines. Plant
and animal products, as well as inorganic matter, are
among them.

Such substances may reach the larynx and respira-
tory tract, either by way of the nose and naso-pharynx,
or directly through the mouth ; but a part of the in-
haled dnst must be carried into the oesophagus, and in
this way may enter the stomach. The portion of the
foreign matter that can be absorbed, either changed or
unchanged in chemical constitution by the secretions
and tissues with which it may come in contact; and
its characteristic general symptoms will then follow if
the amount which thus enters the system is sufficiently
great.

> Boad before the Section of OUnloal Medlolne, Pstbolosr uid
HTgieDO of the Snffolk Dlitriot Hedloal Society, Febrosry 21, 1894.
* Uiiet wtileli eoutain* lead, anenle, etc., of course an ezoeptlou.

To return to the history of the present case, in
which the action of the dust is certainly not that of a
purely mechanical irritant.

J. D. came to the Carney Hospital (A. P. D.) in
January, 1894. His family history was excellent.
He had never been " sick in bed a day in his life that
he could rwiember"; nor had he had any "lung
trouble," except a few days' cough when "he had
taken cold," and when working in the dust of the fac-
tory. On Sundays and holidays never coughed at all.
Habits and personal history good.

For twenty years he has steadily worked in the
same factory, with the exception of a few months
when he was " train-hand " on a railroad, but this was
thirteen years ago. In the factory, "curled hair" is
prepared for mattresses, etc. Both horses' and pigs'
hair is used, but only the latter is dyed ; and it is when
this dyed hair is used that he is troubled with his
present symptoms. The pigs' hair is "disinfected " as
soon as it is received at the factory, and is then
thrown into large vats, which contain a mixture of
logwood (JuematoxyUm) and copperas (iron sulphate,
with copper sulphate as an imparity, and more or less
sesquichloride of iron '). When thoroughly stained,
the hair is removed 'and dried; it is then piled op
ready to be put through a machine called a "separa-
tor." The " separator " pulls apart the tangled masses
of hair, while a blast of air is at the same time forced
through to remove the dirt, broken pieces of hair and
other dust. This dust completely fills the air, and
rapidly accumulates around and on the machine. The
patient " feeds," that is, keeps the " separator " sup-
plied with hair from the heap already mentioned, and
has, therefore, been obliged to breathe the dust-filled
air near that machine for almost twenty years.

He describes his symptoms somewhat as follows :
When actually in the dust he always has more or less
cough, and raises a " little thin, frothy spit, which is
rather blue-colored " ; but as soon as he stops work
the cough stops also. For two or three weeks before
I saw him he had what he called a cold, and was
then raising more or less sputum all day and more at
night. When working with the dyed hair the color
was blue, but in the morning white and "lumpy."
The specimen brought me was muco-purulent, white,
and careful examination failed to show tubercle bacilli.
The chief complaint, however, was of his " stomach,"
which had " hurt him in the same way ever since he
had been in the factory, but was getting worse lately."
When undyed hair was being prepared his " stomach
was much better always." There was a sharp, burn-
ing pain, beginning just below the sternum, and go-
ing straight up to his "Adam's apple " (larynx) and his
" mouth tasted bitter and like brass." There was paiu in
the epigastrium, which increased with pressure. Appe-
tite fair. Bowels always regular, and dejections natural
color. No vomiting ; nausea occasional. These symp-
toms begin two or three hours after he has worked
with the dyed material, and sometimes last a day or two
after he has stopped using the dyed material. No
marked loss of flesh.

On examination, the patient was thin, and, though
poorly developed and hollow-chested, was not emaci-
ated. Marked cyanosis and dyspnoea were absent.
The tongue was thickly covered with a yellowish-
brown fur. The chest showed nothing abnormal, ex-

' Lead, zinc and anenio were teeted for in the dust, but were not
present.

Digitized by

Google

440

BOSTON MEDIO AL AND SURGICAL JOURNAL.

[Hat 3, 1894.

cept slight ligng of a localized bronchitis at the right
base behind.

He wag given ten drops of terebene for coagh
p. r. n., also told to take the white of a raw egg when
he felt the burning pain coming on, and abont ten
minutes later to take ten grains of bicarbonate of soda.
Maltine given as a tonic •

On hia return abont a week later, he reported (con-
siderably to my surprise) that the " stomach trouble "
had entirely stopped, and for two days he had not been
obliged to take the medicine. The day previous he
had worked with the dyed hair, but without the usual
discomfort. The sputum, which he brought me, was :
(1) Specimen raised in the morning before going to
work, and after having been in the dyed dust the day
before : it contained a few small fragments of dyed
hair and unidentified foreign matter. No logwood
fibres. There was a very slight reaction for copiier,
and a well-marked test for iron. (2) Specimen raised
at noon after a half-day's exposure to \.\ift dyed diut :
The sputum was frothy, mucous and strongly tinted
with blue, while in it were many dark-blue specks.
Microscopically, these blue fragments were evidently
plant-fibres of some kind, and around each was a kind
of halo of lighter bine ; they were undoubtedly bits of
logwood. The broken fragments of hair were surpris-
ingly few ; almost all were dyed, but the undyed hairs
were most of them quite different in form from the
stained specimens, and must have been horse-hair.
Chemically, the copper and iron tests were much
stronger than in the first specimen. (3) Specimen
after a morning's work with undyed horse-hair : The
sputum was very small in amount, frothy, thin and
unstained. Microscopically, it showed a few unstained
fragments of hair, similar to the unstained fragments
of the second specimen, but no logwood fibres. The
chemical tests for iron and copper were negative. No
bacilli of tuberculosis could be found in any of the
specimens. The examination of the dust from under
the " separator " corresponded with that of the sputum ;
iron and copper, dyed bits of hair and unstained frag-
ments, evidently from a different animal, bits of log-
wood and foreign matter being found. As already
stated, zinc, arsenic and lead were absent in the dust.

Since he first came to the hospital I have seen the
patient several times, and the gastric symptoms always
return soon after exposure to the dyed-hair dust ; but
they have thus far always yielded to the treatment
first prescribed. The signs in the lung finally disap-
peared, and when he was seen by Dr. F. C. Shattnck,
who most kindly examined him for me a few weeks
ago, nothing abnormal was detected in the chest.

Two points seem to me of special interest in this
case : first, the absence of any signs of an abnormal
condition either in the larynx or lungs after twenty
years of almost daily exposure to this dense dust;
second, the evident symptoms of marked irritation of
the digestive mucous membrane, without a similar con-
dition in that of the respiratory tract, though the lat-
ter would seem likely to be the most easily reached by
the irritating particles. To what extent absorption
has taken place in the present instance — if such has
occurred at all — it is, I think, impossible to say.

To try to determine this question, and also to, if pos-
sible, show the probable condition of the lungs from
exposure to this dust, I have kept some animals for
several hours each day in a close cage, into which
this dust is blown continuously. Judging from similar

experiments with coal-dust, it will be from sixty to
ninety days before any pathological change is likely
to occur.*

Clinical Deiiartinetit.

THE OPEN INCISION IN UNCOMPLICATED
CASES OF HYDROCELE.

BT PAUL OIODBVIX, IC.D., FOKT B&ADY, 8ADLT ST. MABIB, MICB.,
Certain and AMiUtant Surgeon, U. 8. A.

I BKAD with a great deal of interest the paper by
Dr. M. F. Gravin, and the discussion thereon, in your
issue of March IsU I cannot accept the doctor's
dictum, '' No simple, uncomplicated case of hydrocele
ought to be treated other than by injection." And I
must take exception to his statement, " The open inci-
sion, with or without excision of the sac, means the
administration of an ansesthetic [general, I suppose he
means], detention in bed for a varying period from
one week to four, while to undergo an operation has
considerable effect on the minds of most of our pa-
tients."

Permit me to refer to my own experience, limited
though it be, to show the simplicity of the open ind-
sioD in uncomplicated cases.

Casb I. U. K., soldier, German, thirty-two years
old, of fine physique and in vigorous health. This
man presented himself at the hospital November 8,
1891, expressing the desire that I should look at hb
scrotum, and, if possible, relieve his discomfort. In-
spection showed a swelling of five and a half inches in
length by about three and a half inches in greatest
width, situated in the right compartment of the
scrotum. It was easily determined to be a simple
hydrocele. The man stated that he bad first noticed
the swelling six or eight months previously, but bad
paid no attention to it until the tumor became an an-
noyance on account of its size. It was at no time
painful. I had examined this man as a recruit in
November, 1890, and I know the tumor did not then
exist. Despite the fact that the hydrocele was of com-
paratively recent origin, and that the wall of the ssc
presumably was not thickened to any extent — I say
pretumably on account of its recent growth, for the
tumor was so tense that it was impossible to determine
positively the amount of thickening — and notwith-
standing it barely exceeded the limit in size usually
laid down for cases suitable for operation, I decided to
perform Volkman's operation rather than trust to
paracentesis and injection of some irritating fluid,
which, to me, is a most unsurgical procedure.

Having done a Volkman's operation three years
before, and been rewarded by seeing recovery without
the appearance of a single drop of pus, I made every
effort to obtain the repetition of so desirable a result.

1 On Hueb IStb one of the rabbits referred to abore wu fouod
dead In Its cage. During about flra bonra (arerage) each day It bM
been In a oloSed oage, to whicb a steadjr current of atr flUed wits
doflt from ander tbe separator was supplied and kept In motioo bja
forced blast. For two days before deatb ibe animal bad not •Mf"'
well, and bad, tberefore, not been placed In tbe dust cages. Then
bad t>een no cougb and no sneexing, except during tbe tint week ;
and until Marcb letb tbe appeilte was good. Up to Mareb lith (tns
twenty-sixth day) there bad been a loss of one-quarter of tbe original
body-weight. Death occurred on the thirtieth day. On post-morteni
examination, twenty-four hours later, nothing abnormal was '<>■"><■•
except that me macons lining of tbe stomach was througliottt lbiu<7
studded with small spou ana larger patches of dark brown or blaei.
which, microscopically, proved to be not apogPmortem ckmi*, b<it*
lumusrrhagia gattrilU. A pathological change In the longs ws* not
to be expected after so short a time of exposure to the dost ; '■''I" "
as yet too soon to determine the results o( a snjndently long sxposon
nnder tbe same conditions.

Digitized by

Google

J.. CXXX, No. 18.] BOSTON MBDIOAL AND SUttGWAL JOURNAL.

441

fter a Itath, the man's abdomen, pubes, scrotam,
Hnenm and thighs were shaved from the umbilicas
mid-thigh, the parts then scrubbed with soap and
ater, and afterwards with ether, and finally laved
Lth a Bolation of bichloride of mercarv (1-1000).
qaal care was bestowed on the toilet of my bands.
be instramenta were boiled, and afterwards immersed
a solation of carbolic acid (1-20). A length of
ibber tubing (also treated to a bath in the carbolic
Aation) vrtM wound tightly aroond the base of the
BDis and scrotam and secored. Sixty minims of a
>ar-per-cent. solution of cocaine hydrochlorate were
ijected along the line of the intended Incision, result-
ig in complete abolition of painful sensation in aboat
ight minntes. An incision of about two and a half
iches was then made through the integument and
own to the sac. Loops of silk were passed through
be sac wall at the end of the incision and tied, as my
ormer experience had taught me that the retraction
)f the tissues due to the subsequent irritation of the

Oabb I. Oramaater oontnustad.

interior of the sac caused it to be difficult to secure
nice coaptation of integument and serous membrane in
the subsequent suturing. The sac was then incised to
a trifle less extent than was the integument; the hy-
drocele fluid was evacuated ; and the cavity of the sac
(wabbed with a five-per-cent. solution of carbolic acid
in glycerine, as recommended by Gerster. The edges
of the parietal layer of the tunica vaginali* Uttis were
then united to the edges of the integument by a con-
tinaons suture of catgut, very much as a tailor makes
a button-bole. In making this sntnre, it was found
that the skin and the sac wall had both retracted more
than the cellular tissue lying between them. This
was so because of the cocaine injected — such, at
Wt, is my opinion, for it was gelatinous and clear,
and had the appearance of infiltration of fluid ; further-
more, there was no such appearance in my former case,
in which general ausesthesia was obtained by ether.
This redundant tissue was removed by the scissors
^fore Buturiug. The sac was washed out with a bi-
chloride solution (1-3000), and the surrounding parts
Whed in the same. A second swabbing of the inte-
rior of the sac with the carbolic solution was done,
aud the wound was dressed. A drainage-tube was

carried to the lowest part of the cavity and secured by
a safety-pin after slipping it through a hole in a piece
of rubber protective-tissue long enough to cover the
wound with a small margin. This was covered with
a layer of hydroscopic gauze moistened with bichloride
solution (1-3000), which in turn was covered with dry
gauze, and over all a double layer of protective ex-
tending (with a wide margin) over the entire dressing.
The dressing was secured by a firm bandage, so ar-
ranged as to apply considerable pressure and support
the parts. As each layer of the dressing was applied,
a hole was cut in it and the penis drawn through.
The man was directed to turn on his side in urinating,
and cautioned by no means to allow any urine to soil
the dressings. The bandage was arranged to avoid as
much as possible any soiling of the dressing by the
fsBcal discharges, and an inspection of the dressing
after each evacuation ordered made by the nurse.

The man was permitted to sit up as soon as he felt
so inclined, which was on the third day, the only re-

Casb I. Oremaater relaxed,

striction being to refrain from walking around. The
dressing was not disturbed until the bandage became
loose, which occurred on the ninth day, when we were
rewarded by the sight of a clean, dry wound, perfectly
odorless except for the odor of the rubber protective.
The scrotum was considerably swollen, and had a
doughy feel. The sutures had disappeared, and the
drainage-tube had been pushed out and was in the
dressings. The incision was a deep sulcus in the side
of the scrotam, bj parting the lips of which a pink
line could be seen apparently perfectly healed. The
dressing had been stained by the serum, and had a
brownish color, but there was no evidence of pus.
There had been no pain, no rise of temperature.
Mindful of the caution of Knester, as quoted by Senn
in his article on " Hydrocele " in Buck's Hand-book,
that failure attends this operation at times because of
the too early suspension of antiseptic precautions, a
dressing similar to the first one was applied after a
thorough washing of the part with the 1-3000 bi-
chloride solution, discarding the first layer of protec-
tive.

On the fourteenth day the dressings became disar-
ranged on account of the active movements of the

Digitized by

Google

442

BOSTON MEDICAL ASD SURGICAL JOURNAL,

[Hat 8, 1894.

man, and the wound was aeain inspected. The ganze
was slightly stained, and at the lower part of the cut
corresponding to the site of the drainage-tube were a
few granulations. These were touched lightly with
nitrate of silver, a little calomel dusted in the sal-
cus, and a dry dressing applied and held in place by
a suspensory bandage. The man was fit for duty at
this time, but was kept under observation until the
twentieth day, and engaged in such occupations as are
suitable for a convalescent. When the man returned
to duty the scrotum and contents seemed normal in
size. No cicatrix was visible, nothing but a deep sul-
cus (see photograph). The scrotal wall was adherent
at one point; apparently the sac was obliterated.

Case II. The case referred to as operated on
three years previous is that of a young man of twenty,
a railroad brakeman, on whom I operated at Laredo,
Tex. In this case the tumor was five inches in
length and of about a year's growth, situated also on
the right side. I operated precisely as in the case just
reported, except that ether was used for anaesthesia,
and the dressing was the same, except that iodoform
was used. The dressings were removed the eighth
day, disclosing a dry, clean cicatrix. The young man
insisted on going to his home in Corpus Christi, Tex.,
as soon as the second dressing was applied, and went
back to work on the road the next week. Either of
these men would have been at work a week after the
operation had they been professional or business men.

It seems to me that open incision is the only opera-
tion for simple hydrocele of any size. The operation
is not formidable with cocaine anesthesia. My soldier
watched the operation with interest, commenting on
the various steps iu " asides " to the nurse, and seemed
quite cheerful.

I have characterized the practice of paracentesis
and injection with an irritating fluid as unsargical. I
do not draw on any extended experience for this
opinion, for I have treated but one case by this means.
A comrade of my brakeman came to me a short time
after the operation with the request that I operate in
like manner on him. He exhibited a hydrocele about
the size of a large hen's egg, from which I removed
the fluid, having thrown a few drops of cocaine solu-
tion into the site of my puncture, and then injected
the sac with twenty minims of pure carbolic acid, as
recommended by Levis, at the same time promising to
operate as he desired in the event of a recurrence. I
have never seen the man since. I heard indirectly
that he was " all right," by which I felt assured that
none of the accidents which sometimes follow injection
— as suppuration of the sac, gangrene of the scrotum,
or even of the testicle — had occurred, but was left in
ignorance of the success or failure of the purpose of
the operation.

It is on general principles that I object to the injec-
tion of an irritating fluid into the hydrocele sac. It
seems to me unsurgical and unscientific to set up an
inflammation in a closed sac, which at once proceeds
beyond your control, has no drainage, and may do
serious damage to important structures. Agnew states
that he has had but one failure in a number of years
with the injection of tincture of iodine. Other sur-
geons have not had such brilliant success. According
to Seno, in the article above referred to, nearly as
high as fifty per cent, of failures have been reported
as the result of this operation. Nineteen cases were
reported by Bardeleben showing sixty-five per cent

successful ; and there are cases on record of serious
results, involving even loss of life, following the injec-
tion of the tincture of iodine. The use of carbolic
acid seems to promise better results, but I am not able
to find any statistics concerning them.

Injection, then, does not appear to be either safe or
sure; still it is spoken of by Agnew, Wyeth and
others as the conservative method, to be tried in the
majority of cases before attempting the more formid-
able procedure of Volkmann. If we had the power to
set up just a sufficiency of inflammation to obliterate
the sac, and not enough to do any damage to the
structures involved, injection would be the ideal opera-
tion ; but, unfortunately, the most of us have no such
power. To be sure, the interior of the sac is irritated
by swabbing with the carbolic-acid solution in the
open treatment ; but it is quite another matter to irri-
tate a tissue after drainage is established.

The operation of Volkmann appears to me to be the
safest and surest. With cocaine anaesthesia it is not
formidable, and with attention to antiseptic preoaa-
tions it ought not to be serious. The man is incapaci-
tated for duty but a few days, not much longer than
the rest recommended after injection. And with At-
tention to the irritation of the interior of the sac by
the carbolic acid, the result should be fairly sure, the
failure being frequently, if not usually, due to the non-
obliteration of the sac on account of the " too antisep-
tic " healing of the wound.

Vit^nxt^ of JbntisOt^*

BOSTON SOCIETY FOB MEDICAL IMPROVE-
MENT.

J. T. BOWBH, M.S., S^BCaXTABT.

RsaDLAK meeting, Monday, February 12, 1894,
the President, Dr. C. F. Folsok, in the chair.
Dr. a. T. Cabot reported a case, illustrative of

THE OHANGK OV A BENIGNANT TUMOR INTO A 8CIK-
RB0C8 OANCBB IN THE BREAST.

The patient was a lady fifty-four years of age, who
had had more or less trouble in her breast for over
twenty years, this having first appeared at the time
that she was nursing her first child, now twenty-six
years of age. For ten years she had noticed a lump
in the outer segment of the right breast which during
that time had not materially altered in sice.

She was seen by Dr. Cabot in February, 1893.
This little mass then was about the size of a large
English walnut. It was movable, and seemingly not
attached, either below or to the skin. She bad no-
ticed that this lump sometimes increased and became
painful at the times of her monthly sickness, but then
resumed its usual condition.

Dr. Cabot saw it again iu July, when it seemed
possibly a little larger than at the previous examinsr
tion. The skin over it showed a little irregularity of
surface, the irregularity seeming to be caused by a
network of fluid spaces close under the outer layer of
the skin. At no time could anything be felt in the
axilla.

The patient was seen again in December, she hav-
ing in the meantime had some electrical treatment, lo
the hopes of dissipating the lump. The condition of
the skin was unchanged, and it was deemed wise to

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MEDICAL AND SOBQIOAL JOURNAL.

443

remove the maas, not becaase it seemed like a cancer^
but in order to leave no chance of neglecting a aerioas
thing.

Ijhe growth was removed, with considerable tissue
ou both sides of it, and on section, it was found to pre-
sent the characteristic appearance of a scirrhous can-
cer. At once the rest of the breast and the skin lying
over it, and all of the axillary contents, together with
the loose, connective tissue lying between the breast
and the axilla, were thoroughly removed.

Dr. Whitney, who made the microscopical examina-
lion of the specimen, reported the nodule to be a scir-
rhous cancer, and after a careful search through the
glands in the axilla, could find none in which any can-
cerous change had commenced. The dimpling of the
skin seemed to be due to the drawing of little fibres,
running from the growth to the under surface of the
skin at one or two points.

The case was interesting, as showing how a benig-
nant tumor may insidiously take on a malignant char-
acter, and illustrated the importance of keeping such a
tumor under observation and of removing it early, if
any appearance about it suggested a suspicion of its
character.

The wound healed by first intention. Care was
taken to make the section of the growth with a knife
which was not used further in the operation ; and the
hands were carefully washed after this examination
was made, before proceeding with the operation, in
order to obviate the danger of any of the cancerous
cells being transferred to the healthy parts. It seemed
like a remarkably favorable case for a cnre.

Dr. W. T. CODNCILKAN showed specimens of

PIBITOMIT18 DDK TO EMBOLISM OF THE MB8KNTBRI0
ABTBBT.'

Ds. A. T. Cabot said that be had urged at a re-
cent meeting of the Massachusetts Medical Society the
importance of recognizing embolism of the mesenteric
vessels as an occasional cause of obstruction of the
bowels, and that the cases shown by Professor Coun-
cilman were interesting as bearing out this view. He
said that he bad seen cases in which a diagnosis of vol-
vulus was made and in which he had no doubt this
embolism existed.

Db. M. H. Richabdson: I think with Dr. Cabot
that Dr. Councilman's remarks upon this possible
cause of peritonitis are of great interest. That a gen-
eral fatal peritonitis may be due to an interference
with the intestinal circulation which is beyond surgi-
cal relief, is a fact of the greatest importance. I have
considered the question of interference in such cases
several times this last year. In the one of which Dr.
Cabot speaks, volvulus was thought to be present. I
made the autopsy, and sent the abdominal organs to
the hospital. Dr. Fitz was unable to demonstrate the
precise lesion. Dr. Cabot will remember two cases at
the hospital of supposed general peritonitis following
fractures of the thigh. There was some question of
thrombosis or fat embolism at that time.' In the first
case fat embolism was found at the autopsy ; the sec-
ond case was not examined post-mortem. Not long
ago, in consultation with Dr. Shattuck, the question
was considered of operating in the following case of
apparent general peritonitis and obstruction following
typhoid fever. It seemed very probable that there

■ See page 410 of the Joamal.

' See paper by W. F. Whitney, Boston Medleal and Snrgieal Jonr-
nal, Febniary 18, Vm.

was a portal thrombosis or an embolism — something
which no operation could relieve.

Mrs. H., aged twenty-three, was convalescing in the
fourth week of typhoid fever. The attack, mild
throughout, was uneventful till thirty-six hours before
my examination, made at 2 a. m., October 22, 1893.
Eight days before she had had pain in both legs, for
which a hypodermic injection of morphine had been
given. At one o'clock, Friday, she was seized with
severe epigastric pain relieved by half a grain of mor-
phine. This was followed in twelve hours by vomit-
ing, which soon became stercoraceous. Her bowels
moved freely Saturday night from a glycerine enema.
Her pulse Sunday morning was 132, the temperature
99°. The facies was peritoneal and the general con-
dition bad. There was some tenderness above and to
the left of the umbilicus, where distended coils of in-
testine could be felt distinctly. There was no general
distention, though the abdomen was rather full. The
patient's condition was deemed hopeless, and no opera-
tion was advised. The diagnosis by exclusion indi-
cated portal thrombosis as the probable lesion, though
the possibility of some pancreatic affection was con-
sidered. Death took place in forty-eight hours. The
autopsy by Dr. Whitney was unsatisfactory on account
of the interference with the pathological appearances
caused by the undertaker's fluid. There was no le-
sion of the intestinal tube, however, npr was anything
found incompatible with the diagnosis of portal throm-
bosis.

In this case, as in the one referred to by Dr. Cabot,
and in a fatal ' appendicitis the most marked physical
sign was the distended coil of small intestine. In such
cases the segment of bowel is darkly congested, and
heavy with blood and fluid. The sensation of tension
and resistance through the abdominal wall is charac-
teristic of a tightly distended coil, but no inference can
be drawn as to its exact cause without careful consid-
eration of the history and accompanying physical signs.
The clinical features of cases of this kind are of the
greatest interest to me ; a satisfactory pathological ex-
planation of them that will enable us to avoid operat-
ing in hopeless cases will be extremely valuable.

I have no doubt that we have erred in our diagnosis
even at the operations for fatal cases of apparent peri-
tonitis, not only because it is impossible at times to
tell the exact pathological lesion, but because no au-
topsy is allowed. All who operate in acute abdominal
conditions must be able to recall such cases.

I was very much interested in what Dr. Councilman
said about the colon bacillus and its means of invading
the tissues. I have had cultures taken in all abdom-
inal operations in the last six or eight months. The
fact that many of the alimentary micro-organisms will
not grow in the ordinary media is very interesting, but
it does not militate against the important clinical ob-
servation that, as a rule, if the cultures fail the patients
get well ; if the colon bacillus from a general exudate
does grow on the culture media, the patient dies. This
has been the invariable rule since I have made cultures,
but the number of observations is still too small for any
sweeping statements.

STBICTCBE of THE UBBTHBA, WITH SPECIMEN.

Dr. Kiohabdson : This specimen is a firm, fibrous
stricture of the urethra, dilated just in front of the

> Caae of O. W. S., In Boston Medical and Surgleal Journal, Janu-
ary IS, 18S3.

Digitized by

Google

444

BOSTON MBDICAL AND SUBGIOAL JOVBNAL.

[Mat 8, 1894.

T

bulb. The patient, a man of abont thirty, reoeived
gome years ago a blow in the perinaeum which
resalted in a strictare that was almost impervions.
The urine escaped constantly by drops. The bladder
was enormously distended. Nothing coald be intro-
duced. By perineal section the fibrous mass was easily
exposed. Above the constriction the urethra was
much dilated ; below, thongh healthy, it was Battened
and contracted from practical disuse. By transverse
cuts above and below, the whole mass was removed.
The ends of healthy urethra were brought together
easily upon a No. 18 English sound, and fixed in satis-
factory approximation by means of interrupted silk
sutures. The deep union was immediate. The urethra
was at once restored to its normal function. The pa-
tient has gained thirty pounds, and is in perfect health.

SPECIMEN OF APPENDIX.

Db. J. W. Elliot : I removed this appendix abont
ten days ago from a boy of thirteen. He never had an
attack before. The attack began on Thursday, and
his bowels were moved with oil and he was better on
Friday. On Saturday more pain, and on Sunday his
bowels moved again. On Tuesday I saw him and
operated at once. He had a temperature of 101°, pnlse
of 90. The abdomen was not tympanitic, but there
was a certain cakiness, on the right side, which I
thought was omentum and which turned out to be
omentum. The interesting thing about this specimen
is that although the attack was acute, the appendix
looks like a chronic appendicitis. The whole appendix
is thickened and stiff. The acute part was due to the
sloughing of the tip, which is opened and perforated ;
the omentum was wound round the appendix and saved
the boy's life. There was about a teaspoonful of pus
near the gangrenous tip with omentum round it. The
boy made a good recovery.

De. W. T. CoDNCiLUAN : I should like to say that a
short while ago I made an autopsy in which there was
congenital absence of the appendix. I made the dissec-
tion with the greatest ease, and no traces of an appen-
dix could be found either on the outside or in the in-
side, but in the small intestine just above the valv&
there was a small diverticulum extending into the tis-
sue for about one-half to one inch, which I do not think
was at all analogous with the appendix. But it was
interesting to find this diverticulum at the end of the
small intestine with entire absence of an appendix.

Db. H. L. BnBBELL read a paper on

THE AFTEB-TBBATMENT OF APPBNDIOITIB.*

Db. 6. W. Gat : I was interested to hear Dr.
Burrell describe his method of treating the stump of
the appendix. In some cases, as we all know, that is
the only thing we can do ; the appendix is so rotten,
that there is no taking sutures of any sort in the ap-
pendix itself, and in some cases, of course, nature does
all that herself. The ideal way of treating an appendix,
where you can, is to dissect off the outside covering,
tie the appendix itself with catgut, bring the cover up
over, and sew with a fine catgut suture. I most heartily
agree with Dr. Burrell, when he says that he does not
use silk about the appendix. 1 never leave silk in the
peritoneal cavity if I have any suspicion of suppura-
tion afterwards, because it often acts as a foreign
body and keeps up a sinus for an indefinite length of time.
It is not easy to open a wound and find a suture buried
* Sea pace 433 of the JoanuU.

at the bottom ; it may be covered with granulatioDB.
I have in mind two cases of removal of the Fallopian
tubes in which the tubes were tied off with silk, and
the sinuses have never closed. Theoretical!;, the
proper way is to close the stump of the appendix in a
way to bring other tissues together than the macons
tissues. If you cannot do that, I like to use the gaaze
drainage. I do not like rubber tubes for drainage.
The wound shrinks in twenty-four hours so that all
the drainage you get is what is about the tubes, and it
is not so thorough and efficient as it is to pack the
wound with sterilized gauze, leaving that in three to
five or six days. Ton probably get in that way as
good drainage as it is possible to get in these cases,
provided it is not a large pus cavity, wben it is simply
a case of putting in drainage-tubes and washing out as
you would any abscess.

In regard to the use of saline cathartics or cathartics
of any sort, I feel very much indebted to the gentle-
men who have called me in consultation for one thing,
and that is, I have learned the effects of cathartics.
Almost all the cases J have been called to have had
cathartics, and I have had a good chance to. study their
effects. In many cases they have been given where I
should not dare to use them. In some cases they seem
to do good, in some cases harm. In the case of acate
sharp appendicitis I should not dare to give cathartics.
In the case of moderate appendicitis I think it does not
make so much difference if you give a saline or a dose
of castor oil. I have seen a good many cases where
they hare received those remedies, and at the end of
four or five days they have turned the corner and got
well. In a severe case I think it is pretty well agreed
that it is better not to give laxatives at all. After the
operation the question comes, When shall we give
cathartics ? I do not like to give a cathartic under
three or four days. I have the fear that by stardng
up peristalsis I may rupture the catgut ligature or per-
haps produce a leak through the stump of the appen-
dix, which perhaps drainage will not control. That is
an objection which may perhaps be theoretical. As
soon as I feel reasonably sure of the stump of the ap-
pendix, so that if any contents do come out they can
be readily taken care of, 1 believe most thoroughly in
salines given in small doses and frequently repeated.
Vomiting is no bar to giving saline cathartics. I think
I have seen vomiting stopped in peritonitis in other
operations about the pelvis by giving saline cathartics ;
and my rule in threatening peritonitis is to give them
in teaspoonful doses every hour, vomiting or no vomit-
ing, until the bowels are evacuated.

In regard to opiates, 1 never have let my patients
suffer very much for the want of an opiate. I think
that pain has a good deal of depressing action upon
the patient's strength, and I think probably the opium
does more good than harm. One of the beat tonics or
stimulants after these operations, as after all peritoneal
operations, is strychnine. I think it is better even
than the alcoholics or better than anything else I know.

In regard to the time of removing the drainage, as
Dr. Burrell says, it has got to be decided in every case,
and you have got to go by your judgment. If there
is going to be any walling off of the wound, it takes
place within two or three days generally. After that
} ou may begin to remove the gauze and, so far as I
know, I have never seen any symptoms arise, which
showed that the gauze was removed too soon, and the
peritoneal cavity reinfected. Bubber-dam in these

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MEDIO AL AND SUBQWAL JOVBNAL.

445

cases I have not used much for drainage. I have used
it in breasts, and I think it is pretty good there. I
believe where there is no pas, in closing the peritoneal
cavity, as Dr. Burrell says, a line of sutares for the
peritoneum, another for the muscles and transversalis
&8cia, and another for the muscles and skin. I believe
that the more attention wounds get the better. Even
if you close the abdominal cavity up tight, I always
like to see it at the end of three days, and I never let
a wound go over live days without looking at it. If
there is to be trouble, I think you will find it on the
third day, as a rule ; from the third to the fifth day
have been the critical times in my experience. 1 be-
lieve in seeing the wound pretty often, and then you
can take steps to correct mistakes or unfortunate occur-
rences. The other points that Dr. Burrell brings up
are so well founded in my opinion, that I have nothing
to say in relation to them.

Dr. M. U. Biohaboson: This subject should be
divided for discussion into two or three distinct classes :

First, the cases in which the comparatively normal
appendix is removed in the period of abeyance, when
it is possible to close the abdominal cavity at once. In
these cases, as far as I have observed, it makes no dif-
ference whether we use catgut or silk for tying the
appendix or whether we cover the stump with perito-
neum or not ; whether we simply cut oS. the appendix
and sear it with the actual cautery ; whether we touch
the pedicle with peroxide of hydrogen or corrosive
sublimate or whether we drop it back untouched.
These cases all get well as far as I have observed in
this community. Not that in so safe an operation
there is no danger ; the accidents inherent even to the
simplest procedures make a probable mortality in this
of two or three per cent. The only occasion for drain-
age in this class is when there is a septic exudation
aboat the appendix. Under such circumstances a
slender gauze wick should be used, to be withdrawn
in fortj-eight hours.

Secondly, the gangrenous appendices with more or
less e:3(tensive extravasations. In these cases the
material used and the manner of applying the ligatures
are indifferent so long as two things are accomplished
— the restnuning of further extravasations and the
controlling of hsemorrbage. To spend valuable time
in attempting to cover in the stump of the gangrenous
appendix — inflamed, swollen, and friable, like those
I have just exhibited — is often impossible, is always
unnecessary and unwise. The only object for such a
procedure is to make immediate closure and first inten-
tion possible ; for extravasations are effectually re-
strained by the ligature, or if that gives way, they are
provided for by the gauze or tube drainage.

I do not believe in the use of salines before oper-
ation, because the first symptoms in most severe cases
of appendicitis are caused by fteoal extravasation, often
aggravated by cathartics. The opening in the appen-
dix and into the caecum may be as large as the open-
ing of a bullet wound. I have seen thin faecal matter
escaping from the appendix in several instances. I
have not the slightest doubt, therefore, that salines
have killed a good many people who, perhaps, would
otherwise not have died. After operation, when the
appendix has been securely tied, or when extravasation
has been provided for by drainage, salines fulfil a very
useful purpose in exciting abuudant liquid discharges
and in eliminating the toxic products of germ growth.
Yet I cannot help feeling that perhaps too much reli-

ance is placed upon their use ; that in a general perito-
nitis, with the intestines paralyzed, the abdomen dis-
tended, and the patient constantly vomiting, salines do
no good whatever. They may even do harm by add-
ing to the patient's burdens. I have never yet seen
a case recover under these conditions, with any method
of treatment.

With regard to intestinal drainage by enterotomy, I
have seen this done once with marked success by Dr.
Warren. The peritonitis had been going on for some
time, and was not of the fulminating variety. Recently,
in another case of general septic infection, I opened
the caecum after having drained in the median line for
appendicitis with extravasation. The adjacent seg-
ments of the large intestine emptied themselves through
the lumbar opening without any permanent benefit.
The patient soon succumbed.

Third, abscesses in which the general peritoneal
cavity is not infected generally do well, whatever
method of drainage may have been used, provided it is
effectual. I prefer the use of both tube and gauze, the
latter in slender wicks. Gauze tightly packed often
acts as a plug and prevents the escape of pus. I have
used many methods of irrigation in circumscribed ab-
scesses. None is more effectual than thorough flush-
ing with boiled water. Recently I have tried peroxide
of hydrogen in these cases, followed by that of the
normal salt solution, as recommended by Dr. Morris,
of New York. I have not observed any improvement
in results by this method. On the other hand, I be-
lieve that there is a distinct disadvantage in the use of
irrigation in local infections which have not become
general — in which the adhesions are broken down,
but in which there has been as yet no extensive soiling
of intestinal coils. The use of warm water, under
such circumstances, is hazardous, because it may spread
to distant parts colonies of bacteria which by the dry-
gauze method would be confined to the immediate
vicinity of the drainage-tube.

In many cases of circumscribed abscess drainage has
been followed by a fistula. This appears usually some
days after operation, and often results from the slough-
ing of the stump. In these cases, with one exception,
the fistula has closed spontaneously. In two instances
occurring in the practice of others I have closed the
fistula by resecting the intestine. In two cases malig-
nant disease of the caecum eventually complicated, if
they did not cause, the fistula.

I have never seen any bad results from the presence
of germs in a well-drained wouud.

Too much gauze sometimes causes obstruction, either
by direct pressure or by keeping the intestines in a
faulty position until adhesions form and cause acute
obstruction. Such a case I have had in the last four
weeks. By opening the wound and separating the re-
cent adhesions the patient was permanently cured. I
am afraid of iodoform freely used. Except in very
rare instances I use only sterile gauze.

Care must be taken not to drain a cavity too long.
A permanent fistula may be formed which will close
only very slowly.

I cannot believe that it is justifiable always to re-
move the appendix. In circumscribed peritonitis
separation of the adhesions adds enormously to the
dangers of general peritonitis. I cannot understand
how it can be regarded in any other light. Cases of
abscess with localized peritonitis get well almost in-
variably ; as large a percentage recover as in the oper-

Digitized by

Google

446

BOSTOH MEDICAL AND SDUGJCAL JODBXAL.

[Mat 3, 1894.

ation for recurrent appendicitis. I know of one or
two cases in which there have been subsequent attacks ;
in these the first opening was probably near the tip of
the appendix, another fsBcal stone near the base caus-
ing the second attack. Nevertheless I do not believe
that in many cases there is any recurrence of the trou-
ble, even if the appendix is not taken out.

The reopening of the wound for any cause seems a
grave sequel. I dislike very much indeed, once hav-
ing operated, to go in again, for the reason chat the
peritoneum is shut off by adhesions so recent and deli-
cate that you cannot avoid frequently infecting with
your finger the peritoneal cavity. Perhaps this dan-
ger is not 80 great as it seems. When I have been
obliged to reopen the wound and explore extensively,
no untoward results have followed.

I have closed the wound only in the recurring cases,
or in those operations in which the appendix seemetl
but slightly affected. I use the same method which I
learned from Dr. Homans, that of applying but one
row of interrupted stitches. For a short time this
year we united the abdominal wall by layers. There
seemed no advantage in this method, and it was soon
abandoned. I do not think that hernia has followed
any oftener in my abdominal cases than in those of
most surgeons. In my opinion a line of stitches in the
peritoneum is of little importance, and adds no strength.
If you are going to bring together by a separate line
of sutures the strongest layer in the abdominal wall,
you ought to put a row in the external oblique.

1 have had practically about as good results in thosu
cases in which I have left the patient in the hands of
the general practitioner as at the hospital where they
have had the care of experienced men. Certain cases
will die wherever they may be or whatever the treat-
ment. In a small percentage of patients the result will
be directly affected by the knowledge and skill of the
attendant. On the whole, however, the results are
about the same in one place as iu another, by one
method of treatment as by another. A series of three
cases last summer shows that some are essentially,
necessarily fatal. All three cases died. The trouble
was not in the way the tube was put in, or the way
the case was treated afterwards, but in the nature of
the case ; in every one there was general peritonitis.
In one the colon bacillus was found, and in all a fatal
termination was unavoidable. I do not believe that
these cases could have been saved by any method of
treatment that is known at the present time.

I would not be understood as saying that the after-
treatment makes no difference, however. In my
belief and experience it does make some. The result
depends more upon causes beyond our reach than it
does upon any special method of treatment.

Db. Cabot said that while there was no doubt that
the patients did very well when the appendix was
simply tied and cut off, still he preferred the method
of stripping back a cuff of the serous coat, then tying
the mucous and submucous coats with catgut, and after
cutting off the appendix, bringing the serous coat to
gether over the stump with fine silk sutures.

Among the possible causes for persistent vomiting
after the operation, he would include iodoform-poison-
ing, which he thought was sometimes overlooked.

In regard to the closure of the wound, he said that
he always used a single line of sutures, iuclnding the
peritoneum, both deep and superficial fascia and the
skin. He had noticed that in some cases while he was

at work, if the patient coughed, the wound was drawn
firmly together in^ tead of being separated by the ac-
tion of the muscles. He thought that this occDrred
when the incision was carried just through the edge of
the rectus sheath, having the tendinous linea semi-
lunaris just outside of it. He always tried, therefore,
to make his incision at this point.

Dr. Elliot : I would say, in regard to the material
used to ligature the stump, that I have always put silk
in the abdominal cavity in septic cases and every other
case, and never had any sinuses or fistulas coDoected
with the silk. I do not believe it makes the (lightest
difference what material you put in. I think probably
the old sinuses from salpingitis and tubes are due to
part of the tube being left or part of the thickened tis-
sue left. If the silk ligatures are sterilized, I do DOt
believe they often make trouble. Having done several
hundred cases of laparotomy, and having left silk in
all of them, I think I should have seen trouble if silk
was objectionable.

I agree with Dr. Richardson that it does not make
much difference which way yon treat the stump. If I
had time enough, I should du as Dr. Burrell suggests.

So far as the after-treatment of the wound is con-
cerned, I have some rather decided ideas of my own,
and one is I almost never wash out an appendtcids
wound. I am very much afraid of washing into the
peritoneal cavity. I suck and swab it out. I think if
you have a suppurating wound under the fascia, where
pus is forming rapidly, yon need a drainage-tube, be-
cause the fascia closes so tightly on the gauze that it
leaves a very small opening indeed. If the gauze were
changed often enough, it would counteract that palling
together of the fascia ; but yon hardly want to take
the gauze out two or three times a day and put it back
again.

Db. Bcbbbll ; I differ entirely from Dr. Richard-
son in regard to the classes of cases. Up to last June
I felt exactly the way he does in regard to this subject,
that there were a certain number of cases going to die
any way and a certain number of cases going to get
well. I started in on my service last summer with
the intention of investigating and seeing if there was
not some possibility of saving those cases which are
classed as fatal, simply from the fact that they have
general peritonitis ; and I satisfied myself, at least, that
I could save a certain number of them.

I can recall at this moment four cases of distinct
general peritonitis, not of the fulminating type, bat
where the abdomen was tympanitic, and where there
were chills, yet these patients got well by care in their
af ter-treatmen t.

Dr. Richardson: I would not for a moment be
understood as maintaining that these cases of general
peritonitis ought to be left to die unrelieved. Far from
it. I have found at times a much more favorable con-
dition of things than I had expected. Indeed, so com-
pletely may we be misled by the general appearance,
the local conditions, and the constitutional disturbance,
that all cases, unless actually dying, should be explored.
Unfortunately the cases in which we are deceived are
very rare. Only those should be described as general
peritonitis in which by bacteriological examination the
presence of micro-organisms is demonstrated *m th»
general exudate, although, as Dr. Councilman remarks,
some forms of bacteria doubtless fail to grow on the
ordinary culture media. My experience may have
been unfortunate, but in no case has recovery followed

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MBDIOAL AND SUBGJOAL JOURNAL.

447

» general bacterial infection, as showo by caltares
from the general exudate. Cultares from the appen-
dix alone are of no ralue whatever in deciding the
question of a general infection. Practically, all appen-
dices contain either pure colonies of the colon bacillus
or a mixed cnltnre, as shown by Mr. Darling in ex-
amination of my cases. Unless these micro-organisms
have escaped into the general peritoneal cavity, there
can be no general infection, and results following oper-
ations upon a supposed general peritonitis are of no
value.

I have closed the stump as Dr. Burrell has suggested
in every case in which the appendix was not gangre-
nous or infiltrated.

Dk. Bdrrkll : I simply wish to place on record,
Mr. President, that cultures were taken in all of these
cases of general peritonitis, so that we know that the
colon bacillus was present.

Dr. J. G. MuMFORD : When the abdominal wound
has been closed over an amputated appendix stump,
the treatment is the simplest imaginable. I have never
seen harm come from getting the patient onto a plain,
regular diet by the sixth day, moving the bowels by
au enema on the third day and giving a mild laxative
each day subsequently. Even those cases in which a
large incision has been made, and the wound filled with
ganze-wicking and drainage-tubes may be conducted by
common-sense rales.

The more I see of these cases the less I am inclined
to feel that immediate movement of the bowels is
essential. In perhaps the first fifty cases which came
under my care I tried the use of cathartics — salines
— as soon as possible after the operation. During the
past year and more I hare become much less eager to
encourage peristalsis early. The patient's bowels are
usually not loaded, though the rectum is often full. If
there has been vomiting, the small intestine usually
contains nothing but gas. The intestinal drainage is
well accomplished through the artifical opening. It
must be remembered, too, that this wound is an unusu-
ally painful one during the first day or two.

For these reasons I always order a large hypodermic
of morphia to be given before the patient's recovery
from ether, and except for washing out the rectum,
direct that the bowels remain undisturbed for thirty-
six or forty-eight hours. I then begin on cathartics,
and of these I eschew salines. I was led to this first
from finding the frequent impossibility of such treat-
ment in children ; I substituted for salts minute and
frequently repeated doses of calomel. One-tenth of a
grain repeated at fifteen-minute intervals will very often
move the bowels before a whole grain has been thus
given. Patients take this readily, the stomach is not
disturbed, and nausea is apparently thus frequently
checked. When the bowels have once been started
they may be kept open by a mild laxative given every
day.

As to the diet, to give nothing by the mouth the first
sixteen hoars, and then, beginning with liquids, to
gradually work up to a full diet on the fifth day, is a
good safe rule, if the case goes well. Stimulants
should be given freely by rectum or hypodermically
daring the first two days. I prefer large enemata of
the normal salt solution, or four ounces of black coffee
combined with strychnia, given three or four times
during the first twenty-four hours.

In regard to the care of the wound there is little I
can add. The main point is to keep the dressings

clean and the tubes clear during the first two days espe-
cially. The outer layers of the dressing should be
changed once or twice daily and the tubes very gently
syringed out with boiled water. If there is much pain
and distention, I usually order a large creolin pad to
cover the whole belly, and change it every three hours.
This often gives the patient a surprising degree of
comfort.

I think we are inclined to pull out the deep gauze
drains too soon and to leave in the tubes too long.
The gauze wicks may usually be left in four or five
days, and pulled out as they loosen. There is always
some suppuration behind them. The new wicks should
be very lightly placed. At the end of the week, if the
case does well, we may begin to shorten the tubes. I
seldom see occasion to leave them in longer than three
weeks.

MASSACHUSETTS MEDICAL SOCIETY.
SUFFOLK DISTRICT.
SECTION FOR CLINICAL MEDICINE, PATHOL-
OGY AND HYGIENE.

HBHBT JA.0KSOH, I(.D., SBCBETABT.

BEonLAH meeting, Wednesday, February 21, 1894,
Dr. Fbbdkbick C. Sbattcck in the chair.

THE' PRODUOTIOM OF YAOCINB VIRC8.'

Dr. D. D. Gilbert, of Dorchester, gave the report
of a committee appointed by the Norfolk District
Medical Society to investigate the production of vac-
cine virus.

After the reading of this report at the Norfolk Dis-
trict Society a motion was made that a committee he
appointed to urge upon the legislature the establish-
ment of a State institution for the propagation and
supply of vaccine stock ; that since vaccination is made
compulsory by the law of the State it seems incumbent
upon the State to provide for its inhabitants as pure
and efiicient vaccine stock as science can produce.
That vote was passed, and a committee was appointed.
That committee was instructed to ask the co-operation
of the Suffolk District Society in bringing the matter
before the legislature, and I suppose to your knowl-
edge of that fact I am indebted for the privilege of
reading this report to yon to-night.

Dr. S. W. Abbott : My interest in this subject is
not merely a receut one, but dates back thirty years or
more. I think it is not generally known among the
profession that animals were vaccinated so long ago ;
but a considerable quantity of the lymph used in the
army from 1861 to 1865 was obtained from cows.
My preceptors, Drs. Benjamin Cutter & Son, of
Woburu, took a very lively and personal interest
in it at that time. The report upon that subject is
to be had in the reports of the United States army
of that period by Surgeon Milhau.' The method has
been criticised from this fact, that some of the animals
were vaccinated upon the principle of retro-vaccina-
tion, that is, by vaccinating a cow from a healthy in-
fant. There is not the slightest objection to that
method in my opinion. It is endorsed by the German
government,* and advised by them at the present day,

1 See page 433 of the Joonukl.

< See Medieal and Snrgioal Hlstorr of Ww of tbe BabeUlon, Part
lU, Medieal Volnme.

> Eztraot from Deeree of the Bondesrath of April 28, 188T.

Section 18, relative to tbe method to be taken for beginning a sno-
oeirioii of animal Taooinailons : "In tbeTacoinationof aninuut there
may be uaed, (a) humanized lymph taken from the Teslolei of a pri-
mary TaeelnatioD, tabjeet to the laws of the Bundesrath of June Is,

Digitized by

Google

448

BOSTON MJSDICAL AND SVttmCAL JOVttNAL.

[Mat 3, 1894.

provided the infaDt be healthy in all respects, and it is
as easy to obtain a healthy infant as a healthy cow.
There is no evidence to show any real difference in
the vaccine lymph thus- produced, when two or three
removes from the healthy infant, as compared with
that which is obtained by continuous vaccination, be-
ginning with the lymph derived from a case of cow-
pox in the cow. You may vaccinate from an infant to
a heifer to-day and back again indefinitely, or take a
series of infants and vaccinate from one to the other,
or a series of cows from one to the other ; and no evi-
dence is as yet given to show an actual difference in
the character of the lymph produced in efficiency or
protective power. One of the great reasons for the
change was the possibility of communicating syphilis,
which is a very rare occurrence. Dr. Corey, of Lon-
don, submitted himself to be vaccinated from a syph-
ilitic infant, in 1881, and went through the stages of
syphilis himself.

X took up animal vaccination again during the epi-
demic of small-pox in 1872, and continued the prac-
tice some twelve years, but at no time using the
method of extensive scarification spoken of to-night.
I employed a simple incision not over one-fourth of an
inch in length, and just going through the skin, mak-
ing four incisions at once, with an instrument which I
devised for the purpose.* For the last twelve or thir-
teen years I have had little to do with the practical
side of the question in any way.

1 have had some opportunity to stndy the methods
that have been adopted abroad, and find that they dif-
fer in a 'great many points from the methods adopted
here. In almost every country on the other side of
the water the practice that has been advued by the
committee to-night is in vogue, that is, to have the
government take charge of the work. It is not usually
a commercial business abroad. There are, it is true, a
few private vaccinal institutes in France and some
other countries, and lymph may be found for sale in
some large cities, but the possibility of its being a trade
or occupation or money-making business is largely re-
moved, especially in Germany. Some twenty-four cities
in Germany have their own vaccine institutions under
the government of the country, the Imperial Board of
Health having a general supervision. The most im-
portant is that of Berlin, and I think the next in size
is in Cologne ; others are in Munich, Hamburg, Frank-
fort, and almost all the large German cities.

The German law upon this subject is quoted in full
in " Wood's Reference Hand-book," Vol. VIl. The
method of preservation with ivory points is not much
used abroad, it is a very convenient method. The
lymph used abroad is chiefly the glycerinized pulp.
It is, 1 think, the method advised by Dr. Warlomont,
of Brussels, who might well be called the father of
bovine vaccination. His own work in Brussels is so
carefully conducted that every animal is slaughtered
and examined to find out whether the animal is healthy
before the lymph is sent out. That is not done in all
places. In London, the work is under the care of the
Local Government Board, and Dr. Corey, who has
been connected with that work for the last ten or fif-
teen years is well known everywhere as an accom-
plished expert in such work. He has made, as many

188C : (ft) aDlmal lymph (ubjeot to the rame oondltioni u bamanlzed
lymph ; (c) the solid and fluid portions of the

I KHsalled natoral oow-

poz.'

< Figures iu Wood's Befeienoe Hand-lMOk, vol. tU, Art., Taoclua-
tion.

as fifty thousand vaccinations of infants without a
snigle failure, and does not believe in so-called Idbos-
ceptibility of infants to vaccination.* In England, the
parents or guardians are obliged under penalty for re-
fusal to bring the infants at the proper Ume to the
station to be examined, to find out whether the vacci-
nation has taken or not, and in that way they obtuo
the records. In Italy, the government assumes control
of vaccination, but in a more limited manner as to
lymph-production. So also in Austria, Sweden and in
some other countries. The following provision is
made in the Italian law :

Akticle S. Animal lymph may be preserved by the
medical officer of the province, either at an institute for the
production of lymph established by the provincial author-
ity, or at an existing private institute for the production
of lymph which has received official recognition from the
provincial authority. In either case the institute most be
put under the supervision of the medical officer. The med-
ical officer is also empowered to make use of the National
Vaccine Establishment at the office of the Department of
Public Health (in Kome) . [From tbe Regulations issued
at Rome, June 18, 1891.]

There is one other point upon which I should like
to speak, in which there is a great difference in all
foreign countries from the practice now in this coun-
try, and that is as to the time for collecting the lymph
from the animal. The time may be perhaps most ac-
curately stated in hours. One hundred and sixty-
eight hours (7 days) is the time that has been em-
ployed most commonly in this country, that is, a cow
or heifer is vaccinated upon a certain day of the week
and the lymph collected upon the same day of the
week following. I think there may be some instances
where it is taken a day earlier, but in no place either
in Glermany, in Paris or in London is the time longer
than six days, and often it is five days or even less. I
will read a few of the places where the time is stated :
Berlin often 72 hours, Hanover 96 hours, Munich
at the end of the fourth or beginning of the fifth day,
Dresden three and a half days, Strasbnrg 117 to 144
hoars. In one case a period of six days is mentioned.
There is a reason for the difference, and I have no
doubt that the reason is of a commercial character,
so far as American methods are concerned. The
amount of lymph that can be collected on the seventh
day is very much greater than on the fifth or sixth
day ; and, as a general rule, I have no doubt that the
lymph collected on the seventh day is perfectly good
to use, but not always. Frequently on the seventh
day I have seen vesicles that not only had much
lymph in them, but they had also a purulent appeap
ance, and certainly it would not be desirable to use
lymph of that character. It has been used, and no
trouble may have supervened ; but I oan believe that
that is one of the reasons why such lymph is regarded
with suspicion by persons who have made a thorough
scientific study of the subject unbiased by financial
considerations. It seems to me it would be a wise
thing on the part of this Slate to send some young
medical man to study this whole subject for a period
of six months, or more, if necessary : spending two
months with Dr. Corey, two with Warlomont, and
two with the best German authorities, who have made
a scientific study of the whole question. I think we
should gain very much by some such method as that.

• " I have vaceinated close upon 80,000 ohlldren, and have new
seen a ease of Insosoeptibility." Erldenoa before Royal Conunisslon
on Vaooination, vol. ii, p. 142, 1889.

Digitized by

Google

Vol. OXXX, No. 18.1 BOSTON MSDWAL AND SXntQIOAL JOVRSAL.

449

I woald go further than anything that has been said
here upon one point. It has been stated that the bay-
ing and selling of vaccine Ijmph at low prices has a
bad effect ; but I believe it woold be still better if it
were to be given away freely to physicians.. The
State should furnish it, and should bear the whole ex-
peoie and furnish it free; not outside of the State
limits, but to persons within the State of Massachu-
setts, I mean to boards of health, to cities an(L towns,
SDd to all public institutions in the State and to all
physicians in the State, and do away utterly and en-
tirely with the sale of vaccine lymph by middle-men,
apothecaries and travelling agents, and have it issued
directly from the vaccine institution to the persons
who are to use it, free of charge. I would not go so
far as to say it should not be sold; but I think it
should be made so free that no financial hindrance
sbould prevent the vaccination of children.

Db. BKOuaHTOM: I most confess that when we
started to investigate this subject of vaccination I was
oot prepared to find so extensive a field for study.
There is certainly more in it than we have been wout
to believe. I am of the opinion that the profession as
a whole has not paid due attention to many phases of
it. The theme is so trite that even our medical schools
hare not always emphasized it sufiSciently. My first
thoQght, therefore, as a result of our limited study, is
a feeling of criticism of the general attitude of physi-
cians upon the whole subject. There is a vagueness
of view aad a certain looseness of expression among
many that is unfortunate. For instance, we have
some who are prominent in the profession, eminent
for their ability and learning in other departments of
medicine, who have been heard to say, perhaps in a
casual way^, that they do not believe in the necessity
of re-vaccination. Doubtless such a remark may be
made carelessly and without deep conviction behind it,
bat emanating from prominent men the remark is
quoted, and perhaps exaggerated, and a certain amount
of harm is doue. My own feeling is that during the
present epidemic of small-pox the anti-vaccination sen-
timent has in this community gained not a little ground.

My own interest was first aroused by individual ob-
servation. In cur practice at Jamaica Plain we seemed
to meet with a large number of severe arms. Upon
inquiry, many of the profession were of the opinion
that severe cases were unusually prevalent in the city
and vidnity. We began to question why this was. I
am going to speak plainly because we have not the
•lightest personal feeling and intend no injustice to
any. As we inquired further, it seemed as if almost
all the severe cases of vaccine were in those vaccinated
by the city, and we found that the source of the virus
was from the New England Vaccine Company. That
led us to desire to look into the matter, and the Nor-
folk District appointed us a committee to investigate
the subject. Dr. Gilbert has covered the ground, and
1 will only emphasize one or two points. It was ad-
mitted without the slightest hesitation by Dr. Cutler
of the New England Company, that the lymph sup-
plied by him was of a much more active character
than any other virus in the market. He claimed that
this was desirable. The poor were coming into the
headquarters to be vaccinated, and they wanted some-
thing that would take every time. He criticised, how-
ever, the technique of vaccination as ordinarily done
by physicians. He claimed that they frequently made
too large abrasions, and the result was a very large

vesicle with a slough and a good deal of constitutional
disturbance. We asked him why his vaccine lymph
was more active than that from other sources, and I do
not know that he could fully explain it. We queried
whetber it could be explained by the fact that the
cows were four years of age, whereas in the other in-
stitutions the cows were younger; and, secondly,
whether his method of vaccinating the cow — by the
production of such large vesicles — does not produce
a lymph that contains a greater variety of germs, and
perhaps germs of a more active virulence. Adopting
the plan suggested by Dr. Cutler, Dr. Perry vaccinated
a baby with the New England virus making only a
very minute abrasion and the result was a most beau-
tiful and perfect vesicle, hardly larger than the end of
a lead pencil, and it would seem as if possibly there
was some basis for Dr. Cutler's statement that the se-
vere arms are the result of improper methods of tech-
nique. I would say, in conclusion, that loose habits of
vaccinating should be corrected. I have known of
one or two cases where vaccinations have been made
upon the inside of the thigh, a moat inappropriate
place. Many, we fear, make no effort to vaccinate
upon a clean surface, and are not scrupulously careful
as to the condition of the instrument used. The after-
care of the abrasion and vesicle has also been largely
neglected. The profession is more or less responsible
for the incorrect and erratic views afloat iu the com-
munity. Regular physicians should be more careful
what they think, what they say and what they do in
this whole subject. Severe " takes " and unpleasant
complications can be largely prevented I believe by
proper care, and thus popular prejudice will be allayed.
The State makes vaccination compulsory. It would
seem, therefore, that upon her should devolve the re-
sponsibility of providing a standard and uniform kind
of virus.

My feeling is that a committee should present a bill
to the legislature. This, if properly framed and sup-
ported, can ultimately produce some effect. If the
State can control the production of virus many of the
evils will be remedied.

Dr. Mabtin : I am most heartily in favor of Dr.
Abbott's suggestion of establishing a State vaccine in-
stitution similar to those in Europe. As far as I know
I am the only member of this Society engaged in the
production of vaccine virus.

In Europe this idea of using full-grown animals is
not heard of. When my father brought the virus from
France to this country, the system was to propagate it
upon yoQDg heifers not over six months old. That
system we adhered to for some time. The calves have
to be fed on milk and yolks of eggs to keep them along.
We found by increasing the age to eight or ten months
they are old enough to eat hay and meal and they keep
strong and recover quickly and well from the vaccina-
tion as a general rule.

In regard to the use of antiseptics. A good deal
has been said about asepsis and antiseptics in relation
to this matter. Cleanliness and neatness are as desir-
able in this, as any other specialty of medicine, but I
do not think the fact should be lost sight of that this
whole system of vaccination is an artificial production
of disease and not the restraining, killing off of dis-
ease entirely, that is to say, any substance really anti-
septic in its nature will destroy the effect of the vac-
cine virus. The use of perfect cleanliness at the time
of vaccinating or taking points should be insisted on.

Digitized by

Google

460

B08T021 MMDICAL ASD 8VBG1CAL JOCBSAL.

[Mai 3, 1894.

Absolute cleaolineBi while the vesicles are mataring is
practically almost oat of the qaestion, that is to say,
there is in any stable a certain amouut of dost and
dibrit of straw, etc., which make a sort of coating over
the vesicle; but when the points come to be taken,
that objection is practically removed because the ani-
mal is put upon the table and thoroughly washed, the
part vaccinated is thoroughly washed with warm water,
then the crust is removed and under that there is usu-
ally a little whitish sort of material, soft, pulpy, not
offensive pus, no odor to it, — that is removed with a
cloth and the vesicle thoroughly washed with a sponge
to make it perfectly clean, and that I am always very
particular about. If there was any dirt of any sort
about the vesicle visible to the naked eye it would be
shown on the point at once.

Dr. Abbott : I should like to allude to one point.
Dr. Martin is right with regard to the age of animals.
I do not think any animals are used on the other side
more than nine or ten months old. The average is
probably about three months, and even younger than
that. By the terms of the Grerman law, calves of five
weeks old and upward are preferred. The weight is
more often given than the age. One point in regard
to vaccine farms in this country. I have an adver-
tisement here in which the origin of the lymph used is
stated to be the " only authentic case of spontaneous
cow-pox in America."

I think we have got beyond the idea of infective dis-
eases, like cow-pox and small-pox, being spontaneous.
The fact that we cannot find a definite cause for a case
of disease cannot be regarded as a proof that a cause
does not exist. The cases of cow-pox occurring acci-
dentally or incidentally in this country are not one,
but many. 1 have visited and seen twenty-five or
thirty in the cow, and eight or ten in one herd. The
latter were in Lexington, in 1879. It was determined
to be genuine by the appearances of the eruption, and
by the fact that in some of the cases the animals were
vacciuated afterwards and would not take. 1 have
seen just such cases as Jenner described among dairy-
men who milk the cows, with disease upon their thumbs
and fingers exactly such as are figured in the old
plates. The advertising of vaccine lymph from tpon-
taneotu cow-pox is a practice not only unworthy of an
intelligent profession, but contrary to all observations
as to the natural history of infectious diseases. The
cases to which I have referred occurred always during
epidemics of small-pox and at no other time. A por-
tion of them occurred in the great epidemic of 1872-
73, and the others in the milder epidemic of 1880-81.

Dr. a. p. Chadbodrne presented an account of

GASTRIC AND RK8PIRATORT SYHPTOM8 FROM INHA-
LATION OF THE DD8T OF CDHLBD HAIR.*

Dr. AsBOtT : There are in this paper some points
which may explain similar symptoms that occurred in
a factory at Hyde Park. I have visited this factory
once or twice. There is a report of anthrax having oc-
curred among those workers twenty years ago.' Cases
then occurred occasionally of genuine anthrax coming
from the curled hair from Russia, that had been shorn
from aninuls that died from that disease. They were
almost the only cases of anthrax that we have had,
except a very few in towns where tanning of hides is
conducted. There were some unexplained symptoms

' See page ^SB of tbe Jonmal.

' Beoond Report of Bute Board of Hemlth, 1871.

among those people, and also in a smaller epidemic
eight or nine years ago. The people were sick much
longer than with anthrax, with respiratory, and alio
with digestive symptoms. The respiratory symptomi
may have been produced by just such causes as Dr.
Chadbonrne has noted. There was opportunity in thst
factory for great improvement, and it brings up a ques-
tion which 1 wish might be made the subject of legis-
lation, t))at is, compelling all people who own factories
where dusty operations are carried on to a large eb
tent, to ventilate them on the best principles.

Dr. Chadbourne: I would say in connection with
anthrax that since the cases of this disease, mentioned
by Dr. Abbott, the hair is "disinfected," but how
thoroughly this is doiie I do not know. The bone-
hair used is chiefly from the West, Mexico, South
America and Tartary. The pigs' hair comes from
about here. This patient told me that almost all of
the men working in the factory for a considerable time
suffered from the same trouble that he had, the stomach
being decidedly more troublesome than the lungs;
and this is the point I wish to emphasize, that io
this patient symptoms of a chronic interstitial fibroid
change were not apparent, but that there are other
symptoms that may and perhaps do occur oftener thao
we titink of or attribute to this cause.

THE OBSTETRICAL SOCIETY OF BOSTON.

CHABUU W. TOWXSXHD, M.D., BXOKKTABT.

Meeting March 10, 1894, the President, Db.
Cbarlbb M. Green, in the chair.

Dr. a. Worcester read a paper entitled,

what might be done bt the obstetrical socibtt
to advance tbe training of nurses.'

Dr. £. H. Brioham said that a large field was
opened for obstetric nurses, as only the very well-to-do
can afford to pay the present prices. He believed
that as time goes on the number of obstetric nursei
will so increase that prices will have to come dowu.

Dr. F. H. Brown thought that the suggestion of
post-graduate courses was an extremely good one.
Nurses come out of many hospitals as specialists, and
need lectures on other branches.

Db. Edward Ketnolds thought that specialism
among nurses made the best nurses. He would sug-
gest one method of solving the problem of expense by
employing the best obstetric nurses for the first two or
three weeks of the lying-in period, and then haviug
superior nursery-maids for the next fonr or six week^
who had been trained at some children's institution.

Dr. J. G. Blake suggested that nurses might be
trained in the out-patient department of the Lying-in
Hospital who would be willing to go yut as obstetric
nurses for a moderate fee.

Dr. J. Stedman said there was a great call for
nurses at ten or twelve dollars a week.

Dr. Clarence J.- Blake then spoke on the subject
of graduate instruction for nurses, giving a sketch of
the Graduate Nurses' Association.

A committee of three, consisting of Dr. Davenport
(Chairman), Dr. Edward Reynolds and Dr. Washburn,
were then appointed by the chair to consider tbe ad-
visability of the Society examiningobstetrical nurses for
registration, as proposed by Dr. Worcester.

' See page 43e at the Journal.

Digitized by

Google

Vol. CXXX, No. 18.1 BOSTON MEDICAL AJUD SUROIOAL JOURNAL.

451

THE BOSTON

lEeOfcal anD Surgical 3IoumaU

THURSDAY, MAY 3, 1894.

A Joamal o/ JTmNeiiM, Swrgtrf, and Allied Seieueu, published at
B«$ttm, weekt]), if the undenigned.

SOBBOBIPTIOH Tbkhs : VS.0O per pear, i» advanee, postage paid,
for the United States, Caiuida and Mexico ; f 6.56 per gear for all for-
e«^ coamiries beUmging to the PostcU UnUm.

All eonummieatitms for th* KdUor, and all boohs for review, shotM
ie addressed to the BdUor of the Boston Medieal and Surgical Journal ,
283 JTaskintlon Street, Boston.

All letters eomlaining business eommunieatbms, or referring to the
pnUiooNfn, stibsoription, or advertising department of f JU< Journal,
sho»M be addressed to the umdersigned.

Bemittanees should be made bg moneg-order, draft or registered
ietter,paiiable to

DAMRBLL ft UPHAM,
2W WASHmOTOK 8TUBT, BoaTOK, MAIS.

UNEMPLOYED MEDICAL MEN.

Wb hardly desigu to take the ooward march to
Washington of Coxey's army of tisampa as a topic on
which to " point a moral or adorn a tale." Nor is it
a part of oar present parpose to forecast the outcome
of this enterprise (whether serioas or foolish) or to
speculate on the causes or remedies. Alienists may
regard the whole movement as a " craze " ; others will
look upon it as the legitimate result of certain social-
istic theories of political economy which of late years
have been widely enunciated. On this point we do
not intend to expatiate. We shall only touch upon a
certain aspect of the subject which most concerns and
interests medical men.

One of the causes of the unrest and discontent which
pervades society is that multitudes have been educated
to regard manual labor as degrading, and to shirk
hard labor generally. There is a preponderance of
balf'^ducated men in communities, unwilling to engage
in or unfit for humble callings, but with enough smat-
tering of letters to make them effective nuisances to
society ; from this class come too many of our political
agitators, and, we are sorry to say, some of our Con-
gressmen. In Germany the state of things is so bad
as to justify Mr. Dawson's gloomy picture : " Twenty-
two teats of learning are yearly turning oot studied
men in thousands, and the unfortunate ' studied men '
are lucky if at the age of thirty-five they are earning
the wages of English bank clerks. The paternal
State finds mAiey for universities and looks to the
qualifications for the professions and the civil service ;
but that paternal State cannot provide its carefully
examined would-be-lawyers and doctors and civil ser-
vants and teachers with briefs and patients and posts
and pupils ; and, as a consequence, the educated un-
employed increase mightily in numbers year by year.
Still more formidable are the ' breakages,' the borde
of superficially book-learned young fellows of the mid-
dle and lower middle ranks, whom stupidly ambitious
fathers have sent to universities (the State aiding) to

fail in examinations when they ought to be selling
groceries or hoeing potatoes." '

The evil complained of exists equally in this conn-
try, and it is not too much to a£5rm, with a writer in
the journal from which we have quoted, " that college
classes are too large, and that engineers, architects,
chemists, lawyers, doctors and druggists, qualified and
semi-qualified, exist in far too great proportion to the
rest of the community."

In its application to the medical profession, this
statement is justified by reference to every city and
village in New England. The latest statistics, in fact,
give a constituency of only about four hundred and
fifty inhabitants to each physician. In some commu-
nities the ratio is even less than this. Nor is the pros-
pect much more inviting in the West, if we may trust
a correspondent of the Medical Record: " As a result
of our rapid railroad building, new villages are being
located &veTj few days, and it is not the rarest of
sights to see one or two physicians hovering like
shadows around a town which for the time being exists
only on paper. These ' too previous ' aspirants fre-
quently board at country houses, daily visiting the
patch of waving prairie grass, the site of the prospec-
tive metropolis, and waiting sometimes for weeks be-
fore buildings are erected in which offices can be had."
This same writer gives a gloomy picture of the sharp
competition with quacks in Kansas and neighboring
States, and other drawbacks, and of the meagre in-
comes which even sober, iodnstrions, reputable physi-
cians receive, and draws the obvious conclusion that in
the far West, as everywhere, the profession is greatly
overcrowded.

The thousands of graduates who this present spring
season will go forth from the very numerous medical
schools of this country cannot bat augment the great
army of the uneqiployed. The recent graduate, un-
less he has gone into medicine for the love of the
science and art of healing, and wisely, perhaps, decides
to stick to the hospitals for a few years, or for life,
mast (unless Fortune favo.rs him above his competitors)
wait long and patiently before he can obtain practice.
To many, such long waiting (involving, it may be, the
sacrifice of the best years of their manhood) is very
irksome ; and this is especially the case when the phy-
sician is poor and dependent on his practice for his
support.

We have no more to say at this time than to advise
all young men and women contemplating the study of
medicine to weigh well the chances of success in this
profession, and ask themselves whether they are pre-
pared to wait, it may be years, for success ? If money-
making is the object, they would probably do better to
repudiate a calling so little lucrative.

Again, unless the student is prepared to take more
than the old-fashioned, two-years' winter's course, we
would say emphatically. Don't enter medicine. An
instructive illustration on this point is furnished by
Dr. John H. Ranch in his last " Report on Medical
> PopalM Solenoe Monthly, Msj, 1891.

Digitized by

Google

452

BOSTOS MBDICAL AXD SVSeiCAL JOVBHAL.

[Mat 8, 1894.

Education and Medical Colleges in the United States
and in Canada." He says : " Dnring the past nine
years I have followed up with exceptional interest and
care the careers of 789 out of 1,000 physicians who
studied four years and attended at least three terms
before graduating. These are, with few exceptions,
the successful and prominent members of the profes-
sion in the different communities in which they reside.
They are well equipped by general education, by ait
ample period of professional study, by didactic and
clinical instruction, and by hospital practice. They
are successful, as a rule, because they hare fitted them-
selves to command success."

THE POISONOUS PROPERTIES OF ABSINTHE
AND ITS CONGENERS.

The use of absinthe and kindred bitters, the class of
appetizers called by the French aptritif, we are glad
to believe is still small in our country, and it is to be
hoped the habits of the people may not suffer any
change in this respect. We hare undoubtedly enough
bad habits of ourown without importing those of other
countries. At the same time, it is well to be fore-
warned, and we cannot admit the great stream of
foreign immigration which has been pouring in upon
us without the accompaniment, in a certain measure,
of the manners and customs.

Absinthe, as a drink, has long had a bad name. Its
evil effects upon those addicted to its constant use
have often been psinted in lurid colors, which have
sometimes been supposed to be exaggerated. Few,
however, probably know precisely what the ingredients
of absinthe and its congeners are, nor what are pre-
cisely their physiological effects. Charles Mayet has
lately made a clear statement in Le Tempt, of Paris,
in regard to the composition and the physiological ef-
fects of the component parts of absinthe, liqueur, bit-
ters, and vermouth, which, in view of their great con-
sumption in some quarters, is not without a vital in-
terest. His article is based upon the generally accepted
investigations of MM. Cadeac and Meunier.'

The liqueur sold under the name of absinthe con-
tains not only the essence of the plant from which it
is derived, but divers other essences varying in kind
and quantity.

Dr. Lanier presents a formula of three extracts of
absinthe obtained by distillation, which are generally
employed in commerce and known as fine, hdf-fiM
and ordinary. These portions are for five and a quar-
ter gallons of absinthe.

Ordlnar; HaU-flne Fine
IiMTM and flowers ot tbe greet absinthe .600 600 600

LeaTet of little abeinthe 20C 123

Balm-mint (meliase) 125 12B 200

Flowen of b;Hop 100 100 22S

Angelloa-root 2B

Qreen anise 400 COO 1,000

Badlana 400 22B

Fennel 2IS0 F60

C!oriander 22S 228

Alcohol (811%) 11,710 12,000 16,300

Water 9,500 8,000 4,000

(Qoantltlee glTen in grammes.)

1 Experimental Beseaicbes In Essences, Paris, 1892.

An infusion is made of these plants and seedi dur-
ing twenty-four hours in a portion of the alcohol ; it it
then distilled with the water, and to the product is
added the remainder of the alcohol and water. To
obtain the greeu color indigo is often used, and it
heightened with burnt sugar and saffron. A little
alam is added to hold the color in suspension.

In the formula given there are three plants of the
group which produce epilepsy, namely, absinthe,
hyssop and fennel, and a plant of the stupefying group,
the angelica.

The guinea-pigs utilized by Cadeac and Albiu
Meunier in studying the action of the vapor of the
essence of hyssop, were victims of the incense of this
poetic and biblical plant. In one instance it was ad-
ministered solely by the respiratory organs. A guinea-
pig placed under an observation bell glass, staggers,
exhibits spasmodic convulsions, passes into extreme
opisthotonos, and dies at the end of an hour and s
half from having simply breathed the perfume of a
few drops of the essence of hyssop. Another experi-
ment consisted in injecting into the veins of a dog s
few drops of the essence of hyssop, which resulted in
a violent attack of epilepsy. Absinthe produced the
same effect.

Four grammes of tbe essence of hyssop given upon
an empty stomach suffices to kill a dog weighing six-
teen pounds in thirteen hours. Six grammes will kill
a dog of ttiirty-two poands three hours after ingestion.
One gramme will kill an animal weighing one hundred
and fifty grammes. A man cannot absorb two grammes
of this essence of hyssop without danger of falling iu
an attack of epilepsy. One gramme will cause numb-
ness, ocular troubles and trembling. The essence of
hyssop is then, like absinthe, a formidable poison.

The fennel, which Charlemagne commanded to be
cultivated, and which the Russians, the Armenians and
the Tartars consume as a salad as we do the onion and
the water-cress, also figures in the series of plants which
enter into the composition of absinthe. Cadeac and
Meunier, who have experimented with the essence of
this plant upon divers animals, remark that the epilep-
togenic properties of the essence of fennel are unques-
tionable. Its activity is inferior to that of hyssop and
absinthe, but it is far from innocuous.

Angelica-root, which is put in the category of the
ezcito-stopefacients, is recognized as having the property
of stimulating the mental facnlties and the mnscalar
energy. Its salutary effects, however, are transient :
those that are dangerous soon become preponderant.
The proilonged fatigue, the somnolence, the uncon-
scious enfeeblement of all the faculties, are finally the
certain iuheri]»nce of all who misuse it.

From these investigations M. Mayet concludes that
we are amply justified in placing the liqueur of absinthe,
compounded of these divers essences, among the pois-
onous drinks that are particularly dangerons.

Passing to the bitters, the formula used the most in
France is for five and a quarter gallons of bitters,
namely, Dr. Decaisne's formula :

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MEDICAL AS J) SVBGICAL JO USUAL.

453

Anlae 80 gnunmes, ontnge peel 80 gr., calamlnt 80 gr., Jimiper
berries 80 gr., gage 80 gr., great Rbslothe 60 gr., angelica 40 gr.,
mint 40 gr., lavender flowers 40 gr., clove 20 gr., alcohol (80 per
cent.) 660 gr., sugar 600 gr., water 660 gr.

In this list, the absinthe and the angelica already
known make their appearance.

For an analysis of the sage, the mint, and the laT-
ender the prerions authorities are again referred to.
Xhey tell as that the sage is a poisonons and epilepto-
genic factor. If a guinea-pig is put into an atmosphere
saturated with the vapors of this essence, the experi-
ment is attended by all the successive symptomatic
phases observed after the injection of small but strong
quantities of this essential oil into the venous circula-
tion of a dog : a lively excitation, sudden starts, shak-
ings, muscular rigidity, drunkenness, a fall, and then
epileptic convalsions. This is fresh evidence that the
essences produce by their perfume absolutely the same
effects as when taken into the stomach. The poison-
ous character of the sage, however, varies with the
place of its origin. Some specimens are but slightly
poisonous. Considerable doses of such do not cause
in man more serious troubles than affection of the
sight, the subjective sensations of heat and cold, of
nausea, of dizziness and tingling, but associated in the
bitters with epileptogenics and other poisons, there is
much more to fear. There is strong reason to think,
however, that the more poisonons essences of sage are
more commonly employed in the fabrication of bitters ;
such were procured by Messrs. Cad6ac and Meunier in
a warehouse at Leipzig, which given in a dose of five
centigrammes caused a violent attack of epilepsy in a
dog weighing sixteen to eighteen pounds, which was
soon followed by death.

A small quantity of calamint, for example, thirteen
grammes to twenty-six gallons, will be found grateful
to our organic functions. The ingestion of a small
quantity of this essence renders our faculties alert and
active, and gives to the lower animals a sprightly and
intelligent ur. They seem perfectly satisfied with
conscious strength and mastery ; they move about with
pleasure, and promenade with a proud and conquering
gait; but if the dose is strong, drunkenness and epi-
lepsy follow. It will be well to remember that in the
formula for distillation there are eighty grammes of
calamint to five and a quarter gallons, or nearly four
grammes to a quart.

The effect of mint is in dispute. Its essence is
slightly poisonouA An excitant for some, it is anti-
spasmodic and tranqnilizing for others. Soothed by a
feeble dose, a large one will excite. Twenty grammes
introduced into the stomach of a dog will cause death
by asphyxia, with convulsions.

With regard to lavender, an equally integrant part
of the bitter, Cad^ and Meunier declare it to be un-
questionably stupefying. It is a powerful poison :
two and a half grammes of the essence of lavender in-
jected into the veins of a dog weighing thirty-eight
pounds will kill him in four or five minutes.

Having thus obtained positive information in regard
to absinthe and the bitters, we are told what is con-

tained in vermouth, and arquebusade water (eau cT

arqvebuie). Vermouth (a German word signifying

absinthe) is less a liqueur than a white wine, alcoholized

and aromatized with divers plants. The formula for

that commonly consumed in France, is as follows :

For twenty-six gallons of venuoath (100 litres) : wtiite wine
96 litres, alooliol (86 per cent.) 6 litres, great absinthe 126
grammes, gentian 60 gr., angelica-root 60 gr., thistle 125 gr.,
calamint 126 gr., alder 125 gr., little centaary 126 gr., germander
128 gr., 16 natmegs and 6 fresh oranges cnt in slices.

In this formula we still find the absinthe epilepto-
genic and toxic ; the angelica, in the first instance ex-
citant, and then somniferous and depressing ; and the
calamint an excito-stupefacient.

In regard to vulnerary, or arquebusade water, it is
the most complete expression of a type of liqueur which
is aromatic and poisonous. The formula for the essence
for 100 litres (26 gallons) of alcohol (60%), is :

Essences of alwinthe 7 grammes, of angelica 26 gr., of basil
1) gr., of calamint 11 gr., of fennel 60 gr., of hyssop 13} gr., of
marjoram 16 gr., of balm-mint 31 gr., of mint 12 gr., of rosemary
34 gr., of rae6gr.,of saTory27gr., of sage 48 gr., of wild thyme
12 gr., of thyme 12 gr., of bypericum 1 gr., of lavender 97
grammes.

All these essences are noxious ; all, in certain doses,
with diverse manifestations, poison and kill.

" Here, in their brutality " says M. Mayet, " are
the proportions of the* powerful poisons established by
experience for these essences, which figure in French
cordials, aperitives, and in the greater part of liqueurs.
In drinking this liqueur — the type of all those spoken
of — the mother as well as the young girl is preparing
to become the parent of candidates for epilepsy. As
regards the man, after drinking there is a momentary
increase of strength, a transitory excitation which will
be very quickly followed by an intolerant, impulsive
and disputatious disposition, and which, if exaggerated
by abuse of the liqueur makes him a violent, stubborn,
quarrelsome and bad citizen."

MEDICAL NOTES.
Small-Pox in Chicago. — The total number of
cases of small-pox in Chicago during the mouth of
April was five hundred and eight. There is an aver-
age of about twenty new cases daily. The public
schools have been ordered closed for a week upon the
recommendation of the Board of Health.

An Efidbmio of Ttphds Fbvbb in Pbaqde. —
Since the middle of January a considerable epidemic of
typhus fever has prevailed in Prague which is only
just beginning to subside. The causes lay in the filthi-
ness of the bouses, the accumulation of excreta in the
canals, the insufScient sanitation of the streets, and,
particularly, the abominable character of the water-
supply.

Thb Cholbha at Lisbon. — Dr. Montaldo, the
chief medical director of the Spanish Government, who
was sent to Lisbon to inquire into the character of the
disease now raging there, which Portuguese medical
officials designated as "cholerine," reports that the

Digitized by

Google

454

BOSTON MEDICAL AND SORGIOAL JOVRSAL.

[Mat 3, 1894.

disease ia trae Asiatic cholera. On the 25th of April
there were eighty-foar new cases of the disease, since
when the daily nomber of new cases has fallen to about
sixty. At present there are about four hundred pa-
tients under treatment. The Spanish GSovernment
has established additional sanitary stations along the
Portuguese frontier and has ordered an inspection of
the condition of Spanish towns.

AWAKD OF THK Watson Mbdal. — Dr. S. C.
Chandler, of Boston, has been awarded the Watson
Medal of the National Academy of Sciences at Wash-
ington for bis work in astronomy. This medal has
been awarded but four times in the last twelve years,
the last being in 1892 to the distinguished German
astronomer, Auwers.

SOHGICAL iNBTRnMKNTB ARE DUTIABLE. — The

Treasury Department has ruled, through its Board of
Greneral Appraisers, that instruments used by physi-
cians or surgeons for the purpose of carrying on their
profession are mechanical instruments, mere tools, and
cannot be classed as scientific instruments on the free
list, but must be assessed for customs dues.

A Pbizb Offbbkd to Nrw York Pbtsiciams.

— The Medical Society of the State of New York
offers a prize of one hundred dollars for the best origi-
nal essay on any medical or surgical subject. Com-
petitors must reside in the State of New York and be
members of a County Medical Society. Essays are to
be sent to the Chairman prior to January 1, 1895.

The Minnesota Insanity Law Uhconbtitd-
tional. — The law of the State of Minnesota regard-
ing the commitment of insane persons to asylum care,
which was passed in 1898 has been declared by the
court to be unconstitutional. This decision is likely
to cause considerable trouble as about five hundred
persons have been committed under its provisions, and
the next session of the legislature does not meet until
January, 1895, till when no relief can be had.

boston ani> new bnoland.
Acctb Infeotioos Diseases in Boston. — Dur-
ing the week ending at noon, May 2, 1894, there
were reported to the Board of Health of Boston the
following numbers of cases of acute infectious disease :
diphtheria 34, scarlet fever 49, measles 7, typhoid fe-
ver 7, small-pox 6 (no deaths). There are now 10
cases of small-pox in the hospital.

Cambridok School Children's Feet. — The
School Board of Cambridge, Mass., has granted Dr.
6. W. Fitz of the Harvard University gymnasium
permission to take measurements of the feet of school
children in all the public schools of the city upon ob-
taining consent of the child or its parents. So far
there has been practically no objection on the part of
the children examined.

A Bequest to the Waterburt Hospital. —
The will of the late Charles Scott, of Washington,
D. C, bequeaths the sum of five thousand dollars to
the Waterbury, Conn., Hospital.

Election of Officers of the Suffolk District
Mbdioal Societt. — The following officers were
chosen for the coming year at the annual meeting of
the Suffolk District Medical Society, April 28th:
President, A. L. Mason ; Vice-President, John 6.
Blake ; Secretary, Herbert L. Smith ; Treasurer,
Edward M. Buckingham ; Librarian, B. J. Jeffries ;
Commissioner of Trials, C. W. Swan ; Member of the
Nominating Committee of the Massachusetts Medical
Society, W. L. Richardson ; Committee of Supervision,
F. Mioot, W. Ingalls ; Committee on Social Meetings,
H. Williams, G. A. Leland, E. Reynolds, P. Thorn-
dike ; Censors, F. H. Davenport, H. F. Yickery, F.
B. Harrington, R W. Lovett, E. 0. Otis.

new YORK.
COLLBOE OF PhABMACT COMMENCEMENT. — The

sixty-fifth annual commencement of the College of
Phwmacy of the City of New York was held at Car-
negie Mnsic Hall on April 2dth. The degree of
Ph.G. was conferred on a class of 128 graduates by
the President, Samuel W. Fairchild, and an address
was delivered by the Rev. John W. Brown, rector of
St. Thomas's Church.

A New Hospital for Consumptives. — The or-
ganization of a new hospital and dispensary for con-
sumptives has just been perfected. At a meeting held
for the purpose on April 26th at the house of the
President of the Board of Managers, Mrs. Richard
Irvin, Dr. A. L. Loomis made an address, in which he
spoke of the inadequacy of the treatment of tubercu-
losis at the general hospitals, and of the desirability of
institutions providing the most approved means of
treatment. In speaking of the proposed undertaking,
he said : " Where a change of air is necessary, the dis-
pensary ought to be able to send them to a sanitarium
near the mountains. Boston has such an institution,
and it has had the best of results. The lives of many
shop-girls and clerks who cannot receive proper treat-
ment as things exist now might be saved by such an
institution." A house has been secured on West S8lh
Street for the commencement of the work, and it will
be opened early in May. It will be supplied with the
pneumatic cabinet and other appliances for treatment,
and Dr. Charles E. Quimby, who has been associated
with Dr. Loomis for a number of years, will be the at-
tending physician. There will be a board of lady
managers and an advisory medical board, consisting of
Drs. A. L. Loomis, Charles McBTurney, Henry F.
Walker, William M. Polk and A. A. Smith.

THE TREATMENT OF SEA-SICKNESS.

Dr. Charteris of Glasgow reported in 1893 ' that
favorable results bad been obtained from the use of
chlorobrom in sea-sickness. He now states,* as his
conclusion from a study of three hundred cases, that if

> likDOet, FabnuuT IS, 18SS.
•Ibid., April 21, ISM.

Digitized by

Google

Vol. CXXX, No. 18.] BOSTON MEDICAL ASD SVttGlCAL JOVttHAL.

466

suitably administered it has a decided prophylactic
value for both long and short voyages.

"To ensure success in this treatment, it is essential
that the/>rt»9<e vim should be freely moved for two
successive nights before embarkation, and that for the
first two or three days of the voyage the traveller
should eat ' spare and dry,' avoiding above all things
soup, sweeu and pastry. A full dose of chlorobrom
(one tablespoonfnl and a half for a male and one table-
spoonfol for a female) must be Uken for the first three
nights of the voyage. After this period a further use
of the solution will probably be found to be unneces-
sary and all restrictions of diet may be removed.
Idiosyncrasis of the patient may prevent in very rough
weather absolute freedom from sea-sickness, but on the
evidence produced there seems to be every iM-obability
that in the majority of cases immunity may be obtained.

" In thort voyages, when the steamer leaves, perhaps
at 10 p. M., the passenger should immediately retire to
rest, and take one of the doses mentioned. In a
shorter passage across the Channel a teaspoonf nl should
be taken before going on board. By following these
directions imoMinity from sea-sickness is obtained in
the great majority of cases, but if they be not followed
it is to be remembered that chlorobrom has no efEect
in arresting an outburst of vomiting. If it is given in
a teaspoonful dose every ten minutes until a table-
spoonful and a half or a Ublespoonful have been taken,
it will almost invariably check retching and depression."

OBITUARY. — THEODORE METCALF.

Mr. Metcalf was bom in Dedham, Mass., in the year
1812, and was a son of Judge Theron MetciJf, who lived
to be over ninety years old. In 1826, he began an appren-
ticeship at Hartford, Conn., where he remained for ten
years, the last three as partner.

Leaving there in 188 7, he established the apothecary
store at No. 89 Tremont Street, Boston, which has, with
the exception of the years between 1845-1855 (most of
which were spent abroad), been continually under his per^
sonal supervision. Combining with his inflexible integrity
and steadfast devotion to his adopted calling, an intimate
knowledge of drugs, both crude and prepared, he was in-
fluential in elevating the position of the pharmacist from
the rank of a tradesman to that of a professional man.

The natural result of his persistent and consistent en-
deavors was the establishment of an immense business, to
which he was attentive to the close of his long career. Mr.
Metcalf's first associate in business was Mr. Jos. Burnett ;
one of more recent years was Mr. Thomas Doliber. He
had the intuitive perception of character which enabled
him to surround himself with the best executive ability, and
some years ago associated with himself a number of his
leading employees, those in charge of Uie different depart-
ments, and incorporated the Theodore Metcalf Company,
of which he was Treasurer at the time of his death.

Mr. Metcalf has been very active also in affairs outside
of his business, and of a very charitable disposition, and
always ready to assist personally and financially all objects
of a worthy and charitable nature ; and many young men
will testify as to the great assistance and encouragement
given by him which enabled them to successfully prosecute
tiieir aims in life.

Mr. Metcalf was for more than thirty years the treasurer
of the Channing Home, the first president of the Boston
Druggists' Association, one of the founders of the American
Pharmaceutical Association, one of the promoters of the
Massachusetts College of Pharmacy, trustee of the City
and St. Elizabeth's Hospitals, and one of the trustees and
first president of the Catholic Union.

METEOROLOGICAL BECOBD,

For the week ending April 2Igt, In Boston, according to ob-
servations fumislied b; Sergeant J. W. Smith, of the United
States Signal Corps:—

Baro-

Theimom- BeUtlva

Direction

Telocity
of wind.

We'th'r.

1

meter

eter.

humidity.

of wind.

•

Date.

1

i

a

1

t

S

a
a

s

i

■i

8

00

S

00

K

1

i
8

00

a'

§

00

a

■i

s

OO

a
i
8

3

a

■i

8

00

p.

1
F.

a
1

S..16

30.04

44

BO

39

no

SJ

M

N.

8.E.

17

M..:6

30.11

461 ni

40

(17

4!)

M

N.B.

S.E.

10

4

(!.

<)

T..17

3(i.'21

46 62

41

67

m

74

S.K.

S.K.

4

3

V.

(1.

W.18

30.30

81 40

46

M

49

B2

.S.E.

S.W.

«

12

0.

K.

T..19

30.12

fi2 61

44

68

««

76

S.W.

S.W.

20

14

o.

O

F..5!0

19.89

«o;69

S2

82

8C

8(1

S.W.

S.

It

«

o.

O.

S..21

29.88

60

SB

S4
4fi

83

94

88

S.

S.W.

18

12

0.

0.

0.03

or

30.11

69

•O.,eloii<l7i CelMxi F.,(slri O.,f0(i H.,luu7i 8.,«liokx: B.,ralni T.,(lire«l-
•slBKi N. . now. < IndlcalM tn«a of idsbll. aw Mtui for wMk.

RECORD OF MORTALITY
Foa THK Wbkk bndimo Satubdat, Afbh. 21, 1891.

|g

1

9 V

Percentage of deaths from

OttiM.

1^^

|l

1

K 8
o 3

¥

u

1

¥

$

1

^

New York . .

1,891,806

847

382

20.16

18.36

9.36

2.28

3.96

Chioago . . .
Philadelphia .

1.438,000
UU,S62

m

123

8.74

18.67

.23

4.14

.92

Brooklyn . .

978,394

361

186

16.68

22.40

^M

1.40

2.24

St. Loal* . . .

660,000

— .

—

^

—

—

_

Boston . . .

487.397

231

74

15.06

20.21

5.69

6.16

__

Baltimore . .

600,000

—

_

_

—

^

Washiogton .

308,431

109

27

9.20

11.04

1.84

.92

.92

ClDClnnatl . .

30B,U00

120

33

itM

16.60

4.16

—

OleTeland . .

290,000

77

28

13.00

23.40

6.20

1.30

1.90

Pittaburg . .

263,709

—

—

—

_

—

—

MilwaukM . .

2S0,000

66

31

9.24

24.64

—

—

8.06

NaabvlUe . .

87,764

29

6

—

24.16

—

—.

Charleston . .

8S,1«>5

—

^

^

_

Portland . . .

40,000

..—

—

—

—

_

Woroeater , ,

96,217

37

14

6.40

18.90

—

— .

PaUBlTer . .

87,411

—

.

—

LoweU . . .

87,191

29

14

10.36

24.16

—

^

Cambridge . .

77,100

18

4

27.77

_

11.11

16.66

__

Lynn ....

62,666

11

6

—

.~

—

_

Springfield . ,

48,684

—

—

—

_

_»

—

Ldiwreuoe . .

48,366

12

3

16.66

—

_

_

Nev Bedford .

43,886

21

«

28JS6

_

_

Holyoke . . .

41.278

—

—

—

_

—

—

_

Salem ....

32,233

11

9.00

—

—

9.U9

_

Brockton . .

82,140

6

—

33.33

—

_

HaTerhlll . .

31,396

26

3.t5

30.80

._

— .

__

Chelsea . . .

30,2frt

9

—

11.11

—

_

^

Maiden . . .

29,394

7

—

_

Newton . . .

27,666

6

— .

_

._

_

Fltcbbnrg . .

27,146

10

—

_

Taunton . . .

26,972

U

—

—

—

._

Qloucester . .

26,688

8

25.00

-_

—

—

_

Waltbam . .

22.068

6

■^

40.00

—

_

_

Qulncy , , .
PitUfleld . .

19,642

—

—

—

—

—

—

„

18,802

3

— .

33.33

-~

-_

_.

Everett . . .

16,686

6

—

20.00

—

_

Northampton .

16,331

3

—

~

_

— _

Newbnryport .

14,073

4

U

—

26.00

—

—

Ameibury . .

10,920

4

U

—

2S.U0

~*

—

—

Deaths reported 2,511 : under five years of age 9i6 ; principal
infectious diseases (small-pox, measles, diphtheria and croup,
diarrhoeal diseases, whooping-cough, erysipelas and fever) 3S8,
acute Inog diseases 4S9, consamptlon 282, diphtheria and croup
161, scarlet fever 48, measles 4ti, whooping-cough 27, typhoia
fever 27, diarrhoeal diseases 26, smaltpoz It, erysipelas 9,
cerebro-gpinal meningitis 8, malarial fever 6.

From whooping-cough New York 12, Boston 6, Washington
3, Philadelphia, Brooklyn, Cincinnati, Cleveland, Milwaukee
and Lowell 1 each. From typhoid fever New York and Phila-
delphia 7 each, Cincinnati 1, Boston, Washington and Milwaukee
2 each, Brooklyn, Cleveland and Haverhill 1 each. From diar-
rhceal diseases New York 9, Brooklyn. Cincinnati, Lowell and
Oloucester 2 each, Philadelphia, Boston, Wadiington, Cleveland,
.Milwaukee, Worcester, Somerville and Salem 1 each. From
small-pox Brooklyn 7, New York 3, Boston 1. From erysipelas

Digitized by

Google

466

BOSTOS MBDICAL ASD SVBGIOAL JOVBBAL.

[Mat 8, 1894.

New lork 4, Philadelphia and Brooklyn 2 each, Boston 1. From
ceiebro-spinal menlD^tis New York 4, Glonoester 2, Clerelmnd
and Worcester 1 each.

ODKICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT. U. 8. ARMY, FROM APRIL 21, 1894, TO
APRIL 27, 1894.

Majob Valsry Hatard, BurgeoD, is relieved from duty at
Fort D. A. Rnssell, Wyoming, and ordered to David's Island,
N. Y., for duty at that depot, relieving Major Joseph R. Gib-
son, surgeon.

Major Gibson, on being relieved by Major Havard, is
ordered to Fort Snelling, Minnesota, for dnty at that station,
relieving Major Chablks K. Wihhr, surgeon.

Major Charles K. Wimne, on being relieved by Major
GiBSOK, is ordered to duty at Fort McHenry, Maryland, reliev-
ing Captaui Charles B. Ewuro, assistant surgeon.

Captain Ewino, on being relieved by Major Wimmb, will
report for duty at Jefferson Barracks, Mo.

Captain William L. Knsedlbr, assistant surgeon, will, in
addition to his present duties as post surgeon, Fort Mason, Cali-
fornia, perform that of attending surgeon, San Francisco, Cal.,
until further orders.

Leave of absence for one month, to take effect on or about
April 24, 1894, is granted Captain Jambs D. Glbnnan, aasistant
surgeon.

Captain Nathan S. Jarvis, assistant surgeon, will be re-
lieved from duty at David's Island, N. Y., upon the arrival of
Captain Samuel Q. Robinson, assistant snrgeon, and will re-
port In person to the commanding officer, WilTett's Point, New
York, for duty, relieving Captain William P. Kendall, as-
sistant surgeon.

Captain Kbndall, upon being so relieved, will report in
person for duty at Fort Colnmbus, New York.

OFFICIAL LIST OF CHANGES OF STATIONS AND DUTIES
OF MEDICAL OFFICERS OF THE UNITED STATES
MARINE-HOSPITAL SERVICE FOR THE FIVE WEEKS
ENDING APRIL 21. 18M.

MVBBAT, R. D., sorgeon. To inspect quarantine stations of
Florida. April 17, 1884.

Bailhachb, p. H., surgeon. To proceed to New London,
Conn., as inspector. April] 8, 1884.

Mead, F. W., suigeon. To report to chairman, Committee
on District of Columbia, U. 8. Senate, for special duty. April
7, 1894.

Cabmichabl, D. a., passed assistant surgeon. To report to
medical officer in command at San Francisco, Cal., for tempor-
ary duty. April II, 1894. To proceed to Port Townsend, Wash-
ington, and inspect Marine-Hospital Service and Quarantine
Service. April 21, 1894.

Brooks, S. D., passed assistant surgeon. To proceed to
Chicago, 111., for temporary duty. April 3, 1894.

Bbatton, W. D., passed assistant surgeon. To report at
Bureau. April 16, 1894. To proceed to Reedy Island Quaran-
tine and await orders. April 20, 1894.

Vacghan, G. T., passed assistant surgeon. Detailed as
chairman. Board lor physical examination of candidates,
Revenue Marine Service. March 19, 1894.

Cobb, J. O.^passed assistant sargeon. To proceed to Seattle
and Tacoma, Wash., as inspector. April 12, \rVH.

Wertenbakbb, C. p., passed assistant sargeon. Granted
leave of absence for two months. April 3, IKM.

Bbown, B. W., assistant surgeon. Granted leave of absence
for six days. April 7, 1894.

Decker, C. E., assistant sargeon. Placed on " waiting
orders." April 1,1894.

Stbateb, Esoab, assistant surgeon. To proceed to Vineyard
Haven, Mass., for temporary dnty. April 4, 1894.

Oaklet, J. H., assistant surgeon. To proceed to San Fran-
cisco Quarantine Station for temporary duty. April 11, 1894.

Prochazka, Emll, assistant surgeon. To proceed to Cleve-
land, Ohio, for temporary duty. April 2, U94.

SOCIETY NOTICE.

Boston Societt fob Medical Obssbtation.— The next
meeting will be held at 19 Boylston Place on Monday, May
7th, at 8 o'clock.

Regular Reader: Dr. W. B. Hills, " Chronic Arsenical Poison-
ing—Analysis of Urine in 300 Cases." Discussion opened by
Dr. E. 3. Wood.

An important matter of business will come op for diacossion.
J. Q. Mdmfobd, M.D., iSecretary.

NoRTOLK Dibtbict Mkdical SOCIETY. — The annual meet,
ing will be held at the Norfolk House, Eliot Square, Boxbory,
Tneadi^, May 8th, at 12.30 p. m.

The Board of Censors will meet at the same place at 12.45 P. M.

The examinalion of candidates will take place one week later,
on Tuesday, May 16th, at 7 p. m., at the office of the Secretary,
130 Warren St., Boxbury. The written examination will begin
at 7 p. M., the oral at 8 p. m. After the dinner the " Annnal
Address " will be given by W. S. Everett, M.D.

The Secretary particnlarly requests that all who expect to
attend the annual meeting to notify him, that he may be able to
make soitable provision for the dinner.

James C. D. Piobon, M.D., Secretary.

APPOINTMENTS.

Dr. John L. Mobsb has been appointed physician to ont-
patients to the Boston City Hospital.

Dk. W. p. Derbt has been appolnt«d surgeon to out-patients
to the Free Hospital for Women.

Dr. Jamk^I . Jackson has been appointed assistant patholo-
gist to the Fne Hospital for Women.

Drs. John L. Ames and Carroll E. Edson have been ap-
pointed visiting physicians to the children at St. Mary's Infant
Asylum and Maternity Hospital.

RECENT DEATHS.

Theodore Metcalt, a well-known Boston druggist, died in
Brookline, Mass., April 26th, aged eighty-two ybars.

John H. Patterson, M.D., M.M.S.S., died in Harwich,
Mass., April 29th, of scarlet fever, contracted while attendinga
family where three children were ill with the disease. He
graduated from Dartmouth College in 1886 and from the Dart-
month Medical School in 1889.

Albert Day, M.D., H.H.S.d., died in Melrose Highlands,
Mass., April 26, 1894, aged seventy-two years. He lost his
father when only a lad and was obliged to go to work, studying
at night to obtain his education. He early became an earnest
advocate of the cause of temperance in the ase of alcohol. In
1806 he was a member of the State House of Representatives and
worked hard for the establishment of an asylum for the care
and cure of inebriates. On the organization of the Washing-
tonian Home he was made its superintendent. He entered the
Harvard Medical School to make himself more fitted for his
work, and graduated in 1866. In 1868 he took cbarse of the
asylum at Binghampton, N. Y., and afterwards established a

Brivate asylum. In 1876 he returned to the Washingtonian
[ome where be remained till a yev ago.
Arthur Hill Habsall, M.D., died in San Remo, April 10th,
aged seventy-seven years. He was educated at Dublin under
the care of his uncle. Sir James Murray, and became a most
careful and enthusiastic student with the microscope. Bis
early years in practice in London were largely devoted to the
study of histology at St. George's Hospital. In 1862 he pub-
lished a book on " The Microscopic Anatomy of the Human
Body." It contained some four hundred illustrationa of his own
drawing and was the first complete book on this subject in the
Englirh language. He next turned his attention to food adul-
terations and published in 1M7 an exhaustive treatise on " Adul-
terations in food and Medicine." In 1866 his health was so
affected by the beginning of his fatal illness, consumption, that
be was obliged to move bis residence to the Isle of Wight. So
soon as he bad rallied from the bnmoptysis he took op his work
in such a new line as was suited to bis strength and organized
that model system of hospital control of phthisis — known as
the separate or Ventnor system. He remnined the consulting
physician to this National Hospital for Consumptives at Vent-
nor until his death. In 1877 his health required him to live
still farther south and he went to San Remo. Here he retired
from active practice, but spent much time in the study of climatic
conditions, and in extending his microscopic investigations.
He published an autobiography last year entitled " The Narra-
tive of a Bnsy Life."

BOOKS AND PAMPHLETS RECEIVED.

Transactions of the New England Cremation Society. No. U,
1893. Boston. 1894.

T« enty-first Annual Report of the City Physician of the City
of Fitchburg. Mass. 1883.

Early Operations in Head Injuries. By Wm. B. Van Lennep,
A.M., M.D. Reprint. 1894.

Three Illostrative Cases of Abdominal Section. By Aug.
Scbachner, H.D., Ph.G. Reprint. 1894.

Sixteenth Annual Report of the Board of Health of the City
of Lowell for the Year 1893. Lowell, Mass., 1894.

Die Behandlnng der Leuknmie Kritische Stndie. Von Dr.
H. Vehsemeyer, Arzt In Berlin. Berlin: 8. Karger. 1894.

Digitized by

Google

/^fe^jlXX, No. 19.] BOSTON MEDICAL AND SURGIOAL JOURNAL.

467

Anginal $lrttdejee.

•ifc

l< VARIOLA.!

{I, BT a. O. WBBBBS, X.D.

": Dr. Robbst R. Leo distiDgaishes between variola
;^Dd varioloid : " In variola vera will be incladed all
1086 cases in which the more or less thickly standing
astules show complete development, confluence and
ther sequeln resulting therefrom, and in which,
hortly after the critical defervesence of the eruptive
^ ever, a new fever of greater or less severity (the sap-
>arative fever) begins. In varioloid, on the other
^laad, will be included all cases in which the pustules,
more or less scattered, do not attain the highest devel-
opoaent, bat begin their retrocession earlier, and in
which after the rapid defervescence of the fever to an
anasaally low temperature, this gradually returns with
slight accidental exacerbation or slight morning re-
missions and evening exacerbations to the normal
height and there remains." '

The first four patients who entered the hospital were
from the same house; all had been exposed to the
disease by taking care of a friend who had died. None
had ever been vaccinated.

Case I. John S., age twenty-two, blacksmith, was
admitted in the afternoon of October 26, 1869. He
was taken sick on the 23d. Backache was the chief
symptom complained of. On entrance his face was
red and swollen, eyes red. No eruption. Tongue
coated. Pulse 102.

October 27th. He passed a restless night ; passed
blood from his bowels several times during the night.
There was considerable dyspncea at times, again the
respiration was quiet. The whole surface of the body
was livid. Occasionally he started up and stood up to
assist himself or to get relief, and then fell hack on
the bed. Pulse imperceptible. Mind seemingly not
affected ; he answered and asked questions intelligently.
He had severe pain during the night, and received two
doges of morphia. Stimulants were given, hut at
quarter to nine he died. No eruption could be seen
on face, arms or front of body.

This case is remarkable from its rapid course and
sudden termination and the absence of the eruption.
It would have been impossible to determine the nature
of the disease if the case had been solitary ; but he
entered with the three others who all passed through
the regular stages of the disease.

This patient was not a very robust man and had
lived rather freely, but on entrance he did not seem to
be much worse than the others, only complaining more
of headache and backache. He seemed in no special
danger.

The next case is one of mild discrete variola, and is
a good example of the normal course of the disease
except in the slight irregularity caused by bis com-
panion's death.

Cask II. Charles M., entered at the same time
with the previous case. He had marked initial symp-
toms commencing at the same time. When first seen

^ The casM on vhlob these otMerrattoDS are f oanded were under
my oare In the winter of lt'69-70 at the Boston Small-pox Hoepital.
Thay formed the basis of a paper which was read before the Modlcal
UbsurTatton Society, but has nerer been published. Much of that
papor la here reproduced.

■ Berlohi aber das Auftreten der Pooken Im Jacobs Hoepital zn
l«ipzig and beobaohtunsen al>er die Itlelnen Pooken-Epidemie,
nawlbst Im Jahre I8S4. Von Dr. Robert Richard Leo. Archiv der
ntUkmde, Heft S, 1864.

in the afternoon of October 26th, his pulse was 114.
The next day a few pimples were seen in the morning,
and his pulse was 96; in the evening it was 102, and
the eruption was as nearly as possible in the same
condition as in the morning. The death of his com-
panion seemed to have made a strong impression upon
him, and for about twelve hours there was no advance
in the appearance of the ernption as compared with
the progress of another patient who came in at the
same time with the disease in the same stage.

Subsequently the course of the disease was regular.
He was moderately salivated ; his face was swollen ;
the ernption was thick in places, but nowhere conflu-
ent. On November 8th he was allowed solid food, his
tongue being clean, and he desiring it.

Cnrve I gives a very fair idea of the normal course
of the temperature in mild cases. The temperature
was first taken on the sixth day of the disease. It de-
scended not quite to normal ; on the eighth day the
secondary fever commenced ; on the thirteenth day
there was a remission which coincided with the com-
mencement of desiccation. On the eighteenth and
nineteenth days was an elevation corresponding with
the period of desquamation. There was a temporary
rise on the thirty-first day, undoubtedly due to head-
ache and pain in the bowels following exposure at an
open window with insu£5cient clothing.

The next case was one of the severest which recov-
ered.

Case III. John S. M., age twenty-seven, brother
to Charles M., plasterer, not vaccinated, entered at the
same time with the two previous patients. He first
felt sick October 22d, with the usual symptoms. On
entrance the tongue was moist, slightly furred ; there
were pimples and perhaps vesicles on the face, pustules
on the hands. The ernption was not then confluent,
but very thick. There were a few pustules on the
palate. Pulse 100.

. He passed a restless night. The next day the erup-
tion was thicker on his face ; the pulse had fallen to
78. He was less unfavorably affected by the death of
the first case than either of the other two who entered
at the same time. His eyes troubled him and his
throat was sore; his face swelled so as to close his
eyes. On the eighth day of the disease the secondary
fever began. On the tenth day it is recorded that he
had been slightly delirious at night, and began then to
be so in the daytime. On the eleventh day his tongue
was dry and slightly dark-colored ; pulse 102. The
symptoms became more serious ; the typhoidal condi-
tion of the tongue increased, and it could not be pro-
truded beyond the teeth. Subsultus tendinum ap-

Digitized by

Google

458

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Mat 10, 1894.

peared ; chilU were frequent ; the coantenance became
dusky. The eraption bad become confluent orer
nearly the whole of the face, but was less abundant on
the limbe. On the thirteenth day the puUe was 96,
and the delirium continued during the day, though he
knew me. He then became noisy and talkative ; his
hands trembled very much. During the night of the
fifteenth day he had a spasm, cried out, kicked, bent
his head back by jerks and drew himself down to the
foot of the bed ; he then fell asleep. The next night
he had only one spasm, and that not so severe aa on
the previous night. He slept more and was less de-
lirious.

Ca»iSZ:

While he was the sickest he had nearly a quart of
rum in the twenty-four hours ; this was reduced as
soon as he showed signs of improvement. The erup-
tion gradually dried up, and on the nineteenth day his
face was clearing up.

Case IV. A. B. P., age twenty-three, said he had
been vaccinated but it did not " take " well. He did
not enter till after the initial fever had subsided. The
temperature rose until the twelfth day, when it
reached 105.4°. On the fourteenth day a pint of rum
was given during the night, and the temperature fell
to 101°. Afterwards the influence of a previous ma-
larial poisoning may have shown itself in the high
elevation of the temperature every second day.

Casb V. N. R. T., bookkeeper, assisted in the
care of his brother, who had small-pox. On the 4th
of December his brother was attacked, and on the 11th
he was vaccinated. On the 18th he felt the first
symptom of the disease, seven days after the vaccina-
tion and fourteen days after his brother was taken sick.

On his entrance to the hospital the vaccine scabs
were large, dried up, surrounded with an areola about
three sixteenths of an inch wide. The initial fever
seems to have been moderate, the eruption first ap-
peared three days after the commencement of the dis-
ease. On entrance there was a scattered eruption of
vesicles on the forehead, face and arms. One pustule
was on the conjunctiva.

The disease pursued a regular course until the thir-
teenth day when the pustules changed their character
and formed large blisters partly filled with thin, pale-
colored serum. He became delirious, the tongue was
dry, there was a typhoidal condition, he passed urine
in bed, respiration became labored and irregular ; on
the sixteenth day he died, having convulsions just be-
fore death. After his death I learned that he had a
succession of severe chills on the thirteenth day. After
death the skin became very yellow. He died from
pyaemia due to absorption of the pus from the pustules.

The vaccination was performed from five to seven
days after the exposure. Though there was an inter-
val of seven days between the vaccination and the
commencement of the disease the course of the latter
was not modified ; he bad variola vera. When first
seen the vaccine disease appeared nearly normal ; if
any difference, there was a dryer scab than wonld
have been expected and perhaps more areola.

The next case, of varioloid, shows the contrast be-
tween that and variola in the course of the tempera-
ture. The case is also of interest on account of the
exactness with which the period of incubation is de-
fined.

Cask VI. A. G. W. C, age twenty-two, entered
December 3d. He said that he had been vaccinated,
and shows two small scars on the left arm, which woald
generally be considered as of doubtful efficacy. The
day before Thanksgiving, November 17th, he stood ap
in the cars by the side of a man covered with the scabs
of small-pox, some of which were dropping off. No-
vember 27th he felt a little feverish and on going to
bed he took a warm bath. At night, November 29th,
he had one or two spots and the next morning more.
On entering he bad pustules scattered over his face,
limbs and body, they were fully developed, some were
umbilicated. The temperature on entrance and that
evening was high, perhaps on account of his wander-
ing about and getting somewhat excited about finding
the hospital.

There was no secondary fever, the temperature
steadily falling from the time he entered the hospital.

The period of incubation in this case was only ten
days. The eruption appeared two days after the be-
ginning of the disease.

The next case is one of heemorrhagic small-pox.

Case VII. Bridget G., age twenty-three, servant,
not vaccinated, entered February 8th, was first seen on
the 9tb. She was taken sick on the 2d, about 1 1 p. H.
The next day she felt better and went to work ; at
noon she took to her bed with headache, backache,
chills and fever. The eruption came out on the
fourth. She said she vomited all the time until some-
thing was given her which checked it. Her sister
said the vomitus was dark.

When seen her mouth was covered with dried blood
and sordes, the gums were swollen, tongue dry, gums
bled easily. After entrance she vomited about three
quarts of a black liquid and passed the same at stool.
The face, neck and arms were thickly, and body and
legs sparsely, covered with eruption. The catamenia
were present, or there was haemorrhage from the
vagina. Pulse was 90, very weak. Aromatic sulpha-

Digitized by

Google

Vol. CXXX No. 19.] BOSfOtf MSDWAL AND SltRGIOAL JOURNAL.

469

ric acid checked the vomiting and she passed only a
little more blood by stool.

February 11th she continued about the same with-
out vomiting but restless until quarter-past eight in
the morning when she bled from the mouth and the
urine was bloody. About an hour later she died.
About two hours before death the eruption began to
turn purple and about half an hour before death this
became still more marked.

Case VIII. John T., age thirty-three, laborer,
vaccinated, had a rather high fever with a thick erup-
tion, face much congested and swollen. He presented
every appearance to lead one to think that he would
have the fully-developed disease ; but on the ninth,
day the pustules on the hands were reduced to small
red spots with a small crust in the centre ; the tem-
perature was low, pulse 66. An alveolar abscess sent
the temperature up for two or three days.

Case IX. Thomas J.
H., age twenty-three,
was singular only in hav-
ing symmetrical groups
of nearly or quite con-
fluent pustules on the
front of the upper part
of each thigh, over each
instep, and on the median
line over the trachea.
Each group was situated
in a space almost en-
tirely free from other
pustules. The course of
the temperature was nor-
mal, showing, however,
rather exaggerated
morning and evening re-
missions and exacerbations during the secondary fever.
Exacerbations on the evenings of the eighteenth,
twenty-first and twenty-fourth days are not explained,
unless he had small abscesses which he concealed, or
unless it be due to the character of the eruption
which marked this case as belonging to the corymbose
variety.

Dr. Mason in " Reynold's System of Medicine," de-
scribes variola corymbosa as rather rare, and a very
fatal variety, giving a mortality of 44 per cent, among
the nnvaccinated, and of 32 per cent, among the vacci-
nated.

This patient said that he had been vaccinated, but
I could find no scars. This was the only case in
which the eruption was thus grouped. On the twen-
ty-seventh day he was discharged.

Cask X. L. S., age twenty-five, not vaccinated,
was confined with her first child (illegitimate) about
two weeks before this sickness. The eruption ap-
peared not quite two days after the first symptoms.
She fiowed considerably, and had a cough which in-
creased the flow. On the eighth day the eruption be-
came hsemorrhagic, and she died the next day.

Case XI. Henry C, age thirty-two, had not been
vaccinated. He had led rather a dissipated life, and
had been in the habit of taking liquor. On February
14th he had pain in back, headache, pretty severe
chills, vomited. The eruption came out on the 1 8th.
He entered the hospital on the 19th. He became de-
lirious, so that for three days the temperature was not
taken. He became so violent that it was necessary to
secure him in bed.

February 24th he had become calm, and during
the next week he seemed the same as other patients,
except that he had delirium, with trembling, saw large
dogs at the foot of his bed, thought he was to be led
out to be shot, etc. His temperature was high, his
pulse low.

March 1st a few blisters appeared on his legs,
which seemed to be formed by the loosening of the
cuticle between several pustules. He continued to do
well, and took food well until the night between the
third and fourth of March. He was again delirious,
the temperature rose, and the delirium became of a
low, muttering character, with constant picking at the
bed-clothes and fingers. It was learned that the at-
tendant had given him articles of food which had not
been ordered ; more care was taken as to diet, and in
two days he was over the delirium. ''ij^

He bad severe abscesses, and a large amount of pus

collected in the calf and instep, which was evacuated,
and fifty days after admission he was discharged
well.

Delirium tremens was, in this case, an unfavorable
condition. It is not specially mentioned by authors,
though it is said that the intemperate are very likely
to die. The increase of delirium on the fourth of
March was due to the error in diet, but at the time it
seemed as though the patient was doomed to die.
Probably the inflammation in the leg was also an ele-
ment in causing the delirium.

The next case gives a very characteristic tempera-
ture curve, and the patient was very sick ; the pros-
pect for a few days was not favorable, but he recov-
ered finally.

(To 6e ootUinMtd.)

Digitized by

Google

460

BOSTON MBDIOAZ AJfJ> SUBOICAL JOVSSAL.

[Mat 10, 1894.

DIGESTIVE PARESIS.i

BY E. a. WHITTIBB, M.D.

I offer the term as a composite of the group of fuDC-
tioDal disorders, of which diminished peristalsis, lessened
secretioD and delayed digestion are important and repre-
sentative members. Impaired power is a constant fac-
tor in each of these processes.

The muscular tissues of the digestive tube fail to
exert their normal influence in the propulsion of ingesta
from causes so complex as to elude the careful study
of the physiologist in his efforts to determine the un-
derlying, controlling and controllable condition.

We are told that the nerroas mechanism of sto-
machic peristalsis is very obscure: that the quantity
of the contents of the stomach is a prime factor in pro-
voking peristalsis ; that in the intestine quantity soon
ceases to be causative ; and that intestinal peristalsis
may occur wholly independently of the central nervous
system.

It is for the general practitioner not to reason why,
but to recognize clearly and to accept as conclusive
the doctrine of the important part played in the mel-
ancholy drama of digestive disorders by diminution of
peristaltic power.

\a our study of the deviations from normal digestion
induced by changes in the character or in the quantity
of the digestive fluids, we find but little to aid or com-
fort us in the " Theory of Secretion " as set forth by
the physiologut; for the stomachic and intestinal se-
cretions— gastric, hepatic, pancreatic and succns-enteri-
cus— -are paraded as maintaining a struggle mutually
destructive — a kind of eternal internal and intestinal
vendetta. We are told that pepsin in an acid solution
destroys the active constituents of the saliva and of the
pancreatic juice, and in its turn is antagonized or de-
stroyed by the bile and the other alkaline juices of the
intestines.

Both diminished peristalsis and lessened secretion of
digestive fluids, sustain an important causal relation to
delayed digestion ; it is pre-eminently a result, in the
production of which these processes are prime factors,
and it is during this delay, induced by impairment of
the power needful for the proper performance of di-
gestion, that the major portion of those changes take
place in the ingesta, which give rise to the phenom-
ena calling for remedy at our hands.

Delayed digestion is a symptom-complex, into which
neurosal disorders, functional and organic, depraved
blood states, circulatory derangements of the heart and
abdominal viscera enter, and in turn are made worse.
Action and re-action in this condition are well-nigh
equal ; the baneful influence of this process extend to
all parts of the body, whose various members conspire
to return with interest the unwelcome debt of discom-
fort.

No condition is more pitiable than that of the chronic
dyspeptic No disorder has a larger following than
functional dyspepsia. No class of cases is more vexa-
tions alike to the patient and the physician. The vio-
tims of this malady, in ceaseless tramp, vex the corri-
dors of our dispeosaries and hospitals, or in melan-
choly round complete the circuit of our offices.

The general practitioner finds the information gained
from careful study of the literature of this subject, in-
adequate to the task of successful treatment of these

> Bead before the Boston Society for Medloal ImproTement, Feb-
ruary 26, 18M.

disorders. Good knowledge of what is known of the
physiology of digestion and of the functional causes of
departures from normal results, is insufficient ; it must
be complemented by sound judgment and ripe experi-
ence, and by a personal influence powerful to ooutrol
the psychical disturbances which sway the patient from
hope to despair, and alternate courage with fear ; but,
control once induced, it secures the most important con-
tribution to the patient's welfare that can be made, for
by no other method can the physician accomplish more
satisfactorily the desired object of placing the patient
in a position where

" Qood dlnetion wait on appetite.
And health on both."

Prof. £dward H. Clarke, whose portrait-bust adorns
this hall, was one of the leading therapists of his day.
He combined in largest degree close accurate observa-
tion and sound reasoning, essential prerequisites to
high attainments in this branch of our art.

No man ever listened to the glowing words with
which he clothed his argument on the personal influ-
ence of the physician, an argument in which be placed
highest and first in the list of remedial agents, the
personality of the practitioner, without being convinced
of the truth of the words (in which sound logic was
oombined with sincerity) wherein he presented the
therapeutic questions involved in the treatment of the
class of disorders of which my subject is a prominent
type.

■ I am not an advocate of the schedule diet system.
No man may start the digestive train for a through trip
on the main line, with good expectation of making all
the connections, and reaching the terminal station free
from delays, derangements and derailments. The pneu-
matic-block system on the intestinal track works harm
and not protection. Dietetic rules, formulas and care-
fully prepared combinations are scheduled for oar
guidance, and in general they may be said to be right ;
in many essential particulars it must be conceded that
they are too frequently wrong. The situation has not
been materially changed since Lucretius (95 B. C.)

wrote:

" Qood all ciboi eat
AlUi fuat aere Teuenom,"

paraphrased later by Beaumont and Fletcher,

" What's one man's poison, SUpior,
Is another's meat or drlnk.*'^

There are but few conditions in which the patient is
more dependent for a good result upon the experience
and judgment of the physician ; for example, when to
employ and when to discard milk ; when to diminish
or when to abolish starches; when proteids should
predominate or be omitted altogether, with the wide
range of modifications, combinations and interchanges.
One thing I have learned full well, that it is fruitless
to oppose the well-grounded convictions of chronic
dyspeptics, the result of their experience in following a
dietary based upon text-book schedules formulated
from processes which are physiological and normal ;
we must look to other sources for the rules which shall
govern our efforts to secure control over functional
digestive derangements of the stomach, but more par-
ticularly of the intestinal canal.

Changes in the ingesta, effected by digestive secre-
tions, have been carefully reported, in the earlier in
stance of Alexis St. Martin, by Surgeon Beaumont,
U. S. A., and in the more recent (1891) ubnhttions of
MacFayden, Nenckle and Sieber, whose case of an

Digitized by

Google

Vol. CXXX, No. 19.] BOSTON MEDICAL AlfD 8DMGICAL JOUMfAL.

461

ileo-caecal fistula in* a woman afforded the UDique op-
portunity of determining changes wrought by the com-
bined effects of all the digestive fluids. The deduc-
tions of these observers have been ably supplemented
by painstaking experiments carried out in physiologi-
cal laboratories.

Bat it must be conceded that these conclasions based
upon normal conditions and normal results, sustain
unimportant relations, so far as treatment goes, to the
abnormal processes which characterize digestive dis-
orders as a class.

A practice which obtains too often, and perpetuates
an error which is pernicious, is that of treating these
disorders as if the fault was primarily in the digestive
apparatus, and independent of the general condition of
the patient. Until soch views cease to exert their
baneful influence, digestive-paretic states must take
their chance in common with other frequently misun-
derstood self-limited disorders, and the lack of success
by treatment will continue to be an abiding reproach.

The physician should endeavor not only to attract
the patient away from the easily acquired habit of in-
trospection and self-condemnation, and from the " en-
joyment of poor health," but he should also and at the
same time strive to energize other functions than the
digesliTe. Superficial thought, unformed judgment,
or insufficient experience prompts some to overlook
the primary and fundamental cause, and to concentrate
time and treatment on this only, one of the many symp-
toms of a depraved general condition.

With your permission, Mr. President, I will depart
from the farther consideration of this branch of my
topic for the purpose of considering the causes and the
conditions which have brought into so great prominence
the modern method of treating functional digestive
troable. We may not readily discover the explanation
for this centring of treatment. The opinion, that it is
possible to secure and to maintain Internal antisepsis, is
strongest in commercial circles ; it is a bad day for
samples, and for the hoarder thereof when some new
synthetical compound or novel coal-tar product is not
obtruded during our office-hours. The effort to deter-
mine a method by which fermentations in the diges-
tive tube shall be limited, occupies a prominent place
in bacterio-physiological work, but as yet no man has
succeeded in doing for the physician and internal anti-
sepsis, anything in any degree corresponding to the
glorious work accomplished for the surgeon and ex-
ternal antisepsis.

I can find no good evidence of any material advance
towards medical antisepsis daring the past five years,
neither in the literature of the subject nor in the opin-
ion of bacteriologists whom it has been my privilege
to consult ; and 1 cannot obtain much promise for the
immediate future.

Our distinguished associate, Dr. McCollom, assures
me, that although the fulminating power of the bacillus
coli communis, when discharged into the peritoneal
cavity, notably in cases of perforating appendicitis, has
been demonstrated by the resnlts of laboratory work,
but little knowledge has been gained of the bacteriol-
og[y of the digestive anomalies classified as functional.

In spite of the disappointment arising from lack of
success in bacteriological efforts to give us controlling
knowledge of bacterial processes during digestive dis-
turbances we cannot fail to notice the claims to recent
advances in applied therapeutics.

The empiricism of the mercurialise of earlier days

has given place to accurate knowledge of the antisep-
tic properties of the mild chloride, leading some of its
votaries to assign it as prominent a position, as an in-
ternal remedy, as that occupied by the stronger chlo-
ride in surgical practice externally.

The advocates of quinine as an antithermic, have
changed their views since the experiments of Eberth
demonstrated so conclusively its power to check the
growth of the bacillus typhosus, and his deductions are
in keeping with those of Bouchard, to the effect that
quinine as an antiseptic holds a higher position than
quinine as an antithermic, that reduction of tempera-
ture is the result of the arrest of the bacillary develop-
ment in the intestinal canal and the result of the de-
struction of toxines in the blood.

We may not reasonably expect any considerable re-
turn to the heroic and discomforting doses of quinine
in the treatment of diseases of the intestinal canal, not
because of any inherent defect in the action of the
drug, nor because of any unsoundness in the conclusions
formulated, as cited, but because of the lessened in-
convenience and the greater precision which now ob-
tains in antiseptic medication by the exhibition of the
modern synthetical compounds and notably by the
derivatives of the coal-tar series..

Professor Henry describes the difference between
antiseptic medicine and antiseptic surgery, as of de-
gree rather than of kind : that surgical antisepsis is so
precise that it may almost be counted among the exact
sciences ; that while antisepsis in surgery is a preven-
tive of the absorption of toxines from a pathological
surface, it is subject to limitations in medical practice,
because in many instances the processes contended
with are in no essential degree departures from physio-
logical; that disinfection within the body is not a
simple, but a complex process, in which the agents
employed may produce their effect but only after hav-
ing run the gauntlet of the stomachic and intestinal
secretions, exposed to the contingencies of destructive
changes immediate and direct, and to the modifications
incident to absorption and excretion, in the hope of
correcting errors, whose local causative conditions have
not yet with sufficient accuracy been defined, a form of
a sub-way motor process, " running wild " in the dark,
on an unfamiliar track.

Modern medical appliances have given us free access
to the stomach and large intestine. Kussmaul and his
ardent followers have demonstrated the efficiency of
the means employed for the control of fermentative
changes in acute and chronic gastric disorders ; the
ease with which the colon may be flushed, and the
comparative safety with which its contents may be
rendered relatively aseptic are too well understood to
call for remark.

We have, therefore, left for our consideration tliose
measures and those remedies which address themselves
to checking the development of micro-organisms in the
inaccessible portions of the digestive tube.

Fermentative and putrefactive bacteria cannot be
isolated from the contents of the small intestine : even
in disorders of function, they abound in numbers and
in degree of activity exceeding computation ; this, too,
in spite of the hitherto accepted " antiseptic property
of the bile," which Nenckle has demonstrated to have
little or nothing of such influence. Bacteriology has
proven beyond all doubt the part played by micro-or-
ganisms in the origin, development and course of in-
fectious diseases. But until recently it has been suo-

Digitized by

Google

462

BOSTON MEDIO AL AND SVBGIOAL JOUBNAL.

[Mat 10, 1894

ceBsfnlly maintained that the arduoas labors of the
bacteriologist were without practical results, that dis-
infection within the body could not be secured, that
the diBease-producing germs could not be killed, that
their growth could not be hindered, that the power of
various pathogenic micro-organisms to produce toxines
could not be overcome and that once produced the
various toxic products could neither be antagonized
nor destroyed ; but we have great reason for cooclad-
ing that the situation has been changed, and that the
hope expressed by the earlier observers (that some
plan of treatment would be devised whereby fermenta-
tion and putrefactive changes in the contents of the
small intestine would be arrested) has been in consider-
able degree realized.

The subject of internal antisepsis or disinfection
within the living body has, as one of its most promi-
nent chapters, intestinal antisepsis. The literature on
this particular topic is voluminous, comprehensive and
of large practical value, and the conclusions formulated
by the more recent authorities are of deep significance.

The therapeutic problem, to administer such reme-
dies as will supplement the defect in the results of
nature's antiseptic efforts, is rapidly progressing towards
solution. It still ranks as the foremost therapeutical
question of our time, ably set forth as such by Pro-
fessor Henry in his paper read before the Association
of American Physicians in 1891.

Therapeutic intervention is needed in all the cases
which correspond in origin and in effect with that of
the subject I have the honor to present for your con-
sideration and discussion, and those remedies that pro-
mote intestinal antisepsis, with the least danger to the
individual, are deservedly assigned prominent positions
in the pharmaceutical preparations of the day.

But it is not so much an admission of inefficiency in
the modern remedies to induce internal antisepsis, as
it is evidence of the more careful study of the many
contributing causes of intestinal putridity, that more
rigid dietetic rules are now insisted upon ; nor do we
confess essential defects in the power of the remedies
employed to promote intestinal antisepsis, when we in-
sist upon more rigid observance of the rules favoring
elimination of the toxines formed within the body, but
because the important part played by the skin, the
respiratory surfaces and notably the kidneys is now
more highly appreciated.

To Selmi, who in 1872 isolated from the products
of putrefaction the poisonous alkaloids to which he
gave the name of ptomaines, and to Semmola, who but
Uttle later instituted a method of treatment designed
to destroy the toxic substances developed during the
progess of diseases of the intestinal canal, should be
given the honor of having been the first to deal
intelligently with the great principles of intestinal
antisepsis. The aid of chemistry has been invoked
in the preparation of remedies which evade the sol-
vent properties of the salivary and the gastric se-
cretions, and remain unchanged until they reach the
intestinal fluids, where they discharge themselves of
their duty, only as they are split up into their soluble
component parts. It is this peculiarity which confers
upon the intestinal antiseptics the powers claimed for
them by the manufacturers and their gentlemanly
representatives. Take, for instance, salol ; it is this
property of cohesion, until the remedy has found its
way into the small intestine, of disintegration as soon
as it meets the intestinal fluids, which confers upon it

its high reputation as an intestind antiseptic. Nap-
tbalin, hydro-napthol and A and B uapthols belong
to the same class, and in combination with salicylate
of bismuth have gained prominence; but in spite of
the somewhat encouraging contributions to our knowl-
edge of the therapeutics of the napthol groups, objec-
tions to all the members of this series exist to a con-
siderable extent, and are entitled to careful consider-
ation, for these objections are based upon difficulties
of administration, of stomachic disturbances following
the exhibition of this class of remedies, upon the ap-
prehension that changes iu the color of the urine to
dark brown and green, as well as painful micturition,
are evidences of irritation of the urinary organs, pos-
sibly harmful, and because there is ground for fearing
that we are not yet sufficiently well informed as to the
varying and inconstant degree of toxicity residing in
napthalin, hydro-naphthol and the napthols A and B.

Enumeration of new combinations might be defi-
nitely and uoprofitably prolonged. The latest reme-
dies, to the description of whose virtues pamphlets are
devoted, are not of necessity the best. The receat
eruption of five of the napthol-phenol-bismuth series
in one circular may be accepted as evidence of effort
on the part of dealers to satisfy a demand as yet un-
satisfied for a safe, reliable and efficacious intestinal
antiseptic.

The most recent plans proposed for the local treat-
ment of disorders of the digestive tube, include methods
by which there shall be secured for the patient the
largest possible freedom from the influence of the mi-
cro-organisms and their products, and these plans will
be found to be based upon rules which are the oat-
growth of bacteriological research and attainments in
other directions than that of the subject under consid-
eration ; and still further, bacteriological logistics may
be relied upon for the correctness of the conclusion
that at DO distant day concrete examples will be shown
demonstrating our control over the major portion of
the acute and chronic disorders of the iotestinal canal.

Prominent among these plans will be found :

(1) Measures to favor elimination, notably of the
toxines.

(2) Dietetic rules by which the opportunities for
putrefactive changes in the digestive tube shall be
lessened.

(3) Antiseptic medications, or the use of the more
recent internal antiseptics, by which better and more
than formerly the contents of the small intestine shall
be, so far as profitable, sterilized.

While I may claim, with reference to this branch of
my subject, that the limitations of bacteriological thera-
peutics are so pronounced that, in spite of greatly in-
creased etiological knowledge, our power of success-
fully treating intestinal digestive disorders has not been
materially advanced, and that we may, at least, render
the verdict " not proven," I am inclined to yield some-
what these pessimistic views, and for the sake of argu-
ment, side with the optimist, who considers it provi-
dential that such views cannot and do not prevail, and
do not control treatment ; for he believes that disin-
fection within the living body has entered upon a
career, comprehensive, progressive and well-nigh lim-
itless ; he cares but little whether the power to disin-
fect is exercised directly upon the microorganisms,
upon their toxic products, or because it imparts to the
cells of the body an increased power of resistance to
toxines. All this is immaterial, for in hia opinion the

Digitized by

Google

Yoi,. CXXX, No. 19.J BOSTON MEDICAL ASD SURGIOAL JOURNAL,

4()8

demouatration is complete, that immunity to a degree
hitherto uDexpected, and even now with difficulty real-
ized, has already been induced. To him, earneat work-
ers in the physiological and bacteriological laboratories
of this and of other countries, present in their care-
fully-drawn conclusions, arguments of great weight and
power, competent to convince the most sceptical, to
the effect that preventive medicine has entered u[>ou a
new era, a reign of control over disease, wider, deeper
and more beneficent in its influence for good, abound-
ing in larger promise of blessing for the sick and suf-
fering than at any period in the history of mankind.

COMPOUND FRACTUKES.1
A Studt of Three Hundred Cases.

BT J. O. MDJirOBD, M.D.

In reading the articles on compound fractures
published during the past five years I have been im-
pressed by the fact that the writers have striven to
demonstrate the advantages of certain methods of treat-
ment, and that their short and favorable lists have
furnished no proper data for the general consideration
of such formidable injuries. To cite a single instance:
Mr. Treves, in the Annals of Surgery for Febru-
ary, 1893, gives a list of 61 cases, with one death. As
this article fails to define the character of the fractures,
further than to state that they are of the leg, and aims
only at lauding a particular method of treatment, but
little can be concluded from it. Other authors deal
with the subject in connection only with their treat-
ment of some special fracture or gronp of fractures, so
that the practitioner or student must be often in the
dark as to the general characteristics of these lesions.

A year ago I published a paper classifying and
analyzing fractures of the skull. In the present essay,
therefore, I shall omit the consideraUon of head in-
juries, excepting only fractures of the maxillary bones.

It is difiicult in an artide of this kind to properly
limit one's self. A serious railv(ay crush of both femora
or of the pelvis, should be ruled out as essentially
fatal. A similar crush of one arm or leg should be
rated out when it calls unquestionably for amputation.
I shall not consider fractures in the feet and hands,
as they are too complicated in their nature, do not in
these days seriously endanger life, and nearly always
heal up soundly, or call for immediate amputation.

There is a variety of fractures of which I have at-
tempted to treat as conservatively as possible, but
which is often hard to classify. Thus, twenty years
ago a badly comminuted and lacerated leg would have
been amputated. It would not then have come under
the head of the injuries I am dealing with. Ten years
ago a similar leg would have been amputated by some
BurgeoDS and saved by others. To-day we should all
save it. To-day, therefore, it is a compound fracture
in the sense in which I use the term. But there are
fractures seen to-day as to which the question, to am-
putate or not to amputate, rises. If we amputate, we
do not coont this case in our list as a compound fract-
ure. If we save the limb by a miracle, we consider
the case a clever piece of conservative surgery.

In making up this list, therefore, I have not been
able to take into account differences or errors in judg-

> Read before the Boetoo Soetety for Medloal ImproTement, Febm-
aiyKtUM.

ment, and have had to divide this class into cases
essentially hopeless and those presumably hopeful. It is
under the bead of those presumably hopeful that we come
subsequently upon our cases of secoudary amputation.
I shall deal with fractures of the long bones of the ex-
tremities, the jaws, the scapula, and the patella, omit-
ting all such cases as are, in the light of to-day, essen-
tially fatal or which call obviously for immediate ampu-
tation.

The mortality from compound fractures is high ;
that of certain bones very high. The general mortal-
ity is higher than that from typhoid, pnenmonia and
certain other acute infectious diseases. The public,
certainly, and many physicians, I think, underestimate
the gravity of these lesions.

To get at a fair, and, at the same time, a favorable
estimate on the subject I have analyzed 300 consecu-
tive cases taken from the Massachusetts General Hos-
pital records for the past eight years.

Out of a total of 300, 270 recovered and 80 died, a
mortality of 10 per cent. There were but 9 women
and 291 men. One woman died. The following table
gives the relative frequency of the fractures :

Que*.

Ill

S3
33
2S
i!0
14

Tibia and fibals (both) .

Tibia

Humerus

Femur

Radius and ulna (both)

Inferior mazlUa ....

Patella 9

Humerus, radius and ulna (elbow joint) 8

Radios 8

Fibula T

Oleoranon (distinguished from ulna) . 4

Ulna 3

HnmaruB and uluB (both) ... 2

Femur and tibia I

Soapula 1

Superior maxilla 1

Totals

300

Died.
10
7
1
7
2
0
0
1
1
1
0
0
0
0
0
0

30

MorUUUy.

9.009%
13.2

3.33
28
10

0

0

12.fi
12.5
11.28

0

0

0

0

0

0

Io%

From this list it will be seen that 37 per cent, of all
the fractures are those of the tibia and fibula together ;
17.6 per cent, are of the tibia alone, and 2.33 per cent,
of the fibula alone. Practically, fractures of the leg
constitute 57 per cent, of all the compound fractures
in this list. The forearm comes next with 11.6 per
cent., the humerus with 11 per cent., and the femur
with 8.33 per cent., the lower jaw with 4.66 per cent.,
and the patella with three per cent. The other fract-
ures— those of the scapula, upper jaw and unusual
joint complications — are so rare that they may be
classed as surgical curiosities, and together make up
less than 5 per cent, of all the compound fractures. I
have purposely omitted from the list fractures of the
nose, as they were seen only in the out-patient depart-
ment and could not be properly followed up.

Since these cases are taken as they occur in routine
practice and are not selected for purposes of treatment
demonstration, as they are seen by a number of dif-
ferent surgeons, but follow a regular routine of treat-
ment, I will sketch out briefly the method of the man-
agement, when uncomplicated.

With rare exceptions ether is given in all cases of
compound fracture.

In the reduction of fractures of the leg no unusual
plan is followed. Some years ago division of the
tendo-Achillis was thought to be of advantage when
there was great over-riding of fragments, but experi-
ence showed this manoeuvre to l>o of questionable ad-
I vantage. The usual shaving, scrubbing, syringing and

Digitized by

Google

464

BOSTON MEDICAL AND SURGICAL JOURNAL.

[Mat 10, 1894.

general disinfectiDg of the limb have been thoroughly
carried out for many years. Chlorinated soda, snlpho-
naphthol and bichloride are the favorite washes used.
The leg is then put upon a Cabot splint and dressed.
This splint is a simple wire frame, made from a single
piece and bent so as to fit the ankle and knee. The
wound is dressed, simple wooden side-splints are put
on to prevent lateral bowing, and the apparatus is
bandaged above and below the site of the fracture.
An unenclosed area is left open for the renewal of
the dressings.

The only variation in this style of treatment for
many years has been in the first dressing of the com-
poand opening. Up to 1891 it was the almost invari-
able custom to establish the freest kind of drainage.
If necessary, to enlarge the wound ; usually to make
counter-openings, as dependent as possible. Stitches
were rarely taken, and a primary union was seldom
expected. Within the past three years drainage has
become much more infrequent, for reasons which I
shall subsequently discuss ; and stitching, with primary
union, has been common. Plaster as a first dressing
has been rare. After the wound has become simple,
however, the limb has been put up in a plaster splint
and the patient given crutches. The method of treat-
ment by these posterior wire- and side-splints has long
been deservedly popular with those accustomed to their
use. The splints are light, simple, easily kept clean,
readily applied, quickly changed, and provide most
conveniently for secondary dressings without disturb-
ing the limb.

Fractures of the thigh are put up in an extension
apparatus of some kind — the long Dessault or the
Bucks — with a posterior and long outside splint, con-
veniently arranged for proper dressing of the wound.

The patella fracture is put on a posterior splint, with
coaptation splints to control the quadriceps femoris.

Fractures of the upper extremities are put up in a
variety of apparatus, consisting usually of shoulder
cap, coaptation splints, internal angular at the elbow,
and anterior and posterior splints for the forearm.

It is not my object in such a paper as this to dis-
cuss the relative merits of the various apparatus
devised for these injures. So long as the fragments
of a bone are securely immobilized, with due regard to
the patient's comfort, it is of small moment what the
style of apparatus may be. I am most decidedly of
opinion, however, that proper provision should always
be made for subsequent dressings and care of the wound
in titu.

Fifty per cent, of these 800 fractures were due to
crushes, and a large majority of these crushes were
sustained in railway accidents. I have previously
called attention to the extremely serious nature of these
accidents. A description of the results of such crushes
and of the pathological conditions ensuing is given by
Dr. Alexander Ogston, of Aberdeen, in the Medical
Chronicle for November, 1888. The bones in these
cases are nearly always comminuted, the soft parts are
severely lacerated, and there is frequently a resulting
bone necrosis. Of these 151 cases of crush, 102 were
comminuted and lacerated, with a resulting necrosis in
26. Twenty-one of the total 30 deaths followed
crushes; so that we may say that the mortality after
crushed fractures is 13.H per cent. I do not, of coarse,
include those cases which are essentially fatal.

Fractnres from horse-kicks I have put in a spe-
cial class. This may be fanciful, but I find that in

these cases comminution is very common, primary
union rare and long suppuration frequent There were
24 of these cases, with a mortality of 4.16 per cent.
Of other fractures, from blows there were 27, with a
mortality of 7.4 per cent.

Next to crushing accidents the most common cause
of a compound fracture is a fall. Of these there were
1 GO, with a mortality of 6 per cent. It would appear
from a study of the tables that fractnres from this
cause are the least severe of all, and the progDogis
good. The violence is indirect, comminution nncom-
mon and laceration slight. Here we may stitch with
a good prospect of primary anion, and usually withoot
drainage.

Four cases of bone necrosis and 18 of comminotioos
are divided between the classes of blows and falls.

In the whole list, though, I found bone necrosis
recorded less often than I should have expected. It
occurred 30 times, a proportion of 1 in 10. One of
these died of prolonged suppuration, after two oper-
ations for the removal of sequestra. Twenty-one cases
in all required these secondary operations. Thelongest
in healing after the primary accident was twenty-four
months, the shortest was three months.

In a carefully treated hospital case ununited fract-
ure is a great rarity. The reason probably is that the
rigid hospital discipline, the admirable dietary and good
hygienic surroundings, favor proper and rapid anion.
Many cases of non-union which I have seen in private
practice were directly traceable to the negligence of
the patient himself.

In my hospital list there are records of but seven
ununited fractures : Four of the humerus, two of the
radius and ulna, and one of the femur, all were eventn-
ally wired, and recovery ensued.

Fractures with joint complications were found to be
quite common in the list, but the mortality during the
past three years has been surprisingly low, and useful
joints have frequently resulted.

Joint.

TotaU.

Exeiied.

Ank^UAd.

Died.

Jf«<i«n

Knee .

IS

0

9

3

Shonlder .

1

1

0

1

Ankle . . .

. 9*

I

6

3

ElboT .

. 26

T

«

20

Wrlit . . .

1 ((

[angrene,

unp. 3d day

1

0

Totali

SO

20

The total number of joints involved is seen to be 50,
with 3 deaths, a mortality in joint fractures of 6 per
cent., a lower mortality than the total average of 10
per cent. The fact that prompt and thorough excisions
were done in nearly all desperate elbow fractnres,
which include a majority of all the joint fractures, ac-
counts partially for this low mortality. In the elbow
fractures which are amenable to more conservative
treatment it is gratifying to see how, in recent years,
a recovery of function has followed thorough antiseptic
treatment without excision. There were 19 elbow
fractures not excised, 13 of these cases recovered with
good movable joints. Several of the 6 ankylosed
cases were directed to return for subsequent resection,
but their records I have been unable to trace. Most
of them probably preferred to remain as they were,
with the elbow at a right angle.

That 9 out of 13 knee-joint fractures remained
ankylosed must be considered a good result relatively*
Three recovered with motion, and but one died. " '*
a fair presumption that more of the cases wonid have
recovered with motion, had they persisted in the use

Digitized by

Google

Vol. CXXX, No. 19.] BOSTON MEDIOAL AND SUROIOAL JOURNAL.

465

of passive movements — a manoenvre so difficult to
properly carry oat with hospital patients.

Of the 7 elbovr resections it should be said that S
were primary and 4 were secondary, or after the third
day, when it became evident that a useful joint could
not be saved. They all recovered well, the average
length of convalescence being six weeks.

The one ankle-joint excision was secondary, in a
middle-aged alcoholic subject, after two months of sup-
puration. He recovered with a fairly useful false joint.

There was one primary excision of the head of the
hamerus, with a satisfactory joint resulting.

Aside from the joint exci8i9ns the bameras was re-
sected twice, and the bones of the forearm once. A
total of 12 resections with excellent results in all.

Primary wiring of bone was done 27 times. Twenty
of the cases got good union, and 7 had necrosis. It is
noticeable that tliuse 7 cases of necrosis were treated
by the open method, that is, the wound was left un-
gntured and the wires extruding.

One of the cases of compound ankle-joint was com-
plicated by laceration of tendons. Tbe tendon of the
extensor proprius pollicis wm sutured, and good union
followed. The man recovered with a movable joint.

As was said at the beginning of this paper, those
cases of compound fracture are excluded which are
essentially fatal. Tbe question immediately rises.
What cases are these ? I admit at once that such a
question cannot be accurately answered, but that the
decision must be left to the individual surgeon. A
vast number of very serious injuries are in these days
survived, in a manner which would have astonished
onr fathers, so that we have come to regard hopefully
the most grave and extensive lesions. Prosperous
looking cases do occasionally die, however. 1 have
found in this list six causes of death. They are :
sepsis, shock, delirium tremens, fat embolism, gan-
grene (as distinguished from the ordinary suppurative
processes), and nephritis.

Sepsis does not appear to have decreased materially
within the past eight years. There were 20 cases with
10 deaths ; a total mortality from sepsis of 3.88 per
cent. In 1885 there were 4 cases ; in 1886, 2 cases ;
in 1887, 2 cases ; in 1888, 2 cases; in 1889, 3 cases ;
in 1890, 3 cases; in 1891, 1 case; in 1892, 1 case;
in 1893, 2 cases. Secondary amputation was done in
3 of these with 1 fatal result ; 7 died of septicaemia,
and 3 of pytemia. There were 3 cases of erysipelas,
all of which recovered.

Of course, all of these septic cases received the most
thorough antiseptic treatment; the favorite local ap-
plication being baths or constant irrigation with bi-
chloride or sulpho-naphthol.

The age of the patient in sepsis seems to have had
no bearing on the result. Those who died ranged
from nineteen years to sixty-five years. There were
among them 3 fractured femora, 6 fractures of the leg
and 1 of the radius.

The nature of shock and collapse is still so uncer-
tain that it is dit6cu1t to distinguish them always from
other conditions, notably embolism. Those cases which
entered the hospital and died within twelve hours I
have included in the list of essentially fatal cases.
There were 15 cases besides these which fell into a
condition of shock subsequently, the eSect of operation,
ether or secondary htemorrhage ; 8 such cases survived
and 7 died.

There were not many recorded cases of delirium

tremens : 9 in all, and 6 of these died. The deaths
were obviously due to delirium tremens. It happened
that none of tbe injuries were especially severe. The
injuries of the three survivors were as bad as any, but
the men averaged much younger. It is recorded of
one that he was cured of drinking, and a year after his
discharge was a total abstainer. Contrasted with him
was an individual who gave bis name as Yale College.
He was a negro. His injuries were comparatively
trivial ; but he died on the tenth day, after a week of
delirium.

There are 3 recorded cases of fat embolism, with
death and autopsy. All of them were due to extensive
crushing of the leg.

One man died of an acute, presumably septic,
nephritis, which certainly was not present when he
entered tbe hospital ; and three died of gangrene for
which secondary amputations had been done fruit-
lessly.

Eecov^d. Died.

S«p8iS .

Shook .
Delirium tremens
Fat embolism
Gangrene
Nephritla .

10
8
3
0
7

11

10
7
6
3
3
1

Mortatily of
Total FractB.

3.33%
2.33
2
1
1
33

Totals.

20
16

9

8
ID
12

Deatlu 30 (10%).

Some of the cases of gangrene were most unexpected.
One boy with a simple crack through the tibia, no ap-
parent complications and excellent circulation in the
foot on entrance, developed gangrene, and died three
days after an amputation.

Secondary amputations were not common, however.
There were but 20 in all : 7 of the humerus, 5 of the
forearm and 8 of the leg.

One young man with a compound elbow eloped on
the first day. He returned for amputation on the
seventh day. Extensive gangrene had set in.

Of all fractures of the humerus, 21 percent, required
secondary amputation, of forearms 16 per cent., and of
legs 7 per cent.

Though the figures would show that acute general
sepsis is about as common now as it has been at any
time within the past eight years the records prove,
without question, that the geueral results obtained in
the treatment of compound fractures are vastly better
than they were eight years ago, and that within the
past three years, especially, there has been most marked
improvement, Local suppuration is much less com-
mon. Five years ago a certain amount of suppuration
was expected ; but since January, 1891, there are but
15 recorded cases. In the five previous years there
were 89. In the suppurating cases recorded the mor-
tality takes a decided jump upwards, as we should ex-
pect ; 84 per cent. died.

There were a few remarkably good results as far
back as 1885, when a case of fractured leg was recorded
well in two months. Last year a comminuted leg was
simple in one day and sound in two months, without
exciting especial comment. In the same year a com-
pound forearm became sound in six weeks.

A study of the modes of treatment employed in the
last decade and in this, convinces me that the improve-
ment in resolts is not due to any radical change in
method. Indeed, the methods are the same so far as
the sterilizing of the wound and its dressing are con-
cerned.

Why is it then that today we can so frequently dis-

Digitized by

Google

466

BOSTON MEDICAL AUD SVB61CAL JOURS AL.

[Mat 10, 1894.

pense with drainage, especially with the former namer-
oos coDuter-openingg ? In the old days that omiggioD
woald have been thought tnadaess, and when tried led
almost invariably to extensive suppuration. As it ia.
the older charts show regularly a temperature elevated
for ten days or a fortnight Stitching the wound up
tight was seldom practised five years ago. It is fre-
quently done to^lay, with a resulting primary union.
Very often now, after the first dressing, the woood is
left sealed for two or three weeks, when the dressing
is removed and the fracture found simple. The result
is that to-day a permanent plaster splint is put on
within a month of the accident, and that a great many
of these cases give no more trouble than do simple
fractures.

The reason for this gratifying advance lies in the
fact, I believe, that the environments of our surgery are
dean. It has taken many years to accomplish this in
an old hospital like the Massachusetts General ; but
the results in all branches of surgery seem to bear out
the statement Patients used to be carried into an
accident-room which must have been septic, and in
spite of the most scrupulous care in the management
of the wound it very often became contaminated. To-
day I believe that the accident-room is as clean as the
abdominal ward.

In this list it will be seen that the average time of
healing is rather less than stated in the standard books.
Excluding such complications as humerus, radius and
ulna (elbow-joint), humerus and ulna (elbow), and
femur and tibia (knee), the order of the bones, ar-
ranged according to their rate of healing, is as follows :

homgtxt. Shortut. Averaet.

Sopcrior maxlUa .... I mo. I mo. 1 mo.

SoapnU (body) 2 2 2

Inferior mullla . . . , t 1 2.4

Ulna 4 2 2J)

Badios 12 1.5 3

Badliu and alna .... 12 IJi 8.5

Hameriu 8 2 3.6

Oleeraooo 8 3 4.7

Tibia 24 2 4.7

FlbaU 12 2 4.8

Tibia and Abala .... 28 2 6.6

PatelU 12 4 «.«

Femur 24 3 8

Some of these averages, such as upper jaw and
scapula are of little value, as they are taken from too
few recorded cases. The number of these cases is sig-
nificant, however, as indicating their rarity.

All the fractures of the lower jaw did well. Even
with extensive comminutions there were but few
necroses. Methods of treatment were diverse ; but it
is worthy of note that by far the best results were ob-
tained from the use of inter-dental splints, furnished
and fitted by the Dental School.

Of course, it is almost impossible to keep these fract-
ures aseptic, and sinuses often persist until the bone
is sound.

There were but 3 fractures of the ulna alone, all of
which united well without any complications. The
infrequency of fracture of this bone, alone, excluding
fractures of the olecranon, is due to its deep position.
Its fracture is almost always accompanied by fracture
of the radius.

Compound fracture of the radius alone is not very
common. There were 12 out of the total 300. The
radius is usually fractured by falls on the wrist tiDii
this is an unusual seat of compound fracture unless
from a crush or blow. If compound, the wrist-joint is

liable to be opened. In one of the cases thu resulted
in death.

Both bones of the forearm are frequently the seat
of compound fracture, and non-union is not uncommon.
Out of 20 cases, 10 per cent. died. In treating fract-
ures in the forearm it is not very easy to obtain im-
mobilization except with plaster splints. As in fract-
ures of the leg, however, primary union of the soft
parts is more common than it was, and the bony unions
are more rapid than they once were, the reauliiog
callous less and good rotation more certain.

Perhaps the most difficult to treat of the ordinary
compound fractures are those of the humerus. It is
almost impossible to immobilize this bone in any appa-
ratus which will admit of easy access to the wound for
dressings. The practice of fastening the arm to the
side and fixing the shoulder- and elbow-joints is the
most practicable and common, but necessitates some
movement of the arm for dressings.

From the surgeon's point of view an extension appa-
ratus, similar to that used in thigh fractures, with the
patient in bed and the arm extended at right angles is
very satisfactory, but it is almost impossible to get pa-
tients to submit to such confinement.

Owing to these difficulties we find a majority of our
oases of ununited fracture to be of the humerus.
Secondary amputation of this bone is likewise most
common. Out of S3 fractures of the humerus four re-
sulted in non-union, as against 3 non-uuions in 267 of
all other fractures. Secondary amputation was done
in 7 cases of the remaining 29, which leaves un bat
22 cases in which good early union took place. Hcoce
it appears that our prognosis in all these humerus
cases should be very guarded. It is positively good in
but 66.6 per cent, according to these statistics.

Fractures of the olecranon are interesting mainly on
account of its relation to the elbow-joint, and its inef-
ficient blood-supply. When compound, its treatment
is subordinated to the question of saving the joint It
unites more slowly than the humerus, but has a lower
mortality.

There is little to add to what has been already sud
in regard to compound fractures of the leg, except in
regard to the rate of healing. As would be expected,
fractures of both bones heal more slowly than those of
one. The difference in rate being one month. The
tibia, when fractured alone, is sound in about four and
one-half months, both bones in about five and one-half
months.

There is an average and fairly definite relation be-
tween the time a fracture becomes simple and the time
it may be pronounced healed. If the fracture does ab-
solutely well and there is no necrosis this relation Is
as one to five.- If a leg is simple in one month the
bones will be sound in five months. This is true, too,
of the very short cases. Two cases which were simple
in ten days were sound in two months. If there is
necrosis and long suppuration, the ratio may be as
four to five, or the bone may become sound before the
wound is simple, and the figures be reversed.

It seems that certain fractures of the leg are espe-
cially liable to suppuration. All the compound Pott's
fractures suppurated ; and as this is the common fract-
ure of the fibula, it will be seen that this bone when
fractured alone heals more slowly than the tibia alone.

None of the patellar fractures died. Most of these
were wired. Three recovered with good motion in the
knee and in six there was resulting anchylosis.

Digitized by

Google

Yot. CXXX, No. 19.] BOSTON MEDICAL AND SOttGlOAL JOURNAL.

467

As would be expected, by far the highest mortality
wu in fractnres of the femur : 28 per cent, of the 25
cases. The great diflSculty in rendering lacerations of
the thigh aseptic, and the shock in these injuries, were
the caases of death. Some of the cases, however, re-
covered with remarkable rapidity. The shortest con-
valescence was that of a young man of twenty-four,
who walked safely after three months. Eight months,
however, was the average length of convalescence.

In collecting data for these conclusions my difficul-
ties have been very great. Fortunately many of the
ultimate results appeared in the hospital records, and
a great number of the patients answered my notes of
inquiry. The results, as regards deformity, were es-
pecially Kratifying to note. The worst deformities
were from crushes and horse-kicks ; but after the lapse
of years they have frequently become less noticeable,
and very rarely have the functions of limbs been im-
paired after permanent bony union.

It seems fair to briefly conclude from this hasty re-
view of so extensive a subject that, though the mortality
is relatively high, still we have made within recent
years a decided advance in our treatment of this class
of cases ; and that our success is not so much due to
any special variety of apparatus or method of treat-
ment, as to our perfection of technique in working on
the broad lines of aseptic snrgery.

Clinical apepattment.

SATURATED SOLUTION OF POTASSIUM PER-
MANGANATE IN THE TREATMENT OF
CHUONIC ULCER.

BT F. B. WAVOHOP, M.D,,

Interne <tt Botton CUy Hotpital.

Last summer, in the surgical ont-i>atient depart-
ment of the Boston City Hospital there were a num-
ber of very obstinate cases of chronic ulcer. Poul-
tices of corrosive sublimate (1-1000), creoline (1-1000)
and of Labarraque's solution were faithfully employed ;
as also strapping and the tin-plate method ; but with-
out success. Iodoform, aristol and calomel powders
were also unavailing.

Permission was then obtained to try the saturated
solution of potassium permanganate on these cases.
The results were extremely gratifying. One typical
case is herewith submitted in full and a summary
given of twenty-four others — ulcers, abscesses, old
sinuses, etc

Case VIII. Ulcer just above left internal malleo-
Ids. Size of a quarter-dollar and one-quarter of an
inch deep, the bottom being covered with a greenish
slough.

This ulcer had been present for four years, with
very little variation. It had been treated at various
times with poultices of corrosive sublimate (1-1000),
the last time once every two days for three weeks.
The poultices served merely to stop the sloughing
without showing a tendency to heal.

Permanganate Treatment. — The slough was swabbed
out, and the ulcer flooded for ten minutes with the
permanganate solution (severe smarting being pro-
duced the first two minutes). It was next sponged
dry and loosely packed with narrow strips of gauze
soaked in the fluid. A heavy permanganate poultice
(gauze three inches square, dripping-wet with the solu-

don) was then applied, covered in with oiled paper,
and bandaged as lightly as possible with cheese-cloth.
This method was repeated every day for a week. On
the eighth day the granulations were flush with the
surface. Two days of subsequent treatment with eu-
calyptus vaseline was followed by the formation of a
pellicle over the granulations. (Patient disappeared.)
Case I. Gangrenous ulcer of leg. Size of dollar,
and three-quarters of an inch deep. Corrosive three
weeks, without effect. Permanganate heals in ten days.
Cask IIL Old ulcer of leg. Superficial, two inches
by one and one-half inches. Corrosive creoline, flax-
seed, and boric acid ointment five weeks, without ef-
fect. Permanganate applied every other day, heals in
ten days, that is, five applications were made.

Case X. Ulcer of leg, two years' duration. Three
inches in diameter by one-quarter of an inch deep.
Bread-and-milk poultice two months, without effect.
Permanganate, in three weeks, reduces ulcer to one-
half the size. (Patient disappears.)

Cask XI. Ulcer of leg, twelve years'd uration.
Size of quarter-dollar, one-half inch deep. Corrosive
four mouths, without effect. Permanganate heals in
six weeks. (Patient came only twice a week, and was
on his feet constantly, doing heavy work.)

Case XII. Ulcer of leg. Three inches by one and
one-quarter of an inch deep. Corrosive one week,
without effect. Permanganate every other day for
three weeks reduces to a superficial ulcer the size of a
dime. (Patient disappears.)

Case Xill. Ulcer of leg. Size of dollar, and
three-quarters of an inch deep. Very fool. Tar oint-
ment six weeks, without effect. Permanganate heals
in fourteen days.

Case XV. Ulcer of leg. Two inches in diameter
and one-eighth of an inch deep. Corrosive two months,
without effect. Permanganate heals in seventeen days.
Case XX. Ulcer of leg. One inch in diameter
by half an inch deep. Linseed poultices, carbolized
ointment five days. Action too sluggish. Hastened
to a cure by permanganate in eleven days.

Case XXIV. Ulcer of leg. Size of a half-dollar ;
one-quarter of an inch deep. Permanganate produces
severe dermatitis. Heals slowly under iodoform oint-
ment in nine weeks.

Case XXVI. Ulcer of leg. Size of dollar, three-
eighths of an inch deep. Corrosive two weeks, with-
out effect. Permanganate, used every other day, heals
in fifteen days.

CaseXXVIL Ulcer of leg. Tuberculous? Two
and oue-half by one and one-half by one and one-quar-
ter inches. Corrosive seventeen days, without effect.
Permanganate, at irregular intervals, heals in a month.
Case XXXI. Ulcer of leg. Three by two by one
and one-half inches. Corrosive two months, without
effect. Permanganate heals in two months. (Patient
came only twice a week and was constantly doing
heavy work.)

Case XXXIII. Ulcer of leg. Two and one-half
inches in diameter and three-fourths of an inch deep.
Permanganate in fifteen days reduces to about one-
half the original size. Then twenty days of flaxseed
poultice. Ulcer remains stationary, and sloughs a few
times. Then healed by permanganate in seventeen
days.

Case IV. Abscess of arm. Size of quarter.dollar,
and one-quarter of an inch deep. Packed one week
with iodoform gauze. Remains sluggish, Packed

Digitized by

Google

468

BOSTON MSmOAL AND SVRQIOAI JOVSSAL.

[ItfAT 10, 1894.

with permanganate gaaze, (that is, strips of ganze wet
with permanganate). Well in five days.

Case XIV. Abscess of forearm. One-qaarter of
an inch in diameter by tbree-qnarters of an inch deep.
Packed • with corrosive three days, without effect.
Permanganate gauze cures in one week (five applica-
tions).

Case XVI. Abscess of abdominal wall. One and.
one-half inches in diameter, superficial. Iodoform
ointment six weeks, without effect. Permanganate
gauze heals in fourteen days.

Cask XIX. Abscess of arm. Size of dime, super-
ficial, very foul. Aristol ointment two weeks, without
effect. Permanganate gauze heals in one week.

Cask XVII. Old suppurating sinuses along course
of palmar tendons. Hydrogen peroxide and iodoform
gauze ten weeks, without effect. Permanganate ganze
(used every other day) heals in five weeks.

Casb XVllI. Suppurating gland of neck. Packed
with iodoform gauze two weeks, without effect. Per-
manganate gauze heals in two weeks.

Case XXIX. Cellulitis of thigh. Corrosive and
iodoform gauze sixteen days, without effect. Perman-
ganate heals in twenty-six days.

Case V. Crushed fingers, sloughing. Iodoform
gauze and creoline for one week. Too sluggish ; little
progress. Permanganate heals in ten days.

Case XXII. Sloughing lacerated wound of hand
— gunpowder. Iodoform gauze six weeks. Improve-
ment steady, but too slow. Laceration reduced in ten
days by permanganate, from size of dollar to complete
disappearance.

Case XXV. Crushed foot, sloughing. Eucalyptus
vaseline three weeks, and black wash two weeks, with-
out effect. Permanganate heals in sixteen days.

Case XXI. Sloughing chancroids. Aristol oint-
ment for twelve days, without effect. Permanganate
heals in six days.

The above are fair examples. Several hundreds of
these non-syphilitic cases were treated in this manner
during July, August and September, 1893.

The main disadvantage is the pain, which may be
very sharp from one to five minutes after application
(sometimes twenty minutes, in the case of anal fistula).
It then ceases altogether. Rarely, also, a dermatitis is
produced.

If the granulations became over-stimulated, weak
nayrrh wash, lead and opium wash, or some one of the
antiseptic powders, or bland ointments was substituted
for permanganate until the indications ceased. More-
over, permanganate was usually supplanted by one of
these dressings so soon as the ulcer was filled even
with the surface, in the normal process of healing.

The patients mentioned above as "disappearing"
were those who considered themselves cured, and felt
too busy to make their final appearance at the hospital.
The corrosive used in the above tests was always 1 to
1,000.

Very good results were obtained in a few cases of
anal fistula which were slow to granulate after opera-
tion.

Saturated solution of oxalic acid was found to be the
best reagent for removing the stain from the hands.

An International Congress of Sea Bathing and
Marine Hydro-therapeutics will be held at Boulogne-
Bur-Mer from July 25th to 29th.

RECENT PROGRESS IN ANATOMY.

BT THOMAS DWJOHT, H.D.

METHODS OF TEACHING ANATOUT.

Thebe has been a good deal of writing on this ever
fresh, though well-worn controversy, in the English
medical papers towards the close of 1898. The cen-
tral figure in the discussion is Professor Macalister,
perhaps the leading anatomist of Great Britain. He
wrote a paper ' in which among other things be dis-
cussed the relation of the study of frozen sections to
dissection. Without depreciating the latter he taught
that the former should be used for supplementary
study. Dissection he defines as the art of removing
the connective-tissue from around parts so that they
can be properly seen. This must, of course, distnih
the relative position of parts. "Tbe most skilfal
anatomist, when he opens the body cavities, mast dis-
place the viscera in relation to the landmarks, and
cannot avoid doing this to such an extent that, like
the fallen Humpty Dnmpty, all the members of the
Anatomical Society of Great Britain and Ireland can-
not put them back as they were before. . . . Dissec-
tiou is the only way of learning structure and detuls ;
sectional study is the only way of learning relations."

This teaching did not please the old-fashioned anat-
omists who must of late have been chagrined at seeing
the rise of new methods. Mr. Thomas Cooke ' says,
" The conception put forth by Professor Macalister is
not new. It is substantially the same — popular errors
are long-lived — with which I was familiar as a stu-
dent in Paris that to the surgeon, the body (to use the
metaphor of the day) should be, so to speak, like glass-
transparent." He then goes on to prove, what every
one will admit, that this is not necessary for tying ar-
teries which are reached by following certain succes-
sive guides. In regard to the statement that tbe study
of frozen sections is the only way of learning relations,
he says that it is only some twenty years since these
were heard of, and asks " Were anatomical relations
but imperfectly understood by Callender, Furgussoo,
Wood — to name only British surgeons who are no
longer with us ? " No one seems to have replied to
this challenge, but trusting to three thousand interven-
ing miles of ocean, we venture to say that we do not
believe one of those surgeons knew the position of the
stomach, tbe shape of tbe liver, of the spleen or of the
pancreas ; we may add that Wood taught tbe trne
relation of the arch of the aorta which he had learned
by the sectional method somewhat crudely applied.'
Symington in an address extols frozen sections. Cud-
ningbam uses them freely. We are sure that they
have come to stay in Great Britain and Ireland, despite
the old-fashioned exponents of what Goodsir called
"scalpel and forceps " anatomy. We trust that this
will never be superseded but only supplemented by
modern methods.

Another point about which the discussion has raged
is tbe value of embryology and morphology in the
anatomical course. Macalister holds that anatomy
taught from a morphological standpoint is more inter-

> Brittoh Medical Journal, October 21, 1893. There aeema to hstt
been a prerloiii pamphlet by Mr. Tbomaa Cooke, which we hare not
bad the adrantase of seeing.

> The Lancet, NoTember 4, 1893.

> Joamal ol Anatomy and Phyalology, toI. Ill, I86S.

Digitized by

Google

Vol. CXXX, No. 19.] SOSTOlf MSDIOAL At[t) SVttGtCAl JOtJttlfAL.

469

estiag, more intelligible, not less practical. Mr. Cooke *
retorts in eSect, not without justice, " Yes, because
jou know these things ; but they would not be worth
much if taught by one who had crammed them."

This is one of the questions which, it seems to us,
can never be catagorically answered, because the
proper solution depends on the knowledge and the
good sense of the teacher. He will make his lectures
both more valuable and more interesting by giving
glimpses of something beyond, thus explaining facts
like the difference of the right and left recurrent
laryngeal nerves, which at first sight seem UDaccouDtr
able freaks ; but his tact must not let him wander too
far.

THE INFLCBNCE OP FUNCTION ON THE SHAPE OF
BONKS.*

Dr. R. Havelock Charles, Professor of Anatomy at
Lahore, has written two papers of peculiar interest on
the bones of the lower extremity of the natives of the
Paujab. At the beginning of the second paper the
author gives a summary of the first, which we will
quote in his own words, almost in fall : " It was shown
that the articular surface of the head of the femur was
relatively and absolutely greater than in the European,
and that it was prolonged so as to adapt itself to the
modified fades lunata of the cotyloid cavity. That
the upper surface of the internal condyle of the femur
is partly articular. That the upper surface of the in-
ternal tuberosity of the tibia slopes considerably down
and in, being never flat. That the external tuberosity
has its condyloid articalar surface convex from before
backwards, and that the articular area is well pro-
longed down posteriorly. That a facet or facets were
to be found on the anterior surface of the lower ex-
tremity of the tibia for articulation with similar sur-
faces on the neck of the astragalus during extreme
flexion, or during extension or extreme adduction of
the ankle-joint in the squatting and sartorial postnres.
That on the neck of the astragalus were one or two
facets — one external, one internal — the latter con-
tinuous with the pyriform malleolar articular surface."

The application of these facts is in brief that the
orientals do not sit in chairs, but habitually either squat
or sit crossed-Iegged, for which positions these modifi-
cations offer distinct advantages. Now characteristics
similar to these are found in the oldest prehistoric
bones, and have been advanced as evidence that the
knee could not be fully straightened, nor the upright
position maintained. They show nothing of the kind,
for the native of the Panjab can stand as straight as
any, though he can squat as civilized races cannot.

Professor Charles argues that while orientals have
retained the sitting postures of their ancestors, Euro-
peans have not, and consequently have lost through
disuse the bone peculiarities pertaining thereto. The
oriental, on the contrary, inherits as young bones pro-
claim, " variations in structure acquired by his ances-
tors, and transmitted, with accumulations due to con-
tinuity of like habits, as useful heritages." Hence he
concludes the transmission of acquired characteristics
is possible.

This very important line of argument that certain
pecaliarities of ancient bones depend upon function
and posture, has been already pursued by Mr. Arthur
Thomson and by Manouvrier.

• likneet, Movember 2S, 1893.

' Jonnukl of ADStomT and Phfslologr, vol. xxxriil, October, 1893,
•nd April, 1894.

A UIGITO-DORSAL KOVEMENT PECUUAB TO HAN.

While reading this paper by Monsieur Eugene
Mouton * we have repeatedly asked ourselves whether
it was meant as a joke, or as a satire, or as a serious
communication. We have finally accepted the last
alternative, though not without some misgivings. The
movement in question is made as follows : put the fore-
arm behind the back with the palm outward ; then flex
the wrist as much as possible and turn the palm in.
Then extend the wrist and stretch the fingers out as
high up the back as possible, that is to the fourth
dorsal vertebra. Thus man can touch with his fingers
all parts of his body, which according to our author
no other animal can do. This is indeed self-evident
till we come to the monkeys and apes. The author
found that he was able forcibly to put the arms of the
monkeys callithrix and rhoesus into the required posi-
tion, but that they did not execute it naturally. This
could not be done to the orang nor the gibbon. The
very length of the arm made the movement impossible.
For the same reason it would seem to be impossible
for the chimpanzee and gorilla, though the test could
not be made. To our mind the most interesting point
in the paper is the additional evidence that some of
the lower monkeys more closely approach man's bodily
structure than do the so called anthropoids.

THE RELATIONS OF THE HEABT AND LDN6B TO THE
ANTEKIOR CHEST WALL, AS DETERMINED BT COK-
POSITE PHOTOORAPBT.'

Dr. I. S. Haynes has written a very interesting
paper on this subject, which we do not mean to under-
value when we say that the method is the best part of
it; for we cannot accept conclusions based on the
analysis of only three series of observations. The
method is in brief as follows : By way of stating posi-
tions not easily referred to cartilages he draws an
imaginary median line downward from the supra-sternal
notch and at definite points on it draws lines at right
angles to it of known length. Thus in one subject he
describes the position of the apex as two and one-quar-
ter inches to the left of the median line at its seven-
inch point. The heart is usually injected from a
carotid with a thin plaster mixture which should dis-
tend it moderately. The nipples are located according
to the method just given, then cut through the middle
and their positions marked. All soft parts down to
the intercostals are taken away and the surface of
bones aud cartilages cleaned. " Now place a narrow
tape- measure . . . from the supra-sternal notch, along
the middle line to below the ensiform appendix. Upon
each cartilage aud rib indicate the distance in inches,
measured transversely from the mid-sternal line, by
narrow slips of paper as long as the cartilage or rib is
wide aud placed vertically upon the same to the num-
ber of four or five on either side of the middle line."
These are to help in determining the position of the
various ribs and cartilages. The camera is set verti-
cally over the subject. A tube for inflation is put into
the trachea. Two photographs are then taken, on
Plates A 1 and 2, in expiration. The lungs are next
inflated, and two views (B 1 and -A) are taken in inspi-
ration. The air having been allowed to escape, the
sternum is removed from the level of the lower edge
of the first cartilage to that of the upper edge of the
seventh. The cartilages and ribs are taken with it for

' L'Antbropologie, 1893, tome It, No. 4.

' New York Medioal Joamal, 18S3, vol. 11. (Vol. 98.)

Digitized by

Google

470

BOSTON MEDICAL AlSD SVMGICAL JOVSNAL.

[Mat 10, 1894.

a dittance of four or five iochea from the median Hue.
The pleurae are not opened. The langg are again in-
flated to the same degree as before, and Plate B 1 is
again exposed. The plearae are then removed, and
Plate B 2 is again exposed. After the escape of the
air, A 1 is exposed showing the state in expiration with
pleurae gone and pericardium remaining. The front of
the latter is then removed, and A 2 exposed. We are
not told whether the author then proceeds to combine
the corresponding plates of different subjects, but from
the illustrations we infer that this is not done.

As we have implied we think that a far larger series
is needed before the results can be quoted. We will
merely say now that Dr. Haynes finds the apex much
nearer the median line than it is generally given. We
would venture to suggest that in future observations it
would be well to entirely ignore the nipples as land-
marks, owing to the uncertainty of their position even
in males.

RBPBODDCTION OF THE UPPER AIR-PA88AOB8 BT
PLATING CASTS, OBTAINED BT TBE C0BR08IVE
MBTHOD.*

Dr. B. Alexander Randall strongly advocates this
proceeding. The recommendation is by no means new
to us, but it has great merits which make it desirable
to discuss it. As Dr. Randall points out, a cast locks
up a good deal of expensive fusible metal. Further,
being of the nature of a negative in which cavities are
represented by solids, it requires a certain amount of
mental turning inside out, which is often confusing.
This would be obviated by an electrotype plating,
which has the further advantage of being fit to cut into
slices, thus giving new and instructive views. A final
point, which Dr. Randall does not mention, is that even
in a few years fusible metal casts of such weight as
those of the upper air-passages tend to become distorted.
This is a very serious drawback. In our opinion metal
casts should always be electrotyped when their nature
admits of it.

THE RELATION OF THE HEPATIC ARTKRT TO THE
PORTAL VEIN.*

Dr. Retterer, finding discrepancies in the accounts
of this point of anatomy, has studied it for himself.
He finds that the hepatic artery must be divided into
two parts. At the bieginning of its course before it is
in relation with the portal vein, it is in a posterior
(more dorsal) plane. After reaching the vein it turns
round it, lying anterior to it in the remainder of their
course to the liver.

THE PTERTOO-SPINOCS LIOAHENT (OF CITININl).**

This ligament, which is occasionally represented by
bone, is of surgical importance in the operation of re-
secting the third division of the fifth pair of nerves,
and we believe has already been referred to in these
" Reports." In its simplest state it is a fibrous band
passing from the external pterygoid plate to the spine
of the sphenoid, and consequently a little external to
the foramen ovale. The committee of collective in-
vestigation in Great Britain and Ireland have received
218 answers as to the ligament, and 104 as to its rela-
tion to nerves. The ligament is wanting, or merely
represented by membrane, in about 20 per cent, of the

■ The Jonnutl of the Amertoan Medi«al Aasoolstlon, vol zxl,
1893.

' Joarnal do I'Anatomie et de la Pliyslologle, 1893.
10 Journal of Anatomy and Pliyaiology, Ootobar, 188S, vol. xxvUl.

cases. It is a fibrous band in about 65 per cent. It
is partly ossified in about 10 per cent., and completely
so in about 3 per cent. The relation of the nerves
does not appear to have been reported with many detaOs
by most of the observers. The inferior maxillary
nerve, which the editors assume to include merely the
inferior dental and lingual nerves, passed outside of
the baud in 92 instances, and below it in 12. The as-
cending branches natarally are in no immediate rela-
tion to it.

lUport^ of Jbixtitsitfi,

BOSTON SOCIETY FOR MEDICAL IMPROVE-
MENT.

JOHX T. BOWSn, M.D. SBCaBTABT.

Bboclar Meeting, Monday, February 26, 1894,
the President, Dr. C. F. Folsom, in the chair.
Dr. J. H. Wright, by invitation, showed

OULTI3RE8 OF THE GONOCOCCCtt FROM TARIOUS
ORGANS.

Dr. W. T. Councilman showed a

speoihbn of intestinal obstruction.

This specimen is interesting from the extraordinary
manner in which the strangulation was produced. The
symptoms came on suddenly, and the patient died
sixteen hours afterward. The entire small intestine
lies on this plate. At the lower portion of the plate
there is a large mass of intestine, which is intensely
congested and haemorrhagic The lumen was filled
with almost pure blood. Thus the strangulated por-
tion comprises about one-half of the small intestine.
A portion of the mesentery attached to the strangu-
lated intestine is also intensely congested, thickened
and hsemorrhagic. A distinct band of constriction
separates this portion of intestine from the other.
Around this, what appeared to be a loop of intestine
was wrapped. At first it was difficult to understand
the condition. It seemed as though the strangulation
was due to the mass of intestine having passed throagb
a loop in the mesentery immediately beneath the in-
testine. On emptying the gut and examining the con-
stricting band more closely, it was found to be the di-
verticulum of MsBckel which had become wrapped
around the mesentery, with the end passed under,
making a complete tie. I here reproduce the condi-
tion. Although intestinal strangulation due to Meo-
kel's diverticulum is not at all uncommon, it does not
usually take place in this way. The end of the diver-
ticulum may become attached to the peritoneum in va-
rious places, and through the loop so formed the intes-
tine may pass. It is difficult to see just how the
condition I show here could have arisen. The end of
the diverticulum which had passed under the loop was
greatly swollen, and this acted as a regular button, and
could not return.

Dr. £. N. Whittibr read a paper on

digestive paresis.'

Dr. E. 6. CuTLEB : I have nothing to add to what
the reader has said. I can simply reiterate what he
has so very well expressed, that I have been frequently
disappointed in following out the carefully laid down

> See page 460 of the Jonmal.

Digitized by

Google

Vol. CXXX, No. 19.] BOSTON MEDICAL AND SURGICAL JOURNAL.

471

rules and methods of treatment which have been pro-
posed for the care of diseases of the stomach and of
the intestinal tract. I have tried to use drags accord-
ing to the methods of those people who have written
on the subject of intestinal antisepsis, and have been
qnite disappointed at times in the results which I have
obtained. I have been led at times to suppose it was
some error of mine in the exhibition of these remedies.
It is a pretty difficult subject, and I should say of the
different cases which I have had under treatment, each
one was a case in a category of its own ; there were
no cases which could be grouped except in a very
coarse way. It ia an interesting subject, and appar-
ently the success which most of us obtain in the treat-
ment of these diseases is not very great. I see quite
a number of patients who have been through the hands
of others, and I see others treating quite a number of
cases that have been through my hands, so that I think
we are ail considerably disappointed in the use of
many of these remedies which the doctor has spoken
of. It seems as if something might be got from (he
laboratory study of excreta. Comparatively little is
known of the fgeces. I have had occasion recently to
see that in having some examinations made at the dif-
ferent laboratories. The chemists do not seem to be
able to furnish us very much that is of practical use
here. The same thing is true to a less extent of the
bacteriologists. There appears to be a good deal of
work yet to be done.

Db. H. F. ViCKBBT : The paper brought a remark
of Ewald's to my mind ; at least, he is quoted as hav-
ing said that after the most careful study of the me-
chanical and chemical conditions of digestion, there is
beyond it all a certain organic influence which escapes
him and makes the problem almost too difScult to set
down in definite language with a definite answer. The
late Dr. Flint somewhere has said that he never knew
anybody who followed an exact dietary who was not a
dyspeptic. The influence of the mental state upon a
person in these conditions is certainly very great ; the
same person, everything else the same except good
fortune or bad fortune, one time will be comfortable
in his digestion, another time not. Some of the
greatest sufferers from the functional kind of dyspepsia
look so very well that they again suggest that there is
an organic or nervous element very strong in the
causation of the disease, and which we have got to
play upon in the cure of it. I share the doubts that
have been forced upon others by their efforts to use
antiseptics. If I understand the physiologists, the
bacteria are necessary for the digestion of meat, so
that if we made the intestine perfectly free from bac-
teria we might be worse off than we are now. I think
that washing out the stomach in certain cases acts as
an aseptic process, lessening fermentation not merely
by emptying out a load of material, but by getting rid
of a lot of germs which poison whatever food is taken.

Db. J. 6. MoHPOBD read a paper entitled,

COMPOUND FBACTDBES.'

Db. a. T. Cabot : I think we are all very much
indebted to Dr. Mnmford for his very careful presen-
tation of the subject, and the enormous amount of
work he has done in bringing it into shape to give such
exact results. In comparing the cases he has worked
over with cases at large, I think we must remember
that most of these hospital patients are dirty people
> Sm pag« MS o( tlie tTooriuU.

who have been injured at a time when the limb was
not prepared for a compound injury, and consequently,
a good many of these injuries reach the hospital with
bacteria already planted in the culture media supplied.
I should think, as I was able to gather from his statis-
tics, that the number of cases of suppuration about ,
corresponded with what one would expect from sepiis
occurring before the patients reached the hospital.

There is no qoestion that a considerable amount of
dirt may be introduced into a wound, and, under favor-
able conditions, the micro-organisms so introduced may
be afterwards made inert and destroyed by the action
of the tissues. I think that this power of the tissues
to destroy the bacteria introduced is one reason why
wounds that are closed up tightly do so much better
than those that are treated by patting in extensive
drainage, as in the previous plan of treatment. In old
times, a leg coming in with fractured tibia, and with
tissues extensively lacerated, was laid freely open and
riddled with drainage-tubes in every direction. The
result was that large openings were made, through
which micro-organisms could enter, and the irritation
of the tubes led to the formation of fluids, in which
any organisms so entering, or which had been intro-
duced at the time of the injury, could grow and propa-
gate.

I think that in the treatment of these cases there is
no question that the careful irrigation, washing out of
the grosser material, dirt, etc., that has been introduced
is extremely important. It is not probable, however,
that washing out ever entirely removes all the micro-
organisms that have been introduced, and it is probable
that their final destruction is wrought by the tissues
themselves in the way I have indicated. It seems to
me that these cases, particularly those compound
fractures in which joints are implicated, really show
the most triumphant results from aseptic and antiseptic
surgery that we now see. A little impurity introduced
into the comparatively non-vascular cavity of a joint
has much less chance of being properly removed by
the action of the tissues than has an equal amount of
septic material when introduced into the peritoneal
cavity. In old times, we used to regard an abdominal
operation as the acme of aseptic or antiseptic achieve-
ment. 1 think, however, that these joint cases are
much more striking, and are better tests of the thor-
oughness of the asepsis. In view of that fact, it seems
to me that a joint that has suffered a compound fract-
ure, and in which mobility has been preserved by
aseptic treatment, is really one of the greatest triumphs
of aseptic surgery. I confess that I was surprised at
Dr. Mumford's statement of the number of such mov-
able joints obtained. I had not supposed we were do-
ing as good work as that. When we consider the me-
chanics of the elbow-joint, and think that a moderate
amount of inflammation would fasten those intricate
joint surfaces together so that they would not after-
wards move on each other, I think these results are
remarkable.

Lastly, in regard to the methods of patting up these
fractures. Of course, the main principles which are
to be observed are these : thorough cleanliness, asepsis
as far as can be obtained, and immobility. It does not
very much matter in what way the immobility is ob-
tained, provided it is complete, or approximately so.
In the case where we operate and maku antiseptically
a compound fracture, as by Bcctiou of a bone, we are
perfectly sure from the start that we have not iutro-

Digitized by

Google

472

BOSTOS MEDICAL ASD SVMGICAL JOVRSAL.

[Mat 10, 1894.

duced organisms, at least, have taken every precaation
against it, and we can use fixation with plaster, expect-
ing not to remove that dressing until union of the bone
has been pretty thoroughly established. In these cases,
however, where the patients are brought in with a
'dirxy leg or dirty arm with a compound fracture in it,
and where there is a very strong chance of suppura-
tion, it seems to me that we expose our patient to some
risk by closing in that wound, after making it aseptic
as possible, by enclosing it in a stiff dressing. In cut-
ting oS a plaster bandage, there is a certain amount of
motion, churning up of the fracture ; and in putting on
the next plaster that is to take the place of the one
taken off, there is a certain amount more of churning
up, and to avoid that, I think fixation splints have
their advantage over the plaster. They enable yon to
watch the limb more carefully during that period dur-
ing which there is fear that suppuration may establish
itself.

Dr. R. W. Lovett : The only part of compound
fractures that I am competent to discuss is the later
history, which I see as an out-patient surgeon ; and
Dr. Mumford's paper makes plain what I had not
realized so fully before, how long had been the immo-
bilization of these patients before they were competent
to come as out-patients and see about having the
plaster removed. There are some points I have been
interested in observing, and one is especially with re-
gard to fractures of the leg in cases where the joint
has not been involved. After weeks and months of
immobilization the joint is almost always stiff, and it
has beeu perfectly well demonstrated by experimental
work, especially by Dr. Phelps, of New York, that
prolonged immobilization of the healthy joint did not
result in anchylosis except in the case of very old per-
sons or persons markedly rheumatic ; that seems to be
perfectly well borne out by the cases one sees coming
to the ouc-patieni department, and motion slowly comes
back in these joints that have been fixed so long by
the use of hot water and massage. If the foot has not
been put in a proper position at the time of the injury,
and is not fixed in the position of a perfect right angle,
the strain on the tendo-Achillis is felt at once on be-
ginning to walk, and I am sure that the period of dis-
ability is very much prolonged by the slightest drop-
ing of the toe. Another point that comes up, is with
regard to the swelling and the disturbance of the cir-
culation in these legs that have been so long immobilized.
Some years ago I went to Dr. Warren and got the
literature there was with regard to it, and found it was
a subject on which there had been very little formulated
and about which very little was known. Dr. Edward
Reynolds and I got some dogs and went to the Medical
School for the purpose of doing some experimental
work on the subject. The legs of the dogs were
broken, but we found it impossible to reproduce the
swelling. We immobilized them for long periods, but
we could not get reproduction of the swelling. The
disturbance of circulation, the coldness and blueuess
that follow removal of the plaster in some of these com-
pound fractures of the leg and the tremendous swell-
ing and infiltration that follows in some cases is a
pretty serious problem. In some of the cases it has
not seemed to yield to anything ; in other cases it was
benefited by massage or hot water and in the majority
of cases it wears off slowly. I think the causation of
the swelling is a matter about which practically noth-
ing is known. In some cases which have beeu fixed

for months there is comparatively little of it, bat it
forms a most troublesome and obstinate complicatioD
that is to be dealt with in the later stages of these long
continued fractures.

Then another point is with regard to the breaking
down of the arch that follows the long immobilizatioD
of the leg. I fancy it is due to the same set of phe-
nomena that cause the swelling and disturbance of the
circulation, but after months of fixation in the plaster
bandage and after the stiffness of the ankle has been
disposed of, there begins to be felt in a large number
of cases, a pain which indicates that the arch of the
foot has given way, and one can notice in looking at
the foot that it is somewhat pronated and that the
weight does not comedown through the foot but inside
of it. In these cases relief is almost always given by
the application of a felt pad to support the arch of the
foot, a couple of layers of felt are cut so as to fit into
the hollow of the foot and support the arch and are
applied outside of the stockings. This seems to he so
much the case that in my last service at the out-patient
department all cases of fracture, simple and compound,
when the splint was removed, were dressed at first with
a bandage and felt pad under the foot to support the
arch. The results were satisfactory as far as they
went. It seemed as if the people regained the power
of walking with less discomfort and disability than
when they were left to walk directly on the foot. The
impressions of these feet carried out this idea that the
arch was broken down. A permanent flat-foot had re-
sulted in a certain number of cases of fractures done
in previous years where they came to apply for relief
from fiat-foot.

Dr. J. £. GoLDTHWAiT : I fear that what I have to
say will be rather out of place in this discussion, as Dr.
Mumford has carefully avoided the subject of the direct
fixation of the fragments ; nevertheless, as the speci-
mens have been prepared and as they have to do with
the treatment of compound fractures, it seems to me
that I am justified in presenting them. I wish to say,
at first, that the suggestions which I have to make, are
simply the result of some experimental work, and that
as yet they are simply experimental and theoretical,
not having been used upon any patient. I would also
say, that I do not advocate this line of treatment for
every case of compound fracture, but only for those
very severe fractures with laceration of the soft parts,
in which the immobilization of the fragments in the
correct position is so difficult. The class of cases for
which the various forms of wire suture have been
devised, and also for which Langeubeck, Volkmsuo
and others have devised and used the different osseous
splints.

A year ago Dr. Senn, in his address before the
American Surgical Association, described a method in
which he used ferrules of bone for this purpose, they
being slipped on over the ends of the broken bone.
The difficulties with this method were the making and
fitting the ferrule, and that later on it was necessary
to remove this ferrule by a second operation.

With the hope of finding some absorbable substance,
that at the same time could be easily and quickly ap-
plied, I have been experimenting for some time, sod
of the various materials used decalcified bone has
proved to be the best ; and in pieces two or three inches
long and one-eighth of an inch square is quite firm
enough for the purpose. Several of these pieces can
be used, being applied aa coaptation apliats and these

Digitized by

Google

Vol. CXXX, No. 19.1 BOSTOJsr MBDIOAl AJfJ) SUttOlOAL JOVRNAL.

473

beld in place by lilkworm-gut ligatures. Another
waj which accomplighes the same result, is to ase a
segment of the shaft of a bone about two inches long
split longitudinally. This makes a trough into which,
after it is decalcified, the fragments of the bone rest,
while along the apper surface one of the small decalcified
splints, before described, is applied, and the whole
held in place by the silkworm-gut ligatnres.

All of the material used is absorbable, so that a
secondary operation for its removal would not be neces-
sary ; the splints do not require much fitting ; and
they can be prepared and kept for use the same as
ligatures, and other surgical supplies.

Db. Cabot : In regard to the method of fixation of
the ends, which was not discussed in the paper bat
which I think is important, the difficulty has always
seemed to me with those complicated methods proposed
by Senn and others that they necessitate too extensive
an injury of the soft parts. I have always tried to
keep the soft parts not separated from the bone, and
it seems to me any method which requires for its proper
performance a separation of the soft parts from those
ends which are going to unite, is in that degree faulty.
I am interested in what Dr. Goldthwait has said about
Qsing silkworm-gut for tying around these splints.
Lately, since I have used the silkworm-gut more and
more, I have firmly convinced myself that it is quite
strong enough for the ordinary snturing-of bone, and
I question whether a few silkworm-gut sutures be-
tween the fractured ends of the bones, would not ac-
complish as much fixation as is ordinarily necessary
and with a less introduction of foreign material than
in any of the more complicated methods.

Db. Goldthwait : From what little experience I
have had, I should quite agree with Dr. Cabot in his
hesitating to strip the bones of the soft parts, and also
that in the cases iu which wire can be used, I should
think the silkworm-gut would be sufficient, but there
are a certain number of cases in which, as the result of
a severe crush or twist, the soft parts are lacerated and
torn from the fragments, making it very difficult to
maintain the correct apposition. Also the bone at
times is so finely comminuted and the edges so ragged
that it is difficult to pass a silver-wire or any suture
directly through the bone so as to hold them in place.
It was for this small class of cases that I suggested
this mode of treatment. In exposing the bone to apply
the suture, if it is necessary to free any of the soft
parts, by all means do not disturb the periosteum. If
you notice in the illustrations passed around, the
splints raise the sutures so that the intervening space
between the splints is free, and no pressure is brought
upon the periosteum in these places so that the circula-
tion is not disturbed.

Vittmt literature*

A Laboratory Guide in Urinatytit and Toxicology.

By R. A. WiTTBADS, A.M., M.D., Professor of

Chemistry and Physics in the Medical Department,

University of the City of New York, etc. Third

edition. New York : William Wood & Co. 1893.

This book, which has been prepared solely for

laboratory use, contains the work which is followed by

the junior students in the Medical Department of the

University of New York. It is, we presume, primarily

intended as an aid to the author's own classes, and is
well adapted for that purpose. We can recommend it
as a useful laboratory guide. In this edition a system
of qualitative analysis not contained in the earlier edi-
tions has been added.

Hernia: Itt Palliative and Sadical Treatment in
Adults, Children and Infants. By Thomas H.
Manlby, A.m., M.D., Visiting Surgeon to Fordbam
Hospital ; Member of New York Academy of Medi-
cine, American Medical Association, New York
State and County Associations, International Medi-
cal Congress, Pathological Society, National Asso-
ciation of Railway Surgeons, etc. Philadelphia:
The Medical Press Co., Limited.
This book presents the subject of hernia, and tries
to accord " to each therapeutic resource its due merit,
and to strive to indicate the precise limitations of each."
In these days we can hardly glance at a journal, but
what a new operation for the radical cure of hernia is
brought forward. In this state of unrest, it would be
difficult to have any book thoroughly up to date. Dr.
Mauley has succeeded, however, in incorporating in
his book most of the recognized operations. The reader
is never left in doubt as to the value of a proposed
operation, for the author states clearly his belief in the
different measures presented. There is at times ob-
scurity in the author's writing ; as for instance, on
page 13, the following paragraph occurs :

" The change in the pelvic lines, curves and angles,
and the transmutation of tissue ; the widening Inmina
of the emnnctory canals, in obedience to the incessant,
though intermittent movements of their contents, each
and all contribute their share towards effecting a sym-
metry of perfection and the firm closure of the inguinal
femoral and umbilical portals."

The binding is fair, the cuts are indifferent, and the
printing is bad.

Marinesanitdtsordnung. Band I, am Lands ; Band II,

Beilagen; Band III, am Bord. Berlin: £. S- Mit-

tler & Sohn. 1893.

These three volumes contain the official sanitary
regulations, blank forms and other material relating to
the Naval and Marine Service of the German Govern-
ment.

Volume I contains the regulations to be observed in
hospitals, stations and all places on shore.

Volume II contains the blank forms which accom-
pany the regulations published in Volume I. They
are eighty-five in number, and contain very minute de-
tails relating to the management of the hospitals, sup-
plies, food, medicine, baths, heating, lighting, vaccina-
tion, and everything relating to the care of the sick.

Volume III contains, first, the regulations pertain-
ing to the care of the sick at sea; and, second, the
health regulations of ships, including the ventilation,
food-supply, water-supply, clothing, prevention of in-
fections diseases, poisons and methods of disinfection.

The Tear-Book of Treatment for 1894. A Critical
Review for Practitioners of Medicine and Surgery.
Philadelphia: Lea Brothers & Co. 1894.
This book has been compiled, on the whole, with
excellent judgment, and, being in its tenth year, is
already well known. It presents to the profession in
a convenient form a brief summary of the ways pro-
posed during the year for treating a great variety of
diseases. Practitioners will find it a useful book.

Digitized by

Google

474

SOSTOS HELICAL ASD SUJtGJCAL JOVBXAL.

[Hat 10, 1894.

THE BOSTON

IsteDfcal and ^utgical ^joumal.

Thursday, may 10. 1894.

A Journal of lledicint. Surgery, and Allied Scieitca.publiMked at
BoiUm, weekly, by the mtdertigned.

SITBROBIPTIOH Tkkhs: KM per year, in advance, pottage paM,
for the United Statet, Canada and Mexico; (6.66 per year for all for-
eign cowntriet beUmging to the Postal Union.

All oommnnieatiotu for the Editor, and all bookt for review,ihonU
be addrened to the Iditor (^the Botton Medical and Swrgieal Jonmal,
283 Wathington Street, Botton.

All letteri containing Imiineti oomnumieatioHt, or referring to the
pnblication, tubtcription; or advertiting department <tf (M* Jtmrnai,
thotUd be addretted to the undertigncd,

Jlemittaneet thould be made by money-order, draft or registered
letter, payable to

DAMBELL * UPHAM,
288 WAsantOTon Stbbbt, Bostoh, Mass.

THE BRANDT METHOD OF PELVIC MASSAGE.

It is rather extraordinary that the author of a
method of treatmeDt bo pecaliar in its character, and
intended for the cure of diseases of the female pelvic
organs should be a layman. This fact undoubtedly
delayed its professional recognition, but now, largely
through German physicians who have studied it with
Brandt, its claims have become known to the profes-
sion at large. These claims are not that his method
is a universal remedy for the diseases of women, but
that very many of the chronic pathological conditions
which are the result of inflammations of the genital
tract, and some of the functional disturbances, espe-
cially of menstruation, are favorably influenced by this
method of treatment. He also claims that displace-
ments of the uterus are permanently cured by the ap-
propriate manipulations, prolapsus uteri of all degrees
being no exception to the rule.

There seems no doubt that Brandt can substantiate
these claims, and from the reports which a few other
operators have made of their results it seems ptossible
for others to accomplish as much.

In estimating the value, however, of any method of
treatment, especially one which is recommended for so
large a proportion of what may be called minor gyne-
cological affections, two or three considerations must
be borne in mind.

In the first place, it mast be easy of application and
demand no more than the ordinary skill of the average
physician. In the second place, it must be as regards
expenditure of time and expense on the part of the
patient and in permanency of results a marked advance
over other methods. And third, it must be free from
all objectionable features.

A somewhat careful study of what has been written
on the subject forces us to the belief that the method
of pelvic massage under discussion does not fuldl any
of these prerequisites.

As regards the first, it is conceded even by its warm-
est advocates that it is well-nigh impossible to so de-

scribe the technique in print that a phyucian can ap-
propriate and make use of it. Personal instraction
and long practice seem to be a necessity, and even then
BO much delicacy of touch and manipulative skill are
required that few could become proficient. These facts
alone would prevent its widespread application.

As regards the second point, the length of time re-
quired, and the permanency of results, two very im>
portant factors in comparing it with other methods,
we are forced to the conclusion that even in these re-
spects its claims for recognition cannot be substan-
tiated. We think other forms of treatment would ac-
complish equally good results in a shorter time. Dr.
Matilda Wallin, who for three years was Brandt's
pupil and assistant, in a late commanicstion on this
subject before the Philadelphia County Medical Society,
describes the method in considerable detail, and refers
to a case of complete prolapsus uteri, which she taw
treated. The patient came to Brandt the 29th of June ;
on the 9th of September she was well. Who will
doubt that with appropriate operative treatment the
patient would have got well sooner? Much more
would this be true of the numerous minor ailments.

The third point mentioned raises a question which
must, it seems ,to us, suggest itself when this method
of treatment is advocated, namely, the effect of thia
more or less prolonged manipulation of the vagina
upon nervous and excitable women. In our opinion
it cannot fail to be prejudicial, and in so far nullify
any good effect that the massage would otherwise have.

The objections, therefore, which we would feel are
valid against the widespread adoption of this method
of treatment, are that it is complicated, glower in its
action, and not surer in its results than other methods,
and has possible objectionable features.

At the same time, we confess that in a modified
form and as an adjunct to other modes of treatment,
massage is valuable in pelvic disease. It is not the
principle, but the elaborate system which seeks too
wide a field and attempts too much that we object to.
Any method which claims as much as this does must
lie within the possibilities of at least all specialists.
As it is, its practice will certainly be confined to the
favored few who can enjoy special training, and who
will make a sub-specialty of it.

TREATMENT OF DIPHTHERIA BY FREQUENT
SMALL DOSES OF BINIODIDE OF MERCDRY.

FiSDALLC ^ claims extraordinary success in treating
diphtheria by small doses of biniodide of mercury. He
has employed this remedy since early in 1891 in very
many cases, to the exclusion of the usual local treat-
ment, and without a single death. His formula is as
follows :

K. Syrnp UmOM

Iodide of potaaxiam 90.00

Biniodide of mercury 9M M.

The dose of this syrnp for a young child u a tea-
spoonful every two hours. The dose would be about

> BnlL et M<m. de U See. de Th&'apeuttqae, April 6, ISM.

Digitized by

Google

▼oi. CXXX, No. 19.1 BOSTON MBDIOAL AND SUROIOAL JOURNAL.

475

one-thirtieth of a grain of the biniodide and aboat
three graina of iodide of potassiaoi. This may seem
to the uninitiated rather large dosing, bat Pi^dalla
affirmg that to obtain the really specifio local and con-
stitutional effect* of these drags (a share in which cer-
tainly belongs to the iodide of potassium), really heroic
doses are required. He has given as much as 300
grammes of this syrup in the coarse of a week to chil-
dren from four to six years old. At the end of several
hoars, eliminated by the mucous membranes, that is to
say, the signs of iodism appear : coryza, salivation,
etc., and the spittle flows from the child's mouth ; then
the dose is diminished, enough being still given to
keep up the effect. The object of the treatment, in
the words of the writer, is " to maintain in the mouth
and pharynx a permanent antiseptic gargarism." He
advises in case the false membranes are loose, to de-
tach them gently with a spoon-handle, then to touch
the denuded sarfjce with a swab dipped in bichloride
solution, 1 to 1,000; this may be done two or three
times a day.

Fi^allu remarks that it is not until the end of forty-
eight hours that this treatment shows its curative ef-
fect. The false membraues no longer spread, but be-
gin to fall off in a pultaceous mass. In certain rebellious
cases, the amelioration does not show itself until the
fourth or fifth day, but the remedy must be continued
fearlessly, and in doses proportioned to the gravity of
the malady.

This treatment is very well borne by children, and
is very exceptionally attended with colic, vomiting, or
stomatitis. It is well to conjoin with it a rigorous
milk diet to ensure activity of the renal function, but
when the child desires to eat, light food may be al-
lowed.

Pi^dallu urges the profession to try this method
which he says has given him uninterrupted success for
three years. He claims that the mercury and iodide
of potassium in being eliminated by the mucous mem-
branes of the upper respiratory passages, constantly
oppose their antiseptic action to the specific bacilli,
and thus make their habitat unpropitious. Certainly,
this kind of treatment is more easily carried out than
the local treatment by spraying, irrigation and swab-
bing.

It will be remembered that when pilocarpine was
first recommended for internal treatment in diphtheria,
some such action as that above described was claimed
for it, but the result of treatment by pilocarpine and
by jaboraudi was only failure and disappointment.

At the meeting of the Therapeutical Society, there
was some discussion of the above mentioned mode of
treatment. One of the speakers (Barbier) said that
experiments made in Germany and Switzerland demon-
strated the bactericidal value of biniodide of mercury
and iodide of potassium. As these drugs are elimi-
nated by the mucous membranes, the formula of M.
Piedallu appeared to be rational. M. Crequy thought
the doses rather large for children, but Guelpa af-
firmed that children support mercury better than adults.

Others expressed their desire to test the treatment in-
dicated by M. Piedallu, but affirmed their disbelief that
any really specific treatment of diphtheria had yet
been found.

SCALING THE APPROPRIATION FOR THE
LIBRARY OF THE SURGEON- GENERAL'S
OFFICE.

The appropriation for the Library of the Surgeon-
General's Office at Washington has been cut down in
the House of Representatives from $10,000 to $7,000.
An effort will be made to have the amount restored to
the old figure in the Senate. The petty economies
practised by Congress in this and similar matters are
as exasperating as are the gross extravagances in other
directions where it is supposed votes may be made.

Remonstrances against the action of the House are
making themselves heard from many parts of the
country. Tlie following resolutions adopted by the
Academy of Medicine of Cincinnati express a very
general feeling in the Medical Profession :

Whtreat, the Library of the Surgeon-General's Office in
Washington is of the greatest importance to medical educv
tion and to the medical profession throughout the entire
country, it is for the public good that it should receive the
liberal support of the Government;

Resolved, That the Academy of Medicine desire to enter
their earnest protest against the reduction of the appro-
priation for its annual support from $10,000 to $7,000 ;

Resolved, That the Academy of Medicine urge most
strongly the restoration of the former annual appropriation
of $10,000, under which it has become one of the largest
and best appointed medical libraries in the world, and with-
out which its continued growth would be seriously crippled.

A similar memorial to the United States Senate is
being circulated and receiving representative signatures
among the profession in Boston and its neighborhood.
With $7,000 it is impossible to procure even all the
current literature.

MEDICAL NOTES.

Cbkuations in Fhancb. — There were one thou-
sand and five cremations in France during the first
three months of the present year, which is one-third
more than a year ago.

PrOFESSOB RuBNER to 8DC0EED HiRSOH. — Pro-

fessor Rabner has been chosen to succeed the late
Professor August Hirsch in the Chair of the History
of Medicine in the University of Berlin.

A Beqdest to the Elizabeth Hospital. — The
sum of $25,000 has been given to the Elizabeth, New
Jersey, Hospital by some one in New York who for-
merly lived in Elizabeth, on condition that his name
shall not be made public.

Billrotb's Successor. — Dr. Victor Ritter von
Hacker, head of the Second Surgical Clinic at Vienna,
has been unanimously recommended by the Professo-
rial College to succeed the late Professor Billroth in the
Chair of Surgery in the University of Vienna.

Digitized by

Google

476

BOSTON MEDICAL AJUD SVRGICAL JOIBHAL.

\}Aki 10, IbM.

PaoFKSSoa Tboma. — Dr. Richard Thoma, profes-
sor of pathology at the University Jurjew, Dorpat,
has moved to Magdeburg to take charge of the general
hospital in that city. On his departure from Dorpat
he was escorted to the station by his colleagnes and a
large company of students.

AcQCA Di Perugia. — The preparation of that
charming old poison known as Acqua di Perugia was
not so difficult or mysterioas as has been supposed. It
can easily be made, according to a recent writer, by
killing a pig, cutting it up, and salting it down with
arsenic After being cooked the gravy from such a
dish is even more fatal a poison than the unserrified
metal.

A Popular Surgical Consultant. — Professor
von Bergmann, of Berlin, was recently called to Niko-
Isjew to amputate the foot of an eigbty-two-year-old
millionaire. It became rumored in the town that the
great surgeon would also see other patients in consulta-
tion during his short stay, and the crowd of carriages
about the door of his hotel became so great that the
police were obliged to keep a squad of men on duty to
keep the approach from being blocked.

A Fatal Lumoheon. — The Lancet reporU the
following almost incredible luncheon eaten by an En-
glish lad of fifteen years : thirty oranges, an entire
cocoanut, cider, a mince-pie, mineral-water champagne,
tea, cake and lemonade. Immediately after this feast
the boy died of cerebral apoplexy ; and the Lancet re-
marks, " altogether the narrative is a melancholy and
humiliating reminder that pleasure, aboi^e all things,
can only be enjoyed in moderation and is poisonous in
excess."

The Fatality of Success. — The Calcutta Medi-
cal Reporter relates a curious instance of the fatal
effects of "continuous performances" with poisonous
drugs. A fakir at a fair was accustomed to attract
spectators by eating shavings, glass, soap and such
dainty dishes, and at last added matches to his diet
As trade was dull at first, he did himself no harm ;
but his popularity increasing, he was obliged to give
some thirty performances a day, and in the glow of his
success he died of phosphorus-poisoning.

Admission Requirements to Illinois Medi-
cal Colleges. — The Illinois State Board of Health
has revised the regulations concerning admission to
medical schools in that State by depriving the various
faculties of the control of entrance examinations in
elementary studies, and requiring in place of such ex-
amination, a certificate of graduation from a college,
a high school, or a certificate from a second-grade
teacher. Entrance examination must indeed have
been lax when so generous a change raises the standard.

One Difficulty in the wat of an Interna-
tional Medical Language. — In a recent discus-
sion at the New York Academy of Medicine upon the
possibility of adopting Greek as an international lan-
guage for scientific purposes, Dr Boosa said that if we
were to have an international language, it could only

be by a revolution of teaching methods, and he de-
spaired of such a revolution because the hide-bound
notions of college professors were simply beyond any
ordinary assault. For a man from New York to talk
to men from Cambridge or New Haven as to ways of
teaching would be very much as if he should go to the
tomb of the Prophet with his boots on.

boston and new ENGLAND.

Acute Infectious Diseases in Boston. — Dar-
ing the week ending at noon. May 9, 1894, there were
reported to the Board of Health, of Boston, the follow-
ing numbers of cases of acute infectious disease : diph-
theria 86, scarlet fever 38, measles 81, typhoid fever
18. There were no new cases of small-pox, nor any
deaths, during the week. There are now 9 cases of
small-pox in the hospital. During the week the State
Board of Health received reports of the following cases
of small-pox: Natick 1, Worcester 2.

An Aged Pair of Twins. — There are living
in Peterboro, N. H., two maiden sisters who claim,
with not improbable justice, to be the oldest twins in
the country, as they are over eighty-three years old.

Harvard Medical School. — The coarse of
evening lectures to graduates ended with the lectare
given on Wednesday, May 2d. A similar course will
be announced for the winter of 1894-5.

A Medical Magazine at Yale. — A new medi-
cal journal will be published next month by the stu-
dents of the Yale Medical School. It is proposed to
have contributions from physicians in Connecticut and
New York in addition to work of the students.

The Massachusetts State Board of Health
and the Prevention of Consumption. — The
Massachusetts State Board of Health has issued an ex-
tended circular on the prevention of consumption in
which it suggests that much good might be done if local
boards of health would issue a simple notice like the fol-
lowing :

" Gonaamptlon is the most destructive disease of Neir Eog-
land, the Dumber of persons dying annually from this csnie in
Maisachiuetts amoanting to nearly six thonsand.

"The disease is infectious, and can be communicated from
one person to another. The chief danger exists in the expectora-
tion of the sick, and if this expectoration is carefnlly destroyed
little danger need be feared.

" Consnmptives should be instrncted not to spit upon the
floors of rooms, public halls, street and railway cars, and other
vehicles, nor in the streets, but into pieces of cloth, or receptacles
made for the purpose, containing water, or a saturated solution
of carbolic acid (one part of carbolic acid crystals to about fif-
teen parts of water). Such bits of clotb should be destroyed
by fire, before the sputa becomes dry, and other receptacles
should be cleansed with scalding water, their contents having
been destroyed or otherwise carefully disposed of. Handker-
chiefs which may have been used from necessity should be boiled
half an hour before washing.

" A healthy person should not sleep in the same room with s
consumptive.

"Remember that sputa must never be allowed to become
dry."

Boston Citt Hospital House-Officers. —
Under the present new reguiations of the Boston City
Hospital, graduates in medicine of less than three yean'

Digitized by

Google

Vol. CXXX, No. 19.] BOSTON MEDICAL JJHJ) SVBGICAL JOVBBAL.

477

staodiog as well as ondergraduates who have completed
three fall years of study are eligible as candidates for
appointmeDt as house-ofiScers.

Norfolk District Medical Societt. — At the
anuaal meetiog of the Norfolk District Medical Society
held May 8th, the following officers were elected for
the coming year : President, D. D. Gilbert, Dorchester.
Vice-President, Robert T. Edes, Jamaica Plain. Secre-
tary and Librarian, James C. D. Pigeon, Roxbury.
Treasurer, Edw. 6. Morse, Roxbury. Commissioner
of Trials, Benjamin £. Cotting, Roxbury. Nominat-
ing Councillor, O. F. Rogers, Dorchester. Censors,

B. S. Blauchard, Brookline ; D. 6. Eldredge, Dorches-
ter; H. M. Cutts, Brookline; £. B. Lane, Dorchester;

C. W. Sparbawk, West Roxbury.

Connecticut Rivbb Vallet Medical Asso-
ciation. — At the Annual Meeting of the Connecticut
River Valley Medical Association, held at Bellows
Falls, Vt., May 1st, the following officers were elected
for the ensuing year : President, Dr. W. L. Havens,
Chester, Vt ; Vice-President, Dr. D. Groodenow,
Aistead, N. H. ; Treasurer, Dr. E. R. Campbell, Bel-
lows Falls, Vt. ; Secretary, Dr. J. Sutcliffe Hill, Bel-
lows Falls, Vt. Delegates to American Medical As-
sociation, Drs. Holton, Campbell, Ray, Richardson,
Fettengill, Havens, Gleason, Ditismoor, Prouty and
Hill. Delegates to State Societies, Dr. Taylor, to
Vermont; Dr. Miner, to New Hampshire; Dr. Staples,
to Massachusetts ; Dr. Page, to Connecticut.

NEW TORK.

Report on the Bactebiolooical Diagnosis of
Diphtheria. — At a meeting of the Board of Health
held May 1st, Dr. H. M. Biggs submitted a report on
the bacteriological examination of 286 cases reported
as membranous croup, made within the past ten months.
229 of these were proved to be true diphtheria by the
existence of the Klebs-Loeffler bacillus ; or about 80
per cent. Six per cent of the remaining cases were
of doubtful character, and the other 14 per cent were
clearly not true diphtheria. The result of his investi-
gations led Dr. Biggs to recommend that so-called
membranous croup should be included by the Board of
Health in the list of contagions diseases.

The Death of a Cholera Quarantine Nursb.
— On May Ist there died at Bellevue Hospital a
woman whose heroic devotion to duty under the most
trying circumstances deserves to be held in remem-
brance. This was Miss Juliet Henshaw, a professional
trained nurse, who was the first one to volunteer in
response to the call of Health Officer Jenkins for
nurses for the cholera patients on Swinburne Island in
the summer of 1892. The number of nurses was very
small, but she was so indefatigable in her work of car-
ing for the sick that the percentage of mortality was
remarkably low. She won the intense admiration of
the physicians in charge by her self-sacrifice and skill ;
and when her health began to suffer from the strain
upon her she was urged to give up her positiou. She
iDsisted, however, upon remaining at the post of duty

untU the disease disappeared. After the cholera out-
break Dr. Jenkins kept her in his employ, and she re-
mained in the service until the latter part of April,
when she became seriously ill. She was then trans-
ferred to Bellevue Hospital. Daring the attack from
which she suffered the symptoms strongly resembled
those of typhus fever, but the autopsy showed that the
cause of death was acute yellow atrophy of the liver.

The " Craig " State Colonv fob Epileptics. —
The Governor has signed the bill introduced into the
Legislature by Hamilton Fish, providing for the estab-
lishment of a State Colony for Epileptics, which passed
the Assembly by a vote of 96 to 4, and the Senate
unanimously. The colony is to be known as the Craig
Colony, " in honor of the late Oscar Craig, of Roches-
ter, whose efficient and gratuitous public services in
behalf of epileptics and other dependent unfortunates
the State desires to commemorate." The statute pro-
vides for the purchase by the State of the property
heretofore owned by the Shakers, situated near Mount
Morris, Livingston County. Tt includes 1,800 acres
of land in one of the finest locations of the Genesee
Valley, and the soil is well adapted for farming and
horticultural purposes. The supply of water is abun-
dant, the property being divided into two parts by the
Cashanqua Creek, which flows through the land in a
deep gorge, with a fall of one hundred feet, affording
a perfect natural barrier for the separation of the
sexes. The Shakers have erected upon the property
two groups of buildings, valued at $75,000, suited to
all the purposes of the contemplated colony, which,
with slight alterations, will accommodate at least three
hundred patients. ludigent epileptics will be received
and cared for by the State, but the colony is expected,
when fully established, to be nearly self-supporting.
There are now more than six hundred epileptics in the
poor-houses and almshouses throughout the State.

THE EFFECT OF ETHER AND CHLOROFORM
ON THE KIDNEYS.*

WuNDBRLiOH, after the examination of the urine
in 125 cases, before and after anaesthesia, draws the
following conclusions as to the effect of ether and
chloroform narcosis on the kidneys :

(1) An already existing albuminuria is often in-
creased by etherization. No such case in which
chloroform was given was observed.

(2) Albuminuria can be caused by narcotization
with chloroform and ether, more often with chloro-
form, the relative frequency with which it occurs after
the use of chloroform and ether being 11.5 to 6.9.

(3) As a result of the use of chloroform, casts may
appear in the urine. This is less frequent after the
use of ether. The relation of frequency is 34.8
to 24.6.

(4) When casts are already present, both anaes-
thetics have the effect of increasing the number.

1 BaltrXge lar Kiln. Ohlrurgie, Bd. si, Ht. 8, ISM; Annali of Sor-
gsr;. Ma;, ISM.

Digitized by

Google

478

BOSTON MBDIOAL AND SURGICAL JOVJtNAL.

[Mat 10, 1894.

INFANTBY FOOTWEAR.

In spite of all the changM in the tactics of modern
warfare, the greater use of artillery in mass and at
long range, and the more facile means of transporta-
tion of troops, one of the most important elements in
the soocess of an army, and perhaps the prime factor
in determining its real value, is the marching power of
its infantry, whether for long distance or quick strate-
gic movements. In maintaining this superiority, the
chief reliance must be placed, not on the strength,
courage or rations of the men, bnt on the condition of
their feet; not on the character of their patriotism,
but of their boots. Napoleon appreciated this, and
hanged a contractor who stufFed the soles of his shoes ;
and Wellington is said to have enumerated the three
most essential articles of a soldier's equipment as, first,
a pair of good shoes; second, another pair of good
shoes ; third, a pair of half-soles.

Lieut. N. P. Fhister of the First United States In-
fantry calls attention to the general neglect of this im-
portant matter^ in our army. Daring his observa-
tions he has marched about two thousand miles, and
has "seen about five per ceuL of a regiment of three
hundred men disabled for hard marching by sore feet,
in a march of ninety miles over good roads, going at
the rate of about twelve miles a day ; and as a con-
trast, one company of the eight went through without
a sore foot in the entire company, simply because the
captain had looked carefully to his men's shoes, and
had each man prepared with well-broken, well-greased
shoes of proper size. It was not required that the
men of this company should wear the issued shoes, but
no shoe might be worn without the captain's approval."

The five essentials, each of equal importance for in-
fantry footwear, to give increased eSSciency in march-
ing power are: (1) Protection from wear; (2) free-
dom of action for the foot; (8) lightness; (4) flexi-
bility of the shoe ; (5) fit. The first requirement is
at present about the only one regarded, and that in a
manner which is false economy, and is closely related
to the other requirements of freedom for the foot and
flexibility. Mere thickness of the leather is no crite-
rion of its wearing power if the skin has no pliability
or is poorly tanned.

" ODld-tanned oak sole-leather of proper thickness,
and well rolled, to make it compact, is pliable and tough,
and, while it costs about one-third more, is well worth
the difference." As the middle layer of the tanned
hide is fibrous, it cannot be dressed, shaved or pressed
to a permanently smooth surface, or one which will
wear well, and therefore a piece of leather which has
been split or skived down to a required thickness has
been so treated at the expense of one of its wearing
surfaces, and will not retain dressing, rapidly absorbs
moisture, hardens and stiffens till it breaks. *'Oor
soldiers have for years worn shoes from leather of this
kind, fuzzy and cloth-like in appearance. The soldiers
call them boiler-iron shoes, and they deserve the
name."

As regards lightness, there is room for much im-
provement. The cavalry gives careful consideration
to the weight of the horse-shoe. The weight given by
experts as proper for a fnll set of shoes for a cavalry
horse of medium size is forty-eight ounces. A pair of
soldier's shoes, No. 8, of the latest infantry pattern,
weighs forty ounces.

> Joonisl of the MllltsiT Serrloe Instttutlon, VLkj, M94,

Far more care should be given to individual fit of
the shoes. A foot is a foot, and a shoe a shoe — is
not a reasonable, wise principle for the quartermaster's
department to follow, and a shoe well made from the
best material and fitted to the foot is a good economy,
even if it cost more — $4, instead of $1.89, as at
present.

" A cobbler's wagon is a necessity not always pro-
vided for. No forge, forge-wagon or battery is more
so. Some arrangements for mending the shoes of the
soldiers during campaign should always be made. A
soldier can and frequently does fight in his shirt-sleeves
and bare-headed, nor is his military efficiency impaired
by a canvas patch on his trousers ; but if his shoes
give out or his feet get sore he will not be on hand to
fight at all."

CorrejtpottHeitce.

PROPOSED LEGISLATION FOR THE BETTER

PROTECTION OF THE COMMUNITY AGAINST

QUACKERY.

Nkwburtport, May 6, 1894.

Mr. Editor : — The bill > which has recently passed
the Massachusetts Senate and will soon come before the
Lower House is meeting with favor wherever the importance
is recognized of any legislative interference with quackery
in its manifold forms. It is a bill which will not ofiendthe
extremist advocate of the laitsezfabre doctrine of govera-
niental function, because it does not oppose the right of in-
dividuals to employ Christian scientists, faitb-curers, msg-
netichealers, clairvoyants, etc. (see Section II), if they wiih,
nor does it prevent the quack from responding to the de-
mands of those who have faith in his methods ; it simply
takes from the latter — unless he has been in practice at
least three years — his rizht to usurp a name and a tide
which he has not earned by long and laborious study and
suitable experience. This bill recognizes the fact that the
degree of M.D. cannot be assumed at will by individuals,
but belongs to the graduates of legally chartered medical
colleges and universities, liaving power to confer degrees
given them by the CommonweaTth, or to such as pass the
examination of the Board appointed under this bill. It
forbids individuals from advertising themselves as physi-
cians and surgeons, using the letters M.D., or title of doctor
(" meaning hereby doctor of medicine "), until they have
been duly registered, the qualification of registration beio^
the possession of a diploma from a legally chartered medi-
cal school, or in default of this, the passing of an examina-
tion before a Board appointed by the governor.

The proposed bill cannot be regarded as a bill to sup-
press quackery, however it may nave been mispresented
by its enemies, who say that it is at least " an entering
wedge." The suppression of quackery by legislation is
something that has never been accomplished since the
world began. Considering the fate of previous attempts in
this State to obtain medical legislation, it is not probable
that for some time any more stringent bill will pass the
Committee- room.

Such legislation should always be regarded as primarily
and especially intended for the protection of the people,
not for the principal benefit of medical men. The Supreme
Courts of several States have declared that laws regulating
the practice of medicine and surgerv are constitutional
and valid, being for the promotion of the safety and well
being of the community. This decision not only has been
rendered by the Supreme Courts of Minnesota, Illinois and
New York when confronted by test cases, but the Supreme
Court of the United States has affirmed the right of State
Boards of Health and State Governments to make roles
for the r^^ation of the practice of medicine.

> Boston Hedioal and Sorgoal Journal April M, IBM, psge it.

Digitized by

Google

Vol. CXXX No. 19.] BOSTOS MBDICAL ABJ) SVttGlCAL JOtJttSAL.

4T9

It ia tme that many of our foremost physicians look with
indifference if not with positive disfavor upon all such laws ;
chiefly for the reason that it seems to be impossible to ob-
tain such legislation unless physicians demand it and work
to obtain it. There is this hardship, that physicians cannot
ask for such legislation for the benefit oi the public with-
out seeming to ask for it from a mere selfish motive. It
has always, moreover, been the case that in States and
countries where stringent laws regulating the practice of
medicine have existed, physicians have been obliged to en-
force them, often at the cost of much opprobrium and pecu-
niary sacrifice, or else the laws have been a dead letter on
the statute book. This is the reason wbv many excellent
men in the profession are indifferent ; they acknowledge
that such legislation would be just and may even be de-
manded, but they do not desire to be placed in the attitude
of seeming to make requests for legislative enactments to
benefit themselves. " If," they rightly say, " the medical
profession cannot stand on its own merits, it has no claim
whatever even to ordinary respect." They recognize the
fact that one part of their duty is to protect the people
from quackery, but they deprecate doing this by methods
which will certainly lead to a misinterpretation of motive.

A writer in the Medical Record, disgusted with the
working of the law in New York, has well emphasized this
point of view : " Practically speaking," he says, " the people
are not prepared to appreciate our motives, and will never
be till they are sufficiently educated to draw the line be-
tween quackery and legitimate medicine. [Alas, if we must
fold our hands until then, we shall have to wait until their
spiritual leaders cease to give certificates endorsing quack-
ery !] When that time comes, there will be no difficulty
in having suitable laws passed, and the people will them-
selves take the proper steps to punish any offenders. [In
such a time there will be few quacks to punish, culture soil
will be nnpropitious.] If we must legislate at all, let it be
in the direction of improving ourselves. There is a great
deal that may be done in this direction. Our college regu-
lations can be made more stringent, our standard of prelimi-
nary requirements raised, our terms of study extended,
and, in fact, the whole system of medical education can be
elevated. By limiting our efforts to such reforms we can
at least prevent quacks and incompetent persons from com-
ing into our ranks, and this will be a benefit and a blessing
to society." £. P. H.

THE PRODUCTION OF VACCINE VIRUS.

RoxBURT, May b, 1894.

Ms. Editor : — Permit me to say a few words in regard
to the Report under the above heading in last week's
JouRMAl.. As I supply a large number of ^e physicians
and cities throughout the country with vaccine, the matter
la of importance to me. The committee making the report
did not come to me, nor visit my vaccine establishment,
and the first intimation I had of any such committee was
when I heard their report read at the Norfolk District
Society. I was brought up from boyhood, by my father, in
a most careful training and course of study reearding the
whole subject of vaccination, and can fairly cbim a very
different familiarity with the whole matter than any of the
other persons referred to in the report. The "Martin
Establishment " referred to, was the old establishment at
Brookline, which my brother carried on until his death.
The committee obtained their information there from a
former employee of my brother, who was not a physician.

Neither my father nor myself would ever countenance
anything but the most scrupulous care in every detail in
the management of vaccine production, and the reputation
our virus has enjoyed uninterruptedly for twenty-five years,
shows what that care has been. Moreover, the propaga-
tion of vaccine virus by any one but a thoroughly educated
regular physician is bound to lead to trouble and disaster
— to the patients, at any rate, if not to tlie producers.

I mnst ask the profession to in no way confound my es-
tablishment with those mentioned in the report.

Very truly yours, Framcis C. Martin, M.D.

HETEOROLOOICAL RECORD,

For the week ending April 28tb, in Boston, according to ob-
servations fumlsbed by Sergeant J. W. Smith, of the United
States Signal Corpe:—

: Baro-
meter

niermom-! Relative
'eter. IhomiditT.

Date.

S..22
M..23
T..iM
W.26
T..26
r..27
S..28

2S.82
29.92
29.92
30.10
80.0S
'j9.9g
29.90

29.91

Sigi

lll

a|s_

52!60

m;62

Bl'SS
b2\ 63
89 I 72
66 79
6S| 75

,67

DlreotlOD
ot wind.

Valo«i(T
of wind.

W«'th'r.

* ! a

■i

s

E.
S.E.
N.E.
N.K.

W.

W.

W.

8.E.

s.w,

N.W.

S.W.

W.

S.W.

N.

■i h
S ; S

I

1
.07

M

.13

0.03
.25

Oillftl

O.,0loodTi Coleui F.,f*lTi U.,<(ici H.,hEi7i B-imiikji RMnlni T.,tbnal-
■■ftiN..sa<nr. tlDdieaUsliueof rdsfslt. ivMwiforvMk.

RECORD OF HORTAUTT
FOH THB W>KX KNDIXO Satvbi>at, Afrii. 28, 18M.

Olties.

Naw York

Ghloago .

Philadelphia

Brooklyn

St. Louis .

Boston

Baltimore

Wuhlngton

Gtnolniuiti

Cleveland

Pltttburg

Hllwankee

Nuhvllle

Otaarleaton

Portland .

Woroester

Fall Biver

Lowell .

Cambridge

Lynn . .

Springfield

Lawrenoe

New Bedford

Holyoke .

Salem . .

Brockton

Haverhill

Chelsea .

Maiden

Newton .

Pltohbnrg

Taonton .

Qlouoeater

Waltham

Qnlnoy .

PIttafleld

Everett .

Northampton

Newburyport

Amesbory .

If

Is

1^

8j

■a ►.

1,801 ,306

1,438,000

1.11S,6«2

978,894

B60,(JOO

487,397

eoo.ooo

808,431
SOS.UOO
290,000
263,709
2fi0,0u0
87,764
6S,lbS
40i)00
96,217
87,411
87,191
77,100
63,666
48,884
48,366
45,886
41,278
32,233
32,140
31,396
30,264
29,394
27,666
27,146
26,97:^
26,688
22,068
19,642
18,802
16,686
16,331
14,073
10,920

781.

282

16

26

309

12

Peroentage of deaths from

S 15

16.12 17.(

11.60
13.68

10.08

13.60
21.«4

20.16

9.13 14.11
17.48 , 23.00

8.73 16.49
11.^0 I 16.80
12.32 I 20.72

6.66 ' 6.66
10.36 6.90

6.26 ' 6.26

13.06
2-J.20

26.U0
4.36

8.00

6.26
14.28

9.09
14.28

13.06

18.60

8.33

13.06

16.00

6.26
42.84
20.00

16.66
9.09

33.33

25.00
60.00

20.00

1.82

1.76
.70

1.26

2.76

.97

1.12

2.96

7.40
4J6

if

59

8.10

8.76
4.80

4.62

4.98
11.96
4.85
2.24
2.86

6.26
4.36

14.28

9.00

8

a

«

1.85
1.2s

.97
2.24
1.48

Deaths reported 2,611 : nnder five years of age 937 ; principal
infections diseases (small-pox, measles, diphtheria and croup,
diarrhoeal diseases, whoopmg-congh, erysipelas and fever) SSiS,
acute Inng diseases 451, consumption 312, diphtheria and croup
141, diarrhoeal diseases 42, measles 38, scarlet fever 33, typhoid
fever 23, whooping-cough 22, erysipelas 13, cerebrospinal
meningitis 12, smalfpoz 9, malarial fever 2.

From scarlet fever New York 10, Brooklyn 8, Philadelphia,
(!, Bo&ton and Pittsburgh 2 each, Cincinnati, Nashville, Lowell,
Cambridge and New Bedford 1 each. From typhoid fever
Philadelphia 6, Boston 4, Washington, Cincinnati and Uilwan-
kee 2 each. New York, Brooklyn, Nashville, Lowell, Lynn, New
Bedford and Tannton 1 each. From whooping-cough New
York (t, Philadelphia and Pittsburgh 3 each, Boston and Cam-
bridge 2 each, Washington, Milwaukee, Charlestown and Lynn
1 each. From erysipelas New York 7, Philadelphia 8, Brooklyn,

Digitized by

Google

480

BOSTOlf MEDIO Al AND StJMOtOAL JOtJttHAL.

[)fAT 10, 1894.

Boston and Milwaukee 1 each. From cerebro-spinal meningitis
New York 4, Cleveland and Somerrille -1 each, Philadelphia,
Washington, Lynn and Salem 1 each. From small-poz New
Yorli and Brooklyn 4 each, Boston 1.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,468,442, for the week ending
April 14th, the death-rate was 19 3. Deaths reported 3,877:
acute diseases of the respiratory organs (London) 304, whooping-
cough 142, measles 87, diphtheria 72, scarlet fever 50, diarrhoea
38, fever 33, small-poz (Birmingham 3, West Ham 2, Ports-
month I) 6.

The death-rates ranged from 11.8 in Huddersfield to 31.9 in
Wolverhampton ; Birmingham 21 8, Bradford 17.9, Croydon
12.6, Halifax 17.4, Leeds It).2, Liverpool 24.7, London 19.3, Han-
cbester 22.8, Nottingham 18.4, Portsmouth 1S.6, ShefBeld 18.6.

OI^'FICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM APRIL 28, 1894, TO
HAY 4, 1894.

Leave of absence for tiro months, to take effect on or about
May 1 , 1894, with permission to go beyond sea, is grant«d Majob
Calvin DkWitt, surgeon.

Captain C. N. Bkbkblkt Macaulbt, assistant surgeon, is
relieved from duty at the U. 8. Military Academy, West Point,
New York, and ordered to duty at Fort Wingate, New Mexico,
relieving Majob Wasuinoton Matthews, surgeon, who, on
being thus relieved, will repair to Washington, D. C, and re-
port iu person to the surgeon-general for temporary duty in his
office.

So much ol paragraph 13, S. O. 79, A. G. O., April 3, 1894, as
assigns Majob Pbtkb J. A. Clbabt, surgeon, to duty at Fort
Wingate, New Mexico, is revoked.

Leave of absence for two mouths, on surgeon's certificate of
disability, to take effect when his services can be spared, with
permission to leave the Department of the Colorado, is granted
Captain Edwabd Evbbts, assistant surgeon.

ASSOCIATION OF AMERICAN PHYSICIANS,

AND

CONGRESS OF AMERICAN PHYSICIANS AND SUR-
GEONS.

The ninth annual meeting of the Association of American
Physicians will be held in connection with the third Congress
of American Physicians and Surgeons at Washington, D. C.,
May 29, 30 and 31, and June 1. 1894.

The Association will hold its meetings in Hall No. 2, Col-
umbian University, comer of Fifteenth and H Streets. The
sessions of the Association will be held in the morning, between
the hours of ten and one, and those of the Congress will be held
in the afternoon, between the hours of two and six.

The following is the programme of the meetings of the As-
sociation :

Tuesday. - 1. " President's Address." Reginald H. Fitz,
Boston. 2. General Business, Reports, etc. 3. " The Treat-
ment of Certain Symptoms of Croupous Pneumonia, particularly
in Adults " Beverly Robinson, New York. 4. " A Treatment
of Typhoid Fever." Samuel A. Fisk, Denver. S. "Six Cases
of Traumatic Headache." C. F. Folsom, Boston. 6. " Clinical
Report of Two Cases of Raynaud's Disease." Frederick P.
Henry, Philadelphia. 7. "Dr. S. C. Martin's Researches on
the Bacteria of Vaccine." Harold C. Ernst, Boston.

Wednesday .— S. " Modification, Temporary and Permanent,
of Physiological Characters of Bacteria in Mixed Cultures.'
Theobald Smitb, Washington. 9. "The Effect of Various
Metals on the Growth of Pathogenic Bacteria." Meade Bolton,
Baltimore. 10. " Note on tbe Observation of Malarial Organ-
isms in Connection with Typboid Fever." W. Oilman Thomp-
son, New York. 11. " Experiments in Artificial Melanosis."
George Dock, Ann Arbor. 12. "Stomatitis Neurotica." A.
Jaeobi, New York. 13. "Tetany in America." J. P. Crozer
Griffith, Philadelphia.

Thursday.— 14. " Lead Palsy in Children.*' Wharton Sink-
ler, Philadelphia. 15. " A Study of the Temperature in Cerebral
Apoplexy." Charles L. Dana, New York 16. "The Mild
Character and Diminished Prevalence of Syphilis and the In-
freqaeucy of Visceral Syphilis." John H.Muzzer, Philadelphia.
17. " Some Remarks on the SignificaDce of Albumin and Casts,
especially in those past Middle Life." Frederick C, Shattuck,
Boston. 18. " Experimental Fhtbisis in tbe Rabbit with Forma-
tion of Qarities : A Demonstration." T. M. Prudden, New York.
19. *■ A Report of tbe Ultimate Resulta Obtained on Experi-
mental Eye Tuberculosis by Tuberculin Treatment and Anti-
Tubercular Inoculation." £. L. Tradeau, Saranac Lake.

Friday. — 20. " Some of the Chemical and Bacteriological
Characteristics of Milk." Thomas M. Rotch, Boston. . 21. '^The
Chemical Products of tbe Ancerobic Pntrefaution of Pancreatic
and*>Hepatic Tissues, and their Effects upon the Tests for
Morphia." Victor C. Vaugban, Ann Arbor. 22. " Gastro
Enteric Rheumatism." H. M. Lyman, Chicago. 23. "A Case

of Osteomalacia." George Dock, Ann Arbor. 24. "A Case of
Mitral Stenosiv, with great Hypertrophy of the Right Ventricle:
Death from Usmoptysis." A. HcPhedran, Toronto. 26. "A
Case of Calculous Pyelitis with Invasion by the Bacillus Lactis
.firogenes." J. H. Mosser, Philadelphia. 26. ConeludiDg
Business.
The following subjects will be considered by the Congress:
" Morphology as a Factor in the Study of Disease." " Sewer
Gas." " The Distribution and Control of Leprosy in tbe United
States." " Nephritis in its Surgical Aspects." "The Conserva-
tive Surgery of the Female Pelvic Organs." " The Sumry of
the Accessary Sinuses of the Nose." " The Inflneoee oflnlee-
tious Processes on tbe Nervous System."

On Wednesday there will be a Dinner to the guests of the
Congress at the Arlington Hotel; and on Thursday Evening
Dr. Alfred L. Loomis, President of the Congress, will deliver
an Address on "The Influence of Animal Experimentation on
Medical Science," nhich will be followed by a Reception.

SOCIETY NOTICES.

BosTOM Socibty fob Meoicai. Impbotbhbitt.- a regular
meeting of the Society will be held at the Massachusetts Insti-
tute of Technology, Walker Building, corner of Clarendon
Street, on Monday evening. May 14tli, at quarter past eight
o'clock, precisely.

Dr. W. M. Conant will read a paper on " College Athletics."
Tbe discussion will be opened by Dr. H. P. Walcott, President
Eliot, General Walker, Mayor Bancroft and Dr. W. A. Brooks.

Physicians Interested in tbe subject are cordially invited to
be present.

John T. Bowbm, M.D., Secretary.

Hassachusbtts Mxdical Socistt, Bvrroi/K Distbict. -
Tbe Section for Clinical Medicine, Pathology and Hygiene will
meet at 19 Boylston Place, on Wednesday, Hay Uth, at 8
o'clock

Papers: Dr. H. C. Vickery, " Fatal Vomiting without Dis-
coverable Cause."

Dr. J. Bergen Ogden, " Three Cases of Chronic Brlght's Dis-
ease of Different Types."

F. C. Sbattucx, M.D., Chairman.
Hbmet Jackson, M.D., ib'ecretary.

TWBNTT-riBST NATIONAL CoNFEBBNCB OF CHABITIBB AKD

Cobbbction will be held at Nashville, Tenn., beginning May
23d and closing Monday, May 28th.

The membership of the Conference Includes members of State
Boards of Charities, delegates from Charity Organization so-
cieties, officers of public and private charitable and correctional
institutions, official delegates appointed by the Governors of
States, and all other persons directly or indirectly connected
with charitable work. All persons included under this general
description are invited to attend the Conference, and the boards
in charge of charitable or correctional institutions, public or
private, are invited to send delegates.

The Conference is non-sectarian and non-poUtical, and its aims
are purely scientific and philanthropic.

L. C. Stobhs, President, Lansing, Mich.

A. O. Wbioht, Secretary, Madison^ Wis.

John M. Glbnn, TYeaturer, Baltimore, Hd.

• RECENT DEATHS.

Dh. Jclbs Arnold, Professor of Hygiene in the Faculty of
Medicine at Lille and one of the Army Medical Inspectors of
France, died recently, aged sixty-three years. He was an army
surgeon during the Crimean War and In 1862 was professor of
military hygiene at Val de Qrftce.

BOOKS AND PAMPHLET'S RECEIVED.

The Therapeutic Uses of the Salts of Cesium and Rabidinm.
By Theodore W. Scbaefer, H.D., of Kansas City, Mo. Reprint.
1894.

Proceedings of the Inaugural Meeting of the Medical Associa-
tion of India held at CalcutU on February 21, 1894. Reprint.
1894.

Further Remarks on tbe Occurrence of a Form of Noo-Alba-
minous Nephritis other than Typical Fibroid Kidney. By D. D.
Stewart, M.D. Reprint. 1894.

Tbe Medical Annual and Practitioners' Index; a Work of
Reference for Medical Practitioners. Twelfth year. Bristol:
John Wright & Co. 1894.

Thirty-third Annual Report of the Cincinnati Hospital to tbe
Mayor of Cincinnati for the Fiscal Year ending December 31,
1893. Frank W. Hecdiey, M.D., Superintendent. Cincinnati.
1894

Traitement des lUtr^rissements par I'^lectrolyse lin^ire. Ht
le Dr. J. A. Forb, Anclen Interne des Hdpiteauz, Professeur libre
d'anatomie k I'Ecole Pratique de la Faculty de M&lecine de
Paris. Paris: G. Masson. 1894.

Digitized by

Google

Vol. CXXX No. 20.] BOSfOlf MBDlOAL AND StJttOlOAL JOVkNAL.

481

%Vfitt^fi.

ANNUAL ADDRESS

Dklivered at the Openinq of the Twemty-fodbth
Annual Mbbtino or the Medical Society of
the State of California, April, 1894.*

BY C. O. KEirVON, M.D., FBEBIDEMT, BAH FBAMCISCO, OAL.

Ladies and Gentlemen, Members of the Med-
ical SOCIETT OF THE StATB OF CALIFORNIA:

The Architect of the Universe has, with lavish hand,
bestowed his benefits upon our State and upon the
various sections of the State that we severally repre-
sent. We have a soil which, under the touch of the
husbandman and the influence of an unequalled and
varied climate, brings forth in abundance the fruits and
products alike of the temperate and of the tropical
zone. And where, in all the broad domain of our
sunny California, do we find a section more richly blest
than this Santa Clara Valley, enclosed about with
mountain side, bedecked throughout its entire length
and breadth with happy homes, and in its centre seated
the beautiful Garden City, lovely San Jos^, famed
throughout our State for its wealth, its culture, and its
learning ? Our profession is ably represented in this
hall by a large delegation of the resident physicians,
who have ever kept abreast with the general onward
march of the times, no feature of which is more marked
than the great strides taken by our science in the
triumphal procession.

Surrounded as I am by so many who have become
eminent in onr profession, I can hardly flatter myself
that many here expect to learn anything new from a
president's annual address, and it is more than prob-
able that if any did their expectation would be disap-
pointed. But an annual address is a lime-honored
custom, and it seems to me that its office is less to im-
part information than to give public expression to, and,
perhaps, to afford opportunity for, more general discus-
sion of ideas, which, no doubt, have often suggested
themselves to many individual members. I propose to
mention briefly a few matters, which, I think, concern
the good and the welfare of our Society, claiming for
myself no merit as au original discoverer, and leaving
it to this convention to determine for itself to what
extent, if any, the suggestions now presented are ac-
ceptable to the majority of its members.

It is quite the fashion, in addresses by medical men,
for the speaker to lament, in a pessimistic mood, the
deplorable lack of higher education and general profes-
sional attainments in the profession in our own country,
as compared with the standard in other older, and,
especially, European countries. To these jeremiads I
desire to offer my humble protest. While my voice
will always be nplifted in favor of the best type of
manhood, and the highest standard of attainments, as
pre-necessary qualifications for those who would assume
the honorable title of M.D., yet I am pleased to call
your attention to the general activity and earnestness
displayed by the profession within the influence of this
Society, and I venture the assertion that, striking a
general average of the profession in California, no
body of men can be found under the sun better informed
and more capable as a whole than we have here. In
proof of this assertion, 1 refer you to the high standard
adopted by our medical schools, the vast amount of

^ The followins extroota from Dr. Kenton'! Addren are from
■dvanoa shaeta ofttae Oooldental Medical Time*.

medical literature, local and foreign, received and sup-
ported by our profession ; the prevalent custom among
our young men to go abroad to farther qualify them-
selves, in wider fields, for professional work; and the
general activity exhibited in oar local and State organ-
izations.

That this Society is an important, and may be made
to become a more important, factor in maintaining this
standard of excellence, is a statement which I need
hardly make here. Your presence as members of this
organization, many of you coming great distances from
your homes to attend this convention, testifies to your
appreciation of the fact. This being so, is it not well
that we should consider whether by any, and if by any,
by what means we may best extend and widen this
Society's sphere of acknowledged usefulness ? I propose
to offer for your consideration some changes in the
constitution and by-laws of this Society, with the end
in view of increasing oar membership, oar working
capacity, and our power of advancement of the profes-
sion within this State.

We are pleased to call this organization " The Medi-
cal Society of the State of California," a very high-
sounding and comprehensive title. But when we con-
sider the fact that out of 2,700 licensed practitioners
of regular medicine in the State our membership con-
sists of some 360 only, it becomes apparent how short
we fall of fulfilling the high and important mission
which oar title, and our objects as declared in our
constitution. Would indicate.

As I have before intimated, we may assume, with-
out argument, that membership in this Society is bene-
ficial to the members and to the advancement of our
science. It becomes, then, our duty to consider the
proper and best course to pursue to extend those bene-
fits to the utmost limits. That we have been only
partly successful under our present plan of organization,
is too patent to require discussion. Having given this
matter much thought and consideration, I desire to
bring before you some suggestions, which, if they are
found worthy of your approval, will, I believe, increase
our membership and extend our field of usefulness.

[These suggestions included a recommendation of a
reduction of annual dues, the abolition of enforced
continuous membership in the local society, and the
establishment of a quarterly bulletin, containing such
information and contributions as the Committee on
Publication might deem most worthy of space.]

Oovrermoding in the Profusion. — As before stated,
in this State we have about 2,700 practitioners of
medicine and surgery, graduates of regular medicine
and licentiates of its Board of Examiners, without
counting several hundred licentiates of homceopathy
and eclecticism. This vast number has as a field of
labor a State with a population of 1,500,000, which by
a simple process of division shows one doctor to every
500 of population. To say that our profession is over-
crowded expresses a fact too patent to admit of discus-
sion. As an equal distribution leaves only this small ratio
for a clientele, what must be the portion left to some
of the profession, when we find leading physicians who
enjoy the patronage of thousands ? The obvious
tendency of this overcrowding, it is to be feared, is to
lower the standard of professional conduct among
regularly educated and licensed practitioners.

We have also to consider, in addition to this un-
pleasant picture of a small army of medical men striv-
ing for existence in a limited field, a host of quacks of

Digitized by

Google

482

BOSTON MEDICAL AUD SVSGJCAZ JOVttNAL.

[Mat 1?, 1894.

varioas kinds and degrees, who, like the camp-followers
that hang about Sherman's army on its famous " march
to the sea," are ever on the alert to pick up choice
bits of forage and sasteoance that shonld fall to the
lot of the regular soldier, whose mess must suffer to
the extent of the irregnlar depredations. Here we
have a somewhat homely, bat, I think, pertinent illas-
tration of the situation.

But it is easier to depict this unfortunate condition
of affairs than to recommend measures of adequate
relief. The following suggestions, however, seem to
me to be appropriate : We should no longer hold out
to intending students of medicine alluring pictures of
the excellence of this State as a field for practice.
Until the time comes, if ever, when there shall be a
more reasonable proportion between practitioners and
patients, it is bound to be a question of the survival
of the fittest, and meanwhile, only moderate encour-
agement should be given to students, and to those only
who, by more than average ability, and by a high de-
gree of preliminary education, give promise that at the
end of their course of medical study they will come
into the field fully equipped and qualified to engage in
what, at best, must be a struggle for existence.

Again, it is well known that medical men cannot go
from this to other countries on the American conti-
nent or in Europe and assume the practice of medicine
until after a strict examination there, and the securing
of a certificate in accordance with the laws of the gov-
ernment under which they may choose to settle. We,
however, with that excess of liberality found only in
this land of refuge for all people, and of the refuse of
many, the " Heathen Chinee " not excepted, receive
all comers with open arms, welcome them to share our
meagre loaf, and our people patronize them to the ex-
clusion, frequently, of those to the manor born, and at
least equally qualified by natural ability and education.
The halo of mystery and greatness which hovers about
a foreign doctor seems to have a peculiar fascination
for the American mind, and our imported frater is not
always too modest to use this peculiar bent for all the
advantage it may bring him.

Hotpital Cliniei and Free Ditpentariet. — The in-
fluence of hospitals, dispensaries, college clinics, etc.,
upon the general practice, has been considerably dis-
cussed of late. That the increase of such institutions
is having a marked effect upon the field of labor of the
general practitioner, especially in metropolitan centres,
needs no argument. That the best service in all
branches of practice is freely given in the several free
dispensaries or clinics in San Francisco, while the ex-
cellent hospitals offer to the afflicted at small cost, a
haven where capital operations are performed daily by
skilled operators under the advantageous surroundings
of the most modern methods, and that the tendency of
all this is to diminish the field for work for the less
favored who constitute the larger portion of the pro-
fession, is also an accepted fact.

The young man entering the profession, however
well fitted by thorough training, supplemented by hos-
pital experience in the best institutions in the world,
finds but a limited scope for his talents, if he be not
one of the fortunate few holding positions in public or
private institutions that bring to them abundance of
material for the exercise of their acquired skill. He
must content himself with sitting patiently in his office,
waiUng for business that is long in coming or that
may never come. The claim that suffering humanity

alone should be considered in a question like this —
that better service can be rendered in hospitals under
aseptic conditions — is no doubt to a certain extent
just, and the general practitioner, recognizing this and
frequently ready to sacrifice his own interests to that
of his patient, is often quite ready to recommend a
sufferer to the hospital. He even goes there himself,
and, with his bands in his pockets, or behind him (as
a precaution against the conveyance of germs from bis
polluted person) watches his more fortunate brother,
made clean by aseptic ablations and bedecked in a
clean apron, do his work. Then he goes away filled
with a satisfying consciousness of having served liis
patient well, but with an empty pwcketbook and a lack
of that practical experience which properly belougt to
him. He is little benefited even by observing the op-
eration ; it is one that he has probably seen and taken
part in many times before.

The practice thus outlined may b« best for hamaoity,
hot it results in making experts of one class, while the
great mass of medical men are dropping into medioc-
rity and losing the incentive to improve their acquired
ability for lack of opportunity to exercise it. In the
rapid growth of this dispensary system, our medical
men are themselves the most active agents. I speak
only of dispensaries under the management of regular
practitioners, such as college clinics, dispensaries, etc.,
under the auspices of colleges or associations, cod-
ducted in the name of charity, sweet charity, under
whose banner skilled services, medical and surgical,
are free as water. Various means of advertising, all
strictly legitimate, are resorted to to encourage the
afflicted to seek professional aid in these free centres
of practice, while around the corner — many corners

— are seated in their offices well-sMlled medical men
waiting in vain for their fair share of business, which,
if an equal division could be made, would leave them
a clientele of leas than 600.

If all who availed themselves of this gratuitous sys-
tem of service were really entitled to it, there would
be less cause for complaint, but it is well known that
many who can well aJFord to employ a general practi-
tioner, now resort to these institutions whose real ob-
ject is, or should be, to dispense medical and surgical
aid to the poor and needy.

It is well, occasionally, to get down from the high
plane from which this subject is frequently treated.
Medical men are prone to soar to a high level. We
speak of our remuneration as an " honorarium," yet af-
ter all we are only a class of bread-winners in common
with others of our fellow-beings — an honorable clan

— striving to earn a livelihood by the pursuit of oar
profession. The practice of medicine is our bnsineu;
and most of us are, or ought to be, supporting and ed-
ucating families out of the legitimate financial proceeds
of our business. If we could all become suddenly
alive to this important fact, and could at once proceed
like a band of brothers to a fair and equitable diatribo-
tiou of work and its proceeds, then, indeed, should we
see a medical millennium ; but this i?, of course, s
chimera. No medical body, much less an individual,
is likely to change the trend of current events. Some
good, however, may be attained by directing our at-
tention, for a moment, to these problems, and to their
bearing upon the welfare of the medical world.

FaUieidt. — Foeticide, infanticide, and methods of
preventing pregnancy, are subjects tabooed in polite
society, and even in a body of medical men, they gen-

Digitized by

Google

Vol. CXXX, No. 20.] BOSTON MEDIO AL AND SURGICAL JOURNAL.

48S

erally receive little or do atteatioD. The evil, bow-
ever, is becoming one of such magnitude, so far reach-
ing in its effects, that I feel it eucombent upon me, as
the temporary exponent of this Society, to give free
and bold expresBion to the abhorrence in which all
reputable practitioners must.hold the various methods
of prevention of child-bearing, and the very frequent
procurement of abortions, as tending to deteriorate the
moral tone of society, debauch public sentiment and
shake the foundations of society — the domestic rela-
tion, the home. That regular medical men and women,
such as constitute my hearers, do not participate in
these disreputable practices, is a position I desire in
the strongest manner possible to maintain, but that in
the popular mind we escape the odium attached to
them, is, unfortunately, not susceptible of proof. It is
too true that the ui)right regular practitioner shares
with the charlatan or advertising quack whatever pop-
ular opprobrium ihese nefarious secret practices re-
ceive. With the >{reat public a " doctor " is a doctor.
Reputable medical men aud women who indignantly
dismiss a patient who applies to them for such a pur-
pose, are frequently met with the remark, " Why, I
thought all doctors did it." And so the few cases
which are brought to public notice through the death
of the unfortunate woman at the hands of some scoun-
drel man or woman, calling himself or herself " doc-
tor," bring odium on our profession, and usually with-
out remonstrance on our part.

It is high time the regular profession should take a
stand and clear its skirts of the opprobrium. It is our
doty, both by precept and practice, to establish the
fact in the minds of the public that we have no
sympathy with criminal business, or with the criminals
who practise it. When that point is attained we may
reasonably hope for some abatement of the evil. It is
a lamentable fact that a large proportion of the male
population believes that this nefarious business is prac-
tised by almost all medical men, and while that popu-
lar impression prevails juries will not convict, even in
flagrant cases. It has been demonstrated in recent
trials in San Francisco that a man who has openly
practised a criminal business for many years, who
drags his unfortunate victim from his own infamous
den and places her upon a car to die a few hours later
in transportation, may go scot free.

The public prints are frequently filled with the
nauseating details of some of these cases ; many, we
know, are hushed up, while the culprits are left un-
molested to continue their unlawful practices. One
solitary conviction stands out in bold relief, and this,
in the present perverted state of public sentiment,
seems somewhat of a shock. " Why should not this
man have gone free when everybody is doing itP"
asks many a good citizen ; and, in fact, it is doubtful
whether the conviction in ' that case was as much a
mark of the jury's disapprobation of the crime com-
mitted on the living body as it was of its horror of the
barbarous mutilation of the senseless corpse.

The prevention of these unlawful practices is ulti-
mately a matter for the people and for the courts.
The present law seems inadequate, and public senti-
ment does not seem to be strong enough to devise
proper remedies. Does it not behoove us, therefore,
to do what we may towards stemming this tide of im-
morality ? The regular profession should take no un-
equivocal ground, but should, in season and out of
season, contend against the continuanoe of tbe«e pri^

tices, and strive to educate the people to a higher
plane of oiorality. If we do not do so, the fair es-
cutcheon of our time-honored profession will continue
to suffer the opprobrium brought upon it by the prac-
tices of a disreputable class with whom we have no
connection by sympathy or association.

It should be the duty of the physician not only to
frown down these practices, but also to use the great-
est care, lest by a word or hint he carelessly direct an
applicant for criminal relief to one of these dens of
infamy. It will not do to say to an unfortunate sup-
pliant that such and .such persons have the reputation
of doing these things; we canaot afford to become
even indirectly agents, or " steerers," if I may use the
term, for these people, simply as an easy method of
getting rid of an undesirable patron. No ; the proper
thing to do is to answer these deluded women in a
manner short aud sharp, " We have nothing to do
with such cases, and do not know of any one who
practises criminal business."

The statutes in reference to evidence in cases of
criminal abortion should be modified, so that evidence
of the only other witness to the crime beside the
operator might be available to prove guilt.

Embalming. — The disposition of the bodies of the
dead, owing to the growing sentiment in favor of
cremation, occupies a prominent place in the minds of
the medical profession. For sanitary reasons, the
profession is almost a unit iu favor of incineration.
One objection to this plan for disposing of the dead,
however, from a medico-legal point of view, is that by
it all evidence of the cause of death disappears, if we
may be allowed to use the expression, in smoke.

While speaking on this point, it is pertinent to refer
to a custom which is becoming established among
undertakers, and which should be stopped. I refer to
the injection of the body immediately after death with
embalming or preservative fluids, a proceeding in this
climate wholly unnecessary. It is a trick that is being
too successfully worked by undertakers, for their own
profit, on the friends of the deceased. Thoughts of
economy, much less of parsimony, seldom enter the
minds of the grief-stricken family, and so when the
shrewd undertaker, with thoughts of his coming bill,
suggests, " Of course you wish the body embalmed ? "
the answer is rarely in the negative. But I refer to
the matter for the more important reason that the
corpse, after being subjected to this so-called embalm-
ing process, is saturated with mineral poison, obliterat-
ing every evidence of crime, if any exists. I recom-
mend that the Committee on Legislation endeavor to
have a law passed prohibiting the use of any embalm-
ing process until after permission has been granted by
a coroner or other proper officer.

The Oode ofEthiet of the American Medical Attocia-
lion. — The Code of Medical Ethics adopted by the
American Medical Association and by the Medical
Society of the State of California has been the Magna
Charta of the profession throughout the United States
for many years, and has seemed ample for the purpose
for which it was designed — the regulation of the con-
duct of members of the profession. However, the de-
velopment of specialties aud the overweaning desire of
some of the leading medical men in New York City
to enlarge the scope of their practice has of late caused
a departure from some of our long-established prin.
ciples, and the adoption of a woditied Code in the
State of New York.

Digitized by

Google

484

BOSTON MEDICAL ASD SUBOIOAL JOVRBAL.

[Mat 17, 1894.

At a recent meeting of the Americaa Medical Asso-
ciation a committee was appointed to revise the Code,
and the matter will undoabtedly be brooght up at the
meeting to be held this year in San Francisco. 1 do
not propose to attempt to infiueDce the action of mem-
bers of this Society in this matter, but I urge you all
to study the Code thoroughly, and if, after mature re-
flection, that Code, which has stood the test of time,
meets your approbation, I would be glad to see the
profession in California loyal to its tenets. The medi-
cal professiou in the United States has done well
under the present Code of Ethics ; its history is one
upon which we can reflect with pride. Under this
Code, ample scope has been allowed for the progressive
members to make brilliant records by the introduction
of new methods in the practice of medicine and sur-
gery, which have redounded to the credit of the medi-
cal world.

Quarantine and GhoUra. — At the time of the
twenty-third annual meeting of this Society in 1893,
Asiatic cholera threatened to invade England and the
United States. That we were not visited by the
dreaded scourge is due to the enlightened and efficient
measures adopted to arrest it; and although infected
ships arrived off New York, the barriers proved effect-
ual. The loss of human life, not to speak of the
damage to the business interests of the county which
an epidemic of Asiatic cholera would have caused, can-
not be measured. Such an invasion would have de-
moralized all traffic, have paralyzed oar commerce, and
have proved the utter ruin of the great Columbian Ex-
position. The success attending the measures adopted
to avert this disaster is the highest testimony to the
efficacy and value of modern sanitary science.

Xecture.

URINARY DIA6NOSIS.1

BT BDWABD S. WOOD, M.D.,
Profeuar of Chtmittry, Harvard Medical Selwol.

Lkctuke I.

I DO not expect to do full justice to the subject of
" Urinary Diagnosis " in the two hours that are allotted
to these lectures ; but I will endeavor to condense the
material in such a way as to include most of the im-
portant changes which occur in the urine and which
are of diagnostic importance.

In the early history of medicine we learn that the
urine was examined for diagnostic purposes, and this
examination was of assistance in the diagnosis and
prognosis and in deciding as to the treatment of differ-
ent diseases. It so happens that I have in my posses-
sion a work that was published more than three centu-
ries ago, which is devoted entirely to the examination
of the urine. In more recent times, after the chemical
composition of the urine became better understood, and
yet before the microscope was fully developed, certain
changes were detected in the chemical composition of
the urine, which were considered of so much import-
ance that they received a special name, and these names
were generally used as indicating certain diseases.
They are still in use to-day. I refer to the terms
albuminuria, glycosuria, hsematuria, ozaluria, audcysti-

> ETenliig litoture delivered at the Harvard Medical Sohool. Febm-
ary 21, 18M.

naria; these all have a distinct meaning, and the
changes which they represent are of very great impor-
tance. Their use is continued at the present time, as
it should be, but their meaning is very properly so
restricted as to indicate simply a symptom,.possibly of
many different pathologic^ conditions. A great many
of us in the present generation can remember very dis-
tinctly the time when the terms albuminuria and
Bright's disease of the kidney were considered synony-
mous. Of course, we all now know that the term
albuminuria means simply the presence of albamia in
the urine, and that it may occur in a great many dis-
eases. The term is by no means synonymoos with
Bright's disease, and in the majority of cases of albu-
minuria there is no organic disease of the kidney.
The study of this symptom — albuminuria — I shall
defer until later when we consider the character of the
urine in the various kidney diseases.

Glycosuria, which used to be considered as synony-
mous with diabetes mellitus, means simply the pres-
ence of grape sugar in the urine. We now know that
there are other conditions which are characterized by
the presence of grape sugar in the urine. It is of very
great importance to be able to distinguish, from the
examination of the urine, between cases of diabetes
and cases of simple glycosuria. In order to do that,
we must take into consideration several other impor-
tant diagnostic features. One is, as to whether the
grape sugar is present in the urine permanently or tem-
porarily. In diabetes, if the patient remains untreated,
grape sugar is present in the urine in considerable qoao-
tity and for a long time, whereas, in glycosuria due to
other causes, the sugar is present in the urine, usually,
in small quantity and temporarily. The general char-
acter of the urine in diabetes I need only allude to.
The daily quantity is large ; in extreme cases from six
to eight quarts in twenty-four hours. It is of pale
color, high specific gravity, and contains a large amoaot
of grape sugar, varying from two or two and one-half
to nine or ten per cent, of the total weight of urine, so
that a patient suffering from regular diabetes may
eliminate two or three pounds of grape sugar in twenty-
four hours. But, yon will observe in studying the
urine in many cases of diabetes, that there are two dis-
tinct classes of cases, in both of which the daily quan-
tity of urine and of sugar may be very lai-ge, but if the
urine passed at different times of day be examined
separately, it will be found that in some cases nearly
all of the sugar eliminated is contained in the urine
passed after eating, while the fasting urine contaiDS
but a very small percentage of sugar ; whereas, in
other cases, there is bat little if any difference in the
percentage of sugar in the urine secreted at these two
different times. Clinically, these two kinds of cases
are quite distinct. Those cases in which the fasting
urine contains about as large a percentage of sugar as
the after-meal urine, generally resist all treatment, par-
sue a fairly rapid course, and terminate fatally in a
comparatively short period of time. Whereas, those
cases in which the fasting urine contains but a very
small percentage of sugar, the patient may be so much
relieved by treatment that the grape sugar may disap-
pear from the arine entirely, although he may have
had glycosuria for several years. Cases of temporary
glycosuria are of comparatively little coasequenoe
from a diagnostic point of view, since the glycosuria is
secondary to some disease, the nature of which is gen-
erally easily recognized, as in some cases of apoplexy,

Digitized by

Google

Vol. CXXX, No. 20.] BOSTON MEDICAL AND SUSOIOAL JOUSNAL.

485

head iDJaries etc. In these cases the quantity of
urine is not increased as much as in either of the forms
of diabetes.

The term hematuria, which has been in use for
many years, indicates, as its name implies, the pres-
ence of blood in the urine. In recent years, however,
this term has been subdivided according as the urine
contains aU of the constituents of the blood, both glob-
ules and serum, hsematuria, or only the coloring matter,
hemoglobinuria. The distinction between these two
conditions is, that in hematuria, which is due to hem-
orrhage from some portion of the kidneys or urinary
passages, we find upon examination of the urine more
or less of the blood pigment, partly decomposed or not,
in solution in the urine, and, upon microscopical exami-
nation of the sediment, we see a large number of blood
corpuscles, so that weliave all of the elements of blood
present in the urine. In cases of hsemoglobinuria, on
the other hand, we find only blood pigment in the
urine. The blood pigment is set free from the red
corpuscles within the blood-vessels and not in the
urinary passages, and it is simply eliminated from the
blood by the kidneys. Upon microscopic examination
of the urinary sediment, in cases of hemoglobinuria,
we do not see any blood corpuscles in the sediment,
and we have, therefore, only the coloring matter of the
blood in the urine without the blood corpuscles.
Hematuria means simply hemorrhage from the urinary
or genito-urinary passages, while hemoglobinuria means
blood pigment in the urine and it is a symptom of a
disease of the blood and not of the kidneys or urinary
passages.

Oxaluria is a term which signifies the presence of cal-
cic oxalate in the urine and this Condition is sometimes
of diagnostic importance. It is detected by seeing the
calcic oxalate crystals in the sediment upon micro-
scopic examination. This means that oxalic acid has
been formed in the economy, or that it has been taken
into the economy with some article of food or drink.
Its importance depends entirely upon the quantity
which appears in the urine and upon its permanency.
No doubt all of us have occasionally a temporary
oxaluria due to some article of food or drink, which
contains oxalic acid. The drug rhnbarb, as well as
the garden rhubarb, will impart a certain amount of
oxalic acid to the economy. If calcic oxalate is found
in considerable quautity in the urine, we are pretty
sure, also, to find evidence in the sediment, of the
local action of the sharp calcic oxalate crystals upon
the lining membrane of the renal tubules. They
•cratch more or less, and cause mechanical irritation of
the kidneys, the evidence of which may be detected in
the sediment together with a number of the crystals.
If the oxaluria is long continued, there is always dan-
ger that a mass of the crystals may become aggregated
together with fibrin or mucus, and form ao oxalate
concretion. You all know how serious are the effects
produced by the so-called mulberry calculus, which is
composed of calcic oxalate ; its rough surface produces
so much inflammation and hemorrhage that the mul-
berry calculus is almost invariably dark brown or black
in color owing to the decomposed blood pigment which
is present in its structure.

Chyluria is one of the old terms which comes more
nearly meaning a disease than most of the other terms
applied to certain changes in the composition of the
urine. The term chyluria means simply the presence
of chyle in the urine. That can only occur in case

there is some connection between the lymphatics and
the urinary passages, and, we know now, that the dis-
ease of the lymphatics is caused by the presence in
them of a parasite, the filaria sanguinis hominis. Chy-
lous uriue is a milky-lookiug urine, which contains fat
in so finely divided a form that it never separates, if
the urine is prevented from decomposing. The fat
neither settles as a sediment, nor rises to the surface
to form a film. In many cases of chyluria we may
have this peculiar appearance present in the urine
only at certain times of day, or it may be present for a
period of several weeks and then disappear, only to
recur again at some later period. This specimen of
chylous urine, which I have here, was passed by one
of the medical students, a native of Cuba, and when
perfectly fresh was hermetically sealed in this test-
tube, which has not been turned upside down since the
urine was placed in it in 1876. Yet, as you see, the
milky appearance is as evident in the upper as in the
lower layers of the fluid. The fat is so finely divided
that it cannot be detected by examination even with
the highest powers of the microscope in the shape of
oil globules. This fact enables us to distinguish readily
between chylous urine and urine to which milk has
been added. Milk is sometimes added to the urine
by hysterical patients for the purpose of deception.
If the urine contains milk a drop of the milky fluid
examined under the microscope is seen to contain the
oil globules of the milk. Another means of distin-
guishing these two conditions, is to shake a little of the
milky urine in a test-tube with ether. When chylous
urine is shaken with ether the fat is readily dissolved
by the ether, and when the ether separates from the
urine, it is seen that the latter fluid has lost its milky
appearance. Ether will not sepaj-ate the fat from urine
to which milk has been added.

Cystinuria. The diagnosis of cystinuria is made
only by recognizing on microscopic examination the
peculiar crystals of cystin. These crystals are color-
less, hexagonal plates, readily soluble in ammonia and
the mineral acids, but insoluble in acetic acid. It con-
tains a very large percentage of sulphur 26 per cent.,
and is prubably due to some faulty metabolism by
which the sulphur derived from the albuminoids is
eliminated in the form of cystin instead of in the form
of taurine of the bile. The recognition of cystin is of
importance only as enabling us to distinguish between
that form of urinary deposit and others in cases of
urinary concretions, in the examination of the urine
for diagnostic purposes.

Alkaptonuria. This is another condition of the urine
which has received a special name, and I did not in-
tend to mention it all, since I did not consider it of
suflScient importance on account of its great rarity. It
is so rare that I have never seen a specimen until the
present week. This condition of the urine is of greater
importance to the life insurance examiner than to the
general practitioner, on account of the danger of mis-
taking a case of alkaptonuria for one of diabetes mel-
litus. The so-called alkaptou, which the urine con-
tains in this condition, may be one of several substances
which are powerful reducing agents when in alkaline
solution, so that such a urine responds to some of the
tests for a diabetic urine, particularly the Heller and
Trommer tests, and the test with Fehling solution.
A urine containing alkapton is usually normal in color
when passed, but after exposure to the air it becomes
dark brown in color like that of a carboliu-acid urine.

Digitized by

Google

486

BOSTON MBDIOAL AND SUBQIOAL JOURNAL.

[May 17, 1894.

The quantity in the twenty-fonr hoan is apt to be
dimiuighed rather than increased. If rendered alkaline
with 8odic hydrate and shaken in a test-tube, it absorbs
the oxygen from the air io the upper part of the tube,
and becomes dark brown in color, rapidly as you see,
and at the same time it creates a partial vacuum in the
test-tube, so that if the tube be inverted under water,
an amount of water equivalent to the volume of oxygen
absorbed will be sucked into the test-tube. Some
specimens will absorb as much as four-fifths of their
volume of oxygen. A urine containing alkapton may
be readily distinguished from one containing grape
sugar by the following properties : it becomes dark
brown in color slowly on exposure to the air and very
rapidly if rendered alkaline with sodic or potassic hy-
drate. It does not react to the fermentation test as
does diabetic urine. A person whose urine contains
alkapton may enjoy perfectly good health, so that such
specimens are only seen in those who present them-
selves to the life insurance examiner, and those who
enter a hospital or consult a physician for some disease
entirely unconnected with the condition which causes
the alkaptonuria.

In the examination of the urine for diagnostic
purposes, of the utmost importance is the quantity of
urine that is passed in twenty-four hours. It is ab-
solutely essential ia making a differential diagnosis
between certain forms of kidney disease, and it is also
of very great importance to know exactly the quantity
of urine that is passed in many other cases than in
organic diseases of the kidney. Let me here say that
it is never wise to rely upon the statement of the pa-
tient in regard to the quantity of urine passed. You
will very frequently be told that he or she is passing
no more than usual,* whereas, they may be passing
from two and one-half to three and one-half quarts in
the twenty-four hours. You may be told by the pa-
tient that he is passing a much larger quantity than
usual, and upon measuring it you will find that he is
passing a much smaller amount than normal. In all
cases where the examination of the urine is essential
in making a diagnosis of kidney or other disease, it is
in a vast majority of cases essential that the twenty-
four hour quantity should be accurately known. In
some cases, it is also necessary to know the relative
quantity passed in the day and in the night. Recent
observations have shown that in one of the most im-
portant forms of Bright's disease, the quantity of urine
that is passed in the night time far exceeds that which
is passed during the day.

The diagnosis very often depends upon knowing not
merely the iweuty-four hour quantity of urine, but,
also, upon knowitig how much work the system has
been doing, and how much work the kidneys are capable
of doing. But the only estimations which are really
necessary, in the vast majority of cases, are the estima-
tion of the quantity of urine and the estimation of the
principal organic normal solid, urea, which is the final
product of the metabolism of the nitrogenous elements
of the body. This estimation of the urea is an ex-
ceedingly simple matter. 1 have found this little ap-
paratus of Dr. Squibb's to be by far the simplest and
most satisfactory. A full description of the method
of performing ibe operation is given upon the papers
that come with the apparatus, and the whole process
requires but a few minutes, so that the quantitative
estimation of urea is not nearly as difficult as it used
to be. The importance of the estimation of the twenty-

fonr hour quantity of urine is very great ; for instance,
we have some general diseases which are characterized
by a permanent and large increase in the daily quaDtiiy
of urine. The most common of these are the two forma
of diabetes, diabetes mellitus and diabetes insipidua.
There is oo trouble in making a diagnosis of the former
disease, as we have a large quantity of urine with a very
high specific gravity due to the presence of grape sugar.
But there is difficulty in making a diagnosis of diabetes
insipidus, because we have so many other conditions io
which the urine has practically the same characteristics,
namely, — urine passed in very large quantity in
twenty-four hours and of very low specific gravity.
In diabetes insipidus where the symptoms resemble
very much those of diabetes mellitus, loss of flesh and
the wasting of the tissues, the urine is passed in large
quantity and of low specific gravity, although if the
normal solid matters be estimated, we will find the
twenty-fonr hour quantity increased. The daily amount
of urine is from 3,000 to 3,500 c. c. or more, and we
will find the urea running up to eighty or ninety, or
even one hundred, grammes in twenty-four hours, the
normal amount being from 25 to 35 grammes, thus
showing a very large increase. The daily quantity of
chlorine also reaches from twenty to thirty grammes
instead of the normal of nine or ten grammes. Urine
of similar general character, large quantity and low
specific gravity, we may find in health, and, also, Id
many nervous affections existing temporarily, but in
these cases the twenty-four hour quantity of solid
matters will not be increased, but may be diminished.
A small quantity of urine habitually is of less im-
portance from a diagnostic point of view than a large
quantity. We are all familiar with most of the exist-
ing diseases that are characterized by a small quantity
of urine. Some persons in health pass habitually very
small quantities of urine, much smaller than they
should, so that instead of eliminating 1 ,500 c. c. (three
pints) as they should, the quantity is frequently di-
minished to 900 or 1,000 c. c. (about two pints) in
twenty-four hours, and the specific gravity reaches
1,030 instead of 1,021. This condition, if long con-
tinued, may cause irritation of the kidneys. The most
common diseases, characterized by an abnormally small
quantity of urine, are acute diseases. It is rarely
necessary to resort to an examination of the urine in
the ordinary febrile cases, but there are some in which
the testing of the urine is of a good deal of importance.
Those are the acute diseases attended with an exuda-
tion, as pneumonia, peritonitis, etc. In these diseases,
when the effusion is increasing, the chlorine steadily
diminishes from the urine until it may entirely disap-
pear, and it reappears with the beginning of the ab-
sorption of the exuded fluid; so that in a pneumonia
we can determine the exact time at which the absorp-
tion of the exudation from the lung tissue begins more
accurately by the reappearance of chlorine in the urine
than we can by the physical examination. In perito-
nitis, in addition to the absence of chlorine, the
small quantity and the concentration of the urine, we
find an enormous increase of the indoxyl. These
peculiarities are naturally of greater importance to the
urinary examiner, who does not see the patient, than
to the visiting physician who does. Therefore, it is
often of value to me in order to enable me to distin-
guish between one kind of fever and another. From
a case in which the quantity of urine is habitually be-
low normal, we can, of course, elimiaate at once any

Digitized by

Google

Vol. CXXX, No. 20.] BOSTON MSDIOAL AND SXTRGtOAL JOURNAL.

487

disease which is characterized by a constant abnormal
increase.

There is one other condition, so far as the quantity
is concerned, which I wish to mention briefly, called
anuria. That condition is where there is almost no
urine passed. Under this head are included those
cases in which only three or four ounces are secreted
during two or three days, and I have known almost
total suppression of urine to last for a longer time, so
that only a few ounces may be eliminated in the course
of two weeks. We find that condition of almost total
suppression of urine in many diseases toward death, in
which case, of course, its existence is of really no di-
agnostic importance. We sometimes see it in cases of
acute nephritis, where only a few ounces may be se-
creted in twenty-four hours. In the last case of severe
acute nephritis which I saw, only four ounces of black
urine were passed in forty-eight hours.

Where there is an obstruction to the Sow of urine
through the urinary passages, we may have a condition
resembling anuria. This may occur iu some surgical
cases, as for instance, where there is a tight urethral
stricture. There is another condition which is called
obstructive suppression, of which I have seen, perhaps,
half-a-dozen cases. These are due to the compression
of the urinary passages above the urethra eo as to
permit of only a comparatively small quantity of urine
passing into the bladder. A very remarkable case of
this kind was reported a few years since by Dr. J. W.
Farlow,' in which compression of both ureters was
caused by a malignant growth of both Fallopian tubes,
and in that way the calibre of both ureters was so
much constricted as to be at times completely occluded.
At one time a period of twelve days elapsed without
any urine being secreted. Obstruction of the ureters
by calculi ia, perhaps, the most common cause of ob-
structive suppression. As a general rule, the urine of
obstructive suppression is characterized by being passed
in small quantities, of very pale color, and very low
specific gravity, and you may or may not find evidence
of kidney disease by the microscopical examination of
the sediment.

THE ACTION OF RATTLESNAKE VENOM UPON
THE BACTERICIDAL POWER OF THE BLOOD
SERDM.i

BT CBASLES B. BWINO, M.D.,

Medieal Department, United State$ Army.

Am apology would be necessary for introducing a
subject of this character, on the present occasion, if it
were not that the loss of life from poisonous reptiles
has become so great that it calls forth the best effort
of not only the military surgeon but of medical men
generally, to lessen it.

The mortality in India alone reaches the alarming
figure of 20,000 persons annually, hence it was not a
strange coincidence that it should have fallen to the
lot of the British Medical Service, lead by Dr., now
Sir, Joseph Fayrer, to perform the pioneer work iu
that part of the globe.

While much has been written upon this subject in

> From the proceedings of the Waahington meeting of military
snigeODS.

' Boston Hedloal and Sargloal Jonmal, April 4, 1889.

general ; very little has been said or done in the spe-
cial line to which this paper relates.

At Professor Welch's suggestion we conducted a
series of experiments in the pathological laboratory of
the Johns Hopkins University during the spring of
1893, having for their purpose the determination of the
action of rattlesnake venom upon the bactericidal
power of the blood.

Dr. Welch's attention was directed to the investiga-
tion of this subject by Dr. Weir Mitchell. Drs. Mit-
chell and Reichert demonstrated that the poisonous
properties of rattlesnake venom depend upon the pres-
ence of proteid substances. These investigators were
the first to demonstrate the existence of the so-called
toxic albumins.

In their monograph on the subject, as well as from
previous observations, it was apparent that the animals
killed by rattlesnake venom decomposed with great
rapidity, indeed with such rapidity, that Dr. Formad,
who contributed an appendix upou the pathological
anatomy of animals dead of rattlesnake venom, believed
that there was evidence of the spontaneous generation
of bacteria.

Dr. Formad thought it impossible for the bacteria
to make their way into the circulation and multiply
so quickly. This seemed so improbable to Professor
Welch that he suggested to Dr. Weir Mitchell the im-
portance of haviog this point worked up. Dr. Mitchell
kindly gave us a certain amount of poison. We were,
however, fortunate enough to obtain a live rattlesnake
of the diamond species, known as the Orotalus Adam-
anteui, from which fresh venom was obtained and
used in preference to the dried poison supplied us.

It will not be out of place to recall briefly that the
order Ophidia, of the sub-class Beptilia, is divided into
three sub-divisions : (1) the Ophidii Colubriformet,
or innocuous snakes ; (2) the Ophidii Colubriformet
Venenoti or poisonous colubrine snakes ; (3) the
Ophidii Viper/ormes, or viperine snakes, poisonous.

To the last sub-division, viperitie snakes, belong
the OrotilidcB, or rattlesnakes, called by Fayrer " pit-
viper," being distinguished from the ViperidcB or vipers
proper, by possessing a pit or depression between the
eye and the nostrils in the loreal region ; a triangular
broad head and thick body of variable length.

The crotalus is distributed widely over the globe,
and all are terrestrial except in India, where quite a
number of genera are arboreal ; these, however, lack
all semblance to the horny scales or rings at the tip of
the tail, known as the " rattle," except iu the species
called Halyt, where the tail terminates in merely a
rudimentary horny spine.

It is of interest to note that the Indian crotolidise
are not so venomous as their American congeners,
though Asia has a very deadly species known as the
CaUoselasma Shodostoma, resident in Java and Siam ;
while South America is represented by the well-known
Jararacca or Oratpedoeephalut Brazilimtit. Australia
and Africa likewise contain ophidians of this class but
they are little known. <

The crotolidisB of the United States are represented
by ten species and three sub-species, all being equally
poisonous, so far as we now know. Of these the
Adamanteut has three sub-species, one of them, the
Adamanteu* proper, found in this country, extending
from North Carolina to Florida ; a second, the Atrox,
residentin the Indian Territory and Texas, also through-
oat that stretch of country extending to Sonora and

Digitized by

Google

488

BOSTON MBDIGAL AND SUltGIOAL JOVttNAL.

[Mat 17, 1894.

southern and lower California; and a third called
Sctdttdatui, knovrn only to Arizona.

We had in view in the first place to teat the qoestion
as to whether the blood of animals killed bj rattle-
snake-poison had lost any of its germicidal power.

We used Dr. Weir Mitchell's noose for securing the
snake and with a sterilized saucer thrust into the mouth
of the animal, we collected the venom. In this way
we bad no difficulty in getting from 0.5 to 1 c. c. of
nearly clear, slightly straw-colored fluid, quite sufficient
for our purposes. This was diluted with an equal
quantity of sterilized physiological salt solution, and
0.25 to 0.5 c c. of this mixture was inoculated sub-
cutaneously under antiseptic precautions, the dose vary-
ing according to the time wu wished the animal to live.
This was usually from one-half to one hour and a half,
but in one or two cases, three hours after the injection.

The injections were in all cases given subcutaneously,
sometimes beneath the skin of the abdomen and at
other times in the groin. The lesions differed some-
what according to the site of injection. When made
beneath the skin of the abdomen, there were most ex-
tensive peritoneal haemorrhages, whereas, when the
injections were made in the thigh, these lesions were
less extensive, although not absent; here the most
striking effect noted beside the deeply discolored in-
tegument surrouoding the point of injection, were the
underlying haemorrhages into the muscles.

The important lesions were these : moat extensive
haemorrhage, with disintegration of tissue and actual
necrosis of tissue, for a wide distance around the point
of inoculation, with ecchymosis in other parts of the
body, particularly in the serous membranes. Another
point which served our purpose admirably, was that the
blood does not coagulate after death or coagulates only
feebly and after a long interval. We therefore bad
no difficulty in collecting a sufficient amount of the
fluid blood, and we did so by withdrawing the blood in
less than a minute after the animal breathed its last.
We exposed the heart at once, and with sterilized in-
struments made an incision in the right auricle, and
with a sterilized pipette we aspirated from the right
heart; and then passing the pipette down into the ab-
dominal vena-cava, we secured sometimes as much as
seven or eight cubic centimetres of blood. This blood
was collected in a sterilized test-tube apd put in the
refrigerator. After twenty -four hours, the red blood cor-
puscles had settled ; sometimes a small, soft, dark coagu-
lum had formed, and there was a layer of clear serum.

The usual statement is that the blood does not coagu-
late. It looks as if it did not coagulate, and as though
there was merely a sedimentation. But there is in fact
an extremely thin clot, which does not retract from
the sides of the test-tube. It is an extremely viscid,
sticky coagulnm, which adheres to the platinum needle
inserted into it. We pipetted off after twenty-four
hours, the clear serum, usually collecting 0.5 to 1.5 c. c.
The organisms which were used to test the germicidal
power of the serum, were the bacillus coli communis
and the bacillus anthracis. Professor Welch selected
the bacillus coli communis because that is an organism
which is normally present in the intestine and also one
with which he had experimented upon with normal
serum. He took the bacillus anthracis becaase that is
a classic organism in regard to the action of serum.
The resulu were uniform and striking. As a rule, we
made a control experiment with normal serum ; thus
we killed a healthy rabbit and withdrew the serum in

the same way, collected the same quantity, and inoca-
lated at the same time a parallel control, tabes with
the bacteria to be tested. The cultures were twenty-
four to forty-eight hour cultures. Our bacillus anthracis
was obtained in suspension from the spleen of an animal
recently dead of anthrax. We wished to obtain the
anthrax bacillus free from spores, and thought it better
to take it fresh from the animal. Similar results were
obtained also with twenty-four-hour anthrax cultures
grown at room temperature. We made a snepension
in salt solution of the organisms, and inoculated a
known quantity, one to two platinum loops of the sns-
pension, into the serum tube. Then we made roll
cultures.

The following tables, drawn np by Professor Welch,
represent only a certain number of our experimentB,
and are much abbreviated for the sake of clearness.

BACILI.DS AHTHBACIS.
Normal Semm.

No.

lA
IB

IC
2A
SB

No. baellU InoooUted.

48S
8.512

210
6,292
1,628

After
24 boon.

After
on« ve«k.

Vetujm Serum.

No.

lA

IB

2

3

4

II

No. bacilli iooeulated.

8,612
26
68
3,292
3,292
3,292

After
19 bours.

Countlera.

ConntlesB.
Countless.
Conntless.

After
21 hours.

3,233
280,000

BACILLDB COLI COMMVNIB.

Xormal Servm,

No.

lA
IB
2A
2B
S
4

No. baoUll
Inoonlated.

250.000

178,000

29,t«l

3,160

9,990

84,947

Immedi-
ately.

After
24 boars.

After
48 boara.

286

1S7

Conntleaa.

168

60

Ck>antle8s.

63

0

0

18

0

0

13

38

625

238

0

0

After
one week.

GountleM.
Coontless.

0

0
Coontlew.

0

Venom Serum.

No.

No. baoilli InoeaUted.

600,000
3,160
18,860
9,990
84,947
84,947
81,947

Immediately. ajlonJ..

1,077
6
32
36
284
231
182

Coontlet*.

26,000
CoDDtlra.
Countleas.
Countleai.
Conntless.
Conntless.

Digitized by

Google

Vol. CXXX, No. 20.] BOSTON MEDIOAL AND SUR6WAL JOURNAL.

489

With the bacillas coli commanis, it will be observed
that ID the caae of normal serum, we inocnlated 250,000
bacteria. Immediately afterwards, there were 256
colonies; after twenty-foor hours only 157 coloniee.
In other words, there was not only no development,
but an actual diminution in the number of bacteria.
If the organisms are not all killed at the end of twenty-
four hours, the germicidal power ceases, and those
which remain multiply. After forty-eight hours, the
colonies were countless. In the second experiment,
we inoculated 175,000 bacteria, which represented 188
colonies immediately. After twenty-four hours, there
were only SO colonies, and in forty-«ight hours they
were countless. Taking a smaller number of bacteria,
29.161, there were immediately 53 colonies ; after
twenty-four hours none : after forty-eight hours none ;
after one week none. In other words, in twenty-four
hours the normal serum had destroyed 29,000 bacteria.

These experioviits were uniform in results, and
point to one conclusion, that the blood of rabbits killed
in one-half to three hours after subcutaneous inocula-
tion with rattlesnake venom, has lost its germicidal
power. This is of considerable interest, for it is an
indication of a very profound alteration in the blood.
This germicidal power of the blood is one of very
great significance, on which many of the modern theo-
ries of immunity depend.

It is of special interest to ascertain under what con-
ditions the germicidal properties of the normal blood
serum are at their highest, and in what way these
properties affect the composition of the blood.

The principal workers in this field have been Von
Fodor, Nuttall, Wassermann, Kitasato, Bachner, Ogata,
Hankin and others. Von Fodor's work had reference
to the composition of the blood, and was intended to
show that arterial has a more destructive action on
bacteria than venous blood, and also that fresh blood
has a more destructive action than that which has been
standing for some time. It was also found that the
germicidal power of the blood was weakened in an
atmosphere of oxygen or carbonic acid gas, but the
removal of gasses from the blood bad no appreciable
effect.

A series of experiments showing the effect of mov-
ing and stationary blood upon bacteria by means of
small globes containing blood, some of which were
kept in constant motion and others quite stationary,
resulted in no appreciable difference being observed.

Temperature affected very materially the bactericidal
power of the blood, which increased with the rise of
temperature from 88° to 40° C, and then gradually
diminished with the fall.

Von Fodor is of the opinion that the individual pre-
disposition of an animal to an infectious disease stands
in close relationship with the germicidal power of the
blood. A second series related to the influence of
drugs on the power of blood to destroy germs.

Hydrochloric acid had no effect ; tartaric acid and
quinine, respectively, produced a marked decrease. A
slight increase was produced by common salt and car-
bonate of ammonium, but a more marked effect by the
phosphate of sodium, while the carbonate of potassium
and sodium showed a very remarkable increase. From
these experiments the deduction was made that the
bactericidal power of the organism was raised by auy
drug which increased the alkalinity of the blood. The
third series verified the conclusions regarding the alka-
lization of the blood. Of eight rabbits inoculated with

anthrax all died, whilst of nineteen which had been
previously injected with solution of soda only three
died. A majority of the sixteen remaining were per-
fectly free from disease, only a few being fatally af-
fected.

Up to this time, however, the doctrine of phagocy-
tosis as advanced by Metchnikooff held sway, when
Nuttall struck the first severe blow to this theory.
He, iu his most excellent inaugural dissertation at
GSttingen in 1890, showed that the destruction of vir-
ulent bacteria in the blood of animals by the leuco-
cytes, was not at all essential, but that the serum of
blood free from all cellular elements, possessed this
power to a degree equal to the blood in its entirety.

Nuttall's work is graphically shown in some twenty-
eight tables in his " Beitrage zur Kenntniss der Im-
munitat." He here proves very conclusively, that in
the blood bacteria presented marked evidences of de-
generation before being taken up by the wandering
cells, or leucocytes. It was also seen that the bacteri-
cidal power of the blood of different animals varied,
and that while iu some certain bacteria were promptly
killed, in others these were simply restrained for a
time or not affected.

Buchner, Lubarsch, Nissen, Stern and Prudden
have practically verified these observations. Buchner,
particularly, in his experiments upon dogs and rabbits,
verified the findiugs of Nuttall, but went even further
and proved that the bactericidal power of the blood of
these animals did not at all depend upon the cellular
elements, but resided in the clear serum which sepa-
rated from the clot, after the blood had stood a while
in a cool place. He also demonstrated that the germi-
cidal action of blood and serum were destroyed by ex-
posure for au hour to 55° G. or by heating to 52° C.
for six hours, or to 45.6° C. for twenty hours.

Alternate freezing and thawing did not destroy the
bactericidal power of the serum, but it was diminished
or completely checked by dialysis with distilled water,
or by extreme dilution with the same. He preserved,
the anti-bacterial action of the serum by making an
equal dilution with a six-tenths to seven-tenths per
cent, of sodium chloride solution, and was led to be-
lieve that the activity of the serum was greater alone,
than when the cellular elements of the blood were
present, hence he concluded that the active element
is a living albumin, having as an essential constituent
an alkaline base. This albuminoid substance is thought
by Hankin to be identical with his "globulin" iso-
lated from the spleen and lymphatic glands.

According to the views of these experimenters, the
germicidal power of the blood resides in the serum
alone, and phagocytosis is but a secondary process,
the leucocytes taking up the bacteria only after they
have been rendered inert by the germicidal power of
the serum of the blood aud certain other fluids of the
body. For our purpose, however, it is not necessary
to insist upon the humoral as opposed to the phagocy-
tic doctrine of immunity. All that concerns us is the
recognition of the bactericidal power of the blood se-
rum under certain conditions.

The loss of this normal germicidal power helps us
to explain the varying rapidity with which post-mor-
tem decomposition sets in. It is well known that
persons dead of different diseases decompose with va-
rying degrees of rapidity. We cannot explain this
differing rapidity of decomposition simply by variations
iu ^qiperature, for under the same external coadittOQs

Digitized by

Google

490

BOSTON MBDICAL AND SVBOICAL JOVBNAL.

[Mat 17. UK

.1

one body will be decompoied in comparatively few
hours and another may remain undecomposed for sev-
eral days. We selected the animals killed with rattle-
snake venom because it is well known that they de-
compose with great rapidity. The bodies of human
beings killed by snake venom are also said to decom-
pose with great rapidity.

The results of our experiments furnish a satisfac-
tory explanation of this phenomenon. The blood at
the time of death and even before death, has lost all,
or nearly all, power of resisting the invasion and mul-
tiplication of certain bacteria, so that the bacteria of
putrefaction which are normally present in the intes-
tine, develop with astonishing rapidity and even before
the animal is cold, produce this wonderful rapid de-
composition. Our experiments are also suggestive as
regards certain secondary and mixed infections. The
toxic proteids of snake venom belongs to the same
class of poisons as those formed by toxic bacteria, such
as the bacillus of tetanus, of diphtheria, etc.

It is easy to suppose that these infectious diseases
may cause a diminution of the germicidal power of
the blood against secondary invaders, of which com-
mon examples are the pyogenic bacteria presentoften in
our months and intestinal canals, and which in ab indi-
vidual whose resistance is lowered by a loss of the germi-
cidal power of the blood, may grow and multiply. In
other words, we can understand better the causation of
many of these secondary infections.

VARIOLA.

BV S. O. WIDBSB, M.D.

(OoDoluded from No. 19, p. 4m.)

Case XII. Charles B. had had his fingers ampu-
tated on account of an injury, and the wound was still
suppurating when be was received into the hospital.
The eruption was quite thick on his face, arms and
legs. While pustular on the face, it was flat and
bright red on the arms and legs, surrounded by an

areola. It then became confluent on the face, nearly
so on the arms and legs, and became purple. The
purple color increased in intensity for two or three
days ; he trembled much and had chills, with a rather
bad-looking tongue. He was indifferent to what passed
around him, but seemed to be sensible and conscious.
The curve shows that the temperature first fell from

i The oases on which these obserratlons ue founded were ander
my cure in the winter of 1^69-TOitt the Boston Smallpox Hospital.
They formed the basis of a paper whtoh was read before the Medioal
Observatiou Soolety, but has never been published. Much of that
paper Is here reproduced.

the sixth to the eighth day ; then the aecoodary fever
began, and the temperature rose to 105.4 on tketb-
teentb and fourteenth days, then fell and rose igci
during the desquamation, later rising when abKOM
developed, which kept him in the hospital till ik
early part of May.

The next case was complicated with pneamoniL
Cask XIII. John C, age twenty-aeven, said W
had bet-n vaccinated. The scars were not foand. Tke
eruption was semi-confluent. He did well, and site

./<ui« G, Cost x///.

}^tn,lm. . ,

h

t

J- i

> *

9

%

/.

li

'.•

n

H'4'.>

^r

H^^'

^^^f^^i4^\

/OS

yo4
/cJ
lez.
/ei
/»»
?f
9*

\

y\

:A.

j_f

X

ii

t

3

i

^

i

1

^=^^

-\

-

-

:t

x:

±

^

5

f+*?3

— -i-j — pj-

-r

iril

ii \.

;

i

ij'

11

■ l-

1

^

^

3:

t"

.;i

I 1

/

1

:::

~

3:

J

—

t t

I )

4

i

i:

\

-i-

- ■

—-

+

(^

i

pr«B^'

1

w

ii

i .

r.

ZZ

;:

^

1

T

i

i

j

&=ty

-ii

3:: :

5

--:t

=r

r

:.;±

1

T

l:vi

1-:

j-

i-:

I

:

'^--

^

i

*

5

1

-inT

4-

-I.

~

~

f

^

i

zi.

1 -t -I IL±

rT-T.

j_

T

T

z

'■

=--

-T-

:r

_z

^

=f

s

^

LJ

sixteen days his face was nearly clear. He tbeo U
a succession of abscesses ; between March 2?d ui
April 17th twenty-three or more were opened, tal
several opened spontaneously.

March 26th. The sputa was rnsty-colored asd
very tenacious. There were sibilant rales over boci
backs, bat no mucous nor crepitant r&les coold lie
beard. At the base of the right back the reapiratory
sounds were diminished, and there was a dimioatioD of
resonance. By April 6th these symptoms had disap-
peared, and be recovered.

The next case was fatal on account of the oomfdiea-
tion of pregnancy.

V»„./„* i-rf .«•' <*J< *••*

r « /.» // ,L n /*. tr'/i

)/»/»

it

-".

fOl.

i

J-

i

; s

9

10 fl /I

i K IS

1^

: -I

_; - ; :.':

ir"\%

r

:

- -

i-ii

-%-'■

T

^

1

; 1 -

Vv-

- :

'TT

I "1::

;•-

^

'.11

M

f ■

V t-;

-L

.:.

."■ -:h

h Z"

t.M

--

-V

-i-

r " 1

-m

-f

t

'-4.;;

; 7 -. :T^-\

^-

-.

-- -»-

~-.~::\'--:

—

i-

i:

ii

i _ . : -

:::: ;:

B M Casc XV.

( f6 '.■ -t/J -* fT'K

h^"

> s^

f

'C

^'

1

'l ^

10(3 '•-

= = +

■X

X

^

E

~

\\

-4

u.

-i

--

- :;

ei, .,

T - :-

ft

T^

3=

ii

T-1

4-

T

t

ll

" [

-■-

-^

rn

*t

ti

: : . :

3:

^

^

U ♦

!-

^

z-4

-;■■

'"t

~

f ■

-t-

F¥

:x

?F

Cask XIV. Martha A. C, age thirty-one, saidsbe
had been vaccinated ten to fifteen years previoualy.
She noticed the eruption first on her abdomen ; the
next day she was well covered. The eruption m
not well developed, and was accompanied with consid-
erable erythema. She said she had bad her catameois
two weeks before. She seemed to be doing well,
though the temperature was rather high on the eightli
and ninth days for varioloid, yet it was falling, not
rising.

The attendant thought she was pregnant when the
came in, but she denied it. On the twelfth day libor
pains appeared, and then she said she was about

Digitized by

Google

Vol. CXXX, No. 20. J BOSTON MEDICAL AND SURGICAL JOURNAL.

491

seven months advanced. No advance was made
antil the fifteenth day. She vomited a dark liquid
daring the night, and passed blood at atool. The
labor caased the temperatnre to rise.

Uer child was born in the forenoon, entirely free
from any eruption. The uterus contracted well. The
pulse was very feeble, and in the afternoon she died.

Case XV. B. M. This was a case of varioloid.
The curve of temperatnre is given to illustrate the dis-
tinction between the rise caused by bronchitis and the
secondary fever of variola.

The next two cases were interesting in that the pa-
tients had all the symptoms of variola without the
eruption.

Case XVI. The attendant at the hospital had the
care of the first case October 26, 1869. November
6th, just eleven days after, he was attacked with
severe pains in the loins and fever ; chills very slight,
if any, tongue dry, pulse 90. The next morniDg he
was feverish ; pulse 96, eyes congested, temperature
102.6'^, evening 102.6°. The third day he was better ;
pulse 84, temperature 101.6°. The fourth day he
was nearly well.

Case XVII, Beginning on the evening of Novem-
ber 7th, and lasting until November 9th, I had an at-
tack of headache, chilliness and feverishness, which
obliged me to lie down whenever I had the opportu-
nity. The pulse and temperatnre were not taken.

In both these cases there was probably the variolous
poison acting, but not strong enough to produce the
fully-developed disease.

in both these cases there is seen, probably, the ef-
fect of the variolous poison in systems nearly protected,
and these may be compared to the sore throats
noticed during epidemics of scarlet fever.

The treatment in all the cases was chiefly support-
ing. Stimulants were given freely when it seemed
necessary. In each case, that amount was prescribed
which at the visit seemed sufficient to have marked
effect;, but a general order was to give more in case
there seemed to be call for it. The sadden fall of tem-
perature after the ingestion of large amounts of rum in
several cases would favor the view that it was beneficial.
It was also ordered that when the patient's breath had
the odor of alcohol the dose should be diminished or
omitted. Milk was given freely, a mug being left by
the bedside for the patient to drink as he desired. In
most cases the patients preferred the milk to water for
a drink. The amount of milk thus drank was occa-
sionally very great. One patient drank at the crisis
about seven quarts in twenty-four hours ; another took
nearly five quarts in twelve hours. The most reason-
able explanation of this great consumption of milk
may be found in the great drain on the system caused
by the filling out of the large number of pustules and
the consequent exhaustion, which called for the means
of repair. Solid food was given only after the tongue
bad become clean, though eggs, raw or soft-boiled,
were allowed before this.

The only local application to the face was the fol-
lowing :

Add. Carbel.
Olyoetine .
Aquae . .

«r.T
U3i

This was applied freely several times a day, so as to
keep the pustules and crusts moist. The application
was used as soon as the eruption became pustular, or
•ooner. Whenever this was faithfully used it had the

best effect in preventing itching, smarting and burning>
In only two or three cases was there any inclination
to scratch or rub the face, and only once, when the
wash had not been used often enough, was there any
complaint of discomfort. In nearly all cases, when
asked, the patients said there was no uncomfortable
sensation.

The normal course of the temperature has already
been noticed in both variola and in varioloid. In eight
cases there was well-marked increase of temperature
during the period of desquamation. In six cases there
was an increase at that time, but there were also ab-
scesses or inflammation which rendered the cause of
the increase obscure and gave it a different character.
Dr. Leo first attracted attention to this fever of the
desquamation stage. Sometimes there is only one day
of low temperature between the secondary fever and
this, but there is a marked rise as compared with that
interval, however short it may be and the few days
next succeeding.

There is a difference observable in the rise of the
temperature according to the character of the inflam-
mation causing it. In abscesses the variation between
evening exacerbation and morning remission is quite
great ; but in inflammation affecting the lungs the tem-
perature is maintained more steadily at a high figure.

The thermometer then is of value not only as aiding
in the diagnosis between variola and varioloid, which
could be made from other symptoms ; but is also a
guide to judging of the condition of the patient, show-
ing early that there is a new morbid process setting
in. Sometimes it is the first notice given of the occur-
rence of suppuration ending in abscess, and if the pa-
tient is inclined to conceal such an accident, the rise in
temperature would lead to an examination which
would reveal the cause. Also the character of the rise
would show whether there was a probability that the
lung was becoming affected or whether there was
merely an abscess forming.

The thermometer is also valuable as a means in
forming a prognosis and is invaluable as a means of
setting the physician's mind at rest in regard to the
welfare of the patient. If the attendant can be trusted
the physician may leave his patient longer unvisited
with safety, for the thermometer will surely show if
there is reason for sending for him. So long as the
temperature is low there is safety and no complication
is likely to arise except hemorrhage, which gives un-
mistakable notice of its presence.

There were received into the hospital 84 patients
with variola and varioloid, two with measles and two
with other eruptions. Of the 34 patients 21 had vari-
ola, 11 bad varioloid and in two cases there might be
doubt, one entering after desquamation had advanced
considerably, which was probably a case of variola.

These cases may be tabulated thus :

Varitty.
Confluent
Seml-oonfluent .
Hnmorrhaglo
Corymbose .
Uisorete . .
Doubtful
Varioloid) .

No, qf Ouet.

7

Total

2

4
1
8
2
11

SS

Dtatht.
2
0
3
0
V
It
0

ttarUMty,
28.»%

76

U.6

SO

21.21

* From pynmU. t From pragnanoy.
Included in t

t Case* XT and zvi are not
thia table.

In five cases the duration of the period of incubation
was well marked. In one it was ten days, in one it

Digitized by

Google

492

BOSTON MEDICAL AND 8VSG1CAL JOURNAL.

[Mai 17, 1894.

was eleven days, in tvro it was twelve days, in one it
was probably eleven or twelve days.

In eleven cases the eruption was seen two days after
the first feeling of discomfort ; in twelve, three days
after ; in eight, foor days after ; in one, in less than
two days ; in two cases the date was not fixed, and in
one case there was no eruption.

Of those cases whose duration coald be accurately
determined varioloid lasted from IS to 29 days, there
being one case continuing each of the following periods
IS, 16, 17, 19, 20, 21, 23 and 81 days, and two cases
15 days. The cases of variola which recovered lasted
one each daring 31, 32, 41, 45, 56 and 60 days two
cases each 27, 40 and 42 days. The faul cases died,
one in less than five days, one in 8, 9, 14 and 16 days,
and two in 15 days.

Except in the hsemorrhagic variety, which is much
more quickly fatal, the date of greatest mortality and
danger is between the fourteenth and sixteenth days.

Chills which are mentioned as a prominent symptom
at the commencement were absent in many cases, and
in most of the others were so slight as not to be men-
tioned by the patient unless questioned in regard to
that point. Later in the disease daring the suppura-
tion and Btill more during desiccation there were fre-
quently severe chills.

In only one case which recovered, was there entire
absence of salivation ; usually this symptom was well
marked.

In three cases there was pulmonary complication ;
in only one showing decided signs of pneumonia ; the
other two being probablj only bronchitis and pleurisy.

Vomiting at the beginning of the disease occurred
in both severe and mild cases, being, however, rather
more protracted in severe cases. It did not seem to
have much value for prognosis.

In two cases there was a pustule on the conjunctiva
and in one case during the occurrence of abscesees in
other parts there was a collection of pus under the
conjanctiva.

In four cases variola occurred after reported vac-
cination. In one of these the patient said the vaccina-
tion did not take well, in another the scars could not
be distinguished with certainty, in two cases the ex-
amination was not accurate enough to state positively
what was the condition of the scars. The other cases
of variola had never been vaccinated. A winter's ex-
perience in a small-pox hospital during an epidemic
would probably cure one of any prejudice against vac-
cination. In only two cases of variola was it probable
that vaccination may have been well performed, and
both of these were mild cases and recovered. Com-
paring the severity and duration of the disease in
the 15 who had been vaccinated and the 19 who had
not, or had been only imperfectly protected, there can
be no hesitation in regard to a decision in favor of
vaccination.

A few reflections occur, as I now look over this
paper, in regard to the improved sanitary condition
and care of the City as compared with 1870. Then,
a patient with the scabs still on his face could ride in
a public car without giving rise to any inquiry, scarcely
to comment. A patient now would not be sent to the
hospital alone, nor would soch an one wander about
the streets trying to find it, as in case VI. And it would
not now be possible for so many to take care of their
friends ontil they died with the disease, if doctors did
their duty.

THE TREATMENT OF PULMONARY TDBERCU-
LOSIS BY THE SUBCUTANEOUS USE OF
THE CHLORIDE OF GOLD AND SODIUM
WITH THE IODIDE OF MANGANESE.

BT -WM. 8. BOABDMAH, II.D., BOSTOH.

We have read and heard so much abont new
remedies and modifications of new remedies for the
treatment of phthisis, that now to many the subject
fails to excite an interest.

The methods of treatment are too numerous to men-
tion. One is almost startled by the list of drags and
methods proposed, in reading Solis-Cohen's article on
" Tuberculosis," in " Hare's System of Practical Tbera-
peatics." Yet there most be something beneficial in
these remedies, even if there is nothing specific.

The brilliant methods of Koch, dimmed by the
noxious elements in his tuberculin and brought to %
glow again by the researches of Klebs and Hunter, are
undoubtedly more for good than anything hitherto
proposed. Although we seem so near the desired re-
sult, it has not yet been obtained in the ideal that wsa
first conceived ; nevertheless, it behooves us to make
the most of what we have, while striving for something
better.

From the earliest time, the attempt has always been
made to combat the marasmus of phthisis by dietetic
and hygienic measures. How slow and uncertain s
procedure it has been is only too well known to us all.
If in any way we can aid the process of nutrition and
maintain or increase the strength of the patient, a
great deal will be done towards staying the disease, if
not directly tending to a core.

One mode of treatment that has been tried consider-
ably yet spoken of by comparatively few writers, is the
subcutaneous use of a solntion in glycerine, of the
chloride of gold and sodium with the iodide of manga-
nese. In March, 1891, an article in the Medical
Record, by Dr. J. B. White, extolled this oombination
as a treatment for phthisis, and cited a number of cases
to show the beneficial results obtained. Another
article in September, 1892, by the same author, ap-
peared to supplement and confirm the results of the
first paper, being written in a very earnest and pleas-
ing manner. Ah the combination of the chloride of
gold and sodium with the iodide of manganese, is, under
ordinary circumstances, likely to result in the forma-
tion of a precipitate, the author of the above-mentioned
articles was asked to state the method of preparing
the solntion. Since the process was not given and the
injection fluid could only be obtained in New York, it
was thought to be of sufiiciently scientific interest to
the profession to have an analysis of Dr. White's pre-
paration; and Mr. Wm. C. Durkee, Ph.6., kindly
consented to undertake the chemical work with this
result.

" The proximate chemical examination of the injec-
tion fluid is as follows. It has a dark-amber color,
with a specific gravity of 1,260, a styptic taste and a
syrupy consistency.

" According to Dr. J. Blake White's statement, each
drop should contain the equivalent of one-fiftieth of a
grain of the chloride of gold and sodium, and one-
fiftieth of a grain of the iodide of manganese, that is,
each drop should represent one-twenty-fifth of a grain
of the combined salts.

" He does not mention the method of obtaining the
drop, whether from the bottle or a medicine-dropper ;

Digitized by

Google

Digitized by

Google

Digitized by

Google

Vol. CXXX, No. 20.] BOSTON MEDICAL AND SVB6I0AL JOURNAL.

498

and altbongh changes in the viscosity of the liquid
owing to the temperatare, the rapidity with which the
drops are formed, and the shape of the material from
which the drop falls largely govern the size, it was
assamed that a drop from the original five-cubic-centi-
metre bottle, at about 70° F., and forming at a speed
of one in two and a half seconds, would be about the
size usually obtained and probably intended by the
qaoted statement.

" Several carefal weighings of ten-drop quantities of
the liquid were made and the drops found to average
77 milligrammes each, and snpposably contained one-
fiftietfa of a grain (.0013) of U. S. P. strength of chloride
of gold and sodium, and the same quantity of iodide
of manganese, or 169 mg. of each in 10 gm. of injec-
tion.

"Ten grammes of the fluid were found to contain
.01737 gm. of metallic gold, equal to .0535^ gm.
chloride of gold and sodium U. S. P., or about one-third
the amount claimed. The liquid is composed mainly
of glycerine, and contains free iodide, iodine in the
form of iodate (also as iodide), chlorine, sodium, potas-
sium and manganese.

" As the method of preparing the injection fluid
recommended by Dr. White was not made public, the
following process has been devised, which yields a
solution containing the ingredients he has reported as
useful and of the strength he recommends. Take of

> Gold and aodlam chloride, IT. S. P. . 1.e9 gm.

Manganese ralpbate 2.44 gm.

PotaMiom Iodide 4.6^ gm,

Dllnted alcohol 10.0 o. e.

Glycerine i „j ^^j^ , ,„ffloient quantity.

Distilled water / i .>

. " Dissolve the gold and sodium chloride and one
gramme of potassium iodide separately, in sufiScieut
glycerine to make each solution weigh 25 gm. using
only a very gentle heat, if any ; when cold mix the
two solutions. Dissolve the manganese sulphate in
snfBcient distilled water to make 10 c. c, and 8.62 gm.
of potassium iodide in sufficient diluted alcohol to make
10 c. c. ; naix the two solutions, and allow the contain-
ing vessel to stand in powdered ice for several hours,
to thoroughly precipitate the potassium sulphate.
Then decant 10 c. c. of the clear liquid into 40 gm. of
glycerine ; evaporate on a water bath until the total
weight is reduced to 40 gm., and add glycerine to make
50 gm. Mix this solution with the solution of gold
and sodium chloride, and keep in amber glass-stoppered
bottles. Each 77 mg. (about one drop) contains the
equivalent of I-^ mg. (one-fiftieth of a grain), of gold
and sodium chloride and the same quantity of manga-
nese iodide."

The injections were given in the forearm, upper
arm and subclavicular region by an ordinary hypo-
dermic syringe.

The solution prepared has been used in the manner
advised by Dr. White, the initial dose usually being
one drop (equal to one-twenty-fifth of a grain of the com-
bined salts of gold and manganese) diluted with a few
drops of a one-per-cent. solution of carbolic acid, and
increased only as the constitutional disturbance re-
mained at a minimum or ceased to appear after several
doses.

In some patients the reaction appeared within two
hours — as headache, backache and general malaise —

' It li beat to prepare this chemical or to me an article which to
known to be of fall atrength, as market sample* were lonnd to con-
tain lees gold than the labels indicated.

lasting twenty-four to forty-eight hours; in others it
was but little marked and disappeared within one or
two hours after an injection.

The pulse has been found to be full and slow with
subnormal temperature in some, while in others the
pulse was increased in rate with a slight rise in tem-
perature.

The local effect varied, in some the solution caused
considerable inflammation, in others the injection was
only marked by an induration and slight tenderness
about the puncture. It seemed to depend upon the
amount of loose connective-tissue present and the in-
dividual susceptibility to irritation.

Cough-mixtures, tonics and hygienic measures have
also been made use of as opportunity permitted.

One thing was observed quite generally, as noticed
by another writer — within two weeks or thereabouts
after beginning the injections, the appetite was in-
creased, so much as to cause the remark of the patient
to the effect.

The cough and expectoration in some were lessened,
in others not appreciably affected. Night-sweats usu-
ally ceased. The general appearance and feelings of
the patients improved, and they did .not hesitate to
declare themselves greatly benefited.

On making a physical examination of a patient after
a few injections, the former condition of things may
be somewhat aggravated. At such a time I have found
the signs more marked, especially the auscultatory
signs ; later the results were variable.

The theory that the preparation of gold is eutrophic,
while the manganese is anti-auiemic, seems to be well
borne out. That an improvement can be secured in
some cases I feel quite confident, but as to complete
and permanent recoveries I am not so certain.

The exact way in which these injections affect the
pulmonary tissue is more or less a matter of conject-
ure ; nevertheless, the remedy appears to act as a tonic
to the waning strength of the patient, also to cause a
certain amount of irritation and inflammation around
the foci of infection (as sometimes shown by bloody
sputum after a large dose), which may eventually re-
sult in an encapsuling of the pathological portions, or
their replacement by dense fibrous tissue.

However, be it as it may, the subcutaneous use of
the chloride of gold and sodium with the iodide of
manganese certainly improves the majority of patients
subjectively ; and if a cure does not result, they are
at least in a most promising condition for treatment by
modified tuberculin or its allied products. The strong-
est argument in favor of this treatment is the fact that
when properly given no injury can be done, while
there is great probability of an improvement if not a
cure.

Appended is the full report of ten cases treated by
gold and manganese, also the tabulated report of fifty-
four cases, — some having been treated with gold and
manganese, and some with Hunter's modification B.
(kindly furnished by Dr. Trudeau of Saranac Lake,
N. Y.).

In regard to the latter method of treatment, I will
briefly state, that while not obtaining the results of
Dr. Trudeau, I found much in its favor to warrant a
further trial. ,

I have also been using for several months Elebs'
Tuberculocidin, and so far with considerable satisfac-
tion.

In connection with this paper, I wish to thank Dr.

Digitized by

Google

494

BOSTON MBDICAL AND SVSGICJL JOISNAL.

[Mat 17, 1894-

£. M. Greene for his valuable lerviceB in the ezami-
uation of eputum, and Dr. F. C. Cobb for laryngeal
work, also Mr. Wm. C. Durkee, Pb.G., for most per-
fect chemical work, and Dr. E. O. Otis for kindly
Buggestioui.

fl^^ical l^cogce^^.

REPORT ON MENTAL DISEASES.

By HKNKY K. BTBDMAIT, M.D,, BOSTOH.

MKNTAI. DI8TUBBAMCE IN BXOPTHALIIIC OOITKK
AND MTXCEDBMA.

HiRSCHL* considers that ezopthalmic goitre is not
often complicated with a psychosis. Mania is the
ordinary intercarrent psychosis in a simple typical
case. If another form comes on in the course of ex-
opthalmic goitre, it is usually a complication of a coex-
isting or complicating neurasthenia, hysteria or alco-
holism rather than of ezopthalmic goitre itself. The
psychical type of a patient with ezopthalmic goitre is
often between' that of a healthy person and that of
maniacal ezaltation with signs of degeneration. This
is very common, bat not constant. It has equal value
with the three cardinal symptoms, and can aid the
diagnosis in doubtful cases. The ezplanation of com-
plicating mania and this psychic type is not forced if
we regard the disease as due to functional or anatomi-
cal disturbances in the medulla. These conditions can
then be ascribed to vascular paresis of varying degree
in the cortez. By thus localizing the disorder in the
medulla we can better ezpluin the less frequent pulse
and the anxiety in psychical depressed states.

Clouston's* study of the mental symptoms of
myzosdema and the effect on them of the thyroid treat-
ment is instinctive in showing that the contrast which
msirks their physical condition is equally evident in
the mental states of these opposite affections of the
thyroid. The general course of the mental disease in
his cases was, lirst, slowness of mental action ; sec-
ondly, emotional depression ; nezt, irritability, morbid
suspicion, nou-resistiveness to outward causes of dis-
turbance and general loss of control or maniacal out-
bursts ; then, enfeeblement, with some ezaltation in
some cases ; and, lastly, lassitude, hebetude ending in
a condition of mental negation just before death. Two
pathological facts that have lately come under his ob-
servation in regard to the cerebral cortex have im-
pressed him deeply with the possible recuperative
capacity of the cortical structure. One was a puer-
peral case of a few weeks standing — a ewrcMe cote
by every clinical standard — who died of maniacal
ezhanstion, and whose cortical cells were found iu a
state of marked and advanced degeneration, with spider
cells and proliferated nuclei round the vessels and the
neuroglia. If such degeneration is really curable, then
we need not despair of recovery in many advanced cases
of mental disease. The second fact is the actual cure
of the prolonged mental enfeeblement of myxoedema-
tous insanity by the thyroid treatment. He is con-
vinced that we need not be hopeless of some day dis-
• covering remedies that will cure some of our cases of
chronic melancholia, chronic mania and mild demen-
tia, the pathological changes in whose brain cortex

> JahrbUoher (Ui PsTdhlat., xli, BO.
' Journal Henta) Sclenecs, 1894.

he has often seen to be very similar to those found in
one of his myzoedematous cases.

THE ALTKRATIONS OF THE PERIPHEBAL NERVES IH
QENBBAL PARESIS.

G. Datto * reports autopsies of eight cases of paresis
in which he carefully examined by several methods
(both fresh and after hardening) the peripheral nerves
(various cranial nerves and nerves of the brachial and
lumbar plezuses). His general results were as fol-
lows : The alterations met with were those of paren-
chymatous neuritis in different degrees. This was
constant in all the observations, the variations in the
intensity of the pathological process in each, it is sug-
gested, were possibly in relation to the intensity of the
clinical symptoms. The cranial nerves were least af-
fected in comparison with the others. The alterations
were not systematic in their distribution, sometimes in-
volving the motor, sometimes the sensory nerves ; which
fact in part explains, the author holds, the varied clinical
syndromes of the disease. It also supports the view
that we have in paresis a widely disseminated degen-
erative process affecting the most diverse organs of
the nervous system.

Campbell,'* also, has made a careful study of the
neuro-muscular changes in ten cases of general paraly-
sis. He found the vagi extensively and strikingly dis-
eased, more so almost than any of the peripheral
nerves, and decidedly more than any cranial nerve.
It is impossible to attach too much importance to the
remarkable singling out of the vagi for such extreme
degeneration in this disease. The changes in the
mixed spinal nerves and their peripheral terminations
appeared to be a combination of a parenchymatous
degeneration and an interstitial or adventitious inflam-
mation. This investigation confirms those of others in
regard to the remarkable fact that the more peripheral
the site examined in the mixed trunk the more exten-
sive the degeneration will be found to be, and when
the motor and sensory branches are reached it is more
advanced and pronounced. The degree of degenera-
tion of the spinal nerve roots was always considerable,
but never extensive. The changes in the muscles do
not, in the main, differ from those described in con-
nection with other neuriies. They are probably chiefly
secondary effects of the nerve degeneration. It is ex-
tremely difficult to frame a distinct pathology for the
neuro-muscular changes attendant on general paralysis,
as there is so little knowledge of the precise nature of
the pathogenic influence or factor which determines it ;
still, taking these changes in general paralysis sepa-
rately into consideration and comparing them with
those in other varieties of multiple neuritis, we find
that there exists a close resemblance from an anatom-
ical standpoint, and there is further one group with
which the changes in general paralysis can be patho-
genetically compared, namely, the primary intrintie
toxamic; the secondary toxsemic, the purely toxic,
the endemic, the rheumatic, and the cachectic or senile,
being out of the question. This naturally does not re-
fer to cases of alcoholic or syphilitic origin.

INEBRIATE ASTLUM8 IN OERHANT AND SWITZER-
LAND.

Tilkowski ' visited and inspected five of these asy-
lums : In Switzerland, Ellixon in Canton Zurich, Niich-

> EI Pluuil, ziT, p. 169.

* JomtBtl of NarToni and Mental DlSMsee, April, 1891.

° JabrbUeh. f Ur Psyob., zll, I.

Digitized by

Google

Vot.. CXXX, No. 20.] BOSTON MEDICAL ASD SURGICAL JOURS AL.

496

bern in Canton Bern, and Pilgerhtttte in Canton Basel ;
in Germany, the Liuberg groop at Diisseldorf and the
colony at Bielefeld. He gives the special rules of
them all. The common principles involved are :

(1) All asylums in Switzerland and Germany, as at
present constituted, rest on the general principle of
voluntary entrance and voluntary exit. Forced deten-
tion is e:[cluded. [lu one Swiss canton, residents of
the canton (St. Gallen) can be committed against their
will for a definite time ; but here inmates can be ex-
pelled for non-payment of dues or violation of the rules.]

(2) Insane, dements and epileptics are excluded
from all. In Ellixon a certificate of sanity is re-
quired. If an inmate becomes insane, he is sent to an
asylum.

(3) Total abstinence is required in all, even by the
staff and attendants. Moderate use by drinkers is irri-
tating and leads to a relapse, and small amounts do
them harm. The attendants must abstain, for the ex-
ampfe, and also because they eat at the same table.
An inebriate does better if he sees no liquor, and the
normal man can do without it. It is an error to think
that sudden withdrawal of drink is dangerous.

(4) The fundamental principle is compulsory labor.
Physical out-door work is best, and labor makes the
cost of maintenance less.

(5) The food seems very liberal, abundant and
strengthening, but not inviting.

(6) No drunkard can have money, visit taverns, or
go out without leave of superintendent.

AH the German and one Swiss asylum (Pilger-
hiitte)have a religious superintendence, which may aid
in core. Ellixon and Nttchbern are purely humanita-
rian. The religious ones take in depraved patients.
In Lower Austria medical direction obtains, and forced
detention. Hence the inmates need more watching.
He concludes that all treatment must conform to med-
ical and psychiatric science. Beligious-moral influence
is desirable, but chief stress is not to be laid on it.
It is bad to mix the drunkard with the depraved.
Principles 3 and 6 should be adopted by Austrian
asylams also.

THE BOARDING-OUT OF INSANE.

The commissioners in lunacy for Scotland report*
that during the year 1892 this class of patients has in-
creased by 84, which means an increase of four per
cent, and a corresponding diminution in the proportion
maintained iu e^tablibhrnents. At the same time the
relative cost of the two methods has undergone no al-
teration. During the past six years the proportion
of all pauper lunatics boarded out has oscillated between
23% and 24%, and it would almost seem as if this
represented the limit of this method of providing ac-
commodation. With regard to the possibility of the
presence of insane individuals exercising a hurtful in-
fluence on the sane among whom they are placed, an
autborative statement is given by one of the deputy-
commissioners who has had fifteen years' experience of
this method.

"On reviewing," he says, "the private-dwelling
system as a whole, my opinion is that there is no harm-
ful influence on the guardians from the presence of the
insane in their houses ; and this is the verdict of a host
of guardians to whom I have spoken on the subject.
The care of the insane in private dwellings, according
to my experience, has more frequently had an elevat-

* Joonul of Mental SciencM, Janiury, 1894.

ing than a harmful effect on the guardians and their
surroundings, as it has raised the standard of both per-
sonal tidiness and of household order and cleanliness."
While as regards the possible hardships attending the
removal of patients to out-lying parts he remarks that*
this is more apparent than real, that the great majority
of boarded-out insane are more accessible to relatives
than patients in asylums are, and that even in the case
of patients belonging to one of the suburbs of Glasgow
who are boarded out in Islay, there have been no com-
plaints.

THE IHPOBTANCE OF UEN8TBDATION IN OETESHININO
MENTAL IBRE8PONSIBILITT.

Krafft-Ebing ^ reaches the following conclusions on
this subject :

(1) It is useful to consider the mental soundness
of women during menstruation from a medico-legal
point of view.

(2) It is tulvisable where a woman is held on a
criminal charge to ascertain whether the commission of
the act coincided with the menstrual period ; and by
" period " is meant not only the days when there is
actual flowing, but those before and after as well.

(3) It is biest to advise examination of the mental
condition when such coincidence is established. This
is indispensable when there is a personal history of
neuropathic defect, of mental disturbance at the time
of previous menstrual periods, or when the nature of
the act reveals any striking features.

(4) When the menstrual process exerts a powerful
influence on the mental life of the subject the accused
should be given the benefit of extenuating circumstances
in the infliction of the penalty, even although there be
no proof of menstrual insanity.

(5) When the offence or crime has, in a person
whose mind is impaired, occurred during the menstrual
period she must be declared irresponsible, for there is
every reason to think the act due to emotional impulse.

(6) But individuals who by reason of menstrual in-
sanity would benefit by acquittal on this ground should
be considered as dangerous in the extreme and sub-
jected during the times of the menses to close surveil-
lance. It is best to confine them to an asylum for the
insane where they will be comfortably cared for and
often cured of this menstrual instability of mind.

DELUSIONS OF PERSECUTION.

Neisser * reports the case of a man aged forty-three
years who had delusions of persecution ; he bad been
poisoned, attempts bad been made to kill him, etc.
He had been suffering from these delusions for many
months, otherwise he was perfectly normal, conversed
naturally and occupied his time with work. The case
teaches that the claim of many authors that paranoia
is characterized by fixed delusions of persecution is
uot broad enough to serve as a definition for the dis-
ease. Paranoia consists essentially in the tendency to
evolve delusions of persecution. If a paranoiac could
suddenly be robbed of all his delusions, he would still
be insane, and in a short time he would have a new
set of delusions. In the reported case this was en-
tirely wanting. The existing delusions were probably
the sequelae of some acute disease with delirium, pos-
sibly some organic disease of the brain, the result of
syphilis.

{.TobteauMmui.'i

< Jabrbucb. t. Psjoblat., z, 2, S.

> AllBemeln. ZalUob. fttr Piyob. vol. soIt, No. 3.

Digitized by

Google

496

BOSTON MEDICAL AND SUHGJCAL JOUBNAL.

[Mat 17, 1894-

Vitpctt^ of Jtncittitg*

THE NEW YORK NEUROLOGICAL SOCIETY.

Stated Meeting, held at the New York Academy
of Medicine, Tuesday eveuing, April 3, 1894, Da.
M. Allen Starr, Fresident, in the chair.

A CASE OP AMTOTROPHIC LATERAL SCLEROSIS,

presented by Dr. Charles Henrt Brown.

The patient was a boy aged fifteen who two and
one-half years ago began to notice first a loss of proper
speech, difficulty in whistling and in moving the tongue.
These symptoms were rapidly followed by difficnlty iu
deglutition, closing of the eyes, deafness and inability
to move the facial muscles. After a few weeks he
was unable to use the fingers freely in buttoning and
unbuttoning his clothing. At present the patient is
extremely emaciated. There is paralysis of the seventh
nerve on both sides, and the " taper " mouth. There
is trophic degeneration in the muscles of the face and
neck. The tongue is very much atrophied. The
larynx is distorted. He presents all the symptoms of
nuclear implication of the bulb and there is glosso-
labio-laryngeal paralysis. There is atrophy of numer-
ous muscles in the upper extremity and of a few in the
lower extremity. There are general fine and coarse
fibrillary twitchings all over the body j exaggeration
of superficial and deep reflexes and slight tonic and
spastic action iu the movement of many muscles.

A case of progressive MDSCnLAR DTSTROPHT,

presented by Da. Alfred Wiener.

The patient was a male, aged twenty years. He
was in good health up to May, 1893, when he began
to suffer considerable pain in the region of the liver
and spleen. This was most severe on walking. Soon
afterwards he began to experience difficulty in going
upstairs, and he noticed that he was growing very
much thinner. His weakness was at first confined to
the muscles around the thigh ; from here it spread up
along the back and involved the muscles of the neck
and shoulders. There was no vesical or rectal trouble.
There is no history of alcoholism or syphilis. Family
history negative.

The patient's present condition is as follows. No
mental symptoms. Voice and speech appear to be
normal. He is very much emaciated, especially in the
neighborhood of the shoulders, back and thighs. He
assumes the position of one with a marked lordosis,
and walks with a waddling gait. On lying down it is
impossible for him to turn over or lift his head from
the pillow. His muscles are soft and flabby to the
touch. There are no contractures nor fibrillary twitch-
ings ; no vaso-motor or trophic disturbance. The
thoracic and abdominal organs appear to be in perfect
condition. There is present no pseudo-hypertrophy
in any of the lower muscles, nor does the patient give
a history of any having existed. The deep reflexes
are all much diminished. The nerves are not painful
to pressure and there is no special tenderness. The
lordosis is due to the paresis of the muscles of the dor-
sal and lumbar portions of the back.

Da. Joseph Collins said that the case presented
by Dr. Brown was very similar to one under his ob-
servation at the presiiit time, excepting that his patient
was a man thirty-four years old, iu whom the sym|)-
toms came on rapidly about six months ago. It is

very uncommon to see the disease at such an early age
as that of Dr. Brown's patient, but he thought that
cases showing the occurrence of the disease at even s
more tender age have been recorded. The involve-
ment of the fifth nerve that Dr. Brown's patient
seemed to present he had never before beard of. The
patient presented by Dr. Wiener seemed to be a typi-
cal case of muscular dystrophy, and one whose pathog-
nomonic symptoms were in marked contrast to the
case of amyotrophic lateral sclerosis shown by Dr.
Brown.

The President said that the contrast between the
cases shown by Drs. Brown and Wiener was interest-
ing ; one presented the typical features of amyotrophic
lateral sclerosis, namely, atrophy, fibrillary twitchings,
increased reflexes and bulbar invasion ; the other
showed a pure dystrophy, without twitching and with-
out marked change of reflexes.

Dr. E. D. Fisbkr said the cases presented by Drs.
Brown and Wiener represent two distinct classes of
diseases. The first shows apparently a rare conditioD
in which an inflammation has affected the bulbs and
later the anterior horns in the cervical region, with in-
Tolvement of the lateral columns. In other words, we
have amyotrophic lateral sclerosis with bulbar symp-
toms. The usual and not uncommon order of seqaence
is that of involvement of the cord, with extension later
to the medulla. Dr. Fisher said a patient recently
under his observation, aged twenty, presented bulbar
symptoms of rather acute onset ; death resulted sud-
denly, probably from some involvement of the respira-
tory centre in the medulla. The autopsy revealed
softening in the region of the glossopharyngeal and
pneumogastric nuclei. That case would probably have
presented a similar clinical history, if the patient had
lived.

Dr. B. Sachs said he agreed with the diagnosis of
amyotrophic lateral sclerosis iu Dr. Brown's case. Dr.
Wiener's case was undoubtedly one of progressive
muscular dystrophy.

Dr. William M. Lesztnskt called attention to
the fact that in Dr. Wiener's case the upper part of
the trapezius muscle was atrophied, while the lower
part escaped. This partial atrophy, he said, usually
occurs in progressive muscular atrophy of spinal
origin.

Dr. Sachs said that the partial atrophy of muscles
may also occur in spinal dystrophies.

The President said that in three cases of amyo-
trophic lateral sclerosis coming under his observation,
the bull)ar symptoms were very prominent.

Dr. Sachs expressed the opinion that the bulbar
symptoms in amyotrophic lateral sclerosis were due to
a natural extension of the disease upwards. He in-
quired whether there was any involvement of the eye
in these cases.

Dr. Brown said there might be ophthalmoplegia.

Dr. L. C. Gray said he had seen the eye involved
in one case.

Dr. Brown, in closing the discussion, said he pre-
sented his case as a typical one of amyotrophic lateral
sclerosis, but rare in the fact that' it bad commenced
in the bulb and extended downwards. He thought
this type of nuclear trophic and motor disorder was
somewhat acute in its manifestations, and rapidly ran
its course. He considered that his case was iu ftote
quo, and would progress no further so far as degenera-
tion of muscles was concerned. The boy presented a

Digitized by

Google

Vol. CXXX, No. 20-1 BOSTON MEDICAL AND SUHGICAL JOURNAL.

497

tjpical picture of % glosso-labio-IaryDgeal paralysis,
which is aD extremely rare coodition in childhood.
The fibrillary twitcbings and slight spastic actions and
increase of the reflexes undoubtedly contribute to the
picture of a lateral sclerosis.

The Pkesidknt exhibited a diagram showing the
areas of ansesthesia in the arms as the result of lesions
involving different segments of the cervical and dorsal
portions of the cord. This diagram, he said, was the
result of a careful study of a large number of cases —
either coming under bis own observation, or reported
by others — in which the spinal cord was - involved.
The result seems to show that for each segment of the
cord there is an area of the skin which becomes anaes-
thetic when that segment is involved.

A CBITICAL BKVIEW OF THK VABIODS THEORIES OF
UKJSUIA, BASED UPON OBIOINAL EXPERIMENTAL
OBSEBTATIONS.

Db. C. a. Hebteb read a paper on this subject.
He began by stating that few subjects of a medical
nature have received more attention at the band of
clinicians and investigators than that of uraemia. Yet
at the present time there is an uncertainty as to the
nature of the uraemic state that is- discouraging both
to the student of pathology and the practitioner who
seeks to understand the conditions, he is called upon to
treat.

He first gave a brief historical sketch of the growth
of opinion regarding the nature of urgemia, and then
reviewed in detail the various theories that have
been advanced. The first one taken up was that known
as the mechanical theory of uraemia, which has its
chief basis in the clinical and post-mortem studies of
Traube, who was impressed with the facts that in
many cases of Bright's the blood is impoverished in its
corpuscular and proteid elements, the left ventricle is
hypertrophied, and the arterial tension is greatly in-
creased. The hydreemia combined with high arterial
teusion was supposed Eo account for the cerebral oedema
found at autopsy. The uraemic symptoms, Traube re-
ferred not to cerebral oedema, but to the anaemia of the
brain, resulting from the pressure exerted by this
oedema. There are objections to this theory. In the
first place, oedema of the brain is present in only a
small proportion of cases where there have been un-
equivocal symptoms of ursemia during life. There
have been many cases of kidney disease with no hydr»-
mia, no cardiac hypertrophy and no increase of arterial
tension ; yet even when these latter conditions are
present, there is usually no oedema of the brain. In
the second place, oedema of the brain is found in con-
ditions where Bright's is absent, and there are no symp-
toms of uraemia. Then again, drugs which produce
convulsions may produce cerebral oedema, and it is
likely that the oedema of the brain seen in uraemics is
often the consequence rather than the cause of the con-
vulsions. A further objection to the meohauical theory
is that lowering of the arterial tension, where it is
high, does not necessarily relieve the uraemic symp-
toms. The dyspnoea of Bright's is often thus relieved,
but usually not the convulsions. Bleeding frequently
stops the latter, but it checks them often also where
there is no excess of tension. The effects of bleeding
cannot be used as an argument in favor of Traube's
theory, because it may be claimed that the bleeding
relieves the circulation of poisonous substances.

The carbonate of ammonium theory. This was ad-

vanced by Frerichs, and is based upon the following
propositions :

(1) It is a well-known property of urea to be readily
transformed under favorable circumstances into am-
monium carbonate.

(2) Carbonate of ammonium can always be detected
by chemical means in the blood of uraemic patients.

(3) The injection of ammonium carbonate into the
blood of animals gives rise to the symptomic group of
uraemia.

The fate of French's theory hangs on his second
proposition, namely, that the blood of uraemics always
contains ammonium carbonate. From numerous ex-
periments made by Gobee, Oppler, Zalewsky and
others, including the author, the following conclusions
may be drawn : (1) That no ammonium carbonate or
only a small amount is found in the blood of uraemic
persons. (2) That amounts of ammonium carbonate
far smaller than the quantity required to kill are readily
detected. (3) That urea injected into the blood of dogs
is not converted iuto ammonium carbonate. We may
therefore state that Frerich's second proposition is with-
out substantial foundation. It has been stated that
the ammoniacal breath occasionally met with in uraemic
patients is evidence of ammonia in the blood. It is
more likely to be found in uraemics with gastro-intesti-
nal symptoms, and the ammonia probably comes not
from the blood, but from the gastro-intestinal tract.

The theory of Trietz differs from that of Frerich's
mainly in that it supposes the conversion of urea into
ammonium carbonate to take place in the intestine in-
stead of the blood. He holds that it is by the entrance
of the ammonium carbonate into the blood that the
urtemic state arises, and the objections already made to
the proposition of Frerichs, that uraemic blood contains
ammonium carbonate, apply here with equal force.

The potassium theory of Felz and Ritter is based
upon the idea that the potassium of the blood-serum,
which is normally present in very small amount, might
accumulate under pathological conditions and cause
death, the potassium salt being rapidly fatal in animals
when injected into the veins in even inconsiderable
quantity. The experimental and chemical evidence of
various observers is strongly opposed to this theory
and it may be unhesitatingly abandoned.

The theory of Brown-Sequard. According to this
writer, the kidney elaborates an internal secretion
which is essential to health, and the suppression of
which is responsible in a large degree for the phe-
nomena of uraemia, while the accumulation of toxic
substances in the blood is thought to have little or no
influence in causing uraemic symptoms. The follow-
ing are the chief facts upon which this hypothesis rests.

(1) It is claimed that the injection of kidney extract
into the circulation of a nephrectomized dog, causes
the temporary disappearance of uraemic symptoms.

(2) It is held that the well-authenticated cases of sur-
vival of patients with anuria for a week or more with-
out any sigus of uraemia, especially in cases of mechani-
cal obstruction of the ureters, is evidence that it is ow-
ing to the internal secretion of the kidney that this
iuhibition of uraemic symptoms takes place. All the
facts advauced in support of the first proposition. Dr.
Herter said, are equivoctil, and those advanced to sup-
port the internal secretion theory are equally weak.

The theory of extractives and toxines. The extrac-
tive theory of uraemia refers toxaemio symptoms to the
accumulation in the blood of the extractives usually

Digitized by

Google

498

BOSTOS MEDICAL AND SURGICAL JOVSSAL.

[Mai 17, 1894.

found iu urine ; among these may be mentioned xan-
thine, uric acid, creatinine, etc. In order to show that
a substance plays a part in the production of ureemic
symptoms it is necessary to prove that this substance
is present in the blood in ursemia, or is present in ex-
cessive amount, and that the substance is toxic in the
higher mammals. The evidence is not fully satisfac-
tory regarding either of these points. The observa-
tions that have been made hardly establish the fact that
an accumulation of the extractives is a feature of all
or many cases of uraemia. The evidence is even less
strong in regtird to particular members of the extrac-
tive group.

Regarding the view which attributes the uremic
phenomena to the action of toxines, the poisonous basic
products of bacterial activity, there is little to be said,
for the evidence on which it is built, is scanty and con-
iiicting. None of the toxic ptomaines that have been
suspected in this connection have been found in the
blood of ursemics.

The urea theory of uremia. The evidence relating
to urea as a factor in uremia may be grouped in answer
to the following queries : (1) Does urea occur in ex-
cess in the blood of uremic patients ? (2) Is urea
toxic, and if so, to what extent does it explain the
symptoms of uremia ? As regards the first question,
we have a sufficiently large accumulation of observa-
tions made by competent investigators to enable us to
reach a definite decision. In the blood of Bright's
disease, the quantity of nrea is largely increased beyond
that found in the normal blood, and its presence is
readily detected even by imperfect chemical methods.
When we come to the second question, we find that
the facts which favor and those which oppose the idea
that urea is toxic seem to be about evenly balanced.
Dr. Herter then reviewed the observations that have
been made bearing on this question, and detailed a
number of experiments made by himself which go to
prove that pure urea injected into the blood of the dog
and monkey in large amount is in the highest degree
toxic. The autopsies in these cases disclosed marked
congestion of the gastro-intestinal tract. To what ex-
tent and under what conditions nrea is a factor in
uremia, the author said it was not possible for him to
state at the present time. Facts at our command
strongly favor the view that the gastro-intestinal symp-
toms of uremia are due to urea. There is no doubt
that we at present group together under the term
uremia, conditions which are totally distinct as regards
pathology. The evidence is very strong, though not
quite conclusive, that one group of symptoms depends
largely on the accumulation of urea, and perhaps ex-
tractives in the blood, while another set of symptoms
bears the stamp of an infective process operating in
the presence of renal insufficiency. Observations may
show that even further subdivisions of cases are neces-
sitated by pathological considerations.

It is upon the following facts that the author based
the view that urea plays an important part in causing
the gastro-intestinal symptoms of uremia:

(1) The presence of urea in excess in the blood in
such cases.

(2) The property which pure urea possesses of caus-
ing such symptoms when injected in the circulation.

(3) The occurrence in Bright's disease of congestion
of the gastro-iutestinal tract, and the occurrence of a
similar congestion iu animals which is positively due to
the injection of urea into the blood.

(4) The fact that urea is found in the dejecta of
patients with gastro-intestinal uremia.

(5) The absence in many of these cases of aoy
elevation in temperature, or other evidence of acote
toxemia.

(6) The fact that the urine in these cases, even at
the time of the crisis, is no more toxic than normal
urine, which is in sharp contrast to the very toxic
urines found in acute febrile uremias of cerebral type.

Db. W. H. Thomson said the subject of uremia
has always been and still remains a very mixed one in
his mind. Dr. Herter's paper is certainly a very vala-
able contribution to the subject. The cases of aremis
to which Dr. Herter principally confined himself —
those in which the characteristic symptoms are vomit-
ing and purging — form comparatively a small minor-
ity of those that come under our observation. In
many cases there are no gastro-intestinal symptoms
whatever. Theoretically, Dr. Thomson said, he still
felt strongly inclined to the view that toxines play a
very important part in the production of the purely
nervous symptoms of uremia. Regarding the experi-
ments performed by Dr. Herter in order to prove the
toxic effects of urea, Dr. Thomson inquired whether
the injection into the blood of sodium chloride or other
similar substances might not give rise to derangements
of the system to some degree resembling those produced
by the repeated and rapid introduction of increasing
quantities of pure urea.

Db. Sachs expressed the hope that the critics of
the future would deal more leniently with Dr. Herter's
theory than he had dealt with the theories reviewed
in his paper, and that they would expend the same
amount of thought and labor to prove their assertions.
He did not think that any one should attempt to estab-
lish a single theory to explain snch a pomplex of symp-
toms as we have in uremia. Very much the same
symptoms occur under other conditions, and we are
perfectly willing to recognise the different morbid pro-
cesses giving rise to them.

Db. Hebter then closed the discussion. He stated
that in his paper he did not advocate any one theory
to explain all the phenomena of uremia. What he
did advocate was that there is a certain class of symp-
toms, a limited class, namely, the gastro-intestinal
symptoms, which are met with in certain cases of
uremia, and which are due, in all probability, to are.
The proof of this is not absolutely satisfactory, but he
did not see how the proofs adduced by his experiments
could be interpreted in any other light. In reply to
Dr. Thomson's question. Dr. Herter said that large
quantities of sodium chloride can be injected into the
blood without producing symptoms comparable to those
produced by the introduction of urea. As regards the
cerebral symptoms of uremia, he does not know what
they are due to, and in bis paper, he made no attempt
to throw any light on those cases. The autopsies on
the animals which were killed by the introduction of
urea were performed immediately after death, and the
intestinal congestion was very marked.

ELECTION OF OFFICERS.

The following officers were elected for the ensuing
year: President, Dr. E. D. Fisher; Vice-President,
Dr. C. A. Berter ; Second Vice-President, Dr. W. M.
Leszynsky ; Recording Secretary, Dr. Frederick Peter-
son ; Corresponding Secretary, Dr. Mary Putnam-
Jacobi ; Treasurer, Dr. 6. M. Hammond.

Digitized by

Google

Vol,. CXXX, No. 20-1 BOSTON MEDICAL AND SURGICAL JOURNAL.

499

THE BOSTON

jneDfcal ano Surgical 3|ouvnal«

THURSDAY. MAY 17, 1894.

A Jcmmal of Medieime, Swrgerf , and Allied Seieneet.publUhed cU
BoUim, weekly, bff the tuidenigned.

ScuaOKiPTiOK Tbhmi : (S.OO per year, m advatwi, pottage paid,
for the United State; Canada and Mexico ; ttM per year for all for-
eign emmtriee belonging to the Pottal Union,

All eonummieotioiM for the Edxior, and all booke for revieiB, ehould
beaddrteeedloiheJtditoro/the Boiton Medical and SmrgiealJonmal,
283 Waehington Street, Boeton.

All lettert containing buHnett commmnieationt, or referring to the
pnblieation, nbecription, or advertising department of thie Jommai,
thomld be addretted to the undertigned.

Jienittancet should bt made by money-order, draft or registered
letter, payable to

DAMRELL & UPHAM,
283 WASHiiraTOH Stbkkt, Boston, Mass,

HEART-FAILURE.

It has again and again been pointed out that the
term heart-failare, though unfortunately too often used
by physicians in their death returns is vague and in-
definite, conveying no information, though possibly
convenient to cover ignorance — being applicable to
every alteration of the cardiac mechanism, whereby
death results. Thus, heart-failure may be due to influ-
ences of a nervous kind — shock, inhibition through the
pneumogastric, paralysis by narcotics or sedatives.
Booillaud relates an instance of a previously healthy
man who died of syncope in a fright. Lancereauz, in
a recent treatise, reports several cases of sudden death
in previously healthy persons from violent excitation
of the pneumogastric. In two of these cases, attacks
of indigestion paralyzed the vagus centre.' " In both
these patients," he says, " death supervened after a
hearty meal, from syncope, as was proved by the empty
heart-cavities, and the absence of any material disorder
or lesion capable of explaining the cause of the death ;
every thing, moreover, went to show that the syncope
was due to an overloaded stomach." To this category
he referred the sudden death which often follows a
blow on the epigastrium, or even the excessive drink-
ing of cold water (reflex paralysis of heart through
vagus excitation). Moreover, the sodden death which
sometimes takes place in the course of pleurisy or
pulmonary tuberculosis may be due to irritation of the
vagi, " especially in those cases where the almost com-
plete emptiness of the heart's cavities indicated death
by syncope." ' This conclusion is in accordance with
some decisive experiments of Brown Scquard and Paul
Bert. Much more frequent is heart-failure from toxic,
inflammatory and degenerative changes in the myo-
cardium, from acute dilatation due to nutritive disturb-
ances or to exhaustion from overwork.

The toxic lesions of the myocardium have been ar-
ranged under the heads of : (1) toxic, (2) pyretic myo-

> Leoons d« Ollolqae MMicala, 3d leriM, ltt4, p. 22S.
• Loo. dt., p. 2M.

carditis.' Myocarditis toxic is the effect of poisoning
by alcohol, phosphorus, arsenic, mercury, lead, etc.
This affection manifests itself by a diminution of the
muscular power of the heart. The organ, without
presenting changes appreciable to palpation and percus-
sion, " gives a feeble impulse and muffled beats." In
poisoning by mercury, the heart is " flabby, soft, and
friable, of a dirty gray or yellowish color ; in poisoning
by phosphorus, it is tumefied, mottled with purpuric
spots, and is pale yellow or orange yellow." " The
muscular fibre in the one case is pigmented and granu-
lar ; in the other, it is the seat of a transformation
which, to the microscope, manifests itself by the pres-
ence of granules which are strongly refractive and
soluble in ether." Many pathologists, denying the
existence of parenchymatous myocarditis would regard
these lesions as simple parenchymatous and fatty de-
generation.

Pyretic or infectious myocarditis is suSiciently com-
mon as a complication of cholera, yellow fever, diph-
theria, sqiall-poz, malignant scarlet fever, typhoid
fever, etc. The heart-muscle is poisoned by the py-
retogenous agent, becomes fatty and flabby, its pulsa-
tions are feeble and obscure ; the pulse is small, irregu-
lar and accelerated ; syncopal states are frequent, and
are the cause of the sudden death so common at the
close of grave fevers. Bourges, who has studied the
alterations of the heart-muscle in malignant diphtheria,
remarks that it is generally augmented in volume, "di-
lated, but not hypertrophied," " of a dead-leaf color."
" When you dissociate the muscular fibres, you note
their great fragility ; they are tumefied and granular ;
may in fact undergo two kinds of degeneration, the
granulo-fatty and the vitreous. Bourges also points
out the fact that there are also sclerotic changes, so
that it may be said that the diphtheria-poison " deter-
mines at the same time parenchymatous and intersti-
tial lesions." *

Suppurative myocarditis, from septic infarcts in the
walls of the heart (a complication of pyaemia and
septicaemia) ; and acute interstitial myocarditis exist-
ing independently or following rheumatic pericarditis
and endocarditis (also sometimes of syphilitic origin)
are potent causes of heart-failure.

G. C. Henderson, in the " Transactions of the Patho.
logical Society," London, 1883, gives an interesting
report of a case of gummatous myocarditis followed by
death ; the interventricular septum and anterior wall
were the seat of syphilitic nodules surrounded by
sclerous rings which had extensively invaded and de-
stroyed the muscular tissue. Hilton Fagge publishes
a series of cases of " fibroid disease of the heart," and
Dr. A. L. Loomis ' would make of " cardiac fibrosis "
(" arterio-sclerosis of the heart " ) one of the most
common causes of heart failure. He believes that ob-
structive changes in the aorta and at the origin of the
coronary arteries are most usually associated with fatty
degeneration, while fibroid changes are associated with

> LanMrekox, loo. olt.

* Bonrgei : LadiphthMe, Paris, :g92.

• Trannot. Cllmatological Sootet j, 1892, p. 73.

Digitized by

Google

&00

BOSTON MEDICAL AND SVRGICAL JOVBhAL.

[Mat 17, 1894.

obstruction in the coronary arteries. This distinction
appears to as well made.

Fatty degeneration of the myocardium, besides being
a sequel of toxic and pyretic myocarditis {yid» rupra)
follows wasting diseases, chronic anaemia and especially
pernicious auiemia, and, notably, stenosis of the coron-
ary arteries by which the nutritive supplies of the
heart-muscle are cut off. It is a final stage in com-
pensatory hypertrophy from Bright's disease, and in
chronic valvular disease, whether stenosis or insu£R-
ciency. The heart-mnscle, though the most untiring of
all muscles, is perhaps the most prone to fatty degen-
eration. Certainly, persons affected with chronic
valvular disease, with hypertrophy, or with hypertrophy
from renal sclerosis, can expect unbroken compensation
for only a limited number of years, and sooner or later,
from complex causes, the overworked heart-muscle
fails and becomes gran ular and fatty.

Acute dilatation without hypertrophy and without
visible degeneration of the myocardium in its connec-
tion with heart-failure has been studied by Dr. John
Curuow in two recent lectures.' Naturally, he says,
the symptoms of cardiac failure due to a primitive
dilatation of the heart-cavities from insufficient nutri-
tion are precisely the same as those due to a failure in
compensatory hypertrophy subsequent to any grave
circulatory obstruction. In the early stage, they are
pallor, palpitation, headache and dyspnoea on exertion,
with often a distressing angina. As the disease ad-
vances, there is lividity and cedema, and the pulse is
small, irregular and rapid. Dilatation occurs to a
limited extent in antemia and chlorosis, in fatal cases
of leukemia, pernicious anaemia and chronic malaria.
A form of cardiac dilatation frequently follows typhus
and typhoid fever ; the weakened walls of the heart
readily give way, and distention occurs under the in-
fluence of ordinary tranquil work. Curnow, in the
lectures referred to, gives examples of acute dilatation
accompanying chronic malaria, beri-beri and scurvy.

The influence of overwork or overstrain in produc-
ing acute dilatation and sometimes complete cardiac
failure was alluded to in a former number of the

JOCRNAL.'

That sudden death may result by partdysis or rupt-
ure from excessive strain and overfilling of the heart-
cavities is by no means a very rare experience. Never-
theless, as Dr. A. L. Loomis ' well remarks, " it is safe
to assume that heart-failure is impossible so long as
the heart-cavities are of normal size, the heart-muscle
of normal integrity, and the cardiac innervation not
seriously disturbed, the function of the trophic nerves
being normal."

To sum up, when physicians report cases of death
as due to " heart-failure," it may be assumed that the
*' heart-failure " was due either to some overpowering
nervous influence or to toxic, inflammatory or degenera.
tive changes in the myocardium ; or to suppurative or
interstitial myocarditis; or to arterio-sclerosis of the

< LRDcet, JannBr; 6, 13, 1894.

' Bosion Medical and Surglcaljournal, April 26, 1894, p. 421.

> rioceedlDga of the Climatological Anoclatton, 1892, p. 72,

heart ; or to fatty degeneration following wasting dis-
ease, valvular disease, or stenosis of the coronary arte-
ries ; or to acute primitive dilatation from prostrating
fevers, chlorosis, leukaemia, pernicious anaemia, chroDic
malaria, overwork and other depressing influeDces !

At the meeting of the Climatological Society held
at Richfield Springs, N. Y., in 1892, Dr. F. I. Knights,
in discussing Dr. Loomis's paper, made the remark that
a certificate of death from heart-failure was little dif-
ferent from one of death from want of breath. Enter-
ing deaths as due to " heart-disease " is amenable to
almost the same objection, bat certificates are returned
in this manner by reputable physicians every day.

THE ROLE OF THE NOSE IN ZOLA.>

FoK a long time the study of " artistic anatomy,"
80 called, has been recognized as a necessary and
proper training for an artist or sculptor. Latterly,
there has arisen what may be styled a study of literary
physiology. The analytical and realistic school of
writers fill their books with outspread dissections of
the human body no less than of its soul, and remove
the covers from society as from a watch to "show
bow the wheels go round."

The latest aspect of this physiological-romatice
writing is the discovery by a Frenchman that great
writers depend largely upon some special sense for re-
membrance and reproduction of emotions, sensations
and experiences. " Zola," says M. L. Bernard in his
essay npon "Les odeors dans les romans de Zola,"
"has more than any other man lived, suffered and
revelled in the sense of smell," and he offers os ac-
cordingly a study of the smells in Zola's stories. But
first we must begin with the nose of the master.

" In all the portraits of Zola which I have seen it
was the nose which struck me first. The forehead is
broad and well uncovered, circled with short, trimmed
locks; the beard is thick-set, with short, bristling
hairs ; the glance is cold and piercing, though a little
softened by the lenses of his glasses ; the lips and
month are so hidden under the moustache as to lose
half their expression ; but there is the nose alone in
the fnll light of the mid-face. It is large, fleshy,
broad, pierced by two great nostrils, which seem to
qniver and inhale the air. Only to see this mighty
nose explains all the associating descriptions of odon
so well known throughout his books." Being gifted
with such an olfactory organ, it is not to be wondered
at that " Zola is the creator of a new terminology, of
a language of odors, and that he leads his readers to
study to analyze and classify them, to seize upon their
secret harmonies, their mysterious relations to senti-
ments and ideas, their silent but irresistible influence
upon resolve and conduct." Every page, and often
every line, is marked by this masterly peculiarity.

Open any of his books, and examples are at hand.
In " L'Assommoir " we find " the soapy odor," " the
heavy, stale odor of the wash-house of Rue Neove

1 GaMtte dea Hdpiteux, No. 48, 1894.

Digitized by

Google

Vol. CXXX, No. 20.] BOSTON MEDICAL AND SVBGICAL JOVBNAl.

501

made much of; the odor of old dust aod gear filth in
Lorilleax'g room." Each character has a perfome
mi generii beloogiDg to his age, sex, state of health,
godly or vicious habits. So in " Pot-Bouilie," " Bache-
lard exhales an odor of vulgar debauchery," " Madame
Campardon, a fair odor of fresh autumn fruit," and
" Nana, an odor of life, of all-powerf al woman, which
intoxicates one."

In other books we flod the abbe with his " odor of
a priest, of a man made unlike others." " The ruins
of a house have an odor of damnation." We must
admit we have smelt this odor iu bouses which were
not in ruins or uninhabited.

Finally, in " Ventre de Paris," the swarming popu-
lation of the Halles carries in every fold of its gar-
ments "an odor of spawn, one of those heavy odors
which rises from the rushes and shiny lilypads when
the eggs burst from the belly of the fish fainting from
love in the sun."

Such is the interlinear study of the smells and
stinks in Zola's books. Surely the study of literary
physiology of special senses is but just begun. We
nuky yet find a cipher which will disclose a system of
acoustics in Gibbon, of visual physiology in Cervantes,
of tactile sensibility in Thackeray ; and since Scott's
stag drank itself full, there is every chance that we
may find between the lines of Marmion and Ivanboe a
detailed study of the sense of taste.

MEDICAL NOT£S.

Am Honor to Professor Vibchow. — The King
of Italy has conferred on Professor Virchow the
Grand Cross of the Order of SS. Maurice and Lazarus.

A Statue or Dr. Sims. — A bronze statue of Dr.
J. Marion Sims, by Du Bois, of Paris, has been com-
pleted, and will be erected in Bryant Park as soon
as the pedestal is ready.

Small- Pox at New York Quarantine. — Two
cases of small-pox were detained at quarantine in New
York Harbor on May 10th, from the steamer Roland
from Bremen.

A Pbtsioian's Generous Bequest to Nurses.
— The late Dr. S. J. Moore, of Glasgow, has be-
queathed the residue of his estate, after the payment
of other legacies, etc., to found a convalescent home
for nurses, to be called by his name. The amount of
the bequest is likely to be over S200,000.

One Hundred and Five Years Old. — Accord-
ing to the Jbumcd of the American Medical Auoeia-
Hon, Mrs. Hannah Chard, of Glassboro, N. J., was
one hundred and five years old on April 20th, having
been born at Brandy wine in 1789. She is still able
to go out, and has one hundred and eighty grand-
children and great-grandchildren.

The American Association of Railway Sur-
geons, at its annual meeting in Galveston, Texas,
seems to have had a very lively experience over the
election of its oflicers. Pandemonium reigued ; every-

body had the floor and spoke at once ; the presiding
officer was helpless, and epithets were freely ex-
changed. No blood was shed. The Texas air was
not responsible, for the trouble really dated from the
preceding meeting.

boston and new enoland.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon. May 16, 1894, there
were reported to the Board of Health of Boston the
following numbers of cases of acute infectious disease :
diphtheria 51, scarlet fever 58, measles 16, typhoid
fever 18, small-pox 1. There is one case of small-pox
at the Canterbury Street Hospital, and three cases at
Gallop's Island ; no deaths. During the week the
State Board of Health received reports of the follow-
ing cases of small-pox : Holyoke 1, Worcester 1,
Chicopee 1, Randolph 1, Chelsea 1.

Shall-Pox in Providence. — A fourth case of
small-pox was discovered last week in Providence,
which, like the three of a previous week, has not yet
been traced to any origin of infection.

Boston City Hospital. — Mr. A. Shuman has
been re-elected President of the Board of Trustees of
the Boston City Hospital, and Mrr H. H. Sprague
has been re-appointed on the Board. The Board has
requested of the City Government a special appro-
priation of $330,000 for various much-needed purposes
not provided for by present funds and contracts.

Suffolk District Medical Societt. — The Cen-
sors' examination of the Suffolk District Medical So-
ciety will be held on June 7th, at 2 p. h., at 19
Boylston Place. The Censors of the Suffolk District
officiate for the Society at large, and candidates are
requested to make personal application to the Secre-
tary three days before the meetiug.

Progress of the Medical Registration Bill
IN the Massachusetts Legislature. — In the
House last week the Senate Bill to regulate the prac-
tice of medicine was passed to a third readiojg, a sub-
stitute bill, offered by Mr. Hayes of Lowell, to punish
persons illegally using the designation " M.D." being
rejected.

A ResiDUART Legacy to the Cambridge Hos-
pital.— The will of Jacob B. Remick,of Cambridge,
leaves his estate in trust during the life of certain per-
sons named ; but upon their death the entire estate is
to be converted into cash, one-third of which is to be
given to the Cambridge Hospital. The value of the
bequest is about ten thousand dollars. The Avon
Home and the Old Ladies' Home of Cambridge re-
ceive the other two-thirds.

NEW YORK.

Opening of the New Post-Graduate Medical
School and Hospital. — On the afternoon of May
8th, a public reception was given at the new Post-
Graduate Medical School and Hospital, and in the
evening the formal opening exercises of the institution
ook place. The Secretary, Dr. Clarence C. Rice,

Digitized by

Google

602

BOSTON MEDIO AL AUD 8UR0I0AL JOORSAL.

[Mat 17, 1894.

read a report giving the histoiy of the tchool, and ad-
dresses were made by the President, Dr. D. B. St. John
Roosa, the Rev. William R. Huntington, D.D., and
St. Clair McKelway, Esq., of Brooklyn.

Sbizurr of Tcberculods Bekf. — On the 7th of
May the meat inspectors of the Board of Health
seized the carcass of a cow affected with tubercnloais,
which had been cut into quarters, but not yet hung up
for sale, at West Washington Market. It was found
that the carcass bad been shipped from Goshen,
Orange County, by a milk-dealer and stock-raiser by
the name of Smith, and Dr. Johnson, the veterinary
surgeon to the Health Department, is making an in-
vestigation of the case. Pending his report, the Board
has ordered that all meat and milk from Smith's farm
shall be seized when it reaches the city. Several car-
casses of tuberculous beef have lately been discovered
in the markets, and it is feared that a whole herd of
cattle, and possibly several herds, in Orange County
may be infected with the disease.

A Pension Fdnd for EiiPLOTis of tbk
Health Department. — The Governor has signed
(he Lawson Bill, establishing a pension fund for the
physicians, nurses, clerks and other employes of the
Health Department who have served a term of twenty
years, and also for the families of employes dying in
the discharge of duty. The fund from which the pen-
sions will be paid is to be made up of the Bnes and
penalties collected for violations of the city health
laws, and of the fees paid for searches of the records.

The Killing of the Elephant. — The problem
of how best to kill an elephant weighing over five tons
has presented itself to the Park Commissioners dar-
ing the past week. The animal known as "Tip,"
which was presented to the city some years ago by
Forepaugh, the showman, has always been a vicious
creature, and it was finally determined that for the
safety of the keepers at the Central Park Menagerie
and of the general public it would be advisable to
destroy bim. Poison was selected as the most satis-
factory means of accomplishing this object; and Dr.
George S. Huntington, of the College of Physicians
and Surgeons, was asked to lake charge of the killing.
Cyanide of potassium was determined upon, and the
attempt was first made to give it to the elephant con-
cealed in carrots and apples. He quickly detected the
bitter taste, however, and ejected the articles from his
mouth. A half a loaf of rye bread with a cavity in it
filled with the cyanide he also tossed from him.
Finally, the expedient was tried of giving him the
poison in capsules mixed with a bran mash, and this
proved successful. Death occurred in a comparatively
short time, and was evidently quite painless.

PHILADELPHIA.

TiiK University of Pennstlvania will hold its
commencements of all its departments during the first
week in June.

Jefferson College held its commencement exer-
cises May iith, and graduated a class of 163. The

trustees conferred the degree of LL.D. upon ProL
William Goodell, M.D.

The Medico-Cbiruroical Colleoe graduated
the largest class in ito history on the 1 1th inst., 44
students receiving their medical degrees.

The Wistar Institute of Anatomt and Biol-
OGT will be opened May 21st with addresses by Pro-
fessors Pepper, William Osier and Harrison Allen.

New Women Phtsicians. — Fifty women received
the degree of Doctor of Medicine at the commence-
ment of the Women's Medical College of Pennsyl-
vania last week.

OUT-PATIENT HOSPITAL ABUSE.

A physician sends to the British Medical Journal
the following note from a patient, a tradesman with a
good income, describing a bit of out-patient experientw
in Liverpool.

I called at the doctor's residence, and was told that he
was at the Eye Infirmary, and would not be home for some
hours. As I bad not made arrsngements to stay overnight,
I said I could not wait so long, and was recommended to
go and see him at the infirmary. I did so, and found my-
self in a room with about 150 or 160 other persons, mostly,
so far as I could judge, working-class people like myself
and in easy circumstances. Looking around I recognized
an old friend of mine from Blackburn, and asked him what
on earth he was doing there. He said be came up regularly
to have his eyes looked after. " Why," I said, " you could
aSord to pay this man a guinea every time, couldn't you?"
" Yes," said he ; " but what is the use of being such a fool
as to throw away your guineas when this chap will see you
for nothing?"

It might not be impossible to repeat the same expe-
rience at many hospitals in this country, and as the
number increases so will the abuse.

PERMANGANATE OF POTASH IN OPIUM
POISONING.

Dr. Walter L. Ptle* reports from the Emer-
gency Hospital of Washington, D. C, four cases of
opium poisoning in which permanganate of potash was
administered. Although the conditions under which
the cases were treated and the considerable use of
other restoratives make the results of no conclusive
value, the report of all such cases is much to be de-
sired.

There was one fatal case, a man fifty-seven years
old, who had taken an unknown number of morphine
pills, each coutaining one-eighth of a grain. He was
brought to the hospital about five hours after the sup-
posed time of taking the poison. Permanganate of
potash was given by mouth and hypodermatically.
Two hours later the conjunctival and plantar reflexes
returned for a while, but the man died seven hours
after entrance.

A man twenty-two years old took three teaspoon-
fuls of sulphate of morphia ; treatment was began
thirty minutes later. He was given strychnine, atro-

> Madleal News, May 12, ISM.

Digitized by

Google

Vol. CXXX, No. 2«.] BOSTOJi MEDICAL ASD SURGICAL JOVRSAL.

603

pine, caffeine and coffee, and the permanganate of
potash, six grains to a pint of water, was given by
stomach and subcutaneously. In eight hours he was
considered out of danger, and the next day was dis-
charged well.

The other two patients were women, aged twenty-
five and twenty-one years, who took respectively half
an ounce and two drachms of laudanum. In each case
atropine was used, and the permanganate was given by
mouth within a very short time, and a little later sub-
cutaneously. A few hours sufficed to put both women
oat of danger.

OBITUARY.
ALBERT CUSHMAN STANARD, M.D.

The following resolutions were passed at the last
regular meeting of the Harvard Medical Society of
New York :

Whereas, Dr. Albert Cushman Stanard, an esteemed
member of the Harvard Medical Society of New York, has
in the infinite wisdom of God been called thus earlv to lay
aside the duties of life, cut down in the vigor of early man-
hood, as the paths of utefulness and promises of prosperity
were opening wide to him. Therefore, be it

Resolved, That in his untimely death we recognize the
loss to the Society of one of its most promising and worthy
members, and desire to pay to his memory a tribute of
sincere respect;

Resolved, That we extend to his stricken sisters our
heartfelt sympathy at the grief which has come upon them ;

Resolved, Tliat these resolutions be published in the Bos-
ton Medical and Surgical Journal.

[Signed.] John B. Walker, M.D.

John H. Hdddleston, M.D.
William B. Colet, M.D.

METEOROLOQICAL BECOBD,

For the week ending May Sth, in Boston, according to ob-
servations fnrnished by Sergeant J. W. Smith, of the United

States Signal Corps:—

THE AMERICAN MEDICAL ASSOCIATION.

The following letter has lieen received through Dr. H.
O. Marcy :

Boston, May 2, 1894.

Dear Sir : — I take pleasure in advising you that the
Chicago and North-Western Railway Co. have made ai^
rangements for an excursion rate for physicians attending
the San Francisco meeting of the American Medical Asso-
ciation. The fare from Boston to San Francisco and re-
torn will be SI 25.

A palace-car will leave Boston at 2 p. m., Monday, May
28th, via Boston & Albany, New York Central & Hudson
River, and Lake Shore & Michigan Southern Railroads,
connecting at Chicago, where a through palace-car will be
provided, leaving Chicago at 10.30 p. m., Tuesday, May
29tb, via Chicago & North-Western, Union Pacific and
Southern Pacific Railroads.

Diagrams of eleeping-cars will be in this office. No. 5
State Street, Boston, and berths reserved from Boston to
Chicago, and similar accommodations assigned, from Chi-
cago to San Francisco. The price of berths, Boston to San
Francisco will be S21.

Holders of these excursion tickets, will, on pa\'ment of
$15 extra, previous to departure from Missouri River (on

foing trip) be permitted to return via Portland and Union
'acific Railway, or any of the direct Northern routes.
Tickets are valid for return until July 15, 1894. If any
extension of time or reduction of rates are made, I will,
with pleasure, promptly advise of same.

Remittance may be made to this office to cover cost of
tickets and sleeping-car berths. Yours very truly,

J. E. Brittaim, N. E. p. Agent.

Baro-

Tbermom-! Belative

Direction

Velocity
of wind.

We'th'r.

meter

eter. hamlditT.

of wind.

•

Oata.

f

i

a

i

»

^

i

)i

>i

ai

*

a

a

P^

>t

a

■<

Ph

►.

.<

fH

■<

a.

-4

a.

£

•a

S

5

s

S

*co

S

s

S

s

S

S

a

s

s

00

oo

ft

00

ao

ao

eo

OC

CO

S..29

30.28

4«|48

43

44

7B

60

N.

s.

20

10

c.

c.

M..30

30.34

(16172

40

40 46

43

N.W.

s.w.

6

1»

c.

o.

T.. 1

30.M

68|80

W

58 46

62

N.K.

s.w.

3

7

F.

V.

W. 2

29.84

76 '88

64

47 82

5U

W.

w.

11

12

r.

F.

T.. 8

80.18

seeo

S3

64 81

72

N.E.

S.E.

13

5

o.

C.

F.. 4

30.20

46

49

42

88 98

93

E.

B.

8

7

o.

O.

8.. 6

30.06

E6

67

46

82

68

76

S.W.

S.

2

8

0.

C.

a-

30.13

66

49

64

s

.02

.06
.22

.29

•0..cloail7i C.elMri F.,fiiri U.,foxi H.,liuy; 8.,imokyi R.,nln: T.thnat-
enlnfci N. . snow, t IndiCAtco trtuie of rainfall. «V Mean for week.

BECOBD OF MOBTALITT
Fob thk Wmck kmdimo Satukdat, May 6, ISbi.

m

1

£ Percentage of deaths from

Estimated pc
lation for 1

Oitle*.

i1

■s

1

11

5

If

5'

n

So

JSTS

1

New York . .

1,891,306

861

362

18.00

18.12

1.80

7.80

1.92

Chicago . . .
Philadelphia .

1,438,UVU

—

—

—

—

—

1.116,662

386

—

11.70

—

1.30

4.94

1.66

Brooklyn . .

978,394

391

144

16.00

20.00

.75

7.60

2.25

St. Louis . . .

860,000

—

—

—

—

_

Boston . . .

487,397

181

63

13.26

9.&4

1.06

S.83

1.06

Baltimore . .

600,000

—

—

—

—

—

Waablngton

308,431

99

26

12.12

16.16

2.02

2.02

_

Cincinnati . .

306,000

m

4U

11.34

14.5b

2.43

4.05

_

Cleveland . .

290,000

U»

63

12.04

l».7li

1.72

1.72

2.68

Pittsburg . .

263,709

—

—

—

—

—

—

Milwaukee . .

260,0110

—

—

— .

—

—

_

_

NaahviUe . .

87,764

32

9

6.26

9.39

—

3.13

_

CharleBton . .

65,106

39

19

20.48

2.56

15.36

—

—

Portland . . .

40,000

—

—

—

—

—

—

_

Worcester . .

96,217

29

13

17.26

24.16

3.46

10.36

_

Fall RiTcr . .

87,411

31

16

9.69

36.47

3.23

»

Lowell . . .

87,191

42

11

7.14

20.66

2.38

2.38

__

Cambridge . .

77,100

16

3

18-''6

6.26

6.26

—

Lynn ....

62,666

21

—

—

—

—

_

Springfield . .

48,684

18

6

11.11

27.77

—

6.66

Lawrence . .

48,366

—

—

—

—

—

—

New Bedford .

46,886

19

6

21.04

—

—

—

Holyoke . . .

41,278

21

16

33-33

14.28

—

—

4.76

Salem ....

32,233

9

3

11.11

,..

—

U.ll

Brockton . .

32,H0

—

—

—

—

—

Haverhill . .

31,396

4

2

—

—

—

—

_

Chelsea . . .

30,264

18

6

16-86

11.11

^

u.a

_

Maiden . . .

29.384

7

1

14.28

28.66

—

14.28

_

Newton . . .

27,666

9

'.

11.11

11.11

—

11.11

__

Pitchbarg . .

27.146

6

3

—

20.00

—

— ,

__

Taunton . . .

26,972

16

6

12.60

12.60

—

—

_

Olouoester . .

26,688

—

—

—

^

—

—

_

23,068

6

I

^

33.33

—

__

_

Qnlnoy . , .

19,642

—

—

—

—

—

__

Pittsfield . .

18,802

6

4

—

—

—

_

Everett . . .

1«,686

6

6

40.00

—

_

20. DO

Northampton .

"•Si

7

1

—

14.28

—

—

—

Newbnryport .

14,078

4

0

—

—

—

—

—

Amesbory . .

10,920

3

0

33.33

—

^

~~

—

Deaths reported 2,5S1 : under five years of age 836; priucipal
infectious diseases (small-pox, measles, diphtheria and croup,
diarrhtsal diseases, wboopmg-cou^h, erysipelas and fever) 373,
acute lung diseases 363, consamption 3U2, diphtheria and croup
148, diarrhoeal diseases 42, measles 37, whoopin^ough 35,
scarlet fever 33, cerebro-spinal meningitis 29, typhoid fever 26,
small-pox, erysipelas and malarial fever 8 each.

From wbooping-cough New York 11, Philadelphia and Brook-
lyn 4 each, Boston, WashiDgton and Cincinnati 3 each, Cleve-
land and Tannton 2 each, Nashville, Fall River and Cambridge
1 each. From scarlet fever New York 19, Bo&ton 6, Brooklyn
3, Philadelphia and New Bedford 2 each, Cleveland and Holyoke
1 each. From cerebro spinal meningitis New York 12, Wash-
ington, Cleveland and Holyoke 4 each, Brooklyn, Somerville,
New Bedford, Chelsea and Pittsfield leach. From typhoid fever
Philadelphia 6, Brooklyn 6, Cincinnati and Somerville 3 each.

Digitized by

Google

604

BOSTOH MEDICAL ASD SVRGtCAl JOVRHAL.

[Mat 17, 1894.

New York, Boston, Charleston, Worcester, Lowell, Cambridge,
Springfield and New Bedford 1 each. From small-pox New
York 4, Brooklyn 3, Holyoke 1. From erysipelas New York 4,
Philadelphia 2, Washington and Amesbury 1 each. From ma-
larial fever New York a, Brooklyn 2, Philadelphia and Charles-
ton 1 each.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,4fi8,442, for the week ending
April 2lBt, the death-rate was 18 2. Deaths reported 3,054:
acute diseases of the respiratory organs (London) 301, measles
192, whooping-cough 117, diphtheria 7!), scarlet fever 60, diar-
rhoea 31, fever 29, small-pox (London 4, Birmingham 3, West
Ham 2, Manchester 1) 10.

The death-rates ranged from 11.9 in Portsmouth to 26.4 in

; Birmingham 20 2, Bradford 17.9, Croydon 13.0 Derby

15.8, Huddersfield ld.4, Leeds 16.6, Liverpool 14.7, London 18.1,
Manchester 19.2, Newcastle-ou-Xyne 1U.3, Nottingham 16.3,
Sheffield 15.3.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,468,442 for the week ending April
28th, the death-rate was 18.3. Deaths reported 3,665: acnte
diseases of the respiratory organs (London) 256, measles 203,
whooping-cough 148, diphtheria 77, scarlet fever 58, diarrhoea
28, fever 26, small-pox (Birmingham 9, London 6, Portsmouth
3)18.

The death-rates ranged from 11.0 in Portsmouth to 26.9 in
Oldham ; Birmingham 22.6, Bradford 17.6, Derby 12.7, Leeds
16.2, Liverpool 25.6, London 18.6, Manchester 20.9, Nottingham
16.2, Sheffield 16.3.

OFFICIAL LIST OF GUANOES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM MAY 6, 1894, TO
MAY 11, 1894.

Captaih William G. Spbncbr, assistant surgeon, will report
in person to the president of the Army retiring board at Omaha,
Nebraska, at such time as he may designate, for examination
by the board.

Leave of absence for two months to take effect on or about
July 1, 1894, is granted Major William E. Watbks, surgeon,
U. 8. A.

A board of medical officers to consist of Major Joseph K.
CoBSON, Major Valert Havabd and Major Edward B.
Mosblby, surgeons, is appointed to meet at West Point, Neiv
York, June 1, 1894, or as soon thereafter as practicable, for the
physical examination of the cadets of the graduating class at
the U. S. Military Academy and such other cadets of the
Academy and candidates for admission thereto, as may be or-
dered before it.

Gaptaiks Qborob H. Tobmbt and Louis W. Cbampton,
assistant surgeons, will report in person to Colonbl Chas. H.
Aldbn, assistant surgeon-general, president of the examining
board appointed to meet at the office of the surgeon-general,
U. 8. A., on Tuesday, May 8, 1894, at such time as they may
be required by the board for examination as to their fitness for
promotion.

Leave of absence for twenty days to take effect on being re-
lieved from duty at David's Island, N. Y., is granted Major
Joe. R. Gibbon, surgeon.

First-Lieut. Benjamin L. Ten Etck, assistant surgeon,
now ou temporary duty at Fort Clark, Texas, is assigned to
duty at tbat post.

First-Lieut. William F. Liffitt, Jb., assistant surgeon, is
relieved from duty at Camp Eagle Pass, Texas, and ordered to
Fort Leavenworth, Kansas, for duty.

Paragraph 2, S. O. No. 86, April 12, 1894, A. O. O., assigning
First-Lieut. Uablak E. McVat, assistant surgeon, to station
at Angel Island, Cal., is revoked. He will be relieved from
duty at Fort Huachuca, Arizona, and will report for duty at
the Presidio of San Francisco, Cal., relieving Fibst-Lieut.
Cuablxs Willcox, assistant surgeon, who, after being thus
relieved, will report for duty at Angel Island, Cal.

FiBST-LiBUT. John S. Kulf, assistant surgeon, is relieved
from duty at Fort Sheridan, Illinois, and ordered to Fort
Spokane, Washington, for duty.

FiBST-LiBUT. Geobob H. Wblls, assistant surgeon, will
proceed to Fort Bowie, Arizona Territory, and report for tem-
porary duty not later than the 16lh inst., during the absence on
leave of Captain Jbffbbbon D. Poindkxteb, assistant sur-
geon.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. 8. NAVY FOB THE WEEK ENDING MAY
12, 1894.

R. A. Makmion, surgeon, will hold himself to relieve Medical
Inspector O. A. Briobt, on the U. S. 8. " Newark."

G. E. H. Habmon, snrgeon, to the U. 8. 8. " Monongahela,"
June 16, 1894.

W. M. Barnum, assistant surgeon, to the D. 8. 8. "Monon-
gahela," June 1, 1894.

J. M. Strble, surgeon, from the U. 8. 8. " St. Louis " and to
League Island Yard.

H. G. Bbtbr, snrgeon, from Naval Academy and to the
" Bancroft."

Clement Biddlb, passed assistant surgeon, from League
Island Yard and to Marine Rendezvous, Philadelphia, Pa.

J. F. Lets, assistant surgeon, with one month's leave with
permission to go abroad.

SOCIETY NOTICES.

Boston Medical Association. — The annual meeting of the
Boston Medical Association will be held Monday afternoon,
at 4 o'clock. May 21st, at the Boylston Medical Library, 19
Boylston Place.

'This Association, founded in 1806 for the maintenance of a
proper fee table, should be known and joined by every member
of the Massachusetts Medical Society residing in Boston.

Charles L. Scuddbb, MJ>., Stcrttary.

Ambkicam Obtbopjcdic Association. ~ The eighth annual
meeting will be held in Washington, D. C, Tuesday, Wednes-
day, Thursday and Friday, May 29th, 30tb, Slat and June 1st,
inclusive.

The Sessions will be held in the Preparatory Department,
Columbian University, H near 14th Street.

The Annual Dinner will be omitted and instead a Breakfsst
will be given by the outgoing President at 2 p. m., on Wednes-
day at the Shorham, to members of the Association. This will
give the members an opportunity to attend the dinner of the
General Congress on Wednesday evening, to which they are ail
invited.

The President's Address will be delivered on Wednesday after
the Executive Session, on: "Orthopssdic Sorgery, of the Psst
and Future, and the Influence of Surgical Bacteriology and
Modern Pathology npon the Subject."

There are f orty-flve papers already announced and the follow-
ing discussions have been arranged:

>'ir«(0av.— " Fiat-Foot." (a) " Its Etiology and Mechanism
of its Production." Newton M Schaffer, M.D., New York, (i)
" Pathology, Prognosis and Mechanical and Sorglcai Treat-
ment." T. C. Morton, M D., Philadelphia, (c) '^Ovmnastic
Treatment." H. Augustus Wilson, M.D. Royal Whitman,
M.D., New York: Sidney Roberts, M.D., Philadelphia; J. D.
Griffith, M.D., Kansas City; Roswell Park, M.D., and otheii
will take part In the discussion.

Second Day. — " Rachitic Deformities." (a) " EtioloCT,
Clinical History and Lesions." A. Jacobi, M.D., New York.
(6) " Its Various Manifestations, Diagnosis, Differential Diag-
nosis and Prognosis." Benj. Lee, M.D., Philadelphia, (c)
" Mechanical and Constitntional Treatment." Samuel Ketch,
M.D., New York, (d) "Operative Treatment." DeForest
Willard, H.D., Philadelphia.

Third Day. - " Paralytic Deformities." (a) " Etioktgy,
Clinical History and Pathological Conditions Producing Them."
E. H. Bradford, M.D., Boston. (6) " Vkrieties, Diagnosis, Dif-
ferential Diagnosis and Prognosis." E. G. Brackett, M.D.,
Boston, (c) ^' Mechanical l^eatment." John Ridlon, M.D.,
Chicago; Joel Goldthwait, M.D., Boston. (d) " OperatiTe
Treatment, Paralytic and Rachitic Deformities." DeForest
Willard, M.D., Philadelphia.

JoBN BiDLON, M.D., Seeretary.

BOOKS AND PAMPHLETS RECEIVED.

Weekly Abstract of Sanitary Reports issued by the Supervis-
ing Surgeon-General, Marine-Hospital Service. Vol. viU. Wash-
ington. 1894.

De la Maladie de Basedow et en particuUer de sa Pathog^nie.
Par Frederick Chamberlain, Docteur en M^decine da Yale Med-
ical School, U. S. A. : Docteur en Mddeclne de la Faculty de
Paris. Paris: Henri Jouve. 1894.

The Etiology of Osseous Deformities of the Head, Face, Jaws
and Teeth. By Eugene S. Talbot, M.D., D.D.S Third edition,
revised and enlarged, with 461 illustrations, 422 of which are
original. Chicago: The W.T. Keener Co. 1894.

Primer Congreso Medico- Farmaceutico Regional, Celebrado
en Valencia del 26 al 31 de Julio de 1891. Para Commemora-
el Alio 50 de la fundacidn del Institute Medico. Actas Y. Der
talles, publicados bajo la direccidn del Dr. Faustino BarbenS,
Secretario general de dicho Congresso, Valencia. 1894.

Essentials of Anatomy, Inclndiug the Anatomy of the Visceia,
arranged In the form of Questions and Answers, Prepared eq>e-
cially for Students of Medicine. By Charles B. Nancrede. H.D.
Fifth edition, with an appendix on the Osteolorar of the Hamas
Body, the whole based on the last edition ot Gray's Anatomy.
One hundred and eighty fine illustrations. Philadelphia: W.
B. Saunders. 1894.

Digitized by

Google

Vol. CXXX No. 21.] BOSTOHf MBDICAL AND SURGICAL JOURNAL.

605

Xecture*

URINARY DIAGNOSIS.'
Lbcturk II.

Br BDWABD S. WOOD, K.I>.,

Prqfettor qf Chemitlry, Harvard Medical School.

Mbuminuria, — This term simply means the pres-
ence of albumin in the urine. It is not synonymous
with Bright's disease, by which we mean one of the
forms of organic disease of the kidneys ; but, on the
contrary, in the vast majority of the oases in which
this symptom is present, it is due to some other patho-
logical condition. The causes of albuminuria are very
numerous and may be arranged in three principal
classes, as follows :

(1) Organic diseases of the kidneys.

(2) Renal disturbances not due to organic disease.
(8) Diseases of the urinary or genito-urinary pas-
sages attended with suppuration or haemorrhage.

There is another class of cases in which the albami-
naria is due to an altered composition of the blood in
some diseases of the blood, but we need not consider
such cases here since no examination of the urine is
necessary in order to make a diagnosis of them.

We will first take up a study of the changes of the
urine in the first, and by far the most important of the
above classes of cases, namely, the organic diseases of
the kidneys, which are sometimes grouped together
under the general name Bright's disease. Of these
organic diseases there are four which are quite distinct
clinically, and the urinary secretion in these different
affections has decidedly different characteristics, with
the possible exception of the two most chronic forms,
the interstitial and the amyloid degeneration of the
kidneys, between which the differential diagnosis can
generally be easily made by the clinical history and the
physical examination of the patient.

In studying these diseases of the kidneys, I shall
confine myself almost exclusively to the changes which
are found in the urine, particularly those that are of
diagnostic importance, and in referring to the different
diseases, I shall use chiefly the terms of the English
classification with which you are most familiar.

Acute Nephritis. — In this disease, also called acute
Bright's disease, and acute parenchymatous nephritis,
which consists chiefly of an acute inflammation of the
membrane lining the renal tubules, the attack is usu-
ally sudden like that of other acute diseases, and is
liable to follow exposure to cold, or to result from
some infectious disease, such as diphtheria or scarlet
fever. The urine suddenly falls in quantity to 400 or
500 c. c in twenty-four hours, and often much less
than this is passed. In the last case of severe acute
nephritis, which I saw, the quantity was only 1 20 c. c
(4 fluid ounces) in forty-eight hours. The color
changes to a smoky or deep black, and after settling
we can see an abundant dark-brown sediment. The
reaction is usually faintly acid. The specific gravity
may be either higher or lower than normal. The ab-
solute quantity of normal solids in twenty-four hours
is much diminished, and the chlorine is generally
totally absent or diminished to an exceedingly slight
trace, daring the early stage of the disease, while the
dropsy is increasing. During this stage, which in
cases that are to terminate favorably generally lasts

> Ilrenlng Lectnre dellrered at the Harvard Medical School, Febrn-
toy 28, 1884.

but a few days, the percentage of albumin is large,
one-half per cent, or more. The maximum proportion
of albumin reported in this disease is one and a half
per cent.

The sediment in this early stage is seen upon micro-
scopic examination to contain very numerous abnormal
blood globules, by which I mean red corpuscles which
have lost their contents by osmosis, and consequently
their density, so that they have but little refrangibility,
and have become swollen to a spherical form, their
diameter being very much less than that of a normal
corpuscle. In renal haemorrhage, when the hsemor-
rhage is in the cortical portion of the kidneys, the
blood corpuscles have almost universally this abnormal
appearance. The sediment also contains numerous
renal cells which are colored brown with decomposed
blood pigment and are more or less granular, and the
following variety of renal casts; epithelial, blood,
brown-granular, fibrinous, simple granular and a few
hyaline casts. By a fibrinous cast I mean the trans-
parent, dense, highly refracting cast, which is colored
brown or yellow ; it is not composed of fibrin.

This is the condition of the urine during the early
stage of acute nephritis while the inflammation is in-
creasing or at its height, and the dropsy is increasing
or at a standstill. If death occurs at this time, the
kidney is what is called the large red kidney. As soon
as the inflammation begins to subsfde, the character of
the urine begins to change. The first change notice-
able is the beginning increase in the daily quantity,
and with this increase in quantity of urine, we see a
corresponding diminution in the percentage of albumin.
In acute nephritis, we may consider it the rule that, in
the earlier stages of the disease, until the recovery of
the kidney is nearly complete, the smaller the quantity
of urine the larger the amount of albumin and vice
verta. Also, with the beginning increase in quantity
of urine, we find that the chlorine reappears or increases
in amount, and the dropsy begins to diminish. As the
quantity of urine increases, the color becomes less and
less brown until, when the urine has reached about
the normal, the color becomes slightly smoky.

From the beginning increase in the quantity of
urine until it has reached about the normal amount,
we find also a change in the character of the sediment.
The blood globules, brown-granular and fibrinous casts
gradually diminish in number; the proportion of hya-
line and simple granular casts increases ; and the num-
ber of browo-granular renal cells diminishes, most of
them being free from color. At this time, which may
be considered as the very beginning of convalescence,
fatty renal cells appear ; fatty elements (cells and oil
globules) are seen on the casts ; and fatty casts begin
to be found. These fatty elements in the sediment
increase gradually, until, in some cases, they may, for
a day or two, form the predominating constituent of
the sediment. They then gradually diminish and are
found only in small proportion in the sediment of the
urine in advanced convalescence.

If the case progresses favorably, without relapse or
exacerbation, which is by no means the rule, the urine
continues to increase, often very rapidly and with a
correspondingly rapid diminution of the dropsy, from
about the normal to two or three times the normal
quantity, so that it may reach from two and a half to
five litres (or quarts) in twenty-four hours. With the
increase in the quantity of urine the color becomes
pale, the smoky tint gradually disappearing; the

Digitized by

Google

606

BOSTOJf MEDICAL AND SURGICAL JOURNAL.

[Mat 24, 1894

Bpecific gravity falls and the quantity of sediment be-
comes slight. The quantity of normal solids in the
twenty-four hours may exceed the normal, since the
urine contains not only the area and other solids which
are being formed in the economy at the time, but, in
addition, those which were in the dropsical fluid. The
albumin diminishes steadily with the increase of arine
until it ii) present only in exceedingly slight traces.
With the increase in the quantity of urine above the
normal, the brown-granular, fibrinous, blood, fatty
and epithelial casts gradually diminish and finally dis-
appear ; and we have in the sediment during the last
few weeks of convalescence, only a very few blood
globules and renal cells and a few hyaline and finely-
granular casts, some of which have an occasional blood
globule and renal cell attached. When the convales-
cence is nearly complete, the quantity of urine falls
from the high point which it has reached, but without
a corresponding increase in the amount of albumin,
until it finally, with the complete restoration of the
kidneys, reaches the normal, when the albumin and all
of the abnormal constituents of the sediment disap-
pear.

If an exacerbation occurs, and this is the rule rather
than the exception, the quantity of urine suddenly falls
to the normal or below, if the exacerbation be a severe
one, and the colo( generally becomes more or less
blood-red, the albumin increases again, and in the
sediment we see an increase or a reappearance of the
blood and epithelial casts. The blood globules, how-
ever, are almost invariably more nearly normal in
character than in the first stage of the disease, and the
blood pigment is not so much decomposed. This ac-
counts for the blood-red color of the urine instead of
the brown which we saw in the early stage. In some
cases, during the progress of acute nephritis, several
exacerbations may occur - owing to some exposure to
cold, errors in diet, or other causes, and in some cases
the convalescence may be prolonged from one and one-
half to two years before the kidneys become completely
restored to a healthy condition, and the albumin and
casts entirely disappear.

Subacute Nephritis, commonly called chronic paren-
chymatous nephritis, and also chronic tubular nephri-
tis, may result from the acute disease, but it is more
often chronic from the beginning, and frequently ac-
companies chronic wasting diseases, such as phthisis,
syphilis, etc. In this disease, we find the so-called
large white kidney after death. In this form of
Bright's disease, the character of the urine varies ac
cording to the activity of the process going on in the
kidneys. If the parenchymatous inflammation is ac-
tive, the general dropsy increases and, on simple in-
spection, the urine looks like that of a fever urine.
The quantity passed in twenty-four hours is much
diminished, generally from. 400 to 600 c. c, but it may
be much less than this. It is very high in color, not
brown or bloody, of very high specific gravity, gener-
ally 1,026 to 1,030, very acid in reaction, and gener-
ally contains an abundant sediment, which is seen to
consist chiefly of amorphous urates, as in many fever
urines. The normal solids are relatively increased,
with the exception of the chlorine, which is much di-
minished and may be nearly absent, if the dropsy is
increasing; but the daily quantity of solids is found
upon quantitative estimation to be decidedly less than
the normal. In the active stage of this disease the
urine contains a larger proportion of albumin than in

any other kidney affection ; generally the proportion
is about one per cent., but it may reach as high aa
two or even five per cent. The sediment during thii
stage usually consists chiefly of amorphous urates,
which should be removed before examining for the
other constituents. This is done by allowing the urate
sediment to settle, decanting the supernatant urine
and adding to the sediment a considerable volume of
lukewarm water, which will dissolve the urates and
hold them in solution. The organized constituent*
will then settle, and may be seen as a rather heavy
white deposit, which consists of numerous hyaline,
granular and fatty casts, granular and fatty renal cells,
and compound granule cells. It is rare to find any
blood ; and when blood occurs it is due, in my opiDion,
to a complication with acute nephritis.

Almost invariably, in this affection, owing to care
or to appropriate treatment, an amelioration in the se-
verity of the symptoms takes place, dropsy diminishes
and the other severer symptoms subside, and it is evi-
dent that the process going on in the kidneys is more
or less inactive. When this occurs, the urine has an
entirely different character. It is passed in larger
quantity, but is still less than normal, generally from
1,100 to 1,S00 c. c. : it is pale in color, of low specific
gravity (1,010 to 1,015) slightly acid in reaction, and
contains a considerable quantity of white sediment.
The normal solids are diminished both relatively and
absolutely. The albumin is less than in the active
stage, but is still present in considerable quantity, from
one-quarter to one-half per cent. The sediment is
found to contain the same constituents as in the active
stage, with the exception of the amorphous urates, bat
in smaller proportion, namely, hyaline, granular and
fatty casts, granular and fatty renal cells, and com-
pound granule cells.

In the latter stages of this disease, whether the pro-
cess be active or not, we find for some months before
death, in addition to these constituents, the so-called
waxy cast, which is a transparent, dense, highly re-
fracting, colorless cast. The waxy cast resembles the
fibrinous cast seen in acute nephritis in every way,
except that it is absolutely free from color. During
the progress of a case of subacute nephritis we often
see these two conditions of the urine alternating with
each other a considerable number of times.

Ghronie N«pkriti$ {bUerttitiaC). — This is the most
insidious of all of the forms of Bright's disease. It
has generally existed a long time before the physician
is consulted and the urine examined. Some cases
have, apparently, been traced to chronic lead-poisoning
and malaria as a cause ; but in most cases no definite
cause can be assigned. After death from this form of
kidney disease, we find the red, granular, contracted
kidney ; and in almost all cases there is also found
hypertrophy of the left ventricle of the heart.

The urine is increased in quantity more or less,
according to the advancement of the disease until the
very latest stage, and is always more or less dilate
unless complicated with some acute disease. From
the beginning the urine gradually increases until
it may reach four or even six litres (quarts) in
twenty-four hours. But this increase is very grad-
ual since the duration of the affection may be ten or
even twenty years. The reaction is normal, the color
at first normal, gradually becomes pale ; the specific
gravity gradually diminishes until it reaches 1,005
or 1,006; and the amount of sediment is slight, no^

Digitized by

Google

Vol. CXXX, No. 21.] BOSTON MEDIOAL AND SURGICAL JOURNAL.

507

ms] or less than norma]. The normal solids are
diminished relatively and absolutely according to the
extent of the disease, except the iodozyl, which may
be increased. The albumin varies from the slight-
est trace up to about one-quarter per cent. The
sediment, up to the latest stage, consists only of
hyaline, finely-granular, and granular casts. Towards
the close of life the urine begins to fall until it is
secreted in less than the normal quantity, but the
specific gravity and the relative quantity of solids re-
mains the same as when the amount of urine was large,
BO that the twenty-four hour quantity of solids is very
much diminished. We may have only 400 or 500 c. c.
of nrine with a specific gravity of only 1,004 or 1,005,
and in this final stage we may find only a very slight
trace of albumin. The sediment at this time gener-
ally contains waxy casts in addition to the hyaline and
granalar casts. In this form of Bright's disease, the
quantity of urine secreted at night is apt to far exceed
that secreted during the day-time. The quantitative
estimation of the urea is of very great value in this
disease, since after the very earliest stage the twenty-
four hour amount of the urea is diminished below the
normal, and continues to diminish with the progress of
the disease.

Amyloid Degeneration of the Kidneys. — This con-
dition of the kidneys accompanies many wasting dis-
eases such as suppurative diseases of the bones, phthisis,
syphilis, etc, and when it exists in the kidneys, other
organs, especially the liver and spleen, are usually
found to be affected by it. It is very apt to be com-
plicated with subacute nephritis, since both of these
affections may be caused by similar conditions. The
nrine in amyloid degeneration resembles that of
chronic interstitial nephritis, and from the urine alone
it is impossible to make a differential diagnosis between
these two forms of kidney disease. In amyloid degen-
eration, however, since the disease is primarily one of
the blood-vessels and the secreting structure is only
affected later, although the quantity of urine is in-
creased to the same extent as in interstitial, the solids
are not diminished in the same proportion, and hence
the specific gravity is not as low, as a rule. In this
disease, the urine steadily increases until it may reach
three or four litres (or quarts), and the specific grav-
ity correspondingly diminishes. The solids are also
diminished relatively, but a quantitative estimation of
the amount of normal solids in twenty-four hours,
shows that they are more nearly normal in quantity
than in interstitial nephritis. The albumin is only
present in the urine in the very slightest trace at the
beginning of the disease, but it gradually and steadily
increases as the disease advances, and may reach one-
half per cent, or more, especially if, as is usually the
case, it be complicated with parenchymatous inflamma-
tion. The sediment is composed of hyaline and finely-
granular casts, and in some instances of waxy casts
also. If there is any parenchymatous inflammation
we will find, in addition, fatty cells and casts.

Complicationt. — All of the above forms of disease
of the kidneys are liable to be complicated, either with
each other or with one of the hyperEemias, active or
passive. Acute nephritis is especially apt to occur
during the progress of any of the chronic forms, in
which case, the quantity of urine will fall to an ex-
tent corresponding to the severity of the acute attack,
and we will find the blood elements, globules and casts,
in the sediment. Of the other forms of kidney disease,

the most important complication, and one of the most
common, is the combination of the subacute (or chronic
parenchymatous) with the chronic interstitial disease,
which complication is called chronic diffuse nephritis.
In this disease the interstitial element tends to increase
the quantity of urine and the parenchymatous inflam-
mation to diminish it, so that the daily amount of
urine will be found to be largely increased if the inter-
stitial disease predominates, and only slightly increased
if the parenchymatous disease predominates. In the
former case there will be but little albumin, and in the
latter a comparatively large quantity. The 8e<liment
will naturally contain the hyaline and granular casts of
both diseases, and the fatty elements, fatty casts, renal
cells and compound granule cells of the subacute dis-
ease. The extent to which the kidneys are affected,
or the amount of destruction of the kidney tissue, can
be approximately estimated by the average daily
amount of urea secreted. Subacute nephritis and
amyloid degeneration are also very commonly present
in the same case, since both conditions may be due to
similar causes. The composition of the urine and
sediment are practically the same as in chronic diffuse
nephritis, and the two cannot be distinguished from
each other by the urine alone.

In albuminuria caused by renal disturbances, which
are not due to organic kidney disease, morbid growths,
tubercular disease or calculi, the renal conditions are
usually spoken of as active hypersemia or irritation of
the kidneys, and passive hypersemia. I have considered
these conditions elsewhere,^ and will only refer very
briefly here to the character of the urine. In the ac-
tive hypersemia or irritation of the kidneys, the chemi-
cal composition of the nrine varies, so far as the phy-
sical properties and the normal solids are concerned,
according to the cause. The urine may be either con-
centrated or dilute, and the daily quantity of normal
solids may be normal or diminished. The albumin is
always very small in quantity, usually being present
in the very smallest traces except in the very severe
cases, catarrhal nephritis, when we may have from
one-eighth to one-quarter per cent, for a few days.
This quantity of albumin does not persist, however,
for more than two or three days unless it develops into
an acute nephritis. The character of the sediment is
usually that seen during convalescence from acute
nephritis, and it is often impossible to distinguish by
the urine alone between a convalescence from acute
nephritis and an active hypersemia of the kidneys.
With the clinical history in addition, however, there is
usually no difficulty in making the differential diag-
nosis.

In Pattive Hypermmia, the physical properties and
chemical composition of the urine also vary according
to the cause. The albumin is present always in the
very smallest traces except in rare cases of passive
hypersemia of pregnancy, when it may reach nearly
one-quarter per cent. I have known this quantity
of albumin to be present in cases of pregnancy fol-
lowed by eclampsia, when no chronic disease of the
kidneys existed, as was proved by the subsequent his-
tory of the cases ; and in these cases the comparatively
large percentage of albumin persisted for two or three
months before confinement. The sediment in passive
hyperssmia is composed of pure hyaline and finely-
granular casts only, so far as the renal elements are
concerned.

> See Boaton Medleal and Snrgtoal Jonrnal, May 12, 1893.

Digitized by

Google

508

BOSTON MEDICAL ASD SURGICAL JOURS AL.

[Mat 24, 1894.

BXSDIfi!.

To Sam ap briefly, and looking at the subject from
s little different point of view, we see from the' above,
that an abnormally large quantity of urine Ib passed in
advanced convalescence from acute nephritis, in ohronic
interstitial nephritis, in amyloid degeneration of the
kidney, generally in chronic diffuse nephritis, and in
some cases of active hyperaemia of the kidneys. An
abnormally small quantity of urine is passed in the
early stage of acute nephritis, both active and inactive
stages of subacute (or chronic parenchymatous) nephri-
tis, generally in active hypertemia, and always in pas-
sive hyperaemia of the kidneys. Toward death, of
course, we find an abnormally small quantity of urine
in all forms of kidney trouble.

A large amount of albumin, by which I mean one-
half per cent, or more, is found in the urine only in the
early stage of acute nephritis, the active stage of sub-
acute (or chronic parenchymatous) nephritis, and,
sometimes, in the chronic diseases complicated with
these. A moderate amount of albumin, about one-
quarter per cent, we find in early convalescence from
acute nephritis, in the inactive stage of subacute (or
chronic parenchymatous) nephritis, in advanced chronic
interstitial disease and in amyloid degeneration of the
kidneys, generally in chrbnic diffuse nephritis, for a
few days in severe active hyperemia (catarrhal nephri-
tis), and in very rare cases of passive hyperaemia of
pregnancy. Only very slight traces of albumin are
found in advanced convalescence from acute nephritis,
in the early stages of chronic interstitial and amyloid
disease of the kidney, and, generally, in active and
passive hyperaemia of the kidneys.

Blood is found in the sediment, free and adherent to
the casts, and often with blood casts, only in acute
nephritis and active hyperaemia, or other affections
which are complicated with these. Fatty elements,
fatty renal cells, fatty casts, or oil globules free and
on casts, are found temporarily in acute nephritis,
being most abundant in the early stage of convales-
cence ; during the whole progress of a subacute and
chronic diffuse nephritis, and in some cases of long-
continued active hyperaemia of the kidneys, generally,
however, in very small proportion in this last affection.
The presence of calculi in the renal tissue, or the ex-
istence of cancer or other morbid growths affecting
the kidney, produce more or less parenchymatous in-
flammation in those portions of the renal tissue af-
fected, and we will consequently find on examining the
urine and sediment in such cases some evidence of
the parenchymatous inflammation. Generally, the
urine resembles that of an active hyperaemia of the
kidneys, but we may find in the sediment, in addition,
crystalline elements, if there is a concretion, varying
in character according to the nature of the concretion,
or in cases of morbid growths rarely pieces of the
growth or cells from it. Tubercular disease of the
kidneys causes suppuration, and may be detected by
finding the tubercle bacilli in the pus.

An Arkansas Method op Trbatino Suall-
Pox. — A simple and effective method of stopping the
spread of small-pox was tried in a rural district of
Arkansas last week. A negro being found ill with
small-pox in his cabin, the neighbors set fire to the
house and burned it all up — small-pox infection, cabin
and negro.

APPENDICITIS: SOME IMPRESSIONS DERIVED
FROM AN EXPERIENCE OF 44 CASES.*

BT HOMBB OAQS, A.M., H.D., WOBCESTBR, KABS.,

Swrgton to the Wvrcetttr CUy BotpUal, to the Memorial BotpiUU,
and to the Ilouee q/* Providence,

OvK knowledge of the frequency and importance of
inflammation of the vermiform appendix and its re-
sults dates back in this country to the paper of Fitz,
read before the Association of American PhysiciaDs in
1886. From a purely pathological study, he demon-
strated beyond all dispute, not that appendicitis was a
new disease, but that it had always been the unrecog-
nized cause of a great variety of acute abdominal dis-
eases, hitherto classed as inflammation of the bowels,
peritonitis, typhlitis and perityphlitis. His couclusioDS
have been since then confirmed and strengthened by
a constantly increasing surgical experience. Dr. M.
H. Bichardson, whose 281 cases lately reported repre-
sent one of the largest individual experiences, expresses
the opinion that at least 90 per cent, of all cases of
acute peritonitis occurring in young adults originate in
an inflamed appendix, an estimate which is, I tbiok,
not likely to be diminished by further investigation.
Dr. Bichardson further expresses his firm conviction
that "excluding certain zymotic diseases, it is the
cause of more deaths than any other acute abdominal
lesion." No surgical subject has within recent years
attracted so much attention or given rise to so much
discussion. Its frequency and importance have been
strenuously urged on all sides, and very large and con-
stantly increasing personal experiences have been re-
ported. It is confined to no localities, to no conditions
of life. The picture it presents is being recognized by
the profession everywhere as an old acquaintance
under a new name.

In spite of all the discussion, and the large experi-
ence so rapidly acquired, the problems created by the
newly discovered pathology are by no means finally
solved. No one can lay down any rules by which we
can be governed in diagnosis, prognosis or treatment.
We must, for a time at any rate, be content to be ob-
servers only. He who studies and observes much,
finds his opinions changing so often that he is very re-
luctant to attempt the instruction of others. One
opinion alone I find not changed but strengthened
from the beginning, that is, as to the gravity and dan-
ger that exists in every case, no matter how mild it
may appear to be. This one fact I would impress
upon you ; for the rest, I have preferred to give yoa
briefly some impressions as they have been made upon
my mind by the study of these 44 cases, asking yon to
remember that I regard them as impressions only,
which are still subject to change, but from which
further study and experience will, I hope, evolve more
definite conclusions.

In the 14 cases in which the appendix was removed,
a faecal concretion has been found three times, twice
in the appendix itself, once in the bottom of the ab-
scess cavity. I have never found any other foreign
body present. In three cases, traumatism was the
alleged cause, and in one the attack followed the in-
gestion of large quantities of grapes. In a very few
instances, the attack was preceded by diarrhoea, with

< Aq wldreu dellrered before the Tliurber Medloal AaMclation at
Hllford, Mass., February 22, ISM.

Digitized by

Google

Vol. CXXX, No. 21.] BOSTOS MBDIOAL AND SURGICAL JOURNAL.

509

acDte digestive diatarbance ; bat for the great majority
of all cases — I should say at least 75 per cent. — no
caDse could be assigned. I do not believe that the
preponderance of males, in my own series 35 out of
44, can be fairly interpreted to indicate hard labor or
exposure to injury as a predisposing cause. ' My own
feeling is that the cause is usually to be found in the
accidental retention in the appendix of larger or smaller
faecal masses, and that their effect is determined by
the kind and virulence of the bacteria present with
them. Another determining factor is probably to be
found in the congenital or acquired variations in the
length, position and patency of the appendix. These
variations are of still more importance from their ef-
fects upon the clinical history and symptoms of appen-
diciUs.

The appendix is ordinarily from two to four inches
in length, although considerable variations in both di-
rections have been occasionally noted. Its base is
fixed near the ileocecal valve, at the junction of the
longitudinal striae of the colon, and is therefore sub-
ject only to such changes in position as affect the
csBcnm as well. From this point, however, the appen-
dix and its mesentery may lie in almost any direction,
extending downward into the pelvis, transversely across
tfae abdomen, with its tips reaching beyond the median
line, or upwards on either side of or even behind the
ascending colon. Its position, of course, fixes the lo-
cation of pain and tenderness, which may, therefore,
be found almost anywhere within the abdominal cavity.
Many cases of appendicitis are thus the more readily
mistaken for cases of peritonitis of ideopathic or un-
known origin, a diagnosis that occasionally seems to
be verified by a fruitless search for the appendix at
the time of operation. Allow me to cite one example
from my own experience.

£. E., grocer, thirty-five years old, patient of Dr.
George F. Woodbury, was seen December 18, 1891.
He had a history of a previous attack in August, 1891,
since which time he had constantly complained of pain,
chiefly epigastric, for which he sought counsel in Bos-
ton. Present attack came on suddenly in the night,
and on account of absence of local signs, I advised de-
lay, until on the 20th it was clear that a general peri-
tonitis was impending. At the operation, peritoneum
was everywhere injected and there were some fibrinous
adhesions, but no pas and no appendix could be found.
The patient died two days later ; and at the autopsy,
the appendix was found lying behind the caecum and
extending upwards about four inches, its tip resting on
the right kidney. Its end was perforated, and pus
could be squeezed oat of its entire length, and had al-
ready formed a small abscess between the colon and
the kidney.

Here was an appendix which had given rixe to pain
chiefly in the epigastrium, and which from its con-
cealed position had almost escaped detection, and
oould not have been removed. I believe that the
moat favorable position for finding the appendix is when
adherent to the iliac fascia or along the outer side of
the colon. From these places it can almost always be
removed, because the general peritoneal cavity can be
more easily and more perfectly protected, and because
the dissection can be prosecuted with a greater sense
of security ; one has a better view of the field of opera-
tion, and there is less danger of injuring important
structures.

Dr. Bichardson has lately raised the qnestion as to

whether or not the appendix is always perforated, and
expresses his "strong conviction that in all severe
cases, and, in fact in all cases where there is a localized
peritonitis there is a larger or smaller perforation with
extravasation." Without wishing in the least degree
to question this statement, it seems to me that there
must be a few exceptions. I have twice removed ap-
pendices in which no perforation could be discovered
by the naked eye or by the probe. (Both specimens
are shown here.) The first is from a man who had
had three previous attacks, and whom I operated upon
forty-eight hours after the beginning of the fourth.
Upon separating an adherent mass on the inner side of
the colon, I succeeded in isolating the appendix, which
was very much thickened, its surface red and slightly
injected. There was no pus. Immediate improve-
ment followed its removal. The second is from a
young man who had been sick five days, complaining
chiefly of pain in the right iliac 'region. The appen-
dix was found non-adherent, somewhat thickened, with
a bulbous tip, which was directed forward against the
abdominal wall, and corresponded with the point of
maximum tenderness. Microscopical examination of
its contents showed that it contained a faecal concre-
tion with a small amount of pus. In both of these
cases, the inflammatory process, which always begins
from within, in the mucus membrane, had extended
outward, involving successively all the coats of the ap-
pendix and ultimately would have perforated it, per-
haps. Neither perforation nor extravasation had,
however, taken place up to the time of my interference.
The first was certainly one of the severest and most
threatening of my cases, and the second was rather a
late operation.

The most important pathological factor is, I think,
the limitation of the process by protective adhesions.
They may be formed by the adherence of adjacent
coils of intestine, by the envelopment of the appendix
in a fold of omentum, or by its adherence to the iliac
fascia, or along the outer side of the colon, as before
mentioned. At any rate, the result is a localized ab-
scess, which may or may not be adherent to the abdomi-
nal wall. Should extravasation take place before the
formation of adhesions, a general infection follows, and
the case cannot be distinguished from what has always
been called idiopathic general peritonitis.

The typical case of appendicitis presents a picture
so familiar to us all as to require but little attention.
A child or young adult suddenly seized with abdomi-
nal pain and vomiting, the pain at first general, then
more marked in the right iliac region, accompanied by
tenderness, and in the course of time by the develop-
ment of a bunch. This is the type, from which, how-
ever, there may be wide variations. The onset is
almost always sudden. Chills or chilly sensations may
be present, but are just as often wanting, even when
suppuration has taken place. Vomiting is often,
though not necessarily, an early symptom, and when
present usually ceases with the localization of the in-
flammatory process. Its continuance, especially if
changing to simple regurgitation, is always ominous.
I have, however, recently had two cases in which,
after the removal of the appendix and drainage of the
abscess, vomiting of a thin, dark-green fluid persisted
for several days, both patients ultimately recovering.

The pain is at first general and then local. It may
be-very severe, or quite moderate, in cases which at
operation present very similar conditions. Its loca-

Digitized by

Google

510

BOSTON MBDIOAL AND SUROJOAL JOURNAL.

[Mat 24, 1894.

tion is, I think, of but little Talae, becanse the position
of the appendix varies within such wide limits. Ab-
sence of localization is important as indicating a more
general infection of the peritoneal cavity. Tender-
ness, like pain, may be general or local, and in any
part of the abdomen. With the appendix in its ordi-
nary place, the point of maximum tenderness is, as in-
dicated by McBurney, usaally to be found midway
between the anterior superior spine and the nmbilicus.
The exceptions to this are, however, nearly as many
as the observances, and I think Mc Barney's point as a
diagnostic sign should be altogether discarded.

Dalness, when present, helps to the localization of
the inflammation, but its ftbsence is entirely without
significance. Its value in any case is extremely lim-
ited. Abdominal distention, especially if general, is,
I believe, one of the most dangerous symptoms. For-
tunately, it is not an early one, and can generally be
anticipated by operation. Its presence not only indi-
cates a more or less general peritoneal infection, but
also offers a serious obstacle to the mechanical part of
the operation. The effect of its full development I
shall refer to again.

Temperature I have come to regard as of but little
value in indicating the nature or severity of the attack.
I have operated in the face of a normal temperature
for two days, and found a foul abscess with double
perforation of the appendix, and, on the contrary,
with a temperature of 103°, have found no pus, and
simply an inflammatory thickening of the appendix.
It is certainly a much less reliable guide than the
pulse, and I am inclined to agree with Elliot that
many of the most serious cases have a normal or
nearly normal temperature.

One of the most interesting problems in connection
with the clinical history of these cases is their ten-
dency to recur. How great that tendency is cannot
yet be accurately stated. Fitz found it in 11 per cent
of 257 cases. Out of the 44 cases which furnish the
basis of my [taper, 12 gave a definite history of two or
more attacks. It is safe to say that in the very large
proportion of cases the first attack is the last, but that
after one or more recurrences others may be pretty
certainly expected ; and one thing is, I think, pretty
definitely settled, namely, that one can never tell how
severe the next attack may prove. A patient who has
had one or more recurrences is in constant danger of
an attack so severe as to be beyond surgical help from
the outset.

One word about the difiereutial diagnosis: it is not
always easy to distinguish appendicitis from other
acute abdominal affections. When the local symptoms
are not clear, internal strangulation, twists and intus-
susception, with other forms of intestinal obstruction,
must be carefully considered, and the operator must,
of course, be prepared for any one of them. Dr.
Bichardson reports two cases of strangulation in om-
phalo-meseuteric remains which were mistaken for
appendicitis. In one case of suspected appendicitis
which I saw with Dr. W. E. Paul, then of South-
bridge, and which he has lately published in the Bot-
ton Medical and Surgieal Journal, operation was
deemed inadvisable because the patient was already
moribund. Autopsy revealed a hiemorrhagic pancrea-
titis as the cause of death. Many of these conditions
can be eliminated only by exploratory incision, bear-
ing in mind always that in healthy young adults, eape-
oially males, a sudden attack of acute abdominal pain,

with attendant symptoms pointing to the development
of a local or general peritonitis, means in the great
majority of cases an inflamed appendix.

In considering the management of these cases, let
me say a word first about medical treatment, especially
treatment by salines, so strenuously urged by Dr.
Grordon, of Portland. Since the revival of saline
treatment of peritonitis by Tait, we have all seen at
times in appropriate cases most satisfactory results.
The theory of its benefit, as suggested by all of its
admirers, as well as by Grordon, lies in its depletive
effect, not only upon the general, but also upon the
portal circulation; the free watery dejections at the
very beginning of the trouble are believed to cause
the absorption of exudates before they have a chance
to undergo decomposition, and also to subdue inflam-
mation by their local depletion of the blood-vessels.
The advantages of this method are obvious if its safety
can be demonstrated. The dangers are from the
breaking down of protective adhesions by increased
peristalsis, and from favoring the extravasation of the
intestinal contents through the perforated appendix.
The first objection is, perhaps, somewhat theoretical ;
but the delicacy of the adhesions, and the ease with
which they are ruptured during most careful manipu-
lations, are familiar to all who have seen early opera-
tions. I have seen one case in which the adbesions
which separated a localized abscess in a child were
ruptured during sleep, and another in which in a
young adult the rupture took place during an effort at
stool ; in both cases the disappearance of the local
swelling was accompanied by collapse, rapidly pro-
gressing general peritonitis and death. In the second
case, the abdomen was opened ten hours after the acci-
dent, a large quantity of pus lying free in the abdomi-
nal cavity evacuated, but too late to be of any service.
This danger is not only theoretical, but real and very
much to be feared. That salines may promote farther
extravasation of intestinal contents through the per-
forated appendix is denied by Dr. Gordon, on the
ground that at the onset of the attack communication
is shut off between the caecum and appendix by closure
of the natural opening. His statement is unsupported
by any anatomical demonstration, and is contradicted
by the published records of almost all the leading
authorities upon this subject. At the recent meeting
of the Surgical Section of the Suffolk District for the
consideration of this subject, Drs. Richardson, Beacb,
Cabot and Elliot all testified to finding faecal matter in
peri-appendicular abscesses and in the appendix itself,
and at least two of them testified to having seen gas
and intestinal contents escape from the perforation at
the time of operation. I have myself found faecal
matter in the appendix, and have twice after ligation
and removal of the appendix, where there was no pos-
sibility of cecal perforation, had faecal matter dis-
charged through the drainage-tube on the first two or
three days, and not thereafter. I believe it can be
accounted for only on the ground of direct communica-
tion between the caecum and appendix. In spite of
its advantage, 'therefore, I believe the indiscriminate
administration of salines in appendicitis is attended
with the gravest danger. I have once or twice re-
sorted to salines, or, preferably, other laxatives, bat
only in the most guarded way, and in cases where I
felt reasonably sure that perforation had not taken
place.

For the mildest cases, and where for any reason

Digitized by

Google

You CXXX, No. 21.J BOSTON MEDICAL AND SUBOIOAL JOURNAL.

511

temporizing has seemed best, I believe the old-fashioned
treatment by rest, opiates and hot applications to be
the safest. The so-called simple catarrhal inflamma-
tion without perforation will improve as quickly and as
surely under this as under the more active methods,
the only danger is in concealment of graver symptoms
which might demand interference by the opiates, and
this has the advantage of being entirely within our
control.

It is as impossible with our present knowledge to
determine what proportion of cases will recover under
such palliative measures as I have just described, as it
is to lay down any rules for surgical interference. We
do know that while a very considerable proportion
of cases recover perfectly and permanently without
the necessity of interference, an equally large number,
beginning in precisely the same way, quickly develop
most dangerous symptoms, which demand at once
prompt incision and exploration. Until we discover
some way to distinguish at the outset between these
two classes, it is natural that those whose experience
has been more largely with the severe type should
prefer and advocate immediate operation as soon as the
diagnosis is established. It is argued that the danger
from an operation at such a time is extremely small
and that the conditions have not yet been complicated
by the presence of large exudations and by strong ad
hesioiXB, so that they are more easily recognized and
more securely dealt with. The argument has much
to commend it, and I think therp can be no question
that the trend even of the most conservative surgical
opinion is towards a more rather than a less radical
procedure. We are, however, but in the infancy of
our knowledge of this subject, and I feel hopeful that
we may some time be able to draw at least a sharper
line between those cases whose natural tendency is to
recovery and those which are destined to progress.
There is at best some risk of disseminating an inflam-
matiou which nature has attempted to localize, and
much danger of weakening the abdominal wall, a very
serious consideration, especially to the laboring class.
I have not therefore, as yet, been convinced that oper-
ation is always to be advised at the very beginning of
the attack, and yet in some cases I should propose it
unhesitatingly, especially in those where a general
peritonitis seemed imminent.

I wish I might be able to give you the exact reasons
which govern me in forming such a conclusion, but I
cannot. Impressions, even if founded on experience,
which cannot be formulated into words, are, I know,
most unscientific and unsatisfactory, perhaps, often
unsafe guides ; but they exist, and I cannot yet at all
accurately describe them.

Whenever vomiting continues and is accompanied
by any suspicion of increasing distention after the first
twenty-four hours, I am sure that interference cannot
be proposed too quickly. It generally indicates a
greater or less tendency to general peritoneal infection,
and its persistence is a symptom of very grave import.
The more nearly does it approach a condition of re-
gurgitation, the graver does it become. In these cases,
operation most be done in the very beginning, to be of
any value. Patients who are regurgitating a dark-
greenish fluid, even if not stercoraceous, and whose
abdomens are much distended, are the worst possible
subjects for operation. I have operated now four times
under such conditions, and always with fatal result.
Whenever general peritonitis is threatened, operation

must be done within the first twenty-four or forty-eight
hours, and even then may be too late to avert death.
After full development, operation is, I believe, counter-
indicated, and the chance of a favorable result lies in
the use of salines or other purgatives, with opiates
enough to secure quiet. These are the cases in which
the rectal tube, turpentine, euemata and other means
for the relief of distention are indicated. In all cases
of acute appendicitis, with or without localized symp-
toms, where a general peritoneal infection is feared or
its beginning suspected, the time to consider surgical
interference is, I believe, at the very outset. It is
then that any delay is most dangerous. When fully
developed, it is, I believe, almost always too late. The
shock of ether, and the increased manipulation made
necessary by distention of the intestine is almost always
fatal, and if left to nature, such cases may occasionally
recover. I have recently twice had that fortunate ex-
perience.

When after the first onset the symptoms become
definitely localized with the formation of a tumor, and
with a definite sense of local resistance and tenderness,
delay may be less dangerous, and the appropriate time
for interference is always more difficult to determine.
Should the local conditions decidedly improve on the
second day, it is, I think, fair to infer that nature will
effect a complete restoration, or that she has, at least,
succeeded in setting up a temporary barrier to the ex-
tension of the inflammation. I believe that there are
many cases in which the improvement in physical
signs, as well as in constitutional symptoms.is so rapid
and so decided that interference, if proposed at all, is
to be considered only as a safeguard against possible
recurrence. In the great majority of these cases of
acute appendicitis, where the process is distinctly
localized, I believe the most favorable time for inter-
ference is as early as the third day. The risk of
delay seems to me much greater than the danger of
early operation. The second and third days eliminate
the mildest cases ; the others jnay assume a far more
dangerous aspect with little or no warning. Even as
early as this a gangrenous condition of the appendix
may be found, around which an abscess has already
been formed. This has been the condition in three of
my cases.

The first, N. C, male, seventeen years old, was seen
in consultation with Dr. J. O. Marble, of Worcester,
on the 30th of January, 1893. The attack began with
severe abdominal pain and vomiting on the 28th, and
I operated sixty-four hours later, that is, on the third
day. His pulse was 120, temperature 102°, and his
general aspect was exceedingly bad, though he pro-
fessed to feel better. Upon opening the abdomen, I
came at once upon a -mass of gangrenous omentum,
the meshes of which were infiltrated with pus. Just
beneath this was an abscess cavity, containing about
four ounces of very foul pus, lying in which was the
appendix, perforated about two inches from the ctecum
and gangrenous about the perforation. (Specimen
shown.)

Again on May 3d, I operated on Mrs. M., twenty-
seven years old, a patient of Dr. F. G. Fay, of Worces-
ter, who had been suddenly seized with acute abdomi-
nal pain on the evening of the 30ih of April ; the
operation was, therefore, on the third day. The gen-
eral peritoneal cavity was opened and a mass of adhe-
rent coils of intestine found in the ceecal region, not
adherent to abdominal wall. On separating the adhe-

Digitized by

Google

612

BOSTON MEDICAL AND SVSGlCAL JOURNAL.

[Mai 24, 1894.

sioDB, about two ounces of pua was evacuated, and the
appendix found perforated and gangrenous. (Speci-
men shown.)

On October Sd, I operated upon A. W., male,
twentj-one years old, who was referred to me by Dr.
Leonard White, of Uxbridge. His attack began suddenly
on the morning of the 20th. Incision revealed pus
juBt below the ciecum, with a much thickened appendix,
BO adherent that it was torn across at the point of per-
foration, and only about one inch was removed. The
rest was ligatured and left.

These three cases illustrate the severe conditions
which may be found as early as the third day, even
when the inflammatory process has been definitely
limited by adhesions. I believe all would have been
more difficult to manage, and more dangerous to the
patient had there been even twenty-four hours longer
delay. As it was, all recovered.

The most serious objection to early operation is the
danger of breaking down adhesions, and defeating
nature's attempt to localize the peritoneal infection.
Larger experience and greater familiarity with the
conditions to be found must diminish very much the
force of this objection. It is also, I think, far out-
weighed by the greater facility in operating, the greater
ability of the patient to withstand shock in the early
stages, and by the increased chance of doing a thor-
ough and complete operation. I am one of those who
believe that the operation is every way more satisfac-
tory when completed by the removal of the appendix,
and that (whenever possible this ought to be done. I
am sure that when it can be done without too great
violence to the adhesions, convalescence is established
more quickly, is less liable to interruption and recov-
ery is much more certain to be permanent and com-
plete. I have accomplished it now in 14 cases, with
18 recoveries. The only death was in the first case in
which I removed it. I would not, by any means, con-
vev the impression that its removal should always be
attempted. In the ordinary late operation, it cannot
often be found, and even when found, its removal is
usually impossible, so tough and firm are the adhesions
in which it is imbedded. It is to be undertaken only
in early operations, when the adhesions are light and
easily separated, and when the general peritoneal cav-
ity can be fully protected. In cases thus properly
selected, the removal of the appendix makes a more
finished operation, adding very little if any to the im-
mediate danger, and adding much to the rapidity and
permanency of the recovery.

So, also, with regard to the omentum, when it is
found wrapped about the appendix or involved in the
mass of adhesions, if it is gangrenous, or infiltrated
with pus, or engorged with extravasated blood, so that
it looks like a piece of liver, I would always ligate
and remove it. I have done it for all of these condi-
tions, without in any way complicating the operation,
and I think it removes a source of considerable danger.

I have not spoken of the operation between the at-
tacks, because my own experience has been entirely
with acute appendicitis. In recurrent cases, I believe
most heartily in operating during the interval of quies-
cence, but I have had no experience of my own. in
two operations done during exacerbation, in cases of
recurrent or chronic appendicitis, I have, however,
seen conditions which I have found nowhere described
and which seem to me exceedingly interesting.

This first was in a boy thirteen years old, who in

the preceding four months had had several attacks of
appendicitis with very short intermissions, and who for
a month past had had a small hard tumor, very tender,
in the right iliac region. Each attack would begin
with pain in the region of the tumor, vomiting, and a
temperature rising to 101° or 102°. With rest in bed,
counter-irritation and careful attention to diet, each
attack would quickly subside, but the bunch had re-
mained. .1 saw the boy during one of these exacerba-
tions, regarded the case as one of localized abscess,
and, as he was a near relative of mine, I asked Dr. M.
H. Richardson, of Boston, to perform the operation.
He, too, was convinced of the presence of pus, bat ioei-
sioD revealed a hard mass of firm, tough adhesions,
which were separated so as to expose the csaonm, bnt
no pas and no appendix were found. The cavity was
packed with gauze, and healed without suppuratioD,
the boy regained his former health and strength, the
bunch entirely disappeared, and there has been no re-
currence during fifteen months that have passed. Id
October last I had an almost precisely similar experi-
ence in a Swede twenty-seven years old, who had
symptoms off and on for eight weeks, with a well-defined
tumor for at least a month. I operated in the midst
of an exacerbation, found no pus, and only a hard mass
of inflammatory exudation, imbedded in which was the
cscum. So firm were the adhesions that I did not
dare attempt their farther separation to search for the
appendix. The man made a good recovery and has
remained well. ,

These cases illustrate the difliculties that may be
met with in what promise to be the simplest opera-
tions, and they are especially interesting to me, because
I cannot understand the conditions which have caused
them, nor the apparently beneficial effect of exposing
and disturbing them.

With regard to the results in cases of appendicitis,
very little can, I think, be learned from any one indi-
vidual experience ; and until we have some accurate
method of classification, we can learn little from the
study of compiled statistics. Of my own cases there
were 12 not operated upon, 5 of whom died ; 4 were
in a condition which seemed to me to render operation
useless, and the 5th died from internal rupture of the
abscess. One of the cases that recovered, died three
months later from a recurrent attack. In the 32 op-
erations, there were 25 recoveries and 7 deaths. Of
the latter, five were from the continuance of general
peritonitis which was present at tbe time of operation,
one was from pysemia in a late operation upon a large
localized abscess, and one was after an operation done
for rupture of an abscess into the general peritoneal
cavity.

In the 25 cases that have recovered, I have as yet
had no rupture through the cicatrix of the wound. I
believe, however, that this is only because sufficient
time has not yet elapsed; that hernia will oome in
some at least, I feel perfectly sure. It must come,
especially in those cases where drainage has been used.
It is less likely to occur in the early operations where
drainage can be dispensed with, bnt even then it can-
not be wholly avoided. Some firm support ought
always to be worn for years after the operation, and
the thought that we are thus permanently weakening
the abdominal wall, and imposing upon a man a great
inconvenience if not positive danger, ought to make us
exceedingly careful to avoid unnecessary interference.

FsBcal fistula is another occasional sequel of opera-

Digitized by

Google

'oc. CXXX, No. 21.] BOSTON MBDIOAL AND SUBGIOAL JOURNAL.

513

.ion. I have had one fistnla that persisted for seven
noaths after the operation, bat has finally closed spon.
Eaneously. It was in a case of late operation, where
;he appendix conld not be removed, and the abscess
traa siaiply opened and drained. It is a great annoy-
ftooe to the patient and to the physician, but will al-
most Barely heal of itself, and rarely requires opera-
tive interference.

In conclusion, allow me to repeat that we can draw
no bard and fast distinction between those cases which
will require operation and those which will not. I
feel in almost as much doubt as ever each time that
ttie qaestioD is presented to me. There are one or
two points, however, that increasing experience has
impressed more and more strongly upon me, and they
are tbe only definite conclusions which I can present.
They are : (1) appendicitis is one of the most impor-
tant as well as one of the most dangerous of all acute
abdominal affections ; (2) that some cases are fatal
from tbe very nature of the initial attack; (3) that
some have a natural tendency to recover; but (4)
finally, that the great majority can be relieved only by
surgical interference, and that early operations are in
every way less difficult and less dangerous than late
ones. In tbe majority of cases, the presumption is in
favor of early operation, and unless distinctly counter-
indicated the earlier the better. A surgeon seldom
regrets an early operation, but is often disappointed
by delay.

PRIMARY NASAL DIPHTHERIA.*

BT CRA.KLBR W. TOWNSBND, H.D.

That nasal diphtheria is a severe and often fatal
disease, and that it is almost always secondary to diph-
theria in the throat, is the generally-received idea both
from practice and text-books.

Thus Dillon Brown, in Starr's "Text^Book of
Children's Diseases," jnst published, says; "In the
nares diphtheria is very serious, on account of the
abundant lymph and blood-supply," etc.

W. Oilman Thompson, in Pepper's "American
Text-Book of the Theory and Practice of Medicine,"
also just published, says : " Gases of nasal diphtheria
are apt to end fatally unless vigorously treated."

And J. Lewis Smith says, iu Keating's "Cyclo-
paedia of Children's Diseases": "Nasal diphtheria in-
volves great danger, from the fact that it is likely to
give rise to systemic infection of a grave type." Lower
down he says : "Althongh commonly diphtheritic in-
flammation of the nasal surfaces is secondary to that
of tbe fauces, it is sometimes the primary inflamma-
tion. It may exist for some days before the fauces
become affected, and under such circumstances the
diagnosis is frequently not made until tbe disease is in
an advanced stage and profound blood-poisoning has
occurred."

That mild primary cases sometimes occur, the mild-
ness of whose symptoms may. permit them to go un-
recognized, is a point I wish to emphasize, and particu-
larly the fact that these cases are of great danger to
the public health.

Dr. A. L. Mason* refers to these cases when he
says: "Primary nasal diphtheria is probably more

' Bead before the Boeton Society for Hedioal ImproTement, Marah
12, UM.

■ Burnett: System of Dlwasee of tbe Ear, Nose and Throat, vol.
l.».!no.

common than is supposed, and a not infrequent source
of unsuspected danger." Jacobi also alludes to them ;
and Major ' reports five cases very similar to those I
am about to relate. The latter says of nasal diph-
theria : " When of a primary nature, it is very likely
to be overlooked altogether." It seems probable that
some cases formerly supposed to be membranous rhini-
tis were in reality nasal diphtheria.

During the months of November, December and
January of this winter fourteen cases of diphtheria oc-
curred among the patients of the Children's Hospital,
all but two of which came under my charge in the iso-
lating wards.

The bacteriological examinations were made for the
hospitel by Dr. J. H. McColIom at the Harvard Medi-
cal School, and, it is unnecessary to say, were of the
greatest value.

There were seven cases where the nose was affected ;
in six cases the disease was limited to the pharynx ;
and in one case an old tracheotomy wound was
attacked, the disease spreading to the bronchi and
rapidly proving fatal.

The six pharyngeal cases I will pass over briefly.
They illustrate the well-known difiiculty and ofttimes
the impossibility of making a diagnosis of diphtheria
from gross appearances or symptoms. They were all
mild cases ; all recovered. One of the earlier cases
began with ooryza, and had a nose-bleed on the day
preceding the beginning of the throat affection ; and
although there is no positive proof of nasal diphtheria
from the absence of cultures from the nose in this
case, it is extremely probable, in view of the other
cases, that this one was originally nasal diphtheria,
and as such was overlooked.

Of the seven nasal cases of diphtheria, in five the
disease was primarily nasal, being confined to the nares
alone iu four, in one extending later to the pharynx
and larynx, while in the remaining two cases the dis-
ease was at first pharyngeal, and later involved the
nose. These last two oases represent the secondary
nasal forms more commonly seen, partly from the fact
that the diagnosis of the trouble in the throat having
been made, it is natural to suspect an extension to the
nose in case there is a nasal discharge, and to look for
membrane there, and partly because secondary nasal
diphtheria is usually a very severe disease.

The primary nasal cases are easily overlooked ; tbe
diagnosis frequently cannot be made without a bac-
teriological examination, and they are particularly
dangerous as sources of infection from these causes,
and from the fact that the bacilli may be retained for
a long time on tbe voluminous mucous membrane of
the nose after the patient has apparently recovered,
and may even at times elude the search of the bac-
teriologist, as some of my cases show.

Case I. A boy, four years old, began to have a
nasal discharge on January Sd. This increased on
the following day, but there was no rise of tempera-
ture, and tbe pulse showed no weakness. The nasal
discharge was watery and at times muco-pnrulent, and
was not offensive. On the third day of the coryza
careful examination showed some gray membrane in
each nostril, and a bacteriological examination demon-
strated the Klebs-Loffler bacillus. There were nose-
bleeds from time to time. The temperature, as will
be seen by the chart, remained between 99° and 100°

3 Diphtheria and Scarlet Fever at the Boston City Ho»pltal. Bal-
letln 4, Harvard Medical Sohool Auoolalion.

Digitized by

Google

614

BOSTOir MEDICAL AND SURGICAL JOURS AL.

[MiiT 24, 1894.

until the twelfth day of the disease, going once to
101°, the child feeling meanwhile well enough to be
up. Examinations by cultures taken from the nose

DAYS OF
iSONTH.

2 j

rra

4-

[^

7

*"

/

/9

//

/"*

/«r

/J'

DAYS OP
DISEASE.

n

/

V

A

•^

V

6

7

t

?

/#

//

/I.

107'
106'
105.

ro4.

103"
102'
101'
I00<
■99*

r*ur.

98<

KB

MBII

BK B

M B

M ^

M B

a. B

M*

H B

i/b

M B

M B

M B

>

r

V

i

;

4

ui
te.

\

<

3
H

'h

^

CC

%,

1

a.

2

.<^

/

^

5/

-

^

UI

1-

/

/

^

/

A

V"

-^^

Casb I.

by the platinum wire were made from time to time,
and the Klebs-LSfi3er baoilli were still found on the
thirteenth day, or three days after the temperature
had dropped. On the fifteenth day, the day following
the cessation of nasal discharge, a culture was taken
and no bacilli found.

The child was not allowed to go home until six
days later, or a week after the cessation of the nasal
dischar^^e, but the sequel shows he still retained some
of the Klebs-Lofiler bacilli in his nose. Shortly after
returning home, a servant, who had not been away for

are was at once taken from his nose, and the EHebs-
Loffler bacilli were found. On the following day a
little membrane was visible, and there was a watery
discharge from the nose. On the third day there was
apparently nothing the matter with him but a bad
coryza. No more membrane was seen, and tbe tem-
perature came to normal on the fifth day. On this
day the Klebs-L9£9er bacilli could not be found. No
subsequent cultures were taken, but it is probable
that the bacilli would have been found for some time
in his nose.

Cask III. A girl, seven years old, again illustrate*
the purely nasal forms. During the first week a
thick, glistening, gray membrane was plainly visible
in the nose, and the patient suffered from nose-bleed
twice. The Elebs-Loffler bacilli were found until
the fourteenth day of the disease, on which day the
membrane disappeared from sight. As will be seeo
by the chart, the temperature continued between 99"
and 100° for twelve days after the disappearance of
the membrane. She was not discharged from the hos-
pital until all signs of nasal disease had disappeared
and the last bacteriological examination was negative.

Two or three days after her return home her mother
was taken sick with diphtheria, recovered, but died
suddenly a week later with, as far as could be learned,
suppression of urine.

Cask IV. Girl, two and a half years old, began
with a cold in the nose, and at the same time some
white circumscribed pin-head spots appeared on the
tonsils, bat entirely disappeared within forty-eight
hours. The diphtheritic bacilli were found in these
apparently follicular spots, as well as in the nose.
Membrane then appeared in the nose, and there was

DAYS or
MONTH.

b

r

?

Vf

/6

w

/J.

F

w

/r

/A/;

/r

W

io

9J

XA

a

1^

Xsr

46

i>

AT

Ar

f\

P=1

3/.

/

i

sh

DAY* OP

DISEASE.

1

i.

a

V

4*

i

7

f 1

/•

;/

IV

l3

/<>

iS

A

1

/r

ft

i*

V

»2.

2J

Z9

%s

2i

27

K

a
cc

UI

a.

S

UI

I07<
l"o6"
105.
I04<
103'

lor

101"

I00<

99"

■MWI

mr.
98<

■ B

■ X

M B

K B

MX

«B

iia

M>

«B

ti

H X

iB

MB

M B

MB

M B

M ■

M B

MB

Ti

Ml

MB

Ml

M'B

MB

MK

M B

M B

MB

"

.

i

/

{

\l

I /

\l

V

V

\y

V

1

V

V

v

\l

\/

V

w

I i

,

, /

k

/

\ /

J

s^

V

V^

V

V

V

V

v

**^

^^

V

L

\/

s/

I .

^

V.

v

....,

px...

....

...V-

W

Case UI.

over three weeks, came down with diphtheria. That
the child's nose was the probable source of infection
was proved by the fact that the specific bacilli were
discovered there when he presented himself at the
clinic four weeks after his discharge from the hospital,
and over five weeks since his apparent recovery. At
this late date, however, a nasal dischare;e was present,
having started up after leaving tbe hospital.

Case II. A boy, four years old, was the mil lest
case of all. He was kept isolated in the main hospi-
tal, not coming under my charge ; and I am indebted
to the courtesy of Dr. Bradford for permission to in-
clude it with the others. The child began with coryza
and nose-bleed and a temperature of 101.3° A cult-

some sanguino-purulent discharge for a day or two.
After this the discharge was slight and muco-purulent
or watery, coming and going like an ordinary coryza.
At no time after the first three days could one have
made from the gross appearances any other diagnosis
than a coryza, as there was no membrane to be seen.
Except on one occasion, the Klebs-Loffler bacilli
were, however, found at every examination, which
was on alternate days, until the twenty-sixth day of
the disease, and there was some muco-purulent dis-
charge at intervals until the twenty-third day. The
temperature, as will be seen by the chart, started off
at firiit as if in correspondence with the apparent folli-
cular tonsillitis, and then ranged from the third to the

Digitized by

Google

oi.. C3CXX, No. 21.] BOSTON MEDICAL AND SUBQICAL JOURNAL.

515

lorteenth day between 99° and 100°, remaining nor-
tal after tLe fifteenth day.
Xhe palae showed bat little evidence of weakness,

> OF 1
TM.

.?• .A4

r

A

^

Ai

7

t

f

/«

//

/t

/?

>OF
KSE.

/ x-

A

V

J-

i

7

*

i.

/»

r —

<■!.

/J

^

if

\07>

MX

« I

KB

M ■

M K

M I

M B

MB

MB

MB

MB

M B

MB

Itl

MM

106*
105.
104.
103"
102-
101-

too.

^

1

I.

/

V

f\

99"

y

V

\

r

^

„/^

/

^

>->

ys

br

r

r—

/^

Lm

198.

'

CA8B ly.

except of an occasional slight nasal obstniction, the
child appeared perfectly well after the first foar days,
and at home would have been, if ttie diphtheria were
unrecognized, an active spreader of the disease.

For the sceptical, as to the valae of the bacteriologi-
cal method of diagnosis, the following case is of inter-
est, for its later violent coarse confirmed very fally
the early bacteriological diagnosis. This was the only
primary nasal case in which there occurred an exten-
sion of the membrane from the nose.

Cask V. A boy, six years old, said bis nose was

An examination of his temperature chart is inter-
esting. The child was in the hospital for a stifi knee,
and there was no active process going on there to
cause an elevation of temperature. It will be seen
that for a week before the first temporary nasal dis-
charge occurred the temperature was elevated about
100°. This is certainly suggestive of a begiuning of
the nasal diphtheria at this time. Another interesting
point is the normal and subnormal temperature for
three days following the appearance of the membrane
in the nose and the discovery of the specific bacilli.

The continued slight elevation of temperature be-
tween 99° and 100° seen in several cases when the
disease is confined to the nose is interesting. In the
following case this continued for a month after the
membrane had disappeared from the portion of the nos-
trils easily visible. With this temperature in bed, the
patients seemed to feel perfectly well. If they had
been about, they would very likely have shown evi-
dences of debility by feeling tired and irritable. The
early history of this case is very suggestive as regards
the " follicular tonsillitis."

Case VI. Boy, six years old, had an attack of
what appeared to be follicular tonsillitis on October
15th, lasting five days. No bacilli could be found.
On November 2d he again complained of sore throat;
his' tonsils were swollen and covered with white spots.
Again no bacilli could be found. A failure to carry
the wire to the bottom of the crypts may have ac-
counted for this, and it is possible that these were in
reality mild attacks of diphtheria. On November
20th began a third attack, apparently similar to the
others, but the Klebs-Loffler bacilli were found. This
time the spots coalesced, spread to the uvula, and pre-

i| oAvsor

MONTH.

3

y

6-

k

\J

>-

P^

ra

tt

/^

rs

/ft

/a-

n

ry

F

/f

U

Xf

^

is

PI

ls\i

ifiF

E

~"

CMva or

II DISEASL

.

0

^

.

UJ
K

ce.

UJ

a.

z

UJ

1-

10?
106'
lO*).

MX

M B

M B

MB

MB

MB

MX

MB

MB

MB

MS

M I

MB

M B

MX

MB

MX

1

MB

MM

MB

MM

M BM

pMB

M*

'wi

«

i

1

^

ve

;>

<

.

«

'

i

I04<
103'
\0T
IOC

100.

Jit
98<

S

X

^

s

«

t

J
/>

d

i

.«

,

1

' -'

1
>

r

w

^

*

[/

1'

3

/

1 /

/

V

J

s/

A

J

\J

V

\J

/

V

/

■ 1

\/

V

V

V^

V

\t

\i

V

\/

. y

Ok^

I

sJ

/.

\/..

V.

V.

Y.

V

\J..

\J.

"S

d

^

..„.

....i

V-

V

OASB y.

sore 00 January 12th. There was a slight discharge
at this time, which dried up in a day or two, and noth-
ing was thought of it. Seven days later he had a
nose-bleed, and on the following day glistening white
membrane was discovered in one nostril, and a nasal
discharge began. An examination on this day showed
the Eleb8-Ld£9er bacilli. Two days after the mem-
brane appeared it spread to both nostrils, and again two
days later both tonsils and the posterior wall of the
pbarynx were rapidly covered with the membrane.
Again, two days later, evidence of laryngeal infection
vas shown by the croupy cough; and although intuba-
tion was performed by Dr. Gioldthwait, the patient
died on the following day.

seated the clinical appearance of diphtheria. A week
later the membrane was seen in the nose ; bat it dis-
appeared from there on December 7th, and from the
throat on December 16th. A slight nasal discharge
contioned at intervals, and the bacilli continued to be
found in the nose for a month after the membrane
ceased to be visible. The temperature ranged from
100° to 102° for the first three weeks of the disease,
and from 99° to 100° daring the last three weeks,
during which time no membrane was visible.

The child was discharged from the hospital appar-
ently well over a month after membrane had disap- '
peared from sight, and nearly a week after a bacterio-
logical examination failed to find the Elebs-LSfller

Digitized by

Google

516

BOSTON MBDIOAL AND 80BOJOAL JOUSNAL.

[Mat 24, 1894.

bacilli. The terrible bacilli were still concealed in his
nose, however, and would andoubtedly have been dis-
covered if he had been retained longer in the hospital
and more examinations had been made. The lapse of
a month since the disappearance of the membrane, his
apparently complete recovery, as well as the fact that
the last bacteriological culture was negative, served to
justify his discharge. He was given an antiseptic
bath and a complete change of clothing.

Eight days after his return home to a neighboring
town the child's sister developed a violent case of
diphtheria, the membrane spreading to the nose, roof
of the moath, pharynx and larynx, and proving fatal on
the tenth day. The mother and older sister also con-
tracted diphtheria and recovered. There had been no
cases of diphtheria reported in the town for two months
before this, and but one since. The parents had not
visited the diphtheria wards at the hospital for five
weeks before the little girl's sickness.

It would seem as if the boy from whom these cases
spread had acquired an immunity from the effects of
the disease by the length of time in which he harbored
the bacilli. That the virus had not become attenuated
by its long stay in this individual was proved by the
virulence of its action in the fatal case.

Case VII was of the usual type of secondary nasal
diphtheria. The patient was already very sick with
surgical sepsis, which obscured the symptoms of diph-
theria. The case proved fatal.*

All but one of the nasal cases had nose-bleed, slight
or severe, at some time in the course of the disease,
often when no membrane was visible. Only two of
the others had nose-bleed, and in one of them, as I
have already remarked, nasal diphtheria is strongly to
be suspected. A swelling of the cervical glands in
these cases was not noticed.

The source of these cases of diphtheria it is not diffi-
cult to trace, as there had been free intercourse between
the patients at different times. The habit of picking
the nose, so common among children, must furnish an
easy method of infection.

By way of summary, the following points seem to
me to be of interest :

(1) The fact that primary nasal diphtheria may
occur of a very mild type.

(2) The dangerous character of these cases, as they
are likely to go unrecognized for the following rea-
sons:

(a) The resemblance of these cases to ordinary
coryzas, a membrane not being noticed in some cases
except by careful scrutiny.

{b) The normal or only slightly elevated tempera^
ture often present, with but little constitutional dis-
turbance.

(c) The intermittent character of the nasal dis-
charge, absent for several days, and then starting up
again.

(d) The apparent recovery, even with cessadon of
nasal discharge, while Elebs-Lofiler bacilli are still
present.

(«) The fact that these bacilli have not lost their
virulence ; or, in other words, the fact that the patient
having the bacilli in his nose, although apparently
well, may transmit the disease in a fatal form to others.

(J) The difficulty of always finding the bacilli in the
nose, even when they are present.

* Slnoe going off doty onFebriunr 1st fiT* oum ot diphtheria
bave oceorred at tba hoepital, fonr beug ot the mild nasal type.

(3) The importance of bacteriological examinations
in all suspicious cases of nasal discharge.

(4) The importance of prolonged isolation, together
with a refusal to consider a case cured until teverd
consecutive negative cultures have been obtained.

A CASE OF AM(EBIC DYSENTERY.'

Br C. F. WITaiSOTOX, m.d., boxbcbt, kass.

The patient, Olaf Nilson, was a native of Norway,
aged thirty-four years, unmarried. He gave his occu-
pation as that of a longshoreman, and seems to have
done various sorts of work about the wharves in
several seaport cities of this country. When more
distinctly maritime occupations failed, he had, among
other things, tended bar.

For the six months prior to the middle of February
he had been in the South, the first half of the time (or
a little more) in Pensacola, the rest of it in Mobile.
He had also worked for a while in one or both of these
cities on previous occasions.

Up to two weeks before entrance to the hospital he
avers that his health has always been perfect, except
that he had measles in childhood and occasional bead-
aches since. Yet, as he expressed himself, up to the
present illness, nobody had ever been stronger and in
better health than he. His mother died of dropsy,
and a brother of the *' falling sickness " ; three sisters
and two brothers are alive and well.

Coming, then, from Mobile to New York, he was
suddenly taken about the time of his arrival with
chills, which have recurred since. He thinks he has
been feverish, and diarrhoea appeared coincidently
with his first chill. At present he says he has about
ten movements a day, which is not as many as he had
at first. The stools have been dark-brown and bloody.
He has lost weight rapidly. Pain is not complained
of.

On his entrance to my service at the City Hospital,
March 1st, I found him a man of large frame, a good
deal emaciated, with a dusky face; temperature,
97.5°; pulse 116, fair quality. Examination of liver,
heart and lungs was negative. There was slight ab-
dominal tenderness. The splenic dnlness began at the
seventh rib, but the margin was not felt. He had the
odor characteristic of chronic diarrhoea, and seemed a
very sick man. The movements were ten to twelve
in the twenty-four hours, and were not involuotary
The stools were fluid and smooth, about the consist-
ency of thin cream, of a reddish-brown color, and of
not an unusual odor. There was no mucus nor masses
of bright red blood ; and in these respects the stools
did not present the appearance of the common type of
dysenteric colitis.

A specimen was therefore sent to Dr. Councilman for
examination for amt^ eoU, and its discovery was at
once made by him.

The patient was treated at first by a dose of oil, fol-
lowed by starch and laudanum injections, and as soon
as the presence of the amceba was reported the lauda-
num enemata were replaced by rectal douches of
quinine (gr. xvi in a pint of water). They were, bow-
ever, retained but a short time, and no improvement
was observed from their use. The patient failed
steadily, and died in the night of March 3d, about

> Bead before the Boston Society for Hedloal Improvement,
March 12, ISM.

Digitized by

Google

Vol. CXXX, No. 21.] BOSTON MSDICAL AND SVR6I0AL JOVBNAL.

517

geveDteen days from the beginning of hi8 illuess, if hi8
hiatory of the invagion i8 correct.

The temperature remained generally subnormal,
only once reaching 99° ; and the regpirations gradu-
ally quickened toward the end.

Cltmcal aDepartment.

SCARLATINA WITH PERSISTENT HIGH TEM
PERATURE, ASSOCIATED WITH WILD DE-
LIRIUM, FINALLY CONTROLLED BY GUAIA-

COL.

BT rSADK B. PBCKHAM, X.D., PBOVIDBNCB, B. I.

Thkbb were four children in the family, none of
them having had scarlet fever, and the manner of in-
fection could not be learned in this case.

The eldest child, age seven years, came home from
school one night feeling badly and complaining of
nausea. The next day there was vomiting and com-
plete loss of appetite. On the third day, there being
no change for the better, I was called in the evening.

The child at that time was lying quietly in bed, and
the nausea was not so troublesome. The skin was
povered with a mild eruption of scarlet fever. Throat
slightly reddened. Farente had not noticed the erup"
tion before, so the time of ita appearance is unknown.
Treatment : aconite, warm-water sponge-baths, liquid

diet.

Fifth Bay. — At the morning visit the eruption was
well marked all over the body. Child had been very
restless and delirious all night. Tonsils enlarged and
covered with grayish membrane. Temperature 105°.
Treatment: cold-water sponge-baths, phenacetine (grs.
iii every three hours), tincture ferri chloride (gtu. v
four times daily for local effect), peroxide-of-hydrogen
(15 volume) spray for throat and nose.

At the evening visit the temperature was 106°.
Child wildly delirious. Facial expression very bad.
Treatment: tub-baths now ordered, beginning with
warm water, and gradually cooler, until the water was
just as cold as it came from the faucet, which in
March is pretty cold. The first bath lowered the tem-
perature to 104°. The child enjoyed this and subse-
quent baths very much. The eruption became more
and more marked, until the whole surface of the skin
seemed to be raised above its usual level in one red-
dened, scarlet mass. The temperature rose again
soon, and the parents had a hard night of it keeping
the patient in bed. Chloral was given in five-grain
doses up to fifteen grains. The subsequent baths
through the night made no impression on the tempera-
ture. It would be 105° immediately after removal
from the tub.

The temperature was always taken in the axilla,
being, of course, much higher in the mouth or rectum.

Sixth Day. — At the morning visit the temperature
was 105.5°. Lips parched. Eyes sunken. Child
looked badly. The throat was clean, but red, swollen
and angry-looking. The child in her delirium was
constantly tossing around, and had to be held all the
time.

Baths were continued. Phenacetine increase^ to
six grains every three hours. Chloral used per rec-
tum through the day, but when evening came I found
the temperature 106°, and child looking like death.
It seemed impossible for her to live until morning.

At this visit I rubbed tweuty-five drops of guaiacol
into the skin over the abdomen, and in two hours the
temperature bad dropped to 104°. In the night fifteen
drops more were rubbed in, and at the morning visit
on the

Seventh day, the temperature was 103.8°. Child had
been delirious all night, but not quite so wild — a very
slight improvement, which let in a small ray of hope.
During the day fifteen drops of guaiacol were to be
rubbed in. Phenacetine omitted. The tub-baths were
continued. The evening temperature was 108.8°.

Eighth Day. — Patient not yet rational, but more
tractable. Throat looking a great deal better.

Ninth Day. — The eveuing temperature was 101° ;
and the child had had a little refreshing sleep and
looked a great deal brighter. Guaiacol now discon-
tinued.

Tenth Day. — Temperature up to 108°, due un-
doubtedly to the discontinuing of the guaiacol ; but
the patient is really rational, and can talk reasonably
for the first time. Scales appeared to-day.

From this time the temperature gradually fell, until
on the fifteenth day it reached 99°.

The tonsils now became troublesome. First an
abscess developed in the left tonsil, with the swelling
externally. This was opened by an external incision
on the twenty-sixth day of the disease. Then an ab-
scess formed in the right tonsil, which was opened ou
the inside on the forty-third day. After this there
was no further trouble ; and my last visit was on the
forty-seventh day, when scaling had ceased. Patient
was out-of-doors in the eighth week.

T report this case to show that guaiacol may be of
great use in the acute febrile diseases. It has been
tried in typhoid fever, and found to be rather danger-
ous ou account of depressing the temperature too far
and causing collapse.

In this case there was a very high temperature ;
and it seemed to me that the delirium was wholly due
to that, and as soon as the temperature began to
yield the delirium began to subside.

The fact that the temperature rose immediately
after stopping the guaiacol would seem to prove that
it was really due to the drug, and not a coincidence.

Another interesting point was that the cold tub-
baths had so little influence upon the temperature.
These baths were enjoyed immensely by the little
patient, who would quiet down and paddle in the
water even when the delirium was at its height.

The three children in the family who were not
affected were sent away, and did not return until the
house had been fumigated; and up to the present
time they have been perfectly healthy.

fll^^ical t^cogrej^jf.

REPORT ON MENTAL DISEASES.

BT HBNBV B. STBDMAS, M.D., BO8T0H.

(Conolnded from Mo. 20, p. 49S.)

CASK OF ANTIFTBINOMANIA.

Cafpkllbtti* reports the case of an hysterical girl
of twenty-three, weak and nervous. Headache for two
years, treated by antipyrin in small doses. Drug be-

• BiTlstaSporlmeutsle di frenatrla, zlz, 100.

Digitized by

Google

618

BOSTON MEDICAL AND SVSGICAL JOVBSAL.

[Mat 24, 1894.

came necessary to her. The pain became incessant,
and the drug lost its efiect. The dose was increased
to eight grammes a day. She grew worse ; lost her
appetite; had poor sleep; and the pain grew worse,
with tinnitus. She became excited, irritable and
anxious half an hour before the time for dose. Was
agitated, walked about, sighed, etc., if not given it.
Carried it in her pocket. Diarrhoea and convulsions
ensaed when attempt was made to stop it wholly. In
the asylum the dose was cut down to two grammes,
with sulphonal to relieve pain. She then had nausea,
vomiting, anorexia, pallor, small pulse, and was much
depressed. This lasted three days, and was not re-
lieved by food and stimulants. She then became
slightly excited, restless, loquacious and irritable.
Given bromide of potash up to six grammes, and vale-
rianate of quinine, but had bad symptoms set in when-
ever antipyrin was cut down, with weak pulse, mental
depression and hallucinations, etc. Then inert powders
were given, the antipyrin was wholly stopped, and
caffeine and bromide of potash substituted ; finally
these were cut down ; and she at last recovered.
Slow and progressive diminution of symptoms. The
symptoms from withdrawal were much like those from
withdrawing morphine.

MENTAL CONFUSION.

Dr. Charpentier,'* under this title describes a mental
state characterized by perturbation in the ideational
sphere, consciousness, absence of delusion, and coexist-
ence of inquietude. Often it cannot but be considered
as an almost physiological state resultant on passage
from slumber to wakefulness in all adynamic states or
cerebral congestive conditions. It may appear at the
onset of many psychoses as well as among chronic ve-
sanias and epileptics. In all cases, however, the con-
comitant psychic phenomena (hallucinations, amnesia,
stupor, mutism) mark the picture of mental confusion.
It may exist alone, and constitute by its duration, a
true pathological state. It is a rapid, disordered pro-
gress of ideas before coDscionsness, preserved, but as-
tonished and restless. The ideas are not erroneous
but so varied and tumultuous in their course and so
numerous that their numbers and disarray confounds
the patient, who, incapable of directing his ideas al-
though preserving his consciousness, falls into pro-
found inquietude. Mental confusion has been styled
obvilutation, torpor, hebetude, intellectual vertigo and
ideational chorea. What renders the case difficult is
the fact that the patient renders an exact account of it
only when cured. Furthermore, they are apt to ana-
lyze the mental state they have experienced, and for
the patient merely to describe this mental state does
not suffice to reproduce it.

How can, therefore, mental confusion be determined
in a patient who does not complain of it ? Dr. Char-
pentier states that answers to simple terse questions
(age, birthplace, colors) will indicate presence of atten-
tion bnt may appear incoherent because of rapid idea-
tion. UsuaJly the patients seem stupid. This is often
the case with young female dyspeptics. Often mental
confusion occurs in the morning after an insomnic
night, a slumber too profound and prolonged or con-
secutive to excess. The patient appears lost; acts
without will or without taking account of his acts.
Mental confusion among the insane is found chiefly
among the acute confnsional lunatics or the convales-

» Rev. Internt. de Bibllo. Med., Janoarr 26, U9S.

cent ; when it exists among these last they cannot be
regarded as cured.

Diagnosis is only made after recovery. Mental con-
fusion should be distinguished from temporal mental
enfeeblement of intoxications or infections (in these
last there is a parallel enfeeblement of conecionsness
or absence of inquietude) : from stupor (mutism, loss
of consciousness of surroundings) and from vertigo
(loss of consciousness and from involuntary movements).
Mental confusion of prolonged or frequently recurrent
type has a bad prognosis. It occurs in paretic de-
mentia, chronic persecutioual vesanias and precocious
dementia. It may be produced by suggestion, intimi-
dation or surprise.

DIFFEBBNTIAL DIAQN08IS BETWEEN LITIOIOUSNBSB
IN THE SANE AND INSANE.

Dr. Ludwig Home,*' after a careful review of the
literature of the subject arrives at the following con-
clusions :

(1) An amnesis reveals nothing of importance in
sane litigants ; in the qnernloas paranoiacs a heredi-
tary taint, peculiarities in childhood and after-life.

(2) The sane litigant shows no abnormal somnatic
symptoms ; iu the paranoiacs, somatic symptoms are
seldom absent.

(3) The motives in sane litigious people are pleas-
ure in law suits, or the desire to obtain a final decision
in a particular point of law ; in the insane, the motive
lies in an hereditary defect — an inability to submit to
an unfavorable decision.

(4) Characteristics of litigiousness : (a) The sane
litigant maps out his course of procedure; the para-
noiac believes it impossible to lose his case, and does
not plan beforehand, (i) The sane litigant will not
go beyond a certain point, decided upon in the begin-
ning ; the paranoiac does not limit himself, (c) The
sane litigant can end his trial at will ; the paranoiac
is drawn into new trials by his disease.

THE FUTDRB OF A8TLCM SEBTICE.

Under this head A. Campbell Clark,>^ Medical Su-
perintendent of Glasoow IMstrict Asylum, Bothwell,
Scotland, says :

" Where are the defects of the nursing staff and its
work ? A. The defects of our nursing staff are three-
fold: defects of (a) quantity, (i) quality, and (e) or-
ganization. B. The defects of nursing work are
the natural results of the foregoing, but they are also
due to (a) large wards, (i) lack of personal co-opera-
tion of superior officers, (e) the same monotonous
grind from week to week. The present number of
nnrses for acute and curable cases is too small, the
hours of duty are too long, and they are not officially
attached to particular cases. The remedy is, a larger
staff, give much longer leave, and you can have a
larger per cent, of nurses on duty.

" As regards the question of quality, that we want
more style and higher education is a delusion most dis-
astrous for asylums. Placed in the balance against a
bright, sunny temper and obliging disposition, mere
education would be found wanting. Sunshine in our
attendants is dependent upon sunshine in their sur-
roundings. In a word, don't keep them so long in
hanvBss at a time, feed them well, groom them well,
make them as healthy and happy as the nature of their
work will allow.

>i Man. Med. Bloet, No. 46, 1S9S.

" American Jonrnal of Innnlty, Jannaij, U94.

Digitized by

Google

Vol. CXXX, No. 21.] BOSTON MEDICAL AND SURGICAL JOURNAL.

619

" Organization : In the first place, the night super-
visioD and nnrsing of the insane is wofully insufficient.
We cannot hare short watches as on board ship, but
with increased numerical strength, we can assign for
night duty a larger staS with a sopervisor or chief.
Make night service longer and day service shorter, bat
break the night service in two parts, with one hour's
suspension of dnty between. In small asylums it
would be the duty of the supervisor to relieve the
subordinates in turn. In large asylums a relieving
officer would be told off for duty. The leave of the
day staff should be much more liberal than at present.

" The patients should be detailed in small groups
for special written observations ; each nurse should
have a group. Nurses should exchange groups every
three months, so that fresh interest is continually kept
up, and the patients come under new influences.
Change patients from one ward to another oftener
than is done at present. Have medical officers and
supervisors more in the wards collaborating with the
nurses."

The writer recommends the formation of a mental
nursery association, and a provident or pension scheme.
If linked together under the patronage of asylum
boards of management, they can only be followed by
decided success.

GENERAL PAKALY8IS AT PUBEBTT.

Dr. J. Wiglesworth ** records two cases occurring in
girls at twelve and fourteen years, proving fatal at six-
teen and eighteen years, respectively. Both previously
intelligent. Both said to have started from a fall; this,
however, may have simply been an early symptom.
Mental symptoms, those of slowly progressive dementia
without grandiose ideas ; soon grtidual failure of men-
tal power, followed by slow progressive paresis of
limbs, until absolutely paralyzed and contractions de-
veloped; epileptiform convulsions noted in each.
Necropsy showed thickening and opacity of arachnoid,
with adhesions of pia mater to cortex (in one case de-
cortication) ; enormous wasting of convolutions, great
atrophy of cortex ; whilst in one was an old, thick,
organized, subdural membrane. Analysis of these
cases and six others published showed the average age
at which the disease commenced to be fourteen years,
average duration four and on'e-half years. Five of
the eight were girls, a reserve proportion to that shown
in adult paralysis ; mental symptoms showed prepon-
derance of demented type of general paralysis ; signs of
puberty did not appear at all or were arrested and
tended, to disappear ; menstruation in females, absent ;
and arrest of bodily development

The most prominent probable factors in the produc-
tion of the disease were heredity and congenital syphilis ;
traumatism being, perhaps, an additional cause in some
cases.

" THE 1N0BBA8E OF INSANITT."

Under the head of " The Alleged Increase of In-
sanity," D. Hack Tuke ^* presents a critical analysis of
.the statistics of insanity in Great Britain for the last
twenty years. He gives the arguments and facts on
the affirmative side, as presented by Mr. Corbet (in a
forcible article in the Fortnighdy Review) and others,
and follows with his own reasons for denying the al-
leged increase in insanity. His principal points are
thus summarized :

" Britiih Medioal Journal, Haroli, 1883.
14 jonrul Mental 8«ieiMM, April, UM.

There has undoubtedly been since 1870 a large in-
crease in the number of patients in asylums and work-
houses, but proportionately more in the former than in
the latter.

There has not been so great, but still a considerable
rise, in the etdmittiont of patients into asylums during
the same periods, after deducting transfers and read-
missions.

The advance in the number in detention, although
it holds good after allowing for the increase in popula-
tion, does not prove the increased liability of the com-
munity to insanity, seeing the vast accumulation due
to a lower death-rate (even since 1870), the chronicity
of the disease, and the lamentable tendency to relapse.
The advance in admissions again does not prove in-
creased liability to insanity ; as (a) the value and com-
fort of asylums are increasingly appreciated ; (b) there
has been a very large number of patients drafted from
workhouses to asylums ; and (c) there has been an
ever-increasing encroachment on the mass of unregis-
tered lunacy which the census shows to exist.

The increase in the number of the insane has taken
place among the poorer classes of society.

The increase in the ratio of the insane during the
twenty years between 1871 and 1891 has taken place
in persons above the age of forty-five, the significance
of which lies in the accumulation of chronic cases. On
the other hand, there has been a decline during this
period in the proportion of cases of mental weakness
under twenty-five years of age to the population at the
same term of life — a most important circumstance.

The age-distribution of the insane favors, therefore,
the conclusion that the increase of insanity is apparent
rather than real, being mainly due to accumulation.

That, considerable as has been the increase in the
number of the insane, as returned in the censuses of
1871, 1881, 1891, the ratio of inorease has been a de-
clining one ; for although the rise in the ratio to the
population was 7.04 per cent, during the decade of
1871-81, it was only 3.23 percent, in that of 1881-91.
If these results are, on the whole, reassuring, they
are, it must be admitted, nothing to boast of- because
twenty years of social progress and the advance of
medical knowledge ought to have materially lessened
the proportion of the insane to the population.

The lesson to carry away from a study of the fore-
going statistics is not one of congratulation, but the
necessity for making more earnest and definite attempts
to diminish the causes of insanity, and to discourage,
by every possible means, the extension of the disease
by the marriage of individuals of insane stock or who
have themselves been deranged in mind, impracticable
as I believe it to be to obtain this object by legislation.
F. B. Sanborn,^' in an article in the same journal,
finds, on the other hand, that American insanity is
greatly increasing, at least so far as the statistics of
the insane in Massachusetts hospitals are an indication.
Formerly it was held that the accumulation of the in-
sane greatly in excess of the growth of the population
was due partly to better care by which life bad been
prolonged ; partly to better observation, bringing
cases to light that were overlooked ; finally, to stricter
classification of diseases, allowing wider limits to in-
sanity. All these agencies may be allowed up to a
certain point ; but we long since reached that point in
Massachusetts, probably, too, in England and Scotland.
Still we find this insane accumulation going ou as fast

u Joorual Medioal Seieucee, April, UM, p. 211.

Digitized by

Google

520

BOSION MEDICAL AUD SVBGJCAL JOVRHAL.

LMat 24, 1894.

as fifty years ago, and in the face of inflaences that
oaght to yield just the contrary result. He believes
that this can only be accounted for on the hypothesis
that " occurring insanity " (new cases) is also increas-
ing beyond the population ratio. Starting from the
premise that the insane die faster than the sane, he
shows that they should relatively diminish just as a
feeble race relatively decreases among a sturdier race.
Even if they did not recover often, the insane should
decrease by virtue of a greater death-rate, unless a
constantly iocreasing number of fresh cases neutralizes
the effect of speedier death. But if both the surviving
insane and their deaths increase in number steadily
(as with US they do), must there not be an increasing
source of supply, namely, new cases ? In Massachu-
setts we have a reasonably exact registration of the
insane, which shows the first admissions to anff kotpi-
tal, and also the number resident in all, the recoveries,
deaths, and discharges without recovery. During the
past fifteen years the population of the State increased
from about 1,725,000 in 1879 to 2,500,000 in October,
1893. Thus, while the population only gained 45 per

theria. Within a fortnight in the general wards at
the City Hospital have occurred three cases o( that
kind in patients convalescing from other diseases, one
typhoid, another rheumatic fever and a third poen-
monia. They developed sore-throats of the mildest
type with reddening of the pharynx and fauces but do
membrane, no discharge from the nose. In all three
cases the Klebs-Ltiffler bacillus was found, no appear-
ance whatever otherwise indicating diphtheria. Should
we feel obliged in the present state of kuowiedge to
class such cases as diphtheria, and have them isolated
at once and treated in the diphtheria wards? I tbiuk
that we must do so. Whether there is another bacillus
morphologically identical in appearance with the Klebs-
Lofiler bacillus I believe is still an open question.
These three cases were transferred, I must say with
considerable compunction on my part, to the diphthe-
ria ward, where they were isolat^ so far as possible.
They developed no other symptoms and got well in a
few days. If the bacteriological test is decisive we
can never feel safe in the treatment of cases of pha-
ryngitis or sore-throat of any kiud without it. The

cent, in that time (or less), the strictly first admissions | temperature in these cases was but slightly raised.

to any hotpitcU — not merely the one making the re-
turn— increased from 849 to 1,617, or about 100 per
cent. ; and the deaths in all the hospitals and asylums
of the State increased nearly 130 per cent. The resi-
dent insane in these establishments have increased
about 94 per cent, or nearly doubled ; while the unre-
covered insane discharged or transferred each year
have exceeded the recoveries and deaths put together,
and fully account for the noany recommitments in the
whole period covered by the statistics [the figures are
given in a table]. The presence in Massachusetts of
the unrecovered insane that makes the steady accumu-
lation of the chronic class possible and indeed inevi-
table, while the strictly first admissions (nearly 18,000
or 1,200 a year) have prevented the deaths and recov-
eries from checking in the least the rapid increase of
cases new or old.

Heport^ or Jbwittitfi.

BOSTON SOCIETY

FOR MEDICAL
MENT.

IMPROVE-

JOHM T. BOWEir, U.I>., BBCBETABT.

Regular Meeting, Monday, March 12, 1894, the
President, Db. C. F. Folsom, in the chair.
Dr. W. F. Whit.vbt read a paper on

CIRSOID MTXO-NKDROMA OF THE TONGUB, ILLDS-
TRATED BT LANTERN SLID KB.

Dr. C. W. Townsend read a paper on

MILD FORMS OF NASAL DIPHTHERIA.*

Dr. a. L. Mason : It seems to me that there are
two classes of cases which especially interest us in this
connection. The first comprises those with membrane
in the throat and all the aspects of diphtheria, but in
which the specific bacillus of that disease is not found.
It is the part of prudence to treat such cases as if they
were diphtheria. To the second class belong the mild
cases to which Dr. Townsend refers ; and the question
arises whether from the discovery of the Klebs-Loffler
bacillus, in the absence of all visible signs of diphthe-
ria, we must regard and treat such cases always as diph-
> See page 513 of the Jopmal-

Dr. J. H. MoCoLLOM : I have been very much in-
terested in Dr. Townsend's paper, and I think the
point he makes of mild cases of the disease is very im-
portant, for there can be no doubt that these mild cases
are the cause of the prevalence of diphtheria in this
community. The various cultures from the Children's
Hospital were interesting from the fact that in a large
number of cases guinea-pigs were inoculated, and in
the majority of instances the pigs died in from twenty-
four to forty-eight hours, showing clearly that we were
dealing with a virulent form of the Klebs-Loffler bacil-
lus. So far as a bacillus morphologically similar tu
the Klebs-Loffler found iu the mouths of healthy indi-
viduals is concerned — the pseudo-diphtheritic bacillus,
as it is termed — I am inclined to think that too much
stress is laid upon the existence of this organism ; for
after examining the coltures from 250 throats, I have
not found this bacillus. I have iu mind the case of a
patient who was ill with undoubted diphtheria. The
membrane disappeared after four weeks, but a nasal
discharge continued from which a culture was made
which was found to contain the Klebs-Loffler bacillus.
From this a pure cultute was made and a guinea-pig
inoculated ; and the pig died with every indication of
death from diphtheria. One week later a second
culture was made, and no Klebs-Loffler found. This
case had lasted for six or eight weeks, and all this time
the individual might have been a source of danger to
the community. Fortunately, however, the person
was isolated ; but in certain localities he would have
gone about and spread the disease. Only by means of
a bacteriological investigation could the date of his re-
covery be established. Another case iu point is that
of what was supposed to be, by the physician iu attend-
ance, a case of follicular tonsillitis ; but a culture from
the throat revealed the presence of the Klebs-Loffler
bacillus, the virulence of which was demonstrated by
its effect upon a guinea-pig. The patient was isolated,
which would not have been the case if a bacteriological
examination had not been made. It seems to me that
the attempt to throw discredit on bacteriological ex-
aminatious of the throat by the theory that there is a
bacillus morphologically similar to the Klebs-Loffler
bacillus found in the throats of healthy individuals, is
calculated to do much harm.

Digitized by

Google

Vol. CXXX, No. 21.1 BOSTON MEDICAL AITD SURGICAL JOURNAL,

521

In two or three of the Cftses to which allusion has
. been made by Dr. Townsend it is to be regretted that
so few cultures were made, for it seems to me that two
negative cultures made from the throat of a patient
who has been ill of diphtheria are not sufficient to prove
that he has entirely recovered from the disease, and
that he is no longer a source of danger to the com-
munity. I think there should be at least four negative
cultures made at intervals of two or three days, before
we are justified in saying that the individual is no
longer a source of danger of contagion. While by
this means a patient may be isolated longer than seems
to be absolutely necessary, yet it is only by these long
periods of isolation that we can ever hope to accomplish
anything in stamping out diphtheria.

It has been said that sometimes, even in a marked
case of diphtheria, the Klebs-Loffler bacillus is not
found; but if the culture is carefully made, and par-
ticularly if the precaution is taken to pass the needle
throogh the membrane or under it, the chances of a
failure to obtain a culture of the bacillus are so slight
as to be worthy of very little consideration. Another
point to which Dr. Townsend alluded is that of early
diagnosis. There have been several instances in which
cultures made from the throats of persons exposed to
diphtheria have been found to contain the Klebs-Loffler
bacillus before the appearance of any local or general
symptoms. The importance of this early diagnosis,
so far as treatment is concerned, is manifest.

Db. H. C. Ebnst : I do not know that I have any-
thing to add. The work Dr. MoGoliom has carried
on I have watched with great interest. I think some
extremely important results are to be obtained from it
when completed. The results thus far seem to show
that about ten per cent, of the cases submitted to the
laboratory for examination are true diphtheria. As
to obscuring the diagnosis by the so-called pseudo-
diphtheritic bacillus, I am inclined to believe that its
occurrence is not sufficiently frequent in clinical work
to produce any confusion. I have been very much
interested in hearing the cases by Dr. Townsend, and
I think this is a question that comes home to all prac-
titioners of medicine, i am very glad to see it brought
up.

Db. W. T. Coukcilman : I had an opportunity on
Saturday of examining anatomically one of the cases
of nasal diphtheria. My attention was especially at-
tracted to the nose by the presence of small excoriations
on tbe surface of the skin around the nose, which were
covered with a dirty grayish membrane presenting
very much tbe appearance of a diphtheritic membrane.
Tbe edges of the nostril were slightly excoriated and
had the same membrane on them. In the nasal pas-
sages on the mncons membrane there was exactly the
same diphtheritic membrane which we find in the pha-
rynx. In the pharynx there was no extensive forma-
tion of membrane, although on the tonsils here and
there and on the posterior pharyngeal wall there were
some very small patches of membrane, but the most of
the membrane was on the roof of tbe pharynx and ex-
tending from there into the nasal cavities and especially
on each side of the vomer, and it had also extended far
np into the upper turbinate bones. The diphtheria
bacilli were found in cultures made from the excori-
ations around the nostrils and also in the membrane of
the nose.

Dr. M. Prince : I should like briefly to mention
an epidemic of diphtheria which occurred some years

ago in some of the homes for children in this city, and
which I had an opportunity of investigating. If I re-
member rightly there were 50 to 60 cases of diphthe-
ria. These cases were divided up by the doctor in
charge of the homes into three classes, and each class
was in a room by itself. In one room all those that
showed no membrane in tbe throat and that showed
simply symptoms of coryza ; and in another room all
those with membrane, but mild cases ; and in the third
room the malignant cases. In these days we had no
t^st, of course, as this one of determining whether they
were diphtheria ; but there was one piece of evidence
which showed that these nasal cases were diphtheria,
that is, every day some of those children with the nasal
discharges came down with membranes in the throat
and would be transferred to the room of children with
membranes. That experience impressed me then with
the frequency of the nasal form, and how difficult it
was to distinguish the mild cases. I have been im-
pressed with the numbers of these mild cases that exist
in tenement-houses. I would also mention an epidemic
of diphtheria started in Nantucket by a case of diph-
theria in a physician who was supposed to be well and
went to Nantucket and gave rise to an epidemic.

Dr. E. M. BacKiNQHAM : In connection with tbe
case of mine that Dr. McCollom reported, I should
like to add that while coryza lasted many weeks, yet
within a short time of the disappearance of the bacilli
there was marked diminution, and the boy soon got
well. With reference to nasal diphtherias I should
say there are a number of nasal diphtherias that are
not very sick, just as there are a number of tonsillar
diphtherias not very sick, but I should mark the dis-
tinction between those that are sick, and those not
very sick, not so much on the line between primary
and secondary as upon the line between anterior and
posterior nasal diphtheria.'' I think that any of these
cases may at any moment become dangerously ill.
The temperature of diphtheria in my experience is
pretty generally not very high unless the case is
septic.

Dr. Geo. B. Shattdok : It seems to me if the diag-
nosis of diphtheria is to be settled by tbe presence of
the Klebs-Loffler bacillus without reference to other
symptoms at all, and people having this bacillus in the
naso-pharynx are to be isolated and treated as if they
had diphtheria, it brings up a pretty wide question with
reference to the manner of dealing with all those who
come in contact with such people. If the mere fact
that a person carries the Klebs-Loffler bacilli about the
person internally or externally necessitates isolation,
we shall hardly know where to stop in our measures
directed to this end. It seems to me there is a possi-
bility of going too fast and too far with reference to
this bacillus as well as with reference to the bacillus of
tuberculosis.

Dr. Townsend : A weak solution of peroxide of
hydrogen was used in all the cases.

There was one thing I intended to speak of, and that
was a method by which infection takes place. It seems
to me it might arise from the common habit among
children of picking the nose. If there were any Klebs-
Loffler bacilli lying about the wards, the child in pick-
ing its nose might inoculate the mucous membrane. I

> On the morning after tbe meeting, I counted twelre children in
tbe City Hospital all pUflng together with great spirit. All had
coryza with Klebs-LiSMer bacilli in tbe nose ; and in all theae eases
coryza, which was the only eridence o{ disease remaining, was sec-
ondary to severe disease In the posterior nares and throat, alt trace
of wbioh had disappeared.— E. H. B.

Digitized by

Google

522

BOSTOS MEDICAL AND SVBGJCAL JOVBXAL.

[Mat 24, 1894.

think on that account primary nasal diphtheria must
be much more common than is supposed.

Dr. McCoIlom spoke of passing the needle through
the membrane in order to get at the Klebs-Loffler ba-
cilli. That brings up the question of using the swab
or needle. It seems to me as ' if the swab would col-
lect more and stand a better chance of finding the ba-
cilli. But if the bacilli are at the bottom of the mem-
brane, how can you get them on the swab ?

Db. C. F. WiTHiNGTON reported

A 0A8B OF AHiSBIO DT8EMTBBT.'

Dr. W. T. Councilhan : The amoebss found in
this case were very numerous and active. They were
first seen on examination of the fteces by my assistant
at the City Hospital, Dr. Emerson, who had had no
previous experience in looking for them. They ap-
peared to me to be larger than usual, the size varying
a great deal. As a rule, they are eight or ten times
the diameter of a red corpuscle. We can always recog-
nize in them a very granular interior, which is sur-
rounded by a homogeneous portion. The granular
interior is called endo$are and the homogenous exter-
nal portion ectoiarc. In the endosarc there are always
large vacuoles filled with fluid, but I have never found
anything analogous to the contractile vesicle of the
ordinary fresh water amoeba. The movement in some
cases is quite active, appearing first as a protrusion of
the ectosaro, which is followed by the flowing of the
endosarc into the protrusion. The movement some-
times is progressive, and the organism will, in a few
moments, move across the field of the microscope.

The amoebsB always contain various foreign sub-
stances, and it is very common to find red corpuscles
within them. In addition to the red corpuscles, epithe-
lial cells (or fragments of these) are frequently found ;
but it is rare that leucocytes are enclosed in them.
The nucleus cannot be seen in unstained specimens,
and it is made evident by a few staining reagents.
The dysentery which is produced by the amoebee is
always of a perfectly definite type, and can be distin-
guished anatomically from any of the other forms.

Anatomically, dysentery can be divided into three
varieties; amoebic, diphtheritic, and simple or catar-
rhal. The latter, probably, represented etiologically
different forma not included under the amoebsa and
diphtheritic. As far as I have been able to learn from
observation and from literature, the great epidemics of
dysentery seem to have been always of the diphtheritic
form. In this there is necrosis of the mucous mem-
brane extending more or less deeply, combined with
fibrinous exudation. It may or may not be combined
with ulceration. Ulceration is due to the casting ofi of
the necrotic tissue and fibrin. The ulcers are irregular
in form and may be superficial or may extend down
into the muscular coat. In the simple and catarrhal
dysentery there are two more or less distinct forms.
In the first the follicles of the intestines are chiefly
affected. These become enlarged, and suppuration
may take place within them. They may rupture on
the surface, giving rise to small ulcers which extend
some distance into the mucous membrane. The most
common form, and which is frequently combined wiib
this affection of the follicles, is purulent catarrh of the
mucous membrane, combined with more or less erosion
of the surface. The ulcers are superficial, in many
cases do not extend through the mucous membrane.

9 See page 616 of the Joornal.

They are always much broader on the surface than on
the bottom.

In the amoebic dysentery we have a type which is
anatomically distinct, and may be distinguished at once
from either the simple or diphtheritic form. In this
type the stress of the disease does not appear to fallen
die mucous membrane, but it affects the submucosa,
the mucous membrane being involved secondarily.
Neither the glands of the intestines or the follicles ap-
pear to take any part in the process. A great swell-
ing of the intestines is the most marked feature of the
disease. This is due to the infiltration of the sabmu-
cosa. The swelling not only affects the intestine every-
where, but here and there there are nodular projections.
The ulcers begin in the interior of the nodules by the
submucous infiltration breaking through to the mucoas
surface. The ulcers always have deep undermined
edges and sometimes long sinuous tracts, commani-
eating with adjacent ulcers here found in the sabmu-
eosa. Sloughs of the mucous membrane are frequently
found in this form of dysentery, and the pathological
conditions produced are extremely interesting. There
is not so much distinct suppuration of the tissues as
simple softening with following ulceration. The main
feature appears to be softening of the intercellular
connective tissue.

This case was not accompanied by abscess of the
liver. The specimens which I show here have been
preserved in alcohol, and they do not show the typical
lesion as well as they ought when fresh.

Hecettt ftttecatuirc.

A Praetieal Treatise on Diseaiet of the Hair and

Scalp. By Gkobob Thomas Jackson, M.D.

New, revised and enlarged edition. New York : E.

B. Treat. 1894.

Dr. Jackson's book on diseases of the hair and scalp
has reached its second edition. We find the book con-
siderably enlarged and amended, and the little that has
been added to our knowledge of* this subject during
the last five years, receives due notice. New illus-
trations have been added and the valuable bibliography
at the end of the book has been brought down to Janu-
ary, 1893. It more than retains its place as a clear
exposition of what is known of diseases of the hair
and scalp.

A Hand-Booh of Ophthalmic Science* and Practice.
By Hbnbt E. Jdleb, F.B.G.S., Ophthalmic Sur-
geon to -St. Mary's Hospital. Pp. d49, with illus-
trations. 2d edition. Philadelphia : Lea Brothers
& Co. 1893.

This is a second edition of a work previously re-
viewed in this column, and is reproduced with some
additions and alterations. The colored plates, espe-
cially those relative to external diseases of the eye are
new, but are not a great improvement over those in
the first edition, which were far from good. The text
is clearly printed, and headings and sub-headings printed
in bold type and italic in a manner that makes the
book exceedingly convenient for ready reference. The
style of the book is interesting, and it is admirably
adapted to the purpose for which it was evidently in-
tended, a reference hand-book in a physician's library.

Digitized by

Google

Vol. CXXX, No. 21.] BOSTON MEDICAL AND SUBGIOAL JOURNAL.

628

THE BOSTON

Thursday, May 24, 1894.

A Jommdl o/Mtdieine, StHvery, and Allied Seienet»,p»blUhed at
Bo$ton, teeeklf, iy the undtnigtud.

SCBSOBIPTION TXBMB : tS.OO per year, in advance, pottage paid,
tor the Unittd Statet, Canada and Mexico; $8.66 per year far all for-
eign countritt belonging to the Pottal Union.

All eommmnicationt for theBdttor.anttall boott forreview,ihould
be addretted totlie Editor of the Bottan Medical and Surgical Journal ,
183 Wathington Street, Boeton.

All lettert containing butinen communication; or referring to the
publioation, lubtcription, or advertieing department qf (Ui Jowmal,
ihonld be addretted to the undenigned.

Semittemcet thould be made by money-order, draft or regiittred
Utter, payable to

DAMBELL ^k UPHAM,
28S WiLBBDrOTOIt Stbbbt, Bobtos, Mabs.

HAFFKINE'S METHOD OF INOCULATION
AGAINST CHOLERA.*

The preventire inoculadoD against cholera which
Professor HafFkine is pntting to so thorough a test in
India, has already given safficient evidence of its being
of some value, to make an account of the methods em-
ployed of interest.

Two preparations are made of the " vaccine " as
the virus or antitoxine is for some curious reason
called — one an attenuated form, obtained by succes-
sive cultures in nutritive media, and a strong virus
obtained by a culture on a solid medium, as agar-agar,
after several generations have been passed through
guinea-pigs. The vaccines of normal strength are di-
luted for injecUon with sterile water, and the emulsion
carefully examined.

The skin of the patient is made aseptic over the seat
of injection, which is about an inch and a half above the
crest of the ilium and three inches posterior to the ante-
rior superior spine. The first injection, which is occa-
sionally the only one required, is always made with the
weaker preparation. For the first two hours no effect
is noticed, bat from the third to the twelfth hour there
is a rise of temperature, a feeling of malaise and more
or less tenderness over the point of iuoculation. During
the next twenty-four hours the general symptoms dis-
appear, the painful induration lasting for a few days.

Beyond a temporary reddenbg at the point of inoc-
nlation no alteration of the surface of the skin is pro-
duced. No disturbance of the digestive functions is,
as a rale, produced, and no change in diet or occupa-
tion is necessary. In a few persons there is at first
chilliness and a slight diarrhoaa.

The amount of fever varies, and is taken as an indi-
cation of the natural amount of resistance of the pa-
tient against cholera, high fever being considered as a
proof of strong natural resistance. In this case the
second inoculation is sometimes adjudged unnecessary,
or is made with a small dose of the strong virus. On

> Indian Hedioal Quette, April, 1804.

the other hand, when the fever produced by the first
inoculation is not perceptible, this is taken as a proof
of susceptibility to the disease, and a second inocula-
tion is given with an increased dose, five or more days
after the first, on the opposite side of the body, the
stronger virus being used. The symptoms ensuing
are essentially the same as those caused by the first
dose, varying only as the dose is larger or smaller. In
the cases where the first dose is followed by a fall of
temperature, diarrhoea or other mild choleraic symp-
toms, the second injection is always given with an
increased dose, but notwithstanding such larger dose
the choleraic symptoms are produced exclusively by
the first inoculation, fever being the only symptom
after the second inoculation.

RAILWAY SPINES AND SURGEONS.

The seventh annual convention of the National
Association of Railway Surgeons, held two weeks ago
in Galveston, Tex., was a most entertaining gathering.
The meeting was held in Harmony Hall, which was
about all the harmony there was.

Nevertheless, Mr. Clark Bell, of New York, chose
as the subject of his address "Railway Spine," which
he characterized as the Nemesis of the modern rail-
way. Like all proper Nemeses, it had an origin and
an aim. As a means of procuring enormous verdicts
from railway corporations in accident cases, it has
baffled both railway surgeons and counsel, and, vampire-
like, sucked more of the blood of corporate bodies and
railway companies than all other cases combined.
This vampire-like Nemesis has also the property of
the philosopher's stone, of turning injuries to golden
opportunities for wealth. For the better accomplish-
ment of its purpose, this Nemesis first showed itself as
a plant sprouted on English soil after the era of steam,
but rapidly growing in its infancy to a tree like a
banyan, so that it has been " an incubus, and almost a
parasite, upon the modern railway." "Avarice and
greed have been the rain and dew which have watered "
this Nemesis morn and eve.

He most properly considers that "the time has
come when the profession of surgery should define this
injury so that courts, counsel and juries may know and
locate and apply to it those tests which are insisted
upon in regard to all other physical injuries. It
should be brought out of the shadow into the sun, out
of the darkness into the light, out of the mysterious
into the actual — the real." The legal profession is
particularly averse to a. Nemesis; and consequently
both bench and bar are desirous of having an organi-
zation (such as that of railway surgeons) " frame a
correct definition of the disease, if it exists, and to so
describe and characterize it with precision that not
only judges and lawyers may know what it is with
certainty, but that the average juryman shall be able
to do so."

One of the great duties of the near future for railway

Digitized by

Google

524

BOSTON MEDICAL AJUD SVBGICJL JOVBBAL.

[Hat 24, 1894.

- sargeoDS is to establish defioilions, rules and limita-
tions of special iDJories, real and imaginary, and so ef-
fectually put a stop to the enormous verdicts which
are sapping the reddest life-blood of the Nemesis-
ridden modern railway.

The afternoon session, which was devoted to the
election of ofiScers, had a Nemesis (or something else)
to trouble it, for it was a most exciting and spontane-
ous session, especially spontaneous in the calling of
names and the exchange of complimentary crimina-
tions. Finally, the new officers were elected, with a
general belief that the ballot-box was really never
stuffed, and that nobody had really falsified or borne
ill-will.

The morning session the next day began at 9 k. m.
with divine invocation ; but before then the spines of
the railway surgeons had recovered their normal
steadiness and control, and they all had a hop — that
is, the surgeons and their families, not the spines nor
the Nemesis. The women were fair, the men were
brave. Our Texan authority informs us that " Hun-
dreds of couples danced to the time of rhythmic
strains in the parlors of the Beach Hotel. The
occasion was recherche. It was perfect."

COMPULSORY VACCINATION.

A DECI8ION of public interest was rendered by
Justice Wm. J. Gaynor, in the Supreme Court of
Brooklyn, on May 18th. Since the outbreak of small-
pox in that city about three months ago special vacci-
nators, under the direction of Health Commissioner
Emery, have vaccinated over one hundred thousand per-
sons, and in many instances it was against the protest
of the individual. The question of compulsory vacci-
nation was not brought before the courts, however,
until two expressmen were forcibly quarantined in a
stable for refusing to be vaccinated. These men secured
a writ of habeas corpus, and it was upon this that the
decision of Justice Gaynor was handed down.

In the course of it, he says : " To justify this action
the commissioner makes written return to the writ
that, 88 the petitioners are expressmen, and therefore
go about and carry goods, they are, in his judgment,
< unusually exposed' to small-pox contagion. There-
fore he ordered them to be vaccinated, and they refus-
ing to submit their bodies to vaccination, he ordered
quarantine to be placed upon said premises and that
said persons be detained therein until they consent to
be vaccinated. If the commissioner had the power to
imprison an individual for refusing to submit to vacci-
nation, I see no reason why he could not also imprison
one for refusing to take some dose. But the legislat-
ure conferred no such power upon him, if indeed it
has the authority to do so. The law empowers all
health boards to require the isolation of all persons
and things infected with or exposed to contagious or
infectious diseases. There is no claim that the peti-
tioners are infected or have been actually exposed to
infection. Even if they were subjects for isolation by

reason of infection or exposure thereto, they could
only be detained while such conditions existed, and not
indefinitely until they yielded their bodies to vaccina-
tion. ... If the legislature desired to make vaccina-
tion compulsory it would have so enacted. If, how-
ever, it should be made by the legislature a criminal
offence to refuse to be vaccinated, it may well be sug-
gested that the accused under such a law would have
to be tried, like all other offenders, in a competent
court and after the due process of law which is guar-
anteed every one by the constitntion."
The petitioners wefte discharged.

MEDICAL NOTES.

Thk Hospital Sdpplt of New Yobk. — New

York City has eighty-one hospitals, containing ten
thousand eight hundred and seven beds, of which
eighty-five hundred are free.

Editor of thk Abchives of Pediatrics. —
Dillon Brown, M.D., Adjunct Professor of Pediatrics
at the New York Polyclinic, will take the editorial
charge of the Archives of Pediatriet, beginning with
the July issue.

A Summer Sobool of Nkdboloqt and Pst-
CHIATBT. — A summer course of clinical and laboratory
study of nervous and mental diseases is to be given
for six weeks, beginning June 4th, at the Illinois East-
ern Hospital for the Insane.

Prolonged Life aftbb Perforation of the
Heart. — A man was shot in the chest recently in
Erie, Pa., and lived for seventy hours afterwards. A
post-mortem examination of the body showed that the
bullet had passed through the left ventricle.

The Czar's Interest in the Next Interna-
tional Medical Congress. — The Czar of Russia,
who has from the first shown great interest in having
the next International Medical Congress meet in
Russia, has signified his intention of contributing fifty
thousand roubles towards the expenses of the meeting.

The American Medico-Pstcholooical Asso-
ciation. — At the last meeting of the American
Medico- Psychological Association, held in Philudelphia
May 17th, the following officers were elected : Presi-
dent, Dr. Edward Cowles ; Vice-President, Dr. Rich-
ard Dewey ; Secretary and Treasurer, Dr. Henry M.
Hurd ; Auditor, Dr. A. R. Moultou.

State Boabd of Medical Examinees of New
Jersey. — The last meeting of the State Board of
Medical Examiners of New Jersey to examine candi-
dates desiring to practise medicine in that State under
the present law, will be held June I4th at the capitol
at Trenton. The new law, which goes into effect
July 4, 1894, requires all candidates to have a com-
petent common-school education, to be graduates in
medicine, and to have studied at least four years and
to have taken three full courses of lectures before
being admitted to an examination.

Digitized by

Google

Vol. CXXX, No. 21.] BOSTON MEDICAL AJfJ) SVBGICAL JOCB£AL.

626

The Ltnchino Rkcobd. — Daring the year 1893
there were two hundred persons put to violent death
by lynching in the United States, an increase of one
over the year 1892. Of this nnmber, thirty were
white persons and one hundred and fifty negroes (foar
of them women). Fifty-four were killed for rape;
fifty-seven for murder; the rest for various smaller
crimes. During the last twelve years nearly two
thousand negroes have been shot, hanged, or burned to
death by mobs.

The New Jebset State Hospitals fob the
Insane. — This is the present position as to the State
Hospitals for the Insane in New Jersey, and there is
great desire on the part of medical men to have the
Grovernor rightly interpret the law in the appointment
of new officials : " An act has been passed, and is now
in the hands of the Governor, which makes vacant
every position in connection with the State Hospitals
for the Insane ; and as it provides for a non-partisan
Board of Managers, and as this is in accordance with
a suggestion made by the Governor in his annual
message, it is fair to presume it will become a law."

Meat- Eating, Veoetabianibsi and Mannebs. —
A good deal has been said recently about the bad tem-
per caused by meat-eating and by implication of the
mild gentleness of those who subsist on roots and
herbs. The National Popular Bevieto is moved to
champion the flesh-devouring man and says : The
Hindoo professional assassin or murderer is probably
as cold-blooded and as ferocious a being as one may
imagine. The Chinese are great vegetarians. Rice,
beans in the green state, cabbage and large spinach,
water-cresses and fruits enter largely into their diet.
They are besides very fond of fish, and yet there is
nothing more bloodthirsty and bellicose, more wild or
more unmanageable than the Chinaman when aroused.
On the other hand, the native Californians, like the
dweller on the wild pampas of South America, who
lived on an exclusive beef diet, were generous, self-
composed, and not in the least given to either strife or
blood-sbed.

BOSTON AND NEW ENGLAND.

AcDTE Inpectiocb DISEASES IN BOSTON. — Dur-
ing the week ending at noon. May 23, 1894, there
were reported to the Board of Health of Boston the
following numbers of cases of acute infections disease :
diphtheria S\), scarlet fever 17, measles 23, typhoid
fever 23, small-pox 0. There is one patient with small-
pox at the Canterbury Street Hospital, two at Gallop's
Island ; patients nearly well ; no deaths.

Bequests to Hospitals. — The will of the late
Nancy Barilett, of Milford, Mass., bequeaths five
hundred dollars each to the Perkins Institution for the
Blind and the Children's Hospital of Boston.

A FiLTEB Plant fob the Pbovioence Wateb-
Sdpplt. -«The city government of Providence, R. I.,
has taken the preliminary steps towards the construc-
tion of a large and complete filtration plant for its
public water-works.

Bovine Tubeboulosis in Jauaica Plain, Mass.

— Several valuable blooded cows belonging to private
herds in Jamaica Plain have been found seriously af-
fected with tuberculosis, and have been killed.

A Hospital fob Contagious Diseases in
SouEBViLLB, Mass. — The city of Somerville has
fitted up a small building on North Street for patients
with contagious diseases. It is a one-story building,
containing four rooms.

Tbe Boston City Hospital Examination fob
House-Officebs. — There were thirty-nine candidates
for appointment as house-officers at the Boston City
Hospital at the examination last week. There were
nine ^cancies to be filled.

An Emeboency Hospital fob Evebett, Mass.

— A meeting was held in Everett last week to consider
tbe establishment of an emergency hospital. The
proposed articles of incorporation were referred for
final acceptance to a later meeting.

Massachusetts Medical Society. — Tbe an-
nual meeting of the Massachusetts Medical Society
will be held on Jane 12 and 13, 1894. Attention is
called to the fact that the Meetings of the Sections at
2 p. If., and the Shattuck Lecture at 8 p. u., on Tues-
day the 12th of June, will be at the Harvard Medical
School. The Meeting, the Annual Discourse and the
Dinner, on Wednesday, June 13th, will be in Mechanic
Building.

A Small-Pox Hospital fob Chelsea, Mass.

— The occurrence of a case of small-pox in Chelsea
has led the Board of Health of that city to purchase
for a small-pox hospital a building on Bellingham
Street, which has been occupied for some time as a
tenement-house. It contains thirteen rooms, and is
well adapted for its purpose, having formerly served
as a small-pox hospital before being used as a dwelling-
house. It is about five hundred feet from any other
houses.

Babnstable DisTBiCT Mbdical Society. — The
annual meeting of the Barnstable District Medical
Society was held at Hyannis, April Ibtb, and the follow-
ing officers were elected for the coming year : Presi-
dent, Horatio S. Kelley, Jr., of West Dennis; Vice-
President, Edward E. Hawes of Hyannis; Secretary,
F. W. Pierce of Marstons Mills ; Treasurer, George
N. Munsell of Harwich. At the close of the meeting
the Society was entertained at dinner by Dr. G. W.
Doane.

A DiNNEB TO Db. E. H. Bbadfobd. — A dinner
was given to Dr. £. H. Bradford, at the Union Club,
on Tuesday evening, May 22d, by his former col-
leagues and associates of the Boston City Hospital, to
mark their sense of the loss which the hospital and
they themselves have sustained by his resignation
from the hospital staff, of which be has been a most
valued member for fourteen years. The President
and Secretary of the Board of Trustees, the Superin-
tendent, several members of tbe Consulting Board,

Digitized by

Google

626

BOSTON MBDIOAL AND SURGIOAL JOORNAL.

[Mat 24, 1894.

and almost all the memberB of the active staff, were
present. Dr. D. W. Cheever, the President of the
hospital staff, presided very felicitously ; and many in-
formal speeches testified to the flattering appreciation
in which the guest of the evening is held by his former
colleagues. Dr. Bradford was presented with a cap
bearing a suitable inscription.

NEW TORK.

Sterilized Milk fob the Poor. — Mr. Nathan
Straass, who has long been identified with philanthropi-
cal work in the city, has opened four depots in the
tenement-house districts for the sale of sterilized milk
for the benefit of the poor. His aim is to diminish
the death-rate among children in summer, and the
sterilized milk will be sold at a lower-rate that ordi-
nary milk can be procured elsewhere. In addition,
powdered barley and oat-meal for the purpose of pre-
paring food for infants will be sold at the lowest possi-
ble prices. Last summer Mr. Strauss maintained but
a single depot of this kind, and the result seemed to be
very satisfactory.

Tdbercdlodb Meat. — The investigation of the
case recently reported in which the four quarters of a
tuberculous cow were seized at West Washington
Market showed that a number of other cows in the
herd at Gioshen, Orange County, from which the animal
came are affected with tuberculosis. During the year
189S the quantity of meat jcondemned in the city of
New York amounted to 1,175,287 pounds, against
2,862,144 pounds in 1892, when the quantity was
about 90,000 greater than in 1891. For the three
years the average was nearly three tons a day. In
addition to the various markets, the meat inspectors
visit daily all the slaughter-houses in the city. They
not only see the killing done, but insist that the places
are kept clean, the refuse promptly removed, and
every thing done to make the slaughter-houses as free
from anything objectionable from a sanitary standpoint
as is possible. No one is permitted to slaughter cows
except between the hours of 8 a. u. and 5 p. if., in
the presence of an inspector. ' If a cow is found to be
affected with tuberculosis the carcass is promptly con-
demned and sent to the offal dock. Then the case is
followed back, if possible, to the farm from which the
animal came and all necessary precautions are taken
to prevent any more cattle being brought from the
place, while the oflBcials of the State Board of Health
are notified of the condition of affairs.

The New York State Colony for Epileptics.
— In a recent issue there was a brief notice of the
act of the New York Legislature establishing a colony
for epileptics in that State. The very great value of
such an establishment, and the important advance it
marks in State care of these unfortunate persons,
makes a more extended notice of interest. A Board
of Five Managers is provided for, to serve without
salary and to meet at the colony at least once
a month. The Governor appointed as the Board of
Managers: Dr. Frederick Peterson, of New York;

Mrs. C. F. Wadsworth, of Greneseo ; George M. Shnll,
of Mount Morris ; Dr. Charles E. Jones, of Albany,
and W. H. Cuddeback, of Buffalo. At its organiza-
tion in Albany on the Sd of May, the Board made
Dr. Frederick Peterson, President, and George M.
Shull, Secretary. The law requires that all of the
buildings put up shall be on the village plan ; and an
important provision in this bill is that the Managers
may accept any bequests of persons interested in the
welfare of epileptics, and it is believed that many
charitable wealthy people will build cottages upon the
splendid sites on the tract, to bear their names and
exist as lasting memorials to their desire to serve
humanity in this wise. A medical superintendent,
steward, matron, pathologist, nurses, school-teachers,
teachers of various industries and arts, and so on, are
to be appointed as needed ; but the colony will not be
ready probably to receive patients before the autumn
of 1895. It is thought that the colony will ultimately
number fifteen hundred to two thousand members.
As soon as possible the six hundred epileptics in the
various county almshouses will be taken in charge.
Later, private patients will be received at prices corre-
sponding to the accommodations asked for. It is sure
to become self-supporting in the coarse of time, and to
grow into an industrial and agricultural village that
will more than rival the similar and famous colony at
Bielefeld, Germany, upon which to a certain extent

this is modelled.

•

THE OVER-ZEALOUS THERAPEUTICIAN.

In his address before the International Medical Con-
gress, Professor Stokvis, speaking of the vagaries of
modern pharmacy and chemico-therapentics, said :

"The reason of the present situation — or imbroglio
— is obvious. By the side of the chemist stands the
busy practitioner, or the overwrought professor. Both
are oppressed by the sense of insufiicieDcy of their art ;
neither has the time to observe, reason and conclode.
It is the professor who publishes with railroad haste
his observations and impressions, for he is ever haunted
by the fear lest another should precede him in the new
discovery. He it is who makes others follow, sheep-
like, in the wake. He constitutes himself a bustling
impretetrio, always on the lookout for a new sensation,
agitating himself and the public, and, finding that be
has before him a fickle, unquiet, impatient audience,
be hastens to deal with new subjects, if not every day,
at least every week. During the year 1893, sixty-
eight new chemical products have been recommended
to me, this figure not being inclusive of entirely new
drugs or their active principles. In each case we are
told that the new product is of the very first impor-
tance, of exceptional therapeutic value, and perfectly
harmless. Fistula duke eanit volueru dum decipit
aueeps. The wise man will not be taken in. He will
be guided by therapeutic teaching such as that of the
immortal Baglivi, the author of the pregnant phrase,
' Ars tota in observationne,' or by the teaching of my
honored friend, Professor Semmola, delivered with all

> ;i*Doet, April 21, ISM.

Digitized by

Google

Vol. CXXX, No. 21.] BOSTOH MEDICAL AND SVSGICAL JOURNAL.

627

his maettria Italianni from bis chair in the University
of Naples, a university which has lately set a glorions
example to Earope by proclaiming thai a drug that is
efficacious cannot be harmless. Nearly all new reme-
dies have their period of success, be it but for an hour,
and this is due to < suggestions,' either by medical men
or patients : but, with few exceptions, these panaceas
are doomed to be laid aside as forgotten and antique
eoriosities."

CHARLES C. PIKE, M.D.

Resolutions of the Essex South Distbict Medi-
cal Society.

Whereas, Dr. Charles C. Pike, an honored and beloved
member of the Essex South District Medical Society has,
in the infinite wisdom of God, been called from among us
in the prime of his manhood ; therefore, be it •

Resolved, That in his death we recognize the great loss
to this Society, to the community in wmch he lived, as well
as a personal bereavement to those of us who knew and
loved him so well ; and we desire to pay to his memory a
tribute of sincere respect, expressing our admiration of his
attainments as a physician and of his manliness and purity
of character.

Resolved, That we extend to his wife and family our
heartfelt sympathy at the great grief which has come upon
them.

Resolved, That a copy of the above be presented to the
family of the deceased, and also be entered on the records
of the Society.

(Signed) C. A. Cablton,

Charles W. Haddock, y Committee.
Fbamk L. Atwood,

HETEOROLOGICAL RECORD,

For the week ending May 12th, in Boston, according to ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corpe:—

t, C Co

"THE MEDICAL REGISTRATION BILL IN THE
MASSACHUSETTS LEGISLATURE,"

Boston, May 19, 1894.

Mb. Editor : — The worst of this bill is that it will
benefit only the quacks ; that is to say, if any of them will
cram so as to be registered, which may be doubted, gener-
ally. Every M.M.S.S. is registered on or before he be-
comes a member (in fact, even though no word is said
about it at the time). Formerly, tne candidate, after
being licensed, had to wait three years and then ask to be-
come a member. Now, he does not wait a moment, but is
licensed and admitted at the same moment, on his passing
the examination successfully. The Society does all this
for him, and nobody can take this right or power from the
Society without its consent, and no one can prevent its
members from practising medicine and surgery while re-
siding in Massachusetts. The bill can give no further
right to you or to me than we now have, even if we ask
its aeents to register us, which I trust we shall not do.

The bill should be entitled " An act to encourage the
practise of quackery by dignifying persons illegally using
the designation ' M.D.' I " It will only degrade the regular
profession in as far as any of its members permit their
names to be registered with these quacks ; and, as for the
public, it will be worse off than ever in endeavoring to
distinguish by title the reputable from disreputable prac-
tisers of medicine.

Strange that such a bill should be allowed to pass with
so little opposition ; the Boston Advertiser, only, has indi-
cated some of its many " defects."

The intimation that the medical member of the Senate is
the author of the bill is an absurdity not to be encouraged.

Very truly yours,

Baro-

Thermom-

BeUtiTB

Direotion

Velocity
of wiod.

We'th'r.

3

meter

eter.

humldit?.

of wind.

•

Date.

i

a

i

1
1

72

i

a

i

f

%

i

%

a

a

a'

a
1

1

s

00

8

00

^

i

e<

1

S

00

■4

8-

8

00

F.

S.. 6

29.82

no

48

97

90

94

S.E.

S.W.

10

n

B.

O.M

M.. 7

29.70

an,

79

l»

87 69

73

S.W.

S.W.

18

11

O.

0.

T.. «

29.80

(W

78

59

53 33

43

S.W.

w.

3

9

0.

0.

W. 9

30.00

M

73

84

46: 49

47

N.W.

E.

16

6

C.

F.

T..10

80.37

M

89

30

45

64

54

N.E.

S.K.

13

14

C.

C.

P.. 11

80.38

M

66

44

60

78

69

S.E.

S.W.

9

6

F.

F.

S..12

30.32

60

70

49

49

55

52

N.W.

S.W.

8

11

0.

C.

tr

30.05

71

«3

82

•O..oloa(l7i Celewi F., Isiri U.,f(nr; H.,lisiji S.,ilnok7i R.,nlDi T-.tlmM-
■nlngi N., mow. t IndlOAtcs tjmM of nUnffttL tr Mema for woek.

RECORD OF MORTALITY
Fob thb Wbbk >ND»a Satubdat, May 12, 1894.

u

f •

Peroentag

e of deaths from

*i f

Cities.

P

1=

1

si

o 1

1'

1|

ft'

II

n

New York . .

1,891,306

790

ill

18.33

17.81

1.66

9.23

1.82

Ohioaso .
PhllMkilphli

I •

1,438,000
1.115,562

399

124

10.J6

16.00

.76

6.26

—

Brooklyn

978 J94

388

168

16.20

le.jo

1.08

6.76

1.08

St. Lonla .

1)60,000

—

—

—

—

—

—

^

Boeton .

487,387

179

SO

18.44

16.80

.56

10.84

1.12

Baltimore

500,000

—

—

—

.~

—

—

Washington

308,431

98

38

12.24

13.26

2.84

6.10

1.03

Clnolnnatl

806,(X)0

88

26

7.88

9.12

1.14

3.12

Cleveland

290,000

101

50

16.83

18.86

.99

2.97

1.98

Pittsburg

268,709

—

^

^

—

—

—

_

Hilwaukee

2SO,0MI

^

—

—

—

—

—

NaahTllle

87,754

2A

9

8.'32

8.32

—

_

_

Oharleeton

66,1«5

3U

19

7.68

2.66

7.68

^

__

Portland .

40,000

—

—

—

^

— .

—

^

Woroeater

96,217

82

12

6.28

21. «1

6.26

^

Fall Rlrer

87,411

38

26

13.15

21.04

10.52

_

LoweU .

87,191

32

lU

9.39

21.91

S.13

6.26

^

Cambridge

77,100

22

7

13.66

4.55

—

4.6&

4.66

Lynn . .

62,656

19

10.62

__

—

n.26

Springfield

48,684

7

28.66

14.28

—

14.28

Lawrence

48,355

—

—

—

—

—

—

New Bedfor

i .

45,886

18

11

ll.U

27.76

—

—

11.11

Holyoke .

41,278

13

30.76

7.69

7.69

10.88

Salem. .

32,233

1.

—

14.28

—

—

,—

Brockton

82,140

«•

—

—

—

—

—

Haverhill

31,896

16

—

UU.00

—

—

_-

Chelsea .

30,284

12

^

16.66

^

—

..

Maiden .

29 394

8

12.80

12.60

—

^

Newton .

27,866

4

26.00

^

—

Fltchbarg

27,148

6

—

33.33

—

—

—

Taunton .

*«'22

9

•^

—

—

—

—

Oloueester

26,688

—

—

—

—

—

—

—

Waltham

22,068

2

0

—

60.00

— ■

—

..

QninoT .

19,642

—

—

—

—

—

Pittofleld

18,B02

4

u

—

^

—

—

Everett .

1«,586

8

0

33.33

—

—

._

16,331

6

2

20.00

20.00

—

—

20.00

Newbnryport .

14,073

8

V

16.66

16.66

—

—

—

Ameibnr; . .

10,920

3

2

^

66.66

^

^

—

Deaths reported 2,361: under five years of age 881; principal
infectious diseases (small-pox, measles, diphti^erla and croup,
diarrhoeal diseases, whooplng-cou(;h, erysipelas and fever) 331,
acute lung diseases 37S, consumption 301, diphtheria and croup
163, diarrhoeal diseases S3, scarlet fever 32, measles 30, whoop-
ing-cough 2ti, typhoid fever 26, erysipelas 12, malarial fever 10,
cerebro-spinal meningitis 7, small-pox 4.

Prom measles New York 14, Brooklyn 10, Cleveland 4, Phila*
delphia and Boeton 1 each. From whooping-cough New York 6,
Brooklyn and Cleveland 6 each, Philadelphia 4, Washington 3,
Boston, Nashville and Fall River 1 each. From typhoid fever
Philadelphia 11, Brooklyn 6, New York and Cincinnati 3 each,
Cambridge, Lynn, Uolyoke and Newburyport 1 each. From
erysipelas New York 7, Philadelphia and Brooklyn 2 each.
From malarial fever New York 6, Brooklyn 4, Nashville 1.
From small-pox New York 3, Brooklyn 1.

Digitized by

Google

628

BOSTOS MEDICAL ASD SVRGICAL JOVRHAL.

[Mat 24, 1894.

In the thirty-three greater towns of England and Wales with
an estimated popnlation of 10,458,142, lot the week ending
May Sth, the death-rate was 17.2. Deaths reported 8,446:
acute diseases of the respiratory organs (Loudon) 237, measles
200, whooping-coQgh 139, diphtheria 80, scarlet fever SI, fever
88, diarrhoea 'JH, smalt-poz (London 6, Wolverhampton, Birming-
ham and Nottingham I each) 9.

The death-rates ranged from 11.0 in Bolton to 31.3 in Wol-
verhampton: Birmingham 19.9, Brighton 14.9, Cnqrdon 11.2,
Hnddersfield 13.2, Hall 14.5, Leeds ld.2, Leicester 14.9, LivenKwl
21.3, London 17.2, Manchester 18.8, Newcastle-ou-Tyne 18.8,
Nottingham 18.9, Portsmouth 11.3, Sheffield 10.4, SanderiaDd
17.2.

OFFICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE KEDICAL
DEPARTMENT, U. 8. ARMY, FROM MAY 12, 1894, TO
MAY 18, 1894.

Leave of absence for fonr months, on surgeon's certificate of
disability, is granted Majos Vam BaSBN Hubbabd, surgeon.

Leave of absence for three months, on account of disability,
with permission to leave the Department of Texas, is granted
Caftaik Alonzo R. Chapim, assistant surgeon.

MASSACHUSETTS MEDICAL SOCIETY.

OMB HUNDRBD AMD THIKTBBHTH AlTMIVBRSART.

The annual meeting will be held at 9 o'clock a. m., Wednes-
day, June 13, 1894, in the bnildlng of the UassachusetU Chari-
table Mechanic Association, on Huntington Avenue, Boston.

Meetings of Sections will be held at the Harvard Medical
School Building, comer of Boylston and Exeter Streets, on the
preceding day, Tuesday, June 12th.

~ TUBSDAT, JVMB 12tH.

The laboratories and the anatomical musenm of the Harvard
Medical School will be open to Fellows of the Society daring
the day.

At to A. M., the Fellows of the Society are Invited to visit the
Massachusetts General Hospital, on Blossom Street ; the Boston
City Hospital, on Harrison Avenue; the Children's Hospital, on
Huntington Avenue, and the Carney Hospital, South Boston.

Section in Medicine, Harvard Aiedical School, 2 f. M. — Dr.
F. C. Shattnck, of Boston, Chairman; Dr. G. G. Sears, of Bos-
ton, Secretary. "The Protective Power of Vaccination." By
Dr. J. H. McCoUom, of Boston. " The Technique of Vaccina-
tion." ByDr.W. N.Swift, of New Bedford. " Radical Dififer-
ences in Methods of Cultivation of Vaccine Lymph." By Dr.
S. W. Abbott, of Wakefield. Discussion by Drs. J. F. A. Adams,
of Pittsfield; L. F. Woodward, o( Worcester; J. B. Field, of
Lowell.

Section in Surgery, Harvard Medical School. — Dr. P. K.
Paddock, of Pittsfield, Chairman ; Dr. C. L. Scndder, of Boston,
Secretary. " The Cure of Carcinoma of the Breast by Opera-
tion." By Dr. W. T. Bull, of New York City. Dlscassion by
Drs. D. W. Cheever, J. C. Warren, 6. W. Gay. H. H. Richard-
son, of Boston ; T. F. Breck, of Springfield ; S. U. Weeks, F.
H. Gerrish, of Portland, Me. ; J. B. Wheeler, of Burlington, Vt.

Hhatttick Lecture, Harvard Medical School, St. x. — " The
Range and Significance of Variations in the Human Skeleton."
By Thomas Dwight, M.D., of Nahaht. The lecture will be illus-
trated by many specimens.

CouNCiLLOBs' MKBmros.

The Annual Meeting, at 11 o'clock a. m., Tuesday, June 12,
1891 ; Stated Meetings on Wednesday, October 3, 1894, and on
Wednesday, February 6, 1895, at the Medical Library, No. 19
Boylston Place, Boston.

Exhibit.

In the Exhibit Hall, Mechanic Building, there will be an
exhibit of crude drugs and preparations of the United States
Pharmacoposia, prepared by the students of the Massachusetts
College ol Pharmacy, to Illustrate the revised edition of 1890.

The State and other Boards of Health will make an exhibit
pertaining to Sanitary Science. That of the State Board will be
the one shown at the World's Fair.

There will be the usnal exhibit of surgical Instruments and
apparatus, electrical appliances, books, etc.

The Crematory of the Massachusetts Cremation Society, at
Forest Hills, will be open to Fellows of the Society for inspection
from 2 p. M., to 4 p. h., Tuesday, and can be reached by electric
cars or by the Providence B. R. to Forest Hills Station.

Wkdmksdat, Junk 13th.

Annual Meeting, Cotillon Hall, 9 A. M. — Business of the
Annual Meeting. " Icbthyol in Gynecology." By Dr. Malcolm
Storer, of Bo^n. " Chronic Inflammation of the Seminal
Vesicles." By Dr. G. W. Allen, of Boston. "The Frequency
of Puerperal Sepsis in Massachusetts, its Diagnosis and Efficient

Treatment." By Dr. Edward Reynolds, of Boston. IKseossion
by Drs. C. M. Green, of Boston ; B. H. Stevens, of North Csm-
bridge.

Introduction of delegates.

The Annual Diicourtt, 12 m. — By R. H. Fitz, M.D., of Bos-
ton.

The Annual Dinner, 1 p, m . — At the dose of the disoonrae
the annual dinner will be served.

J. C. Wbitx, M.D., President.

E. J. FoBSTSK, M.D., Treantrer,

61 Massachusetts Avenue, Boston.

F. W. Gobs, M.D., Recording Secretary,

217 Warren Street, Roxbory.

SOCIETY NOTICES.

Ambbicak Mkdical Editobs' Association. — The annual
meeting of this Association will be held at the Palace Hotel,
San Francisco, CiJ., daring the meeting of the American Medi-
cal Association.

C. H. HuoKBS, M.D^ Prettdent.

Gbo. M. Gould, M.D., Secretary.

I. N. LoTB, M.D., Chairman Com. ArrangemenU.

RECENT DEATH.

Maubick Kino Habtnbtt, M.D., M.M.S.8,, died in Boston,
Hay 14, 1894, aged seventy years. He graduated from the Har-
vard Medical School in the class of 1869.

BOOKS AND PAMPHLETS RECEIVED.

The Seventieth Annual Report of the Officers of the Retreat
for the Insane at Hartford, Conn., April, 1891.

The Tubercular Diathesis Controlled by Gold and Manganese
in Combination. By J. Blake White, M.D. Reprint. 1891.

About Mushrooms ; A Guide to the Study of Esculent and
Poisonous Fungi. By Julius A. Palmer, Jr. Boston: Lee fc
Shepard. 1891.

Zur Behandlnng der LnngeBtnberculose mittels Eoehseher
Injectioner. Von Dr. E. Thomer, Sanit&lsrath in BerUn.
Berlin : S. Karger. 1894.

Catalogue of the Library of the Royal Medical and Chimigi-
cal Society, Supplement VU, Additions to the library 1892-3.
London: Printed for the Society. 1893.

Emergency and Hygienic Notes for the Militia. By WilllBm
H. Ueviue, H.D., Surgeon, Ninth Regiment, Massachusetts
Volunteer Militia. Boston : Damrell & Upham. 1891.

The Drainage of Fitchburg, Comprising Remarks on the Sub-
ject of Drainage in General and the Disposal of Sewage and
other Waste. By Clarence W. Spring, M.D., City Physician,
Fitchburg.

Transactions of the New York State Medical Association for
the Year 1893. Volume X. Edited for the Association. By E.
D. Ferguson, M.D., of Rensselser County, rublistied by the
Association.

China, Imperial Maritime Customs, U Special Series : No. 2,
Medical Reports for the Year ended March 31, 1890, 38th and
39th issues. Shanghai: Published by order of the Inspector-
General of Customs. 1891.

Medlco-Chlrurglcal Transactions. Published by the Royal
Medical and Cbirurgical Society of London, Volume the sev-
enty-sixth. (Second series, volume the fifty-eighth.) London:
Longmans, Green & Co. 1893.

On the Features which Distinguish Epidemic Roseola (Rose-
rush) from Measles and from Scarlet Fever. By Clement Dakes,
M.D., B.S., Loud., M.B.C.P., Physician to Rugby School, etc.
London : J. & A. Churchill. 1891.

Hydatid Disease. Vol. 11. By the late John Davies Thomas,
M.D. (Loud.), F.R C.S. (Eng.). A Collection of Papers on
Hydatid Disease. Edited and arranged by Alfred Austin I^n-
doD, M.D. (Loud.) Sidney : L. Bruck. 1891.

On Amblyopia from Di-Nitrolienzol : with Remarks on the
Employment of this Substance in the Making of Certain Ex-
plosives and its Effects on those engaged in the Manufacture.
By Simeon Snell, F.R.C.S., Edln., etc. Reprint. 18<«1.

An Aid to Materia Hedlca. By Robert H. M. Dawbam, M.D.,
Professor of Operative Surgery and Surgical Anatomy, New
York Polyclinic. Third edition, revised and enlarged. By
Woolsey Hopkins, M.D. New York: O. P. Putnam's Sons.
1894.

Rapports et M^moires sur le Sauvage de I'Oveyron I'ldioti^
et la Surdi-Mutit^, par Itard avec une Appreciation de ces rap-
poru par Delasiauve. Preface par Boamevilie, Eloge d'ltard
par Bousquet avec portrait du Bauvage. Paris: Publications
du Progr^ Medical. 1894.

Digitized by

Google

Vol. CXXX, No. 22.] BOSTON MEDICAL AJSD SURGIOAL JOVRNAL.

62d

3lltiDce^^.

THE RISE AND FALL OF THE LICENSED
PHYSICIAN IN MASSACHUSETTS, 1781-1860.1

BT BBOIHAU) B. FITZ, M.D., OF BOSTON.

Gentlemen : — In calling to order the Ninth Annual
Meeting of oar Association I desire to express the high-
est appreciation for the honor yoa have bestowed upon
me in appointing me to preside over your proceedings.
To condact the affairs of so aristocratic a democracy has
been made a task so easy that the gift of persuasion,
or the knowledge of parliamentary law become wholly
annecessary qualifications. The one obligation which
has weighed somewhat heavily is the thought of tHe
opening address which is to prepare the way for such
communications as you are to make for the advance-
ment of scientific and practical medicine — all the more
as my own attention has been particularly directed for
the past few months toward a class of practitioners
who have no idea of scientific medicine, and whose
only thought of the practice of medicine is how much
money can be made oat of it. It may not be uninter-
esting to learn what men like yourselves, many years
ago, did in order to discourage such persons — what
they planned, what they accomplished, and why they
failed. I will, therefore, ask your attention to the
rise and fall of licensed physicians in Massachu-
setts, 1781-1860.

In the " Records of the Grovernor and Company of
the Massachusetts Bay in New England " (1854, III,
153), is to be found the first legislation concerning the
regulation of medical practice in Massachusetts. On
the 3d of May, 1649, the General Court, held at Bos-
ton, voted as follows :

" Forasmuch as the lawe of God (Exod. 20 : 13) allowes
no man to touch the life or limme of any pson except in a
jadicyall way, bee it hereby ordered and decreed, that no
pson or psons whatsoeuer that are imployed about -the
bodyes of men, woemen, and children for preservation of life
or health, as phisitians, cbirurgians, midwlves, or others,
shall presume to exercise or putt forth any act contrary to
the knowne rules of arte, nor exercise any force, violence,
or cruelty vpon or towards the bodyes of any, whether
young or old, — no, not in the most difficult and desperate
cases — wU> out the advice and consent of such as are skil-
fall in the same arte, if such may be had, or at least of the
wisest and gravest then present, and consent of the patient
or patients, (if they be mentis compotes,) much lease con-
trary to such advice and consent, vpon such punishment as
the nature of the fact may deserve ; wo** lawe is not in-
tended to diecourage any from a lawfull vse of their skill,
bat rather to encourage and direct them in the right vse
thereof, and to inhibit and restrayne the presumptuous ar-
rogance of such as through prefidence of their oune skill,
or any other sinister respects, dare be bould to attempt to
exercise any violence vpon or towards the bodies of youne
or old, to the preiudice or hazard of the life or limme of
men, woemen, or children."

Until the years immediately preceding the War of
the Revolution there was no more stringent regulation
of medical practice than this. But in 1760 the City
of New York had found it necessary to regulate the
practice of medicine within its limits on account of the
abundance of quacks preying upon the community.
Five years later the Medical School of the University
of Pennsylvania was established, and in the following
year the New Jersey Medical Society was founded.

' The Pre«ld«iit'a Address at the Ninth Annual Meeting of the As-
•ooUtlon of Amerleao Physiolans held iu Washington, May 29, 1894.

In Still another year the Medical School of Columbia
College began its career ; and in 1771 the colony of
New Jersey passed its act regulating the practice of
medicine, to be followed in 1774 by the abortive at-
tempt in Connecticut.

The years thus ripe in revolutionary ideas and acts
produced their fruit in Massachusetts.

Although there were excellent physicians iu the
larger cities and towns of the Commonwealth, and sev-
eral of them possessed medical degrees received in
Europe, they were few and far between. Most prac-
titioners had served merely a sort of apprenticeship to
their seniors. There was no medical school iu the
State, and but two in the country, and these almost as
remote as the leading schools of Europe at the present
day. Any one undertook the study of medicine in
such manner as he saw fit, and entered his practice
with as little preparation as he chose. A considerable
number of wholly unqualified practitioners thus were
to be found, a source of danger to the community, a
disgrace to the name of physician, and a cause of jeal-
ousy, contention and distrust, among the members of
the profession.*

The example set by New Jersey and New York was
one which demanded a speedy following, and thirty-
one of the leading physicians of Massachusetts, sixteen
being from towns outside of Boston, became incorpo-
rated as the Massachusetts Medical Society, " that a
just discrimination should be made between such as are
duly educated, and properly qualified for the duties of
their profession, and those who may ignorantly and
wickedly administer medicine whereby the health and
lives of many valuable individuals may be endangered,
or perhaps lost to the community."

That this purpose might be carried out, the Pres-
ident and Fellows of the Society or their appointees
from its members were given *' full power and author-
ity to examine all candidates for the practice of physic
and surgery, who shall offer themselves for examination,
respecting their skill in their profession, and if upon
such examination, the said candidates shall be found
skilled in their profession, and fitted for the practice
of it, they shall receive the approbation of the Society
in letters testimonial of such examination," etc. They
were obliged, under penalty, to hold this examination,
although candidates were not obliged to present them-
selves for approval.

The State thus did not prevent the practice of med-
icine by any one, but it implied that the letters testi-
monial of the Society discriminated between the duly
educated and properly qualified, and the ignorant and
wicked. By the limitation of the maximum member-
ship to seventyl admission to the fellowship became a
proof of distinction which the better educated and higher
minded physicians were proud to attain. This number,
furthermore, gave evidence of the comparatively few
physicians in the State at that time, who were consid-
ered worthy of this high distinction. Indeed, it re-
peatedly happened in the early life of the Society that
it was impossible to secure the attendance of a suffi-
cient number of Fellows to form a quorum to transact
business.

Two years after the incorporation of the Medical
Society the Medical School of Harvard College was
established ; and it was feared that the power of Har-
vard College to examine medical students and grant
degrees in medicine might interfere with the authority

> Probeedlnga of the Maisaehasetts Medical Soolet;, 1831, 19.

Digitized by

Google

630

BOSTON MEDICAL AUD 8UBGICAL JOVBNAL.

[Mat 81, 1894.

of the Society to examioe oaDdidatea for practice and
iB8ae letters testimonial. According to the memorial
of Dr. John Warren in 1811, this "would have pro-
duced the most unhappy effects, but for the repeal of
an exceptionable article in that establishment, and the
accommodating conduct of those who, at that time,
were the guardians of science and the patrons of the
healing art." *

But doubts arose with reference to the duties and
powers of the Society concerning the examination of
candidates and its authority to demand and receire
compensation for its services and an act in addition to
the act of incorporation was passed in 1789. It was
therein made the daty of the Society, " in order more
effectually to answer the designs of their institution,
from time to time to describe and point out such a
medical instruction, or education, as they shall judge
requisite for candidates for the practice of physic and
surgery, previous to their examination before them . . .
and they shall cause the same to be published in
three newspapers in three differentcounties within this
Commonwealth."

The Society continued to fail in its object to create
a proper standard of medical qualifications. The popu-
lation of the State rapidly increased, and the number
of practitioners likewise. There was no sufficient in-
ducement to lead physicians to apply for the approval
of the Society ; and in the first twenty years of its ex-
istence only some twenty candidates had received the
testimonials in approval of their professional skill.*
In the same period Harvard had conferred its medical
degree upon thirty candidates.

Early in the present century Dr. John D. Treadwell,-
a young, learned, devoted and public-spirited physician
of Salem, impressed with the inability of the Society
to accomplish its aims, endeavored to improve its use-
fulness. An extensive correspondence was instituted
among the members and with the assistance of Mr.
Sewell, afterwards Chief Justice of the State, a bill
was drafted, which, somewhat modified, was enacted
in 1803.

The Massachusetts Medical Society, as it now exists,
was then instituted ; and its plan of organization be-
came a model for other State Societies. It was no
longer a close corporation with a limited membership,
but it was possible for every physician in the State to
become a Fellow. It was only necessary that he should
have been a student in medicine agreeably to the regu-
lations of the Society, and pass a satisfactory examina-
tion before the censors, after whicb he received a
license to become a practitioner of medicine or sur-
gery ; " and after three years of approved practice in
medicine and surgery, and being of good moral char-
acter, and not otherwise," he became a member of the
corporation by subscribing to the by-laws.

The medical graduates of Harvard University were
made licentiates without passing an examination, since
the right to confer degrees had been granted Harvard
College long before the Massachusetts Medical Society
was incorporated. " The only means of avoiding col-
lision with that ancient and respectable institution was
by the compromise which was adopted." *

A duly licensed physician in Massachusetts in 1804
was required to give satisfactory evidence of the fol-
lowing qualifications before being admitted to exami-

> Dr. S. A. Qreen's Cent«nnUd Address, Med. Comm. Masnotan-
Mtts Hedloal Sooietj, 187S-S1, xil, SS9, 6M.
< Ur. James Jaokson's Speeob at the Annaal Dlnuer, 1866.
0 Proceedings Haasachnaett* Medical Sooiet;, 1831, aS.

nation for the license : Some acquaintance with Latin
and Greek, and with the principles of geometry and
natural philosophy ; three full years of study under
the direction of some respectable physician or physi-
cians whose practice he must have attended. Doring
this time he must have read the most approved authors
in anatomy, physiology, chemistry, materia medica,
surgery, and the theory and practice of physic. He
was examined in physiology, pathology, therapeatics
and surgery.

There was still no obligation on the part of any
practitioner to present himself for license ; and the only
privilege enjoyed by the licensed physician, apart from
the right to attend the meetings of the Society and the
use of its libraries, was exemption from service in the
militia.

Notwithstanding the Act of 1803 made it possible
for every properly qualified physician to become li-
censed and a member of the Society, it proved neces-
sary to take further steps to bring them within the
fold, and in 1806 a by-law was passed in the following
terms:

" To promote the laudable design of the Legislature, in
forming and incorporating this Society, to prevent as Iti
as may be all unqualified persona from practising medicine
or surgery, and in order to discourage empiricism and
quackery : it shall be deemed disreputable and shall be un-
lawful, tor any fellow of this Society, in the capacity of
physician or surgeon to advise or consult with any person,
wbo having been a fellow of the Society, shall be expelled
therefrom, or with any person whatever, who shall there-
after commence the practice of medicine or surgery within
this Commonwealth, until he shall have been duly examined
and approbated by the censors of the Society or by those
of some district society," etc.

The object of this by-law was to guard the public
against ignorant, designiugand unscrupulous pretenders.
The Society had provided the means by which physi-
cians could give evidence of having followed a suitable
course of study, and it was its duty to inform the public
that if it employed unlicensed practitioners it must
suffer the consequences.

Notwithstanding these attempts at compelling prac-
titioners to become educated physicians, the standard
was evidently too high for all to attain. Many could
not comply with the requirements ; others did not find
a sufficient inducement in the honors and privileges
bestowed by the Society. The Thomsonians, then be-
ginning their career, required no education and no
license. There was no law to prevent their entering
practice ; and Chief Justice Parsons ' had then made
his famous decision in the case of the Commonwealth
V. Thomson, " that if the prisoner acted with an honest
intention and expectation of curing the deceased by this
treatment, although death, unexpected by him, was the
consequence, he was not guilty of manslaughter. . . .
There is no law which prohibits any man from prescrib-
ing for a sick person with his consent if he honestly
intends to cure him by his prescription ; and it is not
felony, if through his ignorance of the quality of the
medicine prescribed or of the nature of the disease or
of both, the patient, contrary to his expectation, should
die."

The Chief Justice evidently felt that there was
likely to be need of some legislation which should
prevent the occurrence of such cases, for he closes bis
decision by saying : ' " It is to be exceedingly lamented

• Massaohnsetts Baports, 1809, t1, 134.
< Loc. cit., II. 142.

Digitized by

Google

Vol. CXXX, No. 22.] BOSTON MEDICAL AND SURGICAL JOURNAL.

531

that people are bo easily persaaded to put confidence
in these itinerant qaacks, and to trust their lives to
strangers without knowledge or experience. If this
astonishing infatuation should continue, and men are
found to yield to the impudent pretensions of ignorant
empiricism, there seems to be no adequate remedy by
a criminal prosecution, without the interference of the
legislature, if the quack however weak and presump-
tuous, should prescribe, with honest intentions and ex-
pectations of relieving his patients,"

In 1811 an nnsnccessful attempt was made to iu'
corporate a rival society with the same privileges as
those enjoyed by the Massachusetts Medical Society,
nnder the title of the Massachusetts College of Physi-
cians. The announced reason was that two Societies
were better than one ; the real object was thought to
be the establishment of a new medical school.

The Massachusetts Medical Society strongly opposed
the scheme, on the ground that it was unnecessary and
would lead to the rejected candidates of the one society
being accepted by the other, whatever might be their
qualification, thus producing disagreements and animos-
ities injurious to the profession and to the public'

It is possible that in consequence of the recommend-
ation of Chief Justice Parsons, certainly with the view
of discouraging quackery which was rapidly increasing
under the influence of Thomson, the legislature in 1818
passed its first "Act regulating the Practice of Physick
and Surgery," which was supplemented in 1819 by "an
Act in addition to an Act entitled ' an Act regulat-
ing the practice of Physick and Surgery.' "

According to the first of these acts, no person enter-
ing the practice of physic and surgery within the State
could recover by law any debt or fees for his profes-
sional services unless he bad received a medical degree
from some college or university or had been duly li-
censed by some medical society or college of physi-
cians or by three Fellows of the Massachusetts Medical
Society, designated in each county by its councillors,
with power to examine candidates and grant licenses.
Copies of these licenses were to be deposited with the
clerk of the town, district or plantation in which the
licentiate resided.

In the Act of 1819, that the physician might recover
his debts by law, it was necessary that he should be a
licentiate of the S<%iety or a Medical Graduate. of
Harvard. If the candidate for the license was educated
out of the State, the censors might waive a new exami-
nation if they were satisfied that be had received an
edncation agreeably to the regulations provided by
the Society.

It is stated* that this difficult trust was accepted
with reluctance,*" that the law was not sought for by
the Society, and that it was doubtful whether' its
action was not rather injurious than beneficial. Of
this law Chief Justice Shaw said : **

" It appears to us that the leading aud sole purpose
of this act was to guard the public against ignorance,
negligence and carelessness in the members of one of
the most useful professions, and that the means were
intended to be adapted to that object. If the power
of licensing were given to the Medical Society exclu-
sively, there wonld be much more plausible ground, at
least, to maintain that the power was conferred on a
body who would have a temptation to abuse it, so as

* Dr. 8. A. Qreen's Uenteunial Addren, p. 6B1.

* Proeeedlngi Hassaohuaetts Metdioal SooUty, 1840, p. 68,
<• Loe. ax., 1831, 10.

u Hawitt tp. Cluurlw, Jr., 10 ?i«k„ US,

to promote their private interests ; but where the
power is conferred equally on the university charged
with the great interests both of general and profes-
sional education, and which cannot be perceived to
have any such interest, that ground of argument seems
to be wholly removed, and it seems difficult to perceive
how a power which it is important to the community
should be placed somewhere could be placed more
safely. The courts are all of the opinion that the law
in question is not repugnant to the Article of the Bill
of Rights, above cited, and that its validity cannot be
impeached on the ground that it is a violation of any
principle of the constitution."

The licensing of physicians by the Society doubtless
aided in restraining a certain number of practitioners
from adopting some of the methods of the charlatan ;
but it did not interfere with the encouragement of the
latter by the community. I am indebted to Dr. John
Homaus, 2nd, for the opportunity of quoting from a
letter of Dr. George C. Sbattuck to Dr. Homans,
written July *26, 1828. It gives evidence of the fond-
ness for quackery in Boston at that time.

"The city has 60,000 (inhabitants?) and seventy-one
regularly bred physicians. About one-half, from either
youth or age, have not much to do. The irregular physi-
cians are numerous, at the head of which, in popular in-
fluence, we may place Thomson, who has formed his
botanical society, who have individually learned his system
of practice by hot drops and sweating, etc. The disciples
of this system, perhaps, may embrace oae-sixth of the
population of Boston. The patent medicines are em-
ployed in about, I believe, anotner sixth of the cases."

• In 1831 the Society had reached such a degree of
success in carrying out the objects of its incorporation
that it included in its ranks " nearly every educated
practitioner of medicine or surgery in the State." *'

The line of distinction was so strongly drawn be-
tween its members and irregular practitioners " that
the profession is no longer made responsible in the
minds of men for the consequences of their ignorance
and malpractice, nor its harmony disturbed by their
misconduct; and they are much less successful than
formerly in diverting the confidence of the community
from regnlar physicians to themselves." **

At this time, however, there were certain discord-
ant elements within the Society which threatened its
prosperity and usefulness. Some of the younger
physicians were dissatisfied with the clause in the act
of 1803, which demanded a period of three years of
probation in practice before admission to full member-
ship in the Society. The legislature was therefore
requested to repeal this clause, which it did by a
special act in 1831, and approved candidates became
at once Fellows of the Society.

A more serious disturbance, which menaced the
harmony and influence of the Society at this time, was
the appeal to the legislature from the physicians of
Berkshire County, in the western part of the State.
They desired to be incorporated as an independent
body, nominally on account of their distance from
the headquarters of the Society, their limited privi-
leges, and their dissatisfaction with the requirements
of the censors. It was supposed that this action was
largely planned in the interests of the Berkshire
Medical Institution, a medical school incorporated in
1823, but without the authority to confer the degree

» Proceedings MauaoltitKtM Medloal SootetT, 1881, 18,
u Loo, oit„ 1881, 19,

Digitized by

Google

632

BOSTON MEDICAL AJSD 8UBOI0AL JOVBSAL.

[Mat 81, 1894.

of Doctor of Medicine.'* It was situated in Pittsfield,
and was practically a department of Williams College
(not far distant), which had the power to confer
degrees, bnt no medical faculty or medical school.
Williams College sanctioned the degree of the candi-
dates edocated at the Berkshire Medical Institution.
The conditions of this alliance proved important in the
courts'* when the honorary degree of M.D. from
Williams College was offered in evidence as a legal
qualification. It was decided that it was invalid, since
the defendant mast have both the education and the
degree to be a legally qualified practitioner.

In the year following the incorporation of the Berk-
shire Institution it had petitioned the legislature to be
granted the same privileges as belonged to the medical
graduates of Harvard University, the most important
of which was that of being acknowledged and received
by the Magsachusetts Medical Society without exami-
nation as regular practitioners of medicine and sur-
gery.

At that time this petition was successfully opposed,
on the ground that the Berkshire Institution had do
independent board of overseers like Harvard College,
and therefore was not under the same restrictions and
oversight. The petition to form an independent so-
ciety was also successfully opposed ; but in 1837,
with the approval of the Society, an act was passed,
according to which graduates of the Berkshire Medical
Institution were " entitled to all the rights, privileges
and immanities granted to the medical graduates of
Harvard College."

The rights and privileges of the licentiates of the
Massachusetts Medical Society had been somewhat
extended by the Anatomical Law of 1834, according
to which " the dead bodies of such persons as it may
be required to bury at the public expense might be
surrendered to any regular physician duly licensed ac-
cording to the laws of this Commonwealth."

The State had thus definitely committed itself to
the regulation of the practice of medicine by the Acts
of 1818 and 1819, and had placed the duty of licens-
ing practitioners in the han4s of the Massachusetts
Medical Society. It conferred but few privileges on
the licensed, namely, exemption from militia service
and jury duty, the right to obtain and dissect the un-
claimed bodies of those to be buried at the public ex-
pense, and to collect fees by law.

Bnt unlicensed physicians could take their pay in
advance, and were not desirous of the privilege of
consulting with the members of the Society. The
Tbomsonian movement was rapidly spreading through-
out the country, appealing to the people by its sim-
plicity and economy, its dogmatic assertions and re-
ports of wonderful cures, its advocacy of vegetable
remedies, and its cry of persecution.

The efforts of the Society to include within its ranks
all educated practitioners, led in 1886 to the recogni-
tion of dentists as practitioners of medicine, since den-
tal surgery was being studied and pursued scientifi-
cally by gentlemen of regular medical education.'*

In the following year a further attempt was made
in this direction by requiring that every licentiate or
medical graduate of Harvard or Berkshire entitled to
admission to the Society must enter within a year after
being so entitled or be deemed an irregular practitioner.

" Proceedlnn of the Muaaohusettl Medical Society, 1836, 2S.

■0 Wright e. Lanokton, 19 Plok., 291.

<• rro«ee<}iDg> o{ the Mauacbiuett* Medliuil Sooietr, ISSe, Ug,

This term was applied to all practitioners in the State
who were not fellows or licentiates of the Society, or
doctors in medicine of Harvard or Berkshire. The
above regulation was repealed three years later, lince it
took away " the freedom originally intended to be al-
lowed to all regular physicians to join the Society or
not, as they pleased," and stigmatized " as irregular
practitioners gentlemen who have been recognized as
competent physicians merely for the exercise of this
freedom." "

In 1836, the Statutes of the Commonwealth were
revised, and the report of the commissioners (1835,
Part I, 125) includes all the legislation previoosly
enacted, placing the control of the licensing of physi-
cians in the power of the Society.

But the legislature did not accept the first section,
which read as follows :

" No person who has commenced the practice of physic
or surgery, since the year one thousand eight hundred and
eighteen, or who shall hereafter commence the practice
thereof, shall be entitled to maintain any action for the re-
covery of any debt or fee accruing for his professional
services, unless he shall, previously to rendering these ser-
vices, have been licensed by the officers of the Massachu-
setts Medical Society, as hereafter provided, or shall have
been graduated a doctor in medicine in Harvard Univer-
sity, or in the Berkshire Medical Institution, by the aa-
thority of Williams College."

It also negatived a clause making the neglect to re-
cord a license a like disqualification to its nou-possea-
sion.

The legislature approved this part of the report of the
committee with the above exceptions, and it became
Chapter 22 of the Revised Statutes entitled " Regala-
tiouB Concerning the Practice of Physic and Surgery."

According to Dr. J. Mason Warren " the first sec-
tion was omitted in accordance with the wishes of
the greater part of the (State Medical) Society, as
being in its action adverse to their interests. It served
merely to excite sympathy, especially for the Thomso-
nians, and could not prevent them from receiving fees
for services rendered.

The Society continued in its work of licensing phy-
sicians without apparent disturbance until 1848. At
this time its effect in controlling the conditions of med-
ical practice in tl^ State is thuS expressed by Dr. A.
L. Peirson, of Salem, in behalf of a committee of which
he was chairman : '*

" We have steadily elevated our profession, by improv-
ing medical education, encouraging me harmony and hon-
orable intercourse of its members, and have protected from
the mischief of quackery, by discouraging every show of it
among regular practitioners. This simple and efficient
plan of the Society has accomplished all that was ever in-
tended by its organization in 180.3. ... It is to be re-
gretted that from natural causes, no way to be attributed
to the form of organization, the concentrated action of the
Society has not been equally felt in all parts of this ex-
tended Commonwealth."

According to Dr. Z. B. Adams,** there were at this
time 1,237 medical practitioners in Massachusetts, most
of whom belonged to the Massachusetts Medical So-
ciety.

On the contrary. Dr. J. V. C. Smith presented the

" Proceedings of the Mauaehiuetta MedioKl Society, 1840,72.
>• Transactions of the Medical Society of the State of Mew York,
IS4l-IHi.'i, 1S46, vl, app. 4U.
'« i'rocHudingaof the Mauaohutetts Medical Society, 1848, U:!.
<° Trsiuactionv of the American Medioi^I Association, m$, 1, SW-

Digitized by

Google

Vol. CXXX, No. 22.] BOSTOIf MEDJOAL AND SUS6IOAL JOURNAL.

533

minority report of the Bame committee, in which he
states : **

" The Society was once eminently useful in protecting
the community from the encroachment of ignorant pre-
tenders, . . . and it must be obvious to all that circum-
stances have greatly changed, our legislative tables have
been completely turned, and will probably ever remain so.
A license, or medical degree, is no longer requisite for the
practice of medicine in Massachusetts, and no laws of the
State, or of the Massachusetts Medical Society, are of any
avail in guarding the entrance into the profession, or regu-
lating the conduct of its members. . . . Less than one-half
of the regular practitioners of medicine now nominally con-
stitute the Society. In Berkshire, there are one hundred ;
less than twenty belong to the Society. In Hampden, one
hundred and thirty (about) ; and of this number only about
twenty or twenty-five are members of the State Society.
In some other counties there is doubtless a majority, while
in others not one-half of the regular physicians are mem-
bers. The number of Fellows of the Massachusetts Medi-
cal Society is not far from seven hundred, which is not
probably one-half of the physicians in the State."

These reports were called forth by a resolution pre-
sented by Dr. Childs, of Pittafield, involving a change
in the organization of the Society for the purpose of
advancing medical science, promoting harmony and
good feeling in the profession, thereby contributing to
the best interests of society.

Although the councillors largely favored the views
expressed in the majority report, the existence of a
considerable degree of dissatisfaction and the necessity
of remedying it was apparent in the appointment of a
committee to consider the question of altering the by-
laws. This committee consisted of Drs. John Ware,
A. L. Feirson, W. Lewis, J. Jeffries, J. V. C. Smith,
H. H. Childs and John C. Dalton. The report of this
committee is especially valuable from the character of
the latter and the recognition of the necessity of the
Society to increase and consolidate its strength.

They found ^ that many members had often ex-
pressed the opinion that the Society as constituted did
not accomplish all of the purposes of which it was ca-
pable — and failed to secure the favor of the profes-
sion in remote parts of the State. Consequently only
a limited number of physicians found it for their inter-
est to become members. They were called upon to
obey laws which they had no voice in making and to
contribute to the expenses of an organization in which
they found it difficult to take part. The Society was but
little known to those among whom they are thrown,
thus has but little influence over them, and it was not
necessary to their reputable standing among physi-
cians nor to their success with the community that
they should be connected with it.

The committee reported various amendments to the
by-laws involving favorable action of the legislature
which took place in 1850. By-law Y permitted any
reputable practitioner of medicine or surgery who
bad been in practice not less than fifteen years, to be
admitted a Fellow, previously to 1852, by the District
Society where he resides by a vote of two-thirds of
the members present at any stated meeting.

The Society was thus endeavoring to increase its
influence in the one direction by licensing as many
educated and intelligent physicians as possible, and
even without examination in certain instances.

This liberality, however, was to be controlled by

" PtooeedlDss of ths MuiacboMtts Medioal Society, 1&48, ISO.
s> Loo. el(„ 048, p. Va,

what many now see to have been an unwise policy,
namely, the treatment of the homoeopathists.

In 1846" an applicant for membership stated that
he had great confidence in the efficacy of medicine
"especially when prepared and prescribed agreeably
to the directions of fiiahneman." The councillors re-
ferred the application to the censors, with full powers
to settle the matter, and they admitted the applicant to
membership.

In the meantime the influence of homoeopathy was
increasing, and in 1850" it was moved "that all
homoeopathic practitioners are, or should be, denomi-
nated irregular practitioners, and, according to the By-
Laws of this Society, made and provided, ought to be
expelled from membership." This resolve was tabled
on motion of Dr. Bigelow.

At the next meeting, Drs. Hay ward, O. W. Holmes
and J. B. S. Jackson were appointed a committee " to
devise some course of action, to be pursued by the
Society, in regard to all homoeopathists." This com-
mittee reported as follows : ^

"(1) Resolved, That any Fellow of this Society who
makes application to resign his Fellowship in consequence
of having adopted the principles and practice of homoeo-
pathy may be permitted to do so on paying his arrearages ;
but be shall not be entitled to any of the privileges of
Fellowship, nor shall his name be retained m the list of
Fellows.

" (2) Resolved, That a diploma from a homcEopathic in-
stitution shall not be received as any evidence of a medical
education ; nor shall the Censors of the Society regard the
attendance on the lectures of such institutions, nor the
time passed at them, as qualifications which shall entitle
candidates to an examination for a license from this So-
ciety."

This report was adopted. Three years later the
question of homceopathy was again brought before the
Society at the annual meeting.^ The Essex North
District Society there presented the following resolu-
tion:

" Forasmuch as there is no common ground of support
or sympathy between homoeopathy and allopatliy ;

" Resolved, That if the homcEopaths are allowed to retain
their regular standing in the Massachusetts Medical So-
ciety, and ciMm fellowship and counsel with allopaths, we,
as consistent and conscientious individuals, request to be
honorably discharged from our allegiance and connection
with the parent society."

Dr. Spofford presented the following resolution :

" That, while we recognize the right of regular physi-
cians to use medicine in any quantity or doses which they
may consider useful to their patients, we consider all uee
of the name of homoeopathy in public papers, on signs or
otherwise, as quackish and disreputable, and that all per-
sons who make pretensions to homoeopathic practice ought
to be excluded from the Society."

These resolutions, together with the whole subject,
were referred to the councillors, who appointed the
following committee to report upon them : Drs. Bige-
low, Metcalf, M. Wyman, Spofford and Alden. Dr.
Jacob Bigelow reported in February, 1854, and his
report was laid on the table.

In the next year," the censors of the Suffolk Dis-
trict Society rejected a candidate for admission who
avowed himself practising upon the principles styled

» Proceedings of the MaBsaebnsetts Medical Society, 1846, 108,
« Loc. olt., 1850, 32. ■• >

» Loo. cit., IBM, 81.
» Loo. cit., lt'53, 102.
n Loo. oit., 18$6, T,

Digitized by

Google

634

BOSTON MEDIO AL AND SURQIOAL JOURNAL.

[Hat 31, 1894.

homceopathy, on the groand that he was not " fitted
for the practice of medicine." It was roted (Febru-
ary 7, 1855), on motion of Dr. Bowditch, " that the
Councillors approve of the course adopted by the Cen-
sors of thia Massachusetts Medical Society for Suffolk
District."

In the following June this district society called the
attention of the general society to defects in the by-
laws concerning the expulsion of members, with
reference to a remedy; and this question, together
with that concerning the admission of members, was
referred to a committee for a report. A few days
later the latter reported. Their report was referred
to the councillors for adoption. They, in turn, re-
ferred the report to a committee, which altered the
recommendations ; these were adopted by the council-
lors in February, 1856, and by the Society on May 29,
1856.

These alterations made it possible to expel a mem-
ber for any breach of the by-laws, for which censure,
expulsion or deprivation of privilege was a penalty,
and for any conduct unbecoming and unworthy an
honorable physician and member of the Society, in
addition to causes hitherto deemed sufficient. A care-
fully arranged method of conducting trials for offences
was also provided. The report of the committee of
the councillors recommending these alterations stated
that they had no definite measures to offer with regard
to homceopathy, and submitted the subject to the judg-
ment of the councillors. This part of the report was
laid on the table without debace.*"

June 3, 1856, four days after the adoption of the
amended report by the Society, the Homoeopathic
Medical Society was incorporated by the legislature.
It was authorized to examine all candidates for mem-
bership, and, if qualified, give them the approbation of
the Society. Its members were declared exempt from
militia service.

In the following year, the motion that all candidates
for the fellowship bis examined by the censors was re-
ferred to a committee, reported upon favorably, and
the legislature passed a special act March 5, 1859,
making this method the law.

At this time the revision of the statutes was again
under consideration, and the commissioners had made
their report to the legislature, in which the existing
laws concerning the regulation of the practice of medi-
cine were included. This report was referred to a
joiut committee, which was subdivided into special
committees. The general committee referred the
chapter concerning the regulation of medical practice
to one of these special committees on May 16, 1859.
It instructed this committee, " by special order, to in-
quire into the expediency of omitting all that part of
the chapter relating to the Massachusetts Medical So-
ciety and to the regulation of the practice of medicine ;
and on the 21st of May they reported to the general
committee amendments striking out every section, and
every line, and every word in that chapter which gave
the Massachusetts Medical Society any power to ex-
amine or license physicians or surgeons, or to prescribe
a course of study and qualifications for physicians or
surgeons." *

Four days later, the councillors appointed a com-
mittee, consisting of Drs. J. Bigelow, A. A. Gould, J.
Jeffries, 6. C. Shattnck, H. J. Bigelow, U. H. Childs

*• ProeeedtDgi Masgacbusetti Medioal Society, 188S, 3S.
» Argument ol J. U. Beutoo. Jr., before tbe CommilVee on Publio
^•altbiUSS,

and J. 6. Metcalf, and " instructed them to look after
the interests of the Society in the legislature," and
they were " authorized to take such measures to pro-
tect their interests as they may deem expedient." ^

But, in the words of Mr. Benton, "The general
committee adopted these proposed amendments, with
the addition of a change of title of the act from
' Regulations conceruing the Practice of Physic and
Surgery ' to < of the Promotion of Anatomical Science ';
and that chapter now stands, with the same title as
Chapter 81 of the Public Statutes. All the amend-
ments were adopted by the legislature, and were
enacted December 28, 1859. . . . The legislature
then deliberately took out of the law of the Commou-
wealth every provision for the regulation of the prac-
tice of medicine or surgery, or for the examination or
qualification of physicians or surgeons."

The committee of the Society appointed to look
after its interests in the legislature recommended, Oc-
tober 5, 1859, that " no person shall hereafter be ad-
mitted a member of the Society who professes to
cure diseases by Spiritualism, Homoeopathy or Thorn-
sonianism," which was adopted. As evidence of the
state of feeling at the time, it may be said that at the
meeting at which this resolution was approved, it was
voted that the Society disclaim all responsibility for
the sentiments contained in the annual address of the
day previous. This had been delivered by Oliver
Wendell Holmes, and was entitled, "Currents and
Counter-Currents of Medical Science."

Thus we see that the Massachusetts Medical Society
was organized in 1781 with the express purpose of
making a just discrimination between duly educated
and properly qualified practitioners and those who igno-
rantly and wickedly administer medicine. For many
years its Fellows acted most judiciously in endeav-
oring to include within their number every edncated
and moral practitioner in the State. They accom-
plished this largely by the force of example, associar
tion and united encouragement. The State made them
the sole source of licenses to practise. The progress
of Thomsonianism left their responsibilities essentially
intact. The advent of homoeopathy found them weak
where they should have been strong, short-sighted
where they should have been far-seeing. The leaders
were obliged to follow, and the reproval of the censors
prevailed against the wisdom of the councillors.

Homoeopathic diplomas and homoeopathic certifi-
cates are now accepted by the Society. Homoeopathic
physicians have been found fitted to practise by the
great public, which decides this question for all. Ten
years of increasing intolerance destroyed seventy years
of enthusiastic effort, devoted labor, tactful manage-
ment and wise council in the public interest. The
State revoked the control of medical practice, and the
people have been the sufferers. The history of Massa-
chusetts in this respect is the history of the country.
She was one of the last of the States to lay down the
control, and she will be one of the last to resume it.

Thanking you for the patience with which you have
listened to au historical narrative which offers but
little in the way of moral or example to our own
Association, we will proceed to the business of the day.

Mrs. HcMPHBBr Wabo, the novelist, i> said to be
suffering from writer's cramp.

K Prooeedlngi MsfSMUnsetU Madioia Soeletr, UM, UI,

Digitized by

Google

Vol. CXXX, No. 22.J BOSTON MBDIOAL AND SUBOIOAL JOURNAL.

536

METHODS OF TEACHING SURGERY.*

BT JOHN ■. BIUJHOS, M.D., lOBOBON UHITED STATES ABHY.

This paper has been prepared at the request of the
Committee on Programme, to serve as an iutroduction
to a discussion npon the best methods of teaching sur-
gery, and is intended to ask questions rather than to
answer them. We have to consider : (1) Who are to
be taught? (2) What is to be Unght? (3) How it is
to be taught.

Those who are to be taught include two classes : (1 )
The average medical student, who is presumably to
become a general practitioner ; (2) The men who
wish to specially fit themselves for surgical work.
There is a third class, namely, those who wish to learn
only the least possible amount of surgery which will
enable them to get the degree of M.D., bat these we
need not consider to-day.

The sorgical instruction to be given the average
student depends on what he it required to know of
anatomy and pathology before he begins his surgical
studies, upon the amount of time which is allowed for
snrgical instruction, and upon the nature of the final
examination which he mast pass to obtain his degree,
or license to practice.

In any case it should include the diagnosis, and best
method of treatment, of the injuries and surgical dis-
eases which the general practitioner is most often called
npon to treat, including recent wounds and their com-
plications, erysipelas, abscess, ulcers, etc. ; fractures
and dislocations, injuries of blood-vessels, strangulated
hernia, urethral stricture, retention of urine and its
consequences ; obstruction of, or foreign bodies in, the
air passages ; and also the selection and administration
of anaesthetics, the details of aseptic and antiseptic
methods, and of methods of performing the most usual
amputations and ligations of blood-vessels.

Let OS suppose that the instruction is to be given in
a three-years' graded course ; what other subjects be-
sides those above mentioned ought to be fully treated
of by the surgical teacher ? Under such circumstances
is it worth while to go into the details of cerebral and
abdominal surgery, of lithotomy and lithotrity, of ex-
cisions of organs or of the jaws and joints, of plastic
and orthopaedic surgery ? Is it not enough to tell the
average student what can be done in these directions,
and. refer him to special courses or to current litera-
ture for farther information with regard to complicated
and difficolt operations requiring special instruments
and apparatus ? Of course, it is to be practically dem-
onstrated that the teacher is the proper person to whom
cases of this kind should be sent.

Deferring for a moment the consideration of the
needs of the man who wishes to become a surgeon, we
come to the question, " How are these subjects to be
taught?"' There are five principal methods: (1)
Didactic systematic lectures; (2) recitations; (3)
demonstrations and practical instruction by means of
manikins, dummies, cadavers, and operations on ani-
mals, in the details of treatment of wounds, bandaging,
dressings and operations ; (4) theoretical clinical lect-
ures, in which cases and operations are shown in an
amphitheatre; (5) practical clinical instruction to
small groups of students or ward classes, in which, as

' Paper read before tbe American Sargloal ABBOolatlon at Waah-
fngton, Wadneaday, May 30, 18»4.

far as possible, each student has something to do in
the diagnosis or treatment or both.

Tbe modern tendency is to reduce the time given to
systematic lectures. In discussing the wisdom of this,
we must bear in mind the different organization of the
teaching staff in different schools, the increasing num-
ber of chairs or lectureships devoted to specialties, and
the fact that the precise division of subjects among the
instructors in a given school must depend to a consider-
able extent on local conditions, on the character, tastes
and teaching-powers of the different men who makeup
the faculty, on the amount and character of the facilities
for laboratory and clinical teaching present, etc

In tbe old-fashioned type of medical school, in which
the whole instruction was given by seven or eight men,
the professor of surgery taught what was called surgi-
cal pathology, or the principles of surgery, gave con-
siderable attention to surgical anatomy, and was the
clinical as well as the systematic teacher. There was
at least one advantage, namely, that the teaching was
consistent and harmonious ; the student was not much
bewildered with the conflicting views of different pro-
fessors. The professor of anatomy was in training for
the chair of surgery and took very little interest in
comparative anatomy or in embryology. There was
no professor of pathology ; and both the professor of
surgery and of medicine lectured on inflammation,
congestion, suppuration, etc., each from his own point
of view.

At present, in a large and popular medical school,
there are from twenty to thirty teachers of various
grades \ there is a professor of pathology, of surgery,
of clinical surgery, of surgical anatomy, of orthopaedic
sargery, of genito-urinary surgery, etc., and the pro-
fessor of gynaecology takes a large share of the abdomi-
nal surgery.

Now how can the subject of surgery be subdivided
among all these teachers in such a way that the whole
field shall be covered, without involving useless repeti-
tions, embarrassing contradictions, and the expenditure
of an undue amount of time and labor by the student,
or of the production of heart-burnings in some of the
teachers ? This is one of the most difficult problems
in the organization of a large medical school which is
to be really efficient and popular, and it is one to
which no general and universal formula is applicable.

Theoretically, each professor being a thoroughly
wise, unselfish, good-tempered man, desiring only the
best interests of his pupils and of his school, and there
being freqnent consaltations between them to secure
harmony in their teachings, the desired result may be
obtained. Practically there are usually two or three
strong men in the faculty who settle what shall be done,
and the rest find it expedient to submit, although they
may not agree. When there are no sufficiently strong
men, and all the professors are not perfectly good and
unselfish, there may be trouble.

Let us consider details a little. A well organized
medical school should have a professor of pathology
and pathological anatomy, under whose direction a
certain amount of laboratory instruction should be
given — comparatively simple for the average student,
extended and elaborate for post-graduates. The
greater part of his teaching for the average under-
graduate student must be by lectures, with demonstra-
tions.

Given such a teacher, with the necessary facilities,
why should tbe professor of surgery lecture on surgi-

Digitized by

Google

636

BOSTON MBDICAL AND SURGICAL JOURNAL.

[Mat 31, 1894.

cal pathology or bacteriology to the average under-
gradaate ? The only really good reason I think of is,
that he should be thoroaghly familiar with the snbject,
and at times ase experimental methods in devising im-
provements in surgical practice, and that teaching the
subject greatly helps him to obtain, classify and retain
his knowledge. But his teaching on this subject would
be most valuable to a special class of advanced stu-
dents, or post-graduates — who can devote themselves
to it, and give the necessary time to that experimental
work on animals which is absolutely essential to secure
satisfactory results.

At all events, I think we can agree that the rela-
tions between the surgeon and the pathologist should
be intimate and friendly, while each should be entirely
independent of the other, and that the surgeon should
go into details of practical application of principles in
accordance with the more general teaching of the
pathologist.

As regards the teaching of surgical anatomy, and of
operations on the cadaver, by a teacher distinct from,
and entirely independent of, the professor of anatomy
on the one hand and the professor of surgery on the
other, I believe that there are widely different opinions
as to its expediency. Such an independent chair, or
demonstratorship, is usually provided to make a place
for some particular man, and its utility must depend
upon who this man is.

While no general rule on this point can be laid
down, might it not be best that attendance on such an
independent course should be purely voluntary on the
part of the class, and that it should be largely devoted
to the instruction of those who wish to make a specialty
of surgery ? It appears to me that more use should
be made of living animals than is now done, in teach-
ing the results and treatment of wounds, including de-
tails of aseptics and antiseptics, and in special courses
for advanceid students who should be required to per-
form operations under the guidance of the surgeon.

The next question is as to the part which clinical
surgery should play in a course of education leading to
a medical degree. The great majority of students pre-
fer clinical teaching and demonstrations to didactic
lectures, and will go where this clinical teaching is
most brilliant and varied ; and, so far as it goes, we
must admit that this kind of teaching is generally the
most useful to them, because they remember it better.
How far is it possible to cover the field of diagnosis
and treatment of injuries and surgical diseases by clin-
ical teaching alone to the extent that it is desirable for
the average medical student? And how far is it de-
sirable to vary and modify the didactic teaching so as
to make it supplementary to the clinical teaching?

Evidently the answers to these questions must de-
pend in part upon the amount and variety of clinical
material that is available, and hence must differ for
different schools. As a rule, clinical material is not
available to cover the entire field for any school, no
matter how large its hospital and dispensaries — hence
there must be some systematic didactic teaching. Is it
best that this should be a complete independent course
covering the whole field, merely using for any particu-
lar subject such cases as may happen on that day to
be available, thus leaving the greater part of the clinical
teaching to duplicate that which has been given in the
systematic course? This is, upon the whole, the
easiest way, and in favor of it is urged that it is desir-
able that the student should be told the same thing

several times to ensure his remembering it. This is
the argument which used to be used in favor of the
old plan of not having a graded course but compelling
the students to listen to the same course of lectures in
successive years.

On the other hand, it can be seen that there wonid
be certain advantages in deferring the systematic lect-
ures until towards the end of the course, aad then de-
voting them mainly to subjects which had not been il-
lustrated in previous clinical teaching ; but to make
this plan a success it would be necessary that the sys-
tematic lecturer should either have given all the clinical
instruction, or should be perfectly familiar with all
that has been given.

A possible modification of this plan would be to let
two professors divide the field of work, each taking a
certain class of diseases and injuries, giving clinical in-
struction thereon and supplementing it with systematic
teaching as above suggested, and then the two men
exchanging fields of work each year. An objection to
this is that a considerable part of clinical teaching is
given in connection with patients who select their own
surgeon, and who will not make such selection with
reference to any curriculum. Undoubtedly the more
clinical instruction of the right kind that can be given,
the better for the students, and for the reputation and
prosperity of the school.

But this phrase "clinical instruction of the right
kind " brings up a new set of questions. How much
does it profit the student to witness, from the rear
benches of an amphitheatre, such operations as the
ligation of arteries, the extirpation of tumors, lithotomy
or nephrectomy ? Undoubtedly the student is inter-
ested and learns something, and he will go where he
can see — if not the operation itself, at least the beads
of the persons who are busy about the patient ; and
it will not do to restrict his privileges much in this re-
spect. At the same time, should not special opporta-
nities be given to the few who are devoting themselves
specially to surgery to see as much as possible of diffi-
cult and unusual operations ? It appears to me that
more than two hundred men cannot possibly obtain
any special information from surgical clinics in an
amphitheatre which they could not obtain equally well
in a didactic lecture, and which could not be much
better given with illustrations by means of lantern
slides, than by using a patient as a means of demon-
strating an operation. It is quite possible to show by
means of lantern slides, as Dr. Kelly has proved, to
several hundred men, every detail of an operation
which can be seen by the immediate assistants of the
operator.

Now with regard to clinical teaching to comparatively
small sections, or ward classes, the members of which
are to be brought as much as possible into contact with
the patient, and even to assist in the operation of dress-
ing. There is no doubt as to the utility and popular-
ity of this mode of teaching, but in this connection a
word may be said with regard to the relations of hospi-
tals and dispensaries to surgical teaching.

While I believe that a hospital is not doing its full-
est and best work if it is not increasing and diffusing
knowledge, and that patients secure the best and most
careful attention and treatment in teaching-hospitals,
where the work of the staff is keenly scrutinized, yet
it must be admitted that there is sometimes a danger
that people will get the idea that in a teaching-hospital
the interests of the patients are not as fully consulted

Digitized by

Google

Vol. CXXX No. 22.] BOSTON MEDIOAL AND SVR610AL JOURNAL.

537

as they should be, and will avoid that hospital as mncb
as possible. This danger arises mainly from two
things : first, the allowing students to have anything
to do with the treatment, and especially with an oper-
ation. The patient wants to be operated on by the
most skilled man, that is, by the professor ; and if he
has a suspicion that after he is under the influence of
an anaesthetic the professor may hand the knife to a
student to make perhaps his first essay, he will avoid
that place. All of us would do the same, and therefore
in ward-class teaching a patient should never be de-
ceived as to who is to perform the operation, for sooner
or later the deception will be discovered and the news
will spread.

The second danger to the popularity of a teaching-
hospital is that patients are not unfrequeotly made to
wait until their cases can be used for clinical instruc-
tion, sometimes for hours, sometimes for days. In
most cases the patient knows when he is to be put off
for this purpose, and after oue experience of the kind
he will go to another hospital the next time and advise
his frieuds to do the same.

It is well also that the clinical surgical teacher should
remember that his ability to obtain abundant clinical
material depends to a very considerable extent upon
the manners and on the good-will of some of his assist-
ants, the resident physician, the nnrses, etc., who are
often the first to see the patient as an applicant, and
who have much to do with subsequent treatment.

These assistants, residents, receiving-officers, case-
takers and nurses, are not always possessed of the ex-
quisite tact, kindly sympathy, and knowledge of human
nature which it is to be presumed are invariably the
characteristics of the clinical surgeon ; and it is a part
of his business to instruct them and perfect their
manners as much as possible.

Recitations and quizzes are excellent methods of
teaching for the majority of students, but are only
well adapted to small classes or sections. At present
they are, for the most part, conducted as a private
enterprise by persons who may, or may not, be on the
teaching staff. The question as to whether this mode
of teaching should be made use of in the official course
to a considerably greater extent than is now done is
an interesting one and is commended for discussion.
It appears to me more desirable that it should be ap-
plied to the clinical teaching than to the didactic
lectures, and one good result of this would be to dis-
courage the reliance on quiz compends, which I think
invariably do more harm than good.

With regard to modes of lecturing, every man is, of
coarse, a law unto himself ; yet I will venture one or
two suggestions. The teaching for a class of students
should be definite, selective, and, to a considerable ex-
tent, dogmatic ; and critical historical discussions should
be used very sparingly.

What the student hears and sees during the first
half-hour of a lecture is what he will remember best,
and will have the best notes of ; therefore, when there
are several different ways of doing a thing, let the
teacher describe first the method which he prefers, tak-
ing all the time required to fully demonstrate it and
impress it on the student. After that is done the other
methods may be referred to and so much history and
criticism given as time will permit. If the reasoning
is given before the conclusions are stated, the student
is apt to get confused, and to characterize the teacher
as a " wobbler."

If the lecturer will fix in his mind the half-dozen
questions or so that he would ask to test the students'
knowledge of the subject upon which he is going to
speak, and will then make it his main object to answer
those questions clearly, definitely and fully, he can
hardly fail to give a good lecture.

In objecting to too much history in didactic or clini-
cal lectures on surgery, 1 do not wish to be understood
as .underestimating the importance of giving historical
instruction. I think that in every medical school a
coarse of lectures on the history of medicine and sur-
gery, combined with practical instruction in bibliographi-
cal methods, should be given ; and if this is not done,
then I would advise that the professor of surgery de-
vote five or six lectures to the history and literature of
his subject, which lectures will probably be most use-
ful and interesting at the beginning of the last year of
the student's coarse.

It was stated at the beginning of this paper that be-
sides the average medical students, the needs of the
man who wishes to specially fit himself to be a surgeon
should be considered. These relate to post-graduate
work mainly, for a broad foundation of medical knowl-
edge is requisite for the man who wishes to become a
surgeon. The technique of operative surgery, impor-
tant as it is, is secondary in importance to skill in diag-
nosis, and to knowledge of therapeutical methods
which do not involve the use of the knife.

The man who intends to be a surgeon should not
only make a special study of surgical anatomy, but
should do a considerable amount of practical laboratory
work in bacteriology, pathological histology and ex-
perimental pathology and physiology.

It is quite true that the majority of our leading sur-
geons could not perhaps, by tliemselves, make a bacteri-
ological diagnosis, or determine fine distinctions in
new growths, and yet they do good work — having
these points settled for them by younger men trained
in the new methods. But the surgeon of the future
should himself be trained in these methods, even though
he may employ others to carry them out.

And in this connection I would remind you that
bacteriology cannot be profitably studied for two or
three days in a week, but that it needs at least three
hours a day every day for three months for a man to
learn how to begin readily to use its methods. In
general, I think that all studies are best concentrated,
and that the usual plan of dividing studies into an hour
two days a week for this, and an hour three days a
week for that, etc., is much more for the convenience
of the professors than it is for the true interest of the
students.

As for operating technique, much of it can be learned
on animals, but much of it requires also work ou the
cadaver, the repetition over and over again, until, as
Billroth said, a man could do it when he was asleep.
The most important of all is residence in a hospital,
the working as assistant to a surgeon, the seeing and
handling cases, and not merely looking at them from a
distance. The number of men who are able and will-
ing to carry out such a course of study as that indicated
is linfited, and the teacher of surgery cannot do very
much for them except give them opportunities for see-
ing his methods and results ; but is it not possible to
give them better opportunities than can be provided
for a large class of undergraduates ? Should they not
be required to repeatedly perform the many operations
which can be advantageously performed on animals

Digitized by

Google

638

BOSTON MEDICAL AND SURGICAL JOUBNAL.

[Mat 81, 1894.

before they try these operatioos on man ? It seems to
me that in the last year of a four-years' course all
students should be tested in this way ; but it mast be
admitted that, with the present curriculum, there is not
time to spare for this purpose, especially where the
graduating class is a large one.

This leads to two final questions, which, though not
directly connected with " the best methods of teaching
surgery," have nevertheless, an important bearing on
it. The first is : Are there not some subjects which
occupy too much space in the undergraduate curricu-
lum of our largest and best medical schools, such for
example, as inorganic chemistry, and embryology ?
Ought not the student to be required to know so much
as is required of inorganic chemistry before he begins
his medical course ? Is it desirable to make embryology
and general morphology a part of the curriculum for
all medical students, as a buis for the study of anat-
omy, or is it wiser to place these as elective studies
in a post-graduate course, and to insist on more dissect-
ing and a greater knowledge of practical anatomy than
is now generally demanded ? In this connection your
attention is invited to the widely different opinions as
to the best methods of anatomical teaching — as rep-
resented by Professor Macalister for the morphologists,
and Mr. T. Cooke for the old school, which have ap-
peared in the Lancet and in the British Medical Journai
during the past year.

It appears to me that the teaching of anatomy should
begin with a few lectures and demonstrations on gen-
eral morphology, and that the first dissections should
be made on cats and dogs until a good technique has
been acquired, so that the supply of human cadavers,
which is always insufficient, can be fully utilized to
the best advantage. I also think that it is unwise to
have the final examination in anatomy one or two
years before the other final examinations ; the anatomy
should be kept up throughout.

My last question is : Would it not be good policy
for a first-class popular medical school to limit the
number of pupils which it will accept to its capacity
to give them proper instruction in laboratory work, in
practical anatomy, and in clinical medicine and sur-
gery ? Of course, each faculty is prepared to assert
that its own school now does this, and will disapprove
of fixing any limit to the number of its pupils ; never-
theless, it appears to me, as an outsider, that there are
at least two or three medical schools in this country
which would act wisely if they would fix a limit to the
number of students which they would receive either
in the first or in the third year, or in both, and enforce
this limit by competitive examination or by higher fees,
or by both. It would bring the best men to them, and
would enable them to do thoroughly good work.

A Land Without a Microbe. — The Spitsber-
gen group of islands, in the Arctic region, is said to
be the most sterile place on the earth. Analysis of
the air, water and soil of Spitzbergen shows an ex-
traordinary poverty of these regions in bacteria. While
the air of the streets of Paris contains on an average
51,000 bacteria, that of the Arctic Sea contains
only three per cubic metre. The water of Spitzber-
gen not only is devoid of any pathogenic micro-organ-
isms whatever, but is also entirely free from all kinds
of bacilli.

CRYSTALLINE DEPOSITS IN THE URINE:
THEIR CAUSATION AND RELATION TO
RENAL DISEASES.!

BT BDWABD M. OBBKKB, AM., M.D.

Thb object of this paper is to consider the conditions
under which crystalline deposits are formed within the
urinary tract, the injurious effects of these crystals on
the kidneys, and the treatment. We will limit our
inquiry to uric acid and calcic oxalate, which are by
far the most frequent and important of the inorganic
crystalline substances found in the urine.

Uric Acid. — This is present in normal urine and
has also been found in the blood as well as in the liver
and spleen, and, to a less extent, in the brain, pancress
and muscles. The amount excreted daily depends
greatly upon the diet, varying from half a gramme go
a vegetable diet to as high as even two grammes on an
animal diet. It occurs only in traces in the urine of
herbivora, and may be absent in that of carnivora.
On the other hand, in the urine of birds and reptiles
it is the chief nitrogenous ingredient. In various dis-
eases the quantity in the urine is increased, and, at
times, as in gout, uric acid accumulates in the blood
and is deposited in the tissues. It is generally con-
ceded that uric acid is formed in the tissues, and merely
excreted by the kidneys. Experimental evidence
points to the liver as the place of formation of nric
acid, and it is probably formed by the synthesis of
ammonia and lactic acid. Ebstein, however, thinks it
is chiefly produced in the muscles and bone marrow.

Uric acid may be described as a less oxidized pro-
duct of proteid metabolism than urea ; but there is no
evidence to show that the former is a necessary ante-
cedent of the latter. On the contrary, all the facts
known go to show that uric acid is produced by a
somewhat different process of metabolism from that
which results in urea formation. As pointed out by
Foster, " We have no evidence to prove that the cause
of this divergence lies in an insufficient supply of oxy-
gen to the organism at large. On the contrary, uric
acid occurs in the rapidly breathing birds, as well as
in the more torpid reptiles." "Urea is the form
adapted to a fluid, and uric acid to a more solid excre-
ment."

Uric acid is extremely insoluble in water, one part
of uric acid requiring about 15,000 parts of cold water
and 18,000 parts of boiling water. It is insoluble in
all dilute acids. It dissolves freely in weak solutioDS
of the carbonates of lithia, potash and soda and in
common phosphates of soda. The amount of uric
acid capable of being held in solution in the blood de-
pends on the degree of its alkalinity.

Calcic Oxalate. — Although widely distributed
throughout the vegetable kingdom, oxalic acid occurs
only in very slight amount in the animal organism,
and then always in combination with calcium. Calcic
oxalate is insoluble in water, ammonia and acetic add.
It is readily dissolved by mineral acids, and to a less
extent by solutions of sodic phosphate or urate ; chlo-
ride of sodium, sulphate of sodium, chloride of potas-
sium, and even urea, aid in its solution, though in
slight degree. It occurs in urine both iu solution and
in the form of octahedral crystals and dumb-bells.
Neubaner has frequently found tolerable amounts of
calcic oxalate in solution in the urine when no trace of

1 Read before the Boston Society for Medloal ObMtratloii, March
S, 18»t.

Digitized by

Google

rot. CXXX, No. 22.] BOSTON MEDICAL AND SOBOIOAL JOURNAL.

539

t ■fTVLA discovered in . the sediment ; but he has also
reqaently tested normal nrine for calcic oxalate with
k negative resnit, so that it is doubtful whether this
tnlratance is to be reckoned among the normal or ab-
lornttal constituents of human urine.

The calcic oxalate found in urine is derived from
L'wo sources: (I) Articles of diet and drugs; (2) As
» secondary product of the decomposition of animal,
mineral, or vegetable substances.

The first class is composed principally of sorrel,
rhubarb, tomatoes, oxalic acid when used medicinally,
gentian, saponaria, etc.

The second source is illustrated by the formation of
ox.alic acid from the oxidation of uric acid, kreatin,
lencin, etc, and from the imperfect oxidation of sugar,
starch and salts of the vegetable acids, whereby these,
instead of being wholly transformed into carbonates, be-
come in part oxalates which contain less oxygen. It
is, moreover, probable that oxalates may be formed
from carbonates and bi-carbonates when a part of their
oxygen is removed from them by a process of reduc-
tion. These facts in a measure explain why oxalic
acid may be found in the human system under favor-
able circumstances ; thus after taking carbonated
drinks, as champagne and seltzer water, in disturbances
of respiration where the supply of oxygen is dimin-
ished, and after eating sugar in excessive amount, al-
though the special conditions under which this forma-
tion takes place are still undiscovered. [Neubauer.J
Oxalic acid, though insoluble in water, is kept in
solution in the blood and enabled to pass through the
walls of the blood-vessels in the kidney, and thus ap-
pear in the urine, through the solvent action of sodium
phosphate, and, to a less degree, by that of chloride
and sulphate of sodium and even of urea.

It is thus seen that uric acid and calcic oxalate re-
sult from defective processes of metabolism, and affect
the kidney only by throwing upon it the labor of their
excretion and by the formation of crystalline precipi-
tates in the renal tubules and pelvis of the kidney.

It is extremely important to determine the condi-
tions under which these substances crystallize in the
urine, and to study the effect of their prolonged action
on the kidneys. For this purpose I have tabulated
the records of 600 analyses of urine made by me dur-
ing several years past, in all of which careful micro-
scopical examinations of the sediment were made. No
hospital or dispensary examinations are included, as
these were not all made with equal thoroughness. In
many of these cases the urine was normal, although
there usually were symptoms which suggested the ad-
visability of an examination. In very few cases in-
cluded in these records were there more than one or
two specimens from the same patient.
Of the total number of 600 examinations

A crjitalllne Bedlmeiit w» present 180 tlmas or 30 %

0rl<v«cl<i orjstalg were found 102 " 17

Caleio-oxalate crjatala were found 108 " 18
Both oalolc-ozalate and urlo-acld orya-
tall were found 30 " S

Insll the cases containing these crystalline sediments
the reaction was acid in every case and usually strongly
so.

Of 72 times in which uric acid alone was found,

Cryitala wer« present In large amount 30 timea

Albuman waa preaent 45 "

Cwta were preaent 86 "

Blood vaa preaent 20 "

Situ waa preaent 6 "

Of 78 times in which calcic oxalate alone was found.

Cryatala were preeent In large amount
Albumen wa« present ....
Casts ware present ....
Blood waa present ....
Sugar waa present ....

63 times

16
0

Of the SO cases in which both calcic oxalate and
uric acid were present.

Albumen was found
Casts were found .
Blood was found ,

16 times
16 "
8 "

The specific gravity of ^0 specimens containing
much uric acid was

Below 1,016 In 6 oasea

From 1,016 to 1,019 in 5 "

From 1,020 to 1,024 in 6 "

From 1,025 to 1,029 In 12 "

Abore 1,030 In 2 "

Or, in other words, it was below 1,020 in 1 1 cases,
and at or above 1,020 in 19 cases.

Of 53 cases in which calcic oxalate was present in
large amounts the specific gravity was

Below l,0'.>01u .
From 1,020 to 1,026 in
Above 1,026 in

Soases
19 "

To summarize, then, a crystalline deposit was found
in nearly one third of all the examinations which were
made. ' Calcic oxalate and uric acid were found with
very nearly equal frequency, each being present in
about 18 per cent, of the examinations, although large
amounts of calcic oxalate were twice as frequent as
large amounts of uric acid.

Albumen was present in nearly two-thirds of all the
cases containing a crystalline deposit, and was equally
frequent with both kinds of crystals. In a little more
than half the cases it was present only as a very slight
trace ; and in the others it very seldom exceeded one-
eighth per cent.

The nitric-acid test, and boiling with a drop or two
of acetic acid, were the only tests used for albumen ;
and the latter proved the more delicate. By a " very
slight trace " is meant the smallest amount of albumen
which caused very slight but distinct cloudiness when
boiled.

CkuU, usually of the hyaline or finely granular
variety, were present in 89 of the 105 cases in which
albumen was found, and were also present in four cases
in which no albumen was detected. Usually the num-
ber of casts is small and they are associated with mucoid
threads.

Blood was found in more than a fourth of the cases
of uric acid, and in about a fifth of the cases of calcic
oxalate. In only four cases was it present in sufScient
amount to be suspected by its appearance to the naked
eye. In all other cases a few or a moderate number
of blood globules were found by the microscope alone.

Sugar was present in one-twelfth of the uric-acid
cases, but was never found with calcic oxalate.

Acidity was almost always marked with uric acid,
but less so with calcic oxalate.

Specific gravity was above 1,020 in two-thirds of the
uric-acid cases, and in nearly nine-tenths of the calcic-
oxalate cases.

The diagnosis of chronic parenchymatous or intersti-
tial nephritis could not be made in more than 18 of
the 105 cases in which albumen and crystals were
present.

We may then fairly infer that the remaining 87
cases illustrate the considerable amount of irritation of

Digitized by

Google

540

BOSTON MEDICAL AND 8VB0I0AL JOURNAL.

[Mat 81, 1894.

the kidneys produced by nrine containing crystalline
deposits.

In the entire number of 600 examinations, albumen
was found 340 times from all causes.

Comparing this number with that of the cases of
albuminaria due to crystalline irritation (87), we find
that the latter cause accounted for nearly one-fourth
of all the cases of albuminuria.

It is well known that both uric acid and calcic
oxalate may be precipitated from the urine after it has
been voided. All acid urines invariably deposit uric
acid sooner or later. In perfect health the acid held
in solution, by its combination with alkaline bases, does
not deposit its uric acid, even after it has been voided,
unless it stands for a considerable time. The precipi-
tation of uric acid is caused by the acid fermentation
of the urine, during which the extractive coloring-mat-
ter is decomposed with the formation of free lactic and
acetic acids. Uric acid thus precipitated twelve to
twenty hours after emission has no pathological signifi-
cance. The crystals which separate in this manner are
usually larger than those which are found in the urin-
ary tract, and many of them will be found adhering to
fibres of cotton or other foreign substances. The bulk
of the uric-acid crystals is also found on the top of the
natural sediment or adherent to the sides of the vessel.
Crystals of calcic oxalate also may form slowly in the
urine after it has been voided owing to the chemical
decomposition of the acid sodium phosphate, which is
the principal substance holding the calcic oxalate in
solution. Such crystals are generally larger than
those which are formed within the body. Indeed, the
latter are often so minute that they appear hardly
larger than bright points even under a powerful micro-
scope. In case of doubt the presence of a slight trace
of -albumen, and especially of blood globules, would
point to the formation of these crystals in the kidney
or bladder.

The amount of crystalline nrio-acid sediment cannot
be taken as an index of the actual amount of uric acid
excreted. On the contrary, Roberts frequently found
that those days on which a spontaneous deposit occurred,
showed less uric acid than those days on which no uric
acid was spontaneously deposited. The amount of
uric acid actually excreted presents considerable vari-
ations in the same individual from day to day.

The quantitative estimation of uric acid is a difficult
matter and is of slight importance as uric acid in solu-
tion is comparatively harmless. Though urea may be
decomposed into uric acid, both by artificial means in
the laboratory and within the human body, exact ob-
servations have failed to show that there is any inverse
correspondence between the excretion of the two sub-
stances ; usually urea and uric acid increase and de-
crease together.

The conditions of the urine which cause precipitates
of uric acid are stated by Roberts to be as follows :
(1) high acidity, (2) poverty in mineral salts, (3) low
pigmentation, (4) high percentage of uric acid.

The degree of acidity is prolmbly the most impor-
tant element.

Clinically the excretion of uric acid is markedly in-
creased in the febrile state, in certain diseases of the
liver, in tuberculosis, rickets, scurvy, leukemia, and
after an attack of gout. It is diminished during the
paroxysm of gout. I have found a very large amount
of uric-acid crystals in the urine of a rather delicate
boy^six years old, whose father and grandfather both

had chronic, gouty joint-infiammations. Such a case
illustrates the importance of hereditary influences. In
the production of uric acid, especially, habits of luxuri-
ous eating and drinking combined with deficient mus-
cular exercise are important factors.

Von Jaksch found uric acid present in the blood in
all those disease processes in which oxidation was dis-
turbed, either directly, as in affections of the lungs,
such as pneumonia, or indirectly, as in ansmia, in
which the oxygen-carriers are deficient.

In view of these pracdcal observations, as to the re-
lation of oxygen to nric-acid production, the theoretical
inferences drawn by Foster (quoted above) from the
formation of uric acid in birds are found not to apply
to man. According to Haig, the amount in the blood
rises and falls with the degree of alkalinity, as uric
acid is soluble in alkalies, and all circumstances which
increase the alkalinity are associated with an increase
in the amount of uric acid in the circulation.

The conditions favoring calcic-ozalate formation
seem to be somewhat different from those concerned
in uric-acid formation. In the latter, we are more
likely to find that the system is overloaded with nitro*
genous material the oxidation of which is hindered by
a deficient supply of oxygen. In other words, the
organs concerned in the process of assimilation and
oxidation are overcome by the excessive work imposed
upon them. The formation of calcic oxalate depends
rather upon a disturbance of function in these organs,
so that we find that oxalnria is associated with dyspep-
tic and neurffistbenic conditions in which the vital pro-
cesses are at a low ebb. This opinion is somewhat
strengthened by the result of examinations which I
made of nrine of fifty different patients, taken at ran-
dom, at the McLean Asylum. Crystalline deposits
were found in 23 cases — nearly one-half of the pa-
tients examined. Calcic oxalate was almost twice as
frequent as uric acid. Albumen was found with the
crystals 13 times; blood was found with the crystals 11
times; casts were found with the crystals 12 times.
The specific gravity was over 1,020 in 16 of the 23
cases; and it was over 1,025 in IS, reaching 1,033,
1,040, 1,040 and 1,041 in 4 cases, without the pres-
ence of sugar.

Comparing these results with those previously given,
we see that a crystalline deposit, especially of calcic
oxalate, is much more common in the insane than in
other patients. The latter generally took very little
exercise, ate as little as possible, and often suffered
with melancholia or nervous prostration — in short,
were in a poor physical and mental condition.

The question then arises whether '^lithuria," and
" oxaluria " are themselves diseases, as some hold, or
only symptoms of many diseased conditions. Many
writers have described an " oxalic-acid diathesis "
which is accompanied by all the symptoms met with
in dyspepsia, hypochrondriasis and neurasthenia, and
corresponds with the condition attributed by some to
spermatorrhoea. But all of these symptoms may be
present without oxalate of lime ; and, on the other
hand, a large amount of oxalate of lime may be foand
apart from any of the above-mentioned symptoms.

We are forced to conclude, therefore, that the term
" oxaluria " must be restricted to the narrow definition
of the occurrence of a deposit of calcic oxalate in the
urine. " Lithuria," likewise, simply implies a deposit
of urates or uric acid. In this narrow sense the symp-
toms produced by deposits of uric acid or of calcic

Digitized by

Google

>!.. CXXX, No. 22.] BOSTON MBDIOAL AND SURGICAL JOURNAL.

641

alate are simply those of varying degrees of irrita-
»n of the kidueys and arinary tract.
A diHtinction shoald be made between slight, occa-
>nal depoaits and large quantities occurring persist-
lUj. Almost every one has probably bad at some
one or another a few crystals in the arine, and these
e without particular significance. Bat where there
frequently a considerable deposit an abnormal state
ust be recognized, and one which calls for treatment.
he most obvious danger is the liability to the forma-
on of calculus. .
More insidions and harmful is the condition of long-
ootinued hyper»mia of the kidney, dne to irritation,
rhicb may end in chronic interstitial nephritis, the so-
ailed " gouty kidney." In his description of the cou-
racted kidney, Striimpell says : " In the pelvis of the
cidney, which is often somewhat dilated, there are fre-
|oently a number of uric-acid concretions. Striated
iric-acid infarctions in the pyramids are a very char-
kcteristic mark of the gouty, contracted kidney." He
also says that " experience teaches us that there are
three chemical substances which may favor the devel-
opment of contracted kidney : alcohol, lead and uric
acid. Chronic alcoholism is often to be regarded as
the moat probable cause of renal contraction, especially
in people who have * lived well ' otherwise, and have
become corpulent."

This latter condition is what we have just shown to
be the most important factor in uric-acid formation,
and it ia not impossible that alcohol produces its harm-
ful effect on the kidney partly through its influence in
favoring the production of uric acid. Chronic lead-
poisoning and gout, Striimpell also says, " often lead
to the development of contracted kidney, in which we
probably have to do with the noxious action of an ab-
normal amount of uric acid on the renal parenchyma."
" Intense worry and strain of business " are causes as-
signed by Osier and others. These conditions also we
have shown to be productive of calcic oxalate and uric
acid by disordering the digestive and metabolic pro-
cesses generally.

Professors Da Costa and Edward S. Wood, in recent
papers, speak of the frequency with which albuminuria
is produced by renal irritation caused by urine which
is concentrated and contains uric acid or calcic oxalate.
It is to this cause also, in many cases, that Professor
Wood attributes the so-called albuminuria of adoles-
cence.

The occurrence of albumen in these cases is often
intermittent, and I have found that it is much more
likely to be present in the early morning urine, as this
is more likely to become concentrated and to contain
crystals, owing to the necessary abstinence from food
and drink during the sleeping hours.

In organic nephritis, on the other hand, albumen is
much more abundant after the ingestion of food, the
damaged condition of the renal capillaries allowing the
albumen thus supplied to go directly into the urine.

This point is illustrated by the case of a young man
who came to my oflSce one morning last April to be
examined for life-insurance.

He was twenty-three years of age, a clerk in a busi-
ness ofBce, well developed and apparently in very good
health. He said he felt perfectly well in every way,
and there was no prejudicial family history. On ex-
unining the urine, I was surprised to find one-tenth
per cent, of albumen. The urine was highly-colored,
specific gravity of 1,022, acid, without sugar, and con-

tained a considerable sediment. The latter, on set-
tling, showed under the microscope much calcic oxa-
late, a little mucus and a few hyaline casts. A few
days later he came in In the afternoon and brought a
specimen of urine passed before breakfast, which
proved, on analysis, to be the same in every respect as
the above, except that there was not quite so much
albumen and very little calcic oxalate. The specimen
passed in my office the same afternoon was of normal
color, specific gravity 1,020. No albumen, sediment
slight, and found to contain nothing abnormal.

On June 22d, after he had been taking water and
diuretics, a morning specimen showed a specific gravity
of 1,010, no albumen, and a slight sediment which
contained nothing abnormal. After this he neglected
treatment, and I did not see him again until October
14th. On that day the early morning urine was high-
colored, specific gravity 1,022, albumen one-tenth per
cent., sediment slight, but contained a little calcic
oxalate, a little mucus and a few hyaline casts. The
afternoon specimen of the same day had a specific
gravity of 1,012, contained no albumen, and I was un-
able to find either calcic oxalate or casts in the urine.
He informed me that a few days previously he had
been accepted for life insurance by another company,
although he had informed them that he had been re-
jected by me in April for albuminuria. The medical
examiner had had him call at his oflBce several days in
succession, and had found no albumen. On inquiry, I
found that his calls had always been in the afternoon,
and he was required, as is customary, to pass bis water
in the presence of the examiner, who became satisfied
that the urine was normal. It would seem advisable
in such cases with a high specific gravity for the medi-
cal examiner to contrive to secure a reliable specimen
of early morning urine. I have seen the patient
several times since, and usually find albumen and
calcic oxalate in the morning urine. The only cause
for this condition that I could discover was a habit of
drinking very little water, and a disinclination to take
any more exercise than he was obliged to take in
walking to and from the office.

(3V>6ea<m(iiiiied.)

CASES OF ACUTE PNEUMONIA IN CHILDREN .

BY F. GOBDOK XOBBIU., K.D.

Thb tables given in this paper include a great ma-
jority of the cases of pneumonia which have been
treated in the wards of the Children's Hospital, the
exceptions being a few of which the records are not
sufficiently complete to be useful.

The period of life (second to twelfth years inclu-
sive) during which children are eligible for admission
to the hospital must be borne in mind, as it undoubt-
edly influences the views which experience in this par-
ticular institution might lead one to adopt.

By " frank " pneumonia is meant a form of the dis-
ease which has been easily diagnosticated from the far
more serious broncho-pneumonia, and which (so far as
our experience at the Boston Children's Hospital is
concerned) differs from it as radically as any two acute
diseases affecting the same organs can differ in their
history, course and prognosis.

The term " frank " instead of " croupous " or " fib-
rinous " pneumonia, is employed in order to avoid the
confusion which has arisen since the comparatively

Digitized by

Google

542

BOSTON MEDICAL AND SVBGJCAL JOVBNAL.

[Mat 31, 1894.

recent discovery of the fact that there may be consid-
erable quantities of fibrin in cases which are clinically,
and (as recently proved) in their bacteriological pathol-
ogy, broncho-pneumonia. The statement made that
both forms and all grades of the disease ntay coexist in
children is not warranted by oar present knowledge,
and has proved a most unwelcome addition to already
existing perplexities.

That a frank pneumonia may terminate by pro-
louged lysis, that a bronchitis often accompanies it, or
that a broncho-pneumonia may involve the whole (?)
or nearly the whole of an entire lobe, are facts which
when properly weighed do not invalidate the state-
ment in the preceding paragraph.

Cases of prolonged absorption of the products of a
frank pneumonia are by no means rare in adult life,
and the same thing is occasionally observed during
childhood. Cold is assuredly a factor in the causation
of frank pneumonia ; and a bronchitis giving rise to
rales in any or all portions of the lungs may be nat-
urally expected in 15 to 20 per cent of all cases.
When a large portion of lung is involved by a broncho-
pneumonia the history and predominant symptoms of
the case have usually been such as to enable the at-
tending physician to form an early and correct diagno-
sis.

The very small number of autopsies which have been
obtained does not warrant the expression of an opinion
concerning the post-mortem appearances of either form
of the disease.

GUnieally, the children who have been treated in
this hospital, have taken their pneumonias almost
" straight."

SDUUA.Rr.

Mortality about 1^ per cent, in 72 cases, of which 44
were boys, and 28 were girls.

Average age a little over five years.

Months when admitted : January, 4 ; February, 6 ;
March, 6 ; April, 9 ; May, 7 ; June, 9 ; July, 2 ; Au-
gust, 4 ; September, 5 ; October, 7 ; November, 3 ; De-
cember, 10. Spring and winter, 42 cases; summer and
autumn, 30.

Highest temperature in any case while under obser-
vation 106.5° F. Lowest maximum temperature in
any case while under observation 101° F. Highest
average maximum temperature in 68 cases 104.2° F.

Terminating by crisis (the temperature dropping to
normal or below within twenty-four hours) 34. Ter-
minating in " short lysis " (temperature dropping to
normal or below in more than twenty-four and less
than forty-eight hours) 19. By prolonged lysis 12.

The average critical day in 54 cases was the eighth.
In 31 of the cases terminating by crisis it was between
the seventh and eighth. The lower lobes have been
more frequently involved than any other portions of
the lungs. In three cases the location of the disease
was central — by which is meant that no signs of solidi-
fication could be detected, but the symptoms were
sufficiently well marked to make it morally certain that
the disease was frank pneumonia. Such cases as ter-
minated in prolonged lysis, showed the physical signs
of very slow absorption of inflammatory products with
little or no redux crepitation. Pleuritic effusions in
connection with frank pneumonia have been rare, and
as a rule of small extent. But one case of empyema
has been observed.

The disease certainly appears to be very benign so

far as concerns the cases here reported, and the treat-
ment has been quite simple : milk diet; brandy, when
indicated ; digitalis or strophanthus in cases of irregu-
lar or very weak pulse ; and occasionally phenaoetin,
in instances when a high temperature has not been
well borne. Pretty free stimulation (two or three
ounces of brandy per diem) has been used when a
sudden fall of temperature was followed by signs of
collapse. No cough mixtures of an expectorant char-
acter have been employed ; but occasionally an opiate
has been given to check troublesome night-cough.

The expectoration of rusty sputa has been exceed-
ingly rare, and the main points upon which the diSereo-
tial diagnosis has been made are : sudden onset of the
attack (history of cough accompanied by high fever,
nausea, convulsions or delirium, and abdominal pain),
the quiet type of the dyspnoea and detection of solidi-
fication giving rise to coarse (as a rule) crepitant r&les,
bronchial respiration and exaggerated vocal resonance.
The average age of the children admitted for frank
pneumonia, five years ten mouths, as compared with
the age of those entering with broncho-pneumonia (a
little over three years) would seem to show pretty con-
clusively that in New England the latter disease is
most prevalent among children who are of an age to
easily shed and rapidly proliferate the epitheliam of
their mucous membranes.

The following table includes the cases of broncho-
pneumonia which have been treated in the wards with
the exception of five cases, in which the records are
very incomplete. The total number of cases (33)
when compared with the number of frank pneumonias
(72) goes to prove which is the most common type of
the disease between the second and twelfth years.

This hospital is a poor field for the observation of
broncho pneumonia, which is essentially a disease of
very young children and infants, and is apt to break
out in epidemic form in institutions where large num-
bers of them are congregated. This epidemic type is
infectious, and is characterized by its sudden onset. It
is this form of the disease (particularly in cases where
a large extent of lung is involved) which has given
rise to conflicting views of both clinicians and patboio- -
gists. The children treated in this institution are of an
age which usually exempts from this fatal form of
broncho-pneumonia, and the non-admission of measles
affords further protection. Many of the cases reported
here might be more properly called chronic broncho-
pneumonia, or phthisis following closely after the acute
form of the disease. Cases in which an acute bron-
cho-pneumonia is merely the death mask of a miliary
tuberculosis are usually of an explosive type, and prove
rapidly fatal. So far as I am aware, we have had but
one example of this form of the disease in the hospi-
tal, and the diagnosis in this case was made at the
autopsy.

A brief summary of the table shows that 14 of the
cases were girls and 19 boys : and the average dura-
tion of illness from its commencement (as nearly as
could be ascertained) in 29 cases has been between 10
and 12 weeks. There are so many types of the dis-
ease, varying from that which suddenly overwhelms a
child (as in the epidemic and very infectious kind,
such as occurs among children who are crowded
together) to the long sickness which eventually kills
by subacute or perhaps fibroid phthisis, that I think it
quite impossible to fix any definite average of duration
of cases which custom has sanctioned our calling

Digitized by

Google

Vol. CXXX, No. 22.] BOSTON MEDICAL AND 8UB6I0AL JOURNAL. 54

" broocho-pneumonia." A very acute attack may prove
to be merely the wind-up of a miliary tuberculosis ; it

~. — vm :.

as these have beea observed in children, where reg
lation of the dose is not so exactly carried out, althoui
"*^=- -*^' • "- relatively mu.

to the frequen
•ress the opini
y guarded in tl

positively bar
I resume of the
retics, mention
curred one ho
, which was i
t. The stage
a by a feeling
le symptoms a
e intensity of d
erate quantity <
orded by the la
> the hospital i
l-developed mai
Df the asphyzii
the boweh wei
D was a dall-r«
his admission, h
I powder of ant
vhen he fell inl
ireatment he r
\ depression ai

3M, which may I
ent temporaril;
leads not infn
atient complaic
cert himself an
t, there is estal
ntions headachi
^j IS as occasionall

2 ing of the visio

f** tger-oails. Blu(

e commonest ui
various degree
) a deep cyanos
It is to be e:
system, and espi
obiusemia is pri
lis are destroye(
tod through th
lany of the symj

'diac depressiot
ia was frequei
' of the membei
>f the occurreuc
tal writers. Sue
of great cautio
phthisis and tj
'her profuse pei
erious drawbact
larance of a ras
iters of these r(
oms observed b
^^^. Qoerature instea

effects ai

^ZS

1^

93

ttimulation before she was considered out of danger
twelve hours later. A small proportion of results such

■ The Praotltloner, 1893.

- , o '■^'y •'»'■'

Shortly after the introd Hey wei

not uncommon, on acci larg(

doses then in use. The i ve n(

Digitized by

Google

542

BOSTON MEDICAL AND SVBGJCAL JOUBXAL.

[Mat 31, 1894.

recent diaooverj of the fact &»t

erable quantities «'

and (as recently p»t

ogy, broncho-ptt^i

both forms and «.l 1

childreo is not ^ira

and has proved » \

existing perplexi ti

That a frank,
longed lysis, that *
that a broncho-p>i3
or nearly the irhol

when properly wv*

ment in the prece<
Cases of prolon

frank pneumonia >

and the same thi

childhood. Cold.

of frank pueamon

r&les in any or »1

urally expected ■

When a large portJ

pneumonia the bi

the case have uso

tending physician

sis.

The very small

obtained does not

concerning the po*

of the disease.
GlinieaUy, the

this hospital, ha«

" straight."

mar be consid- far as concerns the cases here reported, and the treat-

- J»S»i.w. t^w— »»—h,i„i i, 1 I iMi linn, hMadv. »Uii

Mortality about
were boys, and 2€

Average age a

Mouths when I
March, 6; April «
gust, 4; Septembc
cember, 10. Spri:
autumn, 30.

Highest tempei
vation 106.5° ^.
any case whilo i
average maximu o

Terminating kyj
normal or belovir '
minatiug in " sb<
normal or beloW
than forty-eight b

The average c**
In 31 of the cas0<
the seventh and *
more frequently
the lungs. In th
was central — by
fication could kH
sufficiently well O
the disease was f-'-
minated in prolo'
of very slow abs<
little or no redu

connection with frank pneamonia have been rare, and
as a rule of small extent. But one case of empyema
has been observed.

The disease certainly appears to be very benign so

together) to the long sickness which eventually kills
by subacute or perhaps fibroid phthisis, that I think it
quite impossible to fix any definite average of duration
of cases which custom has sanctioned our oalliog

Digitized by

Google

Vol. CXXX, No. 22.] BOSTON MEDICAL AND SVS6J0AL JOURNAL.

643

" broncho-pneamonia." A very acute attack may prove
to be merely the wind-ap of a miliary tuberculosis ; it
may kill in a very few days without the aid of tuber-
cle, or the child may recover quite epeedily. On
the other haud, a similar attack may be followed by a
slow form of pulmonary phthisis ; and the period of
death, or possibly recovery, is quite indefinite. A
mortality of 45 per cent, as in the cases here given, is
perhaps what might be naturally looked for in the
type of the disease which they represent

I have been unable to discover in the records any
case of so-called " capillary bronchitis," for the reason
that when children have presented the symptoms usu-
ally attributed to this disease (as they have in one or
two instances) they have been treated for, and recov-
ered or died of, broneho-pneumonia.

Sl^etittal ^togxt^^.

REPORT ON THERAPEUTICS.

BT FBAKCIS H. WILLIAMS, M.D.

THE UNTOWARD BFFE0T8 OF ANTIPTRIN, ACETANILIDB
AND PHBMAOETIN.

Dr. D. R. Patterson • states that circulars were
sent oat to the South Wales Branch of the British
Medical Association asking for information as to the
alleged ill effects following the administration of anti-
pyrin, acetanilide and phenacetin, the nature and com-
parative frequency of their occurrence, and their rela-
tive importance. Twenty-five replies were received ;
and these were from men engaged in active practice,
in some instances both hospital and private, and re-
siding in different parts of the district. The writer
also discussed the subject with many of the members
who sent in reports, and thus learned their views at
greater length than could be expressed in a circular
reply.

Antipyrin. — It is as an analgesic that this drug is
prescribed so largely by practitioners, and all are agreed
that it is an invaluable remedy. Large doses depress
the nervous system. Of the twenty-five reports, seven-
teen note positive results, varying from an unpleasant
diaphoresis to severe collapse. Most of them may be
referred to the action on the nervous system, producing
exhaustion and collapse following the fall of temper-
ature; and there may be disturbance of the circula-
tion for the same reason or secondarily from the effect
on the blood-corpuscles and the production of methsemo-
globinaemia. Other symptoms, such as affections of
the skin and pronounced psychical disturbance, are
more rare. Depression with collapse has usually been
noticed after doses given with a view to reduce fever.
Thus, a dose of twenty grains was followed in a male
adult in a short time by great collapse and fall of tem-
perature, requiring hypodermic injections of ether and
digitalis to tide the patient over the difficulty. The
writer cites another case in which ten grains given to
a lady convalescent from influenza led to extreme
depression and collapse ; the patient became deeply cy-
anosed, unconscious and pulseless, and required free
stimulation before she was considered out of danger
twelve hours later. A small proportion of results such

' Tha Pntctltloner, 1883.

as these have been observed in children, where regu-
lation of the dose is not so exactly carried out, although
the amount borne by a child is often relatively much
larger.

Several of the reports call attention to the frequency
of depression in pneumonia, and express the opinion
that the use of the drug should be very guarded in that
disease, one member holding that it is positively harm-
ful even in small amounts. Falk, in his resumi of the ill
effects of recently introduced antipyretics, mentioned
a case of pneumonia where death occurred one hour
after the administration of antipyrin, which was re-
garded as the cause of the fatal result. The stage of
collapse is not infrequently ushered in by a feeling of
anxiety and great prostration, and the symptoms are
sometimes relieved by vomiting. The intensity of de-
pression that may follow even a moderate quantity of
antipyrin is illustrated by a case, recorded by the late
Paul Guttmann, which was sent into the hospital as
one of cholera. The patient, a well-developed man,
had the symptoms and appearance of the asphyxia!
stage of cholera-morbus, except that the boweh were
confined. On the chest and abdomen was a dull-red
miliary rash. Five days previous to his admission, he
had taken for headache a fifteen-grain powder of anti-
pyrin twice a day, in all 150 grains, when he fell into
this condition. Under stimulating treatment he re-
covered rapidly. Minor degrees of depression are
represented by unpleasant diaphoresis, which may be
so profuse as to prostrate the patient temporarily.
Continued use of even small doses leads not infre-
quently to a condition in which the patient complains
of loss of energy, is disinclined to exert himself and
becomes depressed mentally, in short, there is estab-
lished an antipyrin habit. Falk mentions headache,
giddiness and other nervous symptoms as occasionally
brought ou by antipyrin.

One of the members report blurring of the vision
along with blueness of the lips and finger-nails. Blue-
ness of the lips and face is one of the commonest un-
toward effects, and was noticed in various degrees,
from that which is just perceptible, to a deep cyanosis
associated with profound collapse. It is to be ex-
plained by the action on the nervous system, and espe-
cially the blood by which methsemoglobinsemia is pro-
duced. In extreme doses the red cells are destroyed.
The circulation of the altered blood through the
medullary centres is responsible for many of the symp-
toms observed.

Several of the reports note cardiac depression.
Cardiac failure in cases of pneumonia was frequent
even with doses of ten grains. None of the members
have apparently had any experience of the occurrence
of haemorrhages reported by Continental writers. Such
an occurrence points to the necessity of great caution
in the administration of antipyrin in phthisis and ty-
phoid fever. In the former, the rather profuse per-
spiration produced by the drug is a serious drawback.
Two of the reports mention the appearance of a rash
after the use of antipyrin. The writers of these re-
ports did not observe various symptoms observed by
others, such as convulsions, rise of temperature instead
of the anticipated fall, etc.

As to the frequency with which the ill effects are
met, all the members agreed that they were very rare.
Shortly after the introduction of the drug they were
not uncommon, on account, no doubt, of the larger
doses then in use. The reports of those who have not

Digitized by

Google

544

BOSIOS MEDICAL AUD SVttGJCAL JOVBSAL.

[Mat 31, 1894.

observed any uopleasant after-effecU or Bigns of intox-
ication show that the doses they were in the habit of
giving were, on the whole, smaller. A single dose of
ten grains or five grains every three hours is the usual
practice of three out of eight who report negative
results ; others give two ten-grain doses, with an in-
terval of two or three hours between. Two members
state that when giving antipyrin as an antipyretic, they
always combine it with a stimulant, such as sal vola-
tile, brandy, or tincture of digitalis. In this way large
doses, even to the extent of twenty grains every four
hours, until 120 grains had been reached, were admin-
istered without depression being felt.

Aeeianilide {antifehrin). — Its action in lowering
temperature is striking, but the disadvantages attend-
ing it have seriously limited its administration. The
frequent occarrenue of symptoms of intoxication, and
the alarming appearance they Sometimes assume, led
many practitioners to abandon its use very early.
Eight members report results after a considerable use
of the drug ; aud among them a few speak of its great
value when used with due care. The dose generally
given varies between five and ten grains, but some give
as low as three grains to an adult. The general expe-
rience seems to be that the larger doses are soon fol-
lowed by symptoms of intoxication. Some practition-
ers combine the drug with a stimulant — brandy, or
digitalis, or caffeine — with excellent results. The
consensus of opinion gathered from the reports coin-
cides with that generally expressed, that symptoms of
depression and collapse are more readily produced and
more marked than with antipyrin ; and this may be
explained by the fall of temperature being greater and
more rapid. One observer, whose extensive use of
acetanilide makes his opinion very valuable, states that
there is less collapse in children than with antipyrin.
In pneumonia, the depressant action on the heart ren-
ders it very unsafe. Most of the reports mention
cyanosis, and to a greater degree than after antipyrin.
Anaemia may be induced by the continued use of the
drug, and become a grave condition. The anemia is
due to the action of acetanilide on the red blood-cells ;
minor forms of it are noticed after a few doses.

Phenaeetin. — This drug is more free from ill effects
than either of the other two drugs. It is generally
given in doses varying from five to ten grains, and it
is very useful in neuralgia of the fifth nerve, sick-
headache, etc. Its depressant action on the nervous
system and heart is manifest only when very large
doses are given, small amounts taken frequently being
borne without ill effects. It is not, however, absolutely
free from unpleasant consequences, as is illustrated
by a case of Eisenhart. An adult male was given for
pain in connection with a carious tooth three powders,
each containing fifteen grains of phenaeetin, within
three and a half hours ; half an hour after the last
powder palpitation and oppression of breathing came
on; later, the palpitation and oppression increased,
dulness of hearing came on, and then nausea and vom-
iting. With the onset of sickness, all traces of intox-
ication vanished, and the patient felt well. Skin
eruptions, chiefly urticarious, are said to follow the
use of phenaeetin.

[It is not alone the immediate depression which
may follow one or two doses of these drugs against
which we should guard, but rather the more insidious
depression which may follow their continued use in a
long illness like typhoid fever but which may not be-

come apparent until the later stages of the disease. It
is a good rule to avoid these drugs in serious illnesses
where we need to husband the patient's strength.
Acetanilide (antifebrin) is the most likely of the three
to have an untoward action. — f. h. w.J

8TSON6 HTDROOEN FEBOXIDK ACID SOLUTIONS
LOCALLY IN DIPHTHERIA.

Dr. Francis H. Williams,' in an article on diphthe-
ria, outlines in a few words the general treatment of
this disease, speaking of the need of special attention
to the food of the patient and of the service of alcohol
in some cases, and adds that the oases of Behring
treated with the blood-sernm of immune animals, en-
courage us to hope that a feasible internal remedy may
yet be found. He then goes on to say that at present
local remedies are our best means for the treatment of
diphtheria, aud obviously they are best adapted to
those cases that are seen early, before much of the
poison has been absorbed, and in which the membrane
is accessible. He then briefly touches upon various
of the local remedies that have been used, but does not
recommend any of them, citing three cases, the diag-
nosis of which was based on cultures, to show how the
membrane may persist under the use of corrosive sub-
limate. Two of these cases entered the hospital on
the third day of the disease and were treated with cor-
rosive sublimate (I to 10,000) in the one case, and
with corrosive sublimate aided by the ordinary solution
(7.5 volumes) of hydrogen peroxide in the other. In the
first case, the patient was finally discharged on the one-
hundredth day of the disease. The corrosive subli-
mate seemed to have inhibited the growth of the bacilli
so that for a time none appeared in the cultures and
treatment was therefore stopped ; they were, however,
apparent later. In the second case, the patient was dis-
charged on the forty-first day of the disease. Both of
these patients had weak hearts, aud the latter had
paralysis. The writer then discusses more in detail
the special local treatment which he has found to be
most efficient, namely, strong hydrogen peroxide acid
solutions, by which he means strength of 25 to 50 vol-
umes (old style 50 to 100) ; 7.5 volume solutions are
weak germicides. He first proved, by experiments
made in the laboratory, that the strong acid solutions
were efficient germicides against the Klebs-Ldffler ba-
cillus ; he lays stress upon the important part played
by the acid contained in them, and shows that the
hydrogen peroxide has the special quality of breaking
up and disintegrating certain portions of the diphthe-
ritic membrane without injury to the healthy tissue,
thus rendering the bacilli more accessible. In stating
his clinical experience, he describes two cases of diph-
theria, the diagnosis of which was based on cultures
where, although only partial use of the strong hydro-
gen peroxide solutions was made, good results fol-
lowed. These two patients entered the hospital on
the second day of the disease ; in the first case, a final
application of the peroxide was made on the fifth day
after entrance and the patient left the contagious ward
six days later. In the second case, a final application
of the peroxide was made on the third day after en-
trance, on the fourth the throat was clear, and the
patient was discharged after being kept under observa-
tion ten days longer. In neither case was there car-
diac weakness, depression or paralysis.

The writer states that he has found nothing that

' American Journal of Medical Soienoei, NoTemtwr, 1898.

Digitized by

Google

Vol. CXXX, No. 22.1 BOSTON MEDICAL AND SUltGICAL JOURNAL.

546

will remove the membrane due to the diphtheria ba-
dlli BO well aa the gtroDg solatioDg of hydrogen perox-
ide, gives a general rule for ueing them, describes the
instraments with which they should be applied, and
then says that any local treatment must be frequently
applied to be efficient, as the bacilli reproduce them-
selves in a very short period. The use of the strong
hydrogen peroxide acid solutions reduces the number
of applications to a minimum, as the more thoroughly
the membrane is disintegrated and removed the less
frequent is the necessity for treatment, and the shorter
its duration. The usefalness of good local treatment
is in direct ratio to the stage of the disease, the acces-
sibility of the membrane, the age and strength of the
patient, and the ability of the practitioner to apply it
with the least tax on the patient's strength combined
with the greatest destruction of the bacilli. The writer
emphasizes the importance of early treatment, and says
that the strong hydrogen peroxide acid solutions are
the most efficient local treatment of which be knows.

[Further use of these solutions in cases of diphthe-
ria, the diagnosis of which was based on cultures, shows
good results, especially in those cases treated early.
Over 90 per cent, of those which were treated within
the first three days recovered.]

THE OBTAINING AND THB DSB OF SBBUH FOB THB
CUBE OF DIPHTHBBIA.

Ehrlich, Kaseell and Wassermann * in a very inter-
esting paper state that the animals principally used to
furnish serum in their experiments were goats, which
they found especially adapted to the purpose. The
manner of rendering them immune is alluded to and
the method of testing the power of the antidote de-
scribed. By an agreement with Behring the best of
the serum made by them was used in several hospitals
and the whole number of cases treated was 220, all of
which were children. The cases were not selected.
These injections of serum confirmed earlier observa-
tions in proving them to be perfectly harmless. At
first, one injection only was used, but experience gained
iu the treatment of severe cases induced them later to
use repeated injections in certain hospitals. Of the
220 cases treated, 168 recovered and 52 died; 67 of
the 220 cases had tracheotomy performed; of these 37
recovered. A table given shows that the success of
the treatment by serum depends essentially upon how
early in the disease treatment is begun.

The writers noticed that the temperature and pulse
were influenced only by the stronger injections. An
immediate fall in temperature does not customarily
follow the injections of serum, and this may be due to
the fact that the pure Klebs-Loffler bacillus was only
found in the very early stages of the disease in these
cases, and even then it was proportionately rare. In
the later days of the disease other bacteria were asso-
ciated with the diphtheria bacilli, and the antidote for
the poison of this bacillus does not counteract that of
the other organisms. In some cases where the treat-
ment was begun very early, the writers noticed an al-
most critical lowering of the temperature and of the
very high pulse. They close by saying that the fate
of the child is decided in the first three days of the
disease and therefore the serum should be injected as
early as possible ; that according to their experience
the initial dose in serious cases and in all cases of
tracheotomy should be double that of the light cases ;

* Santttfbe Medleliiliohe Woobensohrif t, April, 1894.

that the treatment with serum should be continued
according to the course of the fever, to the pulse, and
to the local appearances; that the total amount in-
jected should be according to the severity of the case.

THE TREATMENT OF ITCHING.

Dr. Edward Bennet Bronson,* describes at some
length the means that may be employed to remove this
distressing affection, and groups them as follows :

Meatwret to Remove Local ExcitatUt. — These will
include, first of all, such as directly tend to prevent
scratching. Irritating contacts of all sorts should be
most scrupulously avoided. Attention should be given
to the underclothing. Woollen is almost never toler-
ated. The clothing next the skin should be of the
softest material — cotton, linen, or possibly silk. Of
further importance is the avoidance of immoderate
temperatures, whether of heat or cold, and especially
of sudden changes, which are peculiarly apt to excite
itching. The local excitants may not only be extra-
cutaneous, but also intra-cutaneous. Often they are
incidental to the trophic changes of one of the so-
called prariginous diseases, in which case the treatment
of the pruritus is included in that of the disease of
which the itching is a symptom. When they arise
from the toxic materials conveyed to the skin by the
blood, the endeavor is to eliminate these materieds by
depurative remedies, more especially diaphoretics and
diuretics. These measures faUing or proving insuffi-
cient to secure the desired rest, it becomes necessary
to have recourse to certain sedatives.

Sedativet. — Used internally, these are apt to be dis-
appointing. The degree of general sedation that is re-
quired to affect the nerves of the skin, in so intense a
disturbance as pruritus often is, affords a sufficient
reason why this method of treatment is usually objec-
tionable. Further than this, the depressing and atonic
after-effect on the nervous system tends to exaggerate
the general hypersesthesia, which is already essentially
an atonic condition, and thereby increases the tendency
to itching. Especially objectionable on this score are
most of the narcotic sedatives. The bromides, on the
other hand, are often indispensable, and may be re-
quired in liberal doses. To avoid the enervating
effects of loss of sleep, sulphonal or some other
hypnotic is occasionally needed. In connection with
this class, two internal remedies, namely, cannabis in-
dica and gelsemium, are worthy of mention. The
latter has proved of benefit in some cases, more espe-
cially according to the writer's experience in protracted
cases of urticaria, but the doses required are so large
as to forbid their long continuance. Finally, the
antipyretics, phenacetin and antipyrin, have some
effect upon pruritus, though less than upon the sensa-
tion of pain. The local sedatives used in this disease
are generally far more satisfactory in their effects
than the remedies just considered, especially where the
disease is limited in extent. They are for the most
part agents that tend to retard vital action. The fact
that many of them are antiseptics probably implies
something more than mere accidental coincidence.
Typical among the remedies of this class is the group
which includes carbolic acid, salicylic acid, salol and
thymol, all antiseptics, and all having undoubted vir-
tues as antipruritics. Carbolic acid is, perhaps, all
considered, the most reliable and most generally useful
antipruritic. It is preferably employed in oils or oint-

* Hedleal B«oord, 189S.

Digitized by

Google

546

BOSTOS MEDICAL JJfJ) SVBGICJL JOVBHAL.

[Mat 81, 1894.

ment. The following has been largely employed by
the writer:

B AoM.earboUo 3i-il

Uq. poUM. 31

Ol.llnl 3J M.

Slg. Slukke before oiIiiK.

Salicylic acid and salol, thongh lesi energetic in
their effects, act similarly to carbolic acid. They may
be used in combination with other drugs, or by them-
selves in oils or ointments, or sometimes alcohol, and
also in superfatted soaps. Thymol is also useful in
certain cases, bat, on account of its irritating effect,
cannot be used when the skin is very sensitive. Cor-
rosive chloride of mercury also has a reputation as an
antipruritic CJocaine has proved disappointing for
two reasons : first, because of the diflSculty of making
its action felt through the intact epidermis; and,
second, for the reason that any tissue, when long or
frequently subjected to its action, suffered a certain
stony and enervation that seems to render it more
predisposed after than before to the irritation or irri-
tability the drng was intended to alleviate. These ob-
jections by no means preclude its use entirely. It is
often resorted to with most satisfactory results in
localized forms about the mucous orifices, upon raw or
abraded surfaces, and sometimes with appreciable ef-
fect even where the epidermis is apparently intact.
Hot water, to be effective, should be over 100° F.,
and the applications should be prolonged for several
minutes.

Seniory StimidanU. — Electricity, whether in the
form of galvanism or faradism, has sometimes proved
of decided benefit. Strychnia, in those cases of pruri-
tns which may be called atonic, is a remedy of value.

SHbtUlutivt Irritants. — One of the best palliatives
of itching is menthol, together with the peppermint
preparations generally. Menthol relieves itching as
it relieves pain, not by direct inhibitory action on the
molecular movements of the sensory nerves, but chiefly,
if not solely, as the writer believes, by substituting an
eza^erated temperature sense for the perturbed sense
of contact, or for the sensation of pain. It is usually
employed in alcoholic solutions (grs. v-z to §i), and
may be used in ointment. It is also with advantage
combined with salol or thymol.

Alterative* of Oulaneoui Nutrition. — They indnde
not only absorbent and anti-catarrbal remedies to re-
move the products and curtail the processes of inci-
dental inflammations which may act as contributory
causes of the itching, but such agents as tend to control
blood-supply and overcome hyperaemia. In this way
act diaphoretics, and possibly diuretics, as well as by
their substitutive and eliminative or depnrative action.
Thus it is probable that jaboraudi, which is recom-
mended by so many writers, acts in all three ways.
This drug is especially useful when the skin is hot and
dry, and where it has become the depot of noxious
materials deposited from the blood, as, for example, in
the itching of icterus. The local remedies belonging
to this class include certain resinous or tarry sub-
stances. Such are ichthyol (five to ten per cent.),
occasionally tar, resorcin (three per cent.), and ben-
zoic acid or benzoin. Hydrogen peroxide has also
proved beneficial.

Motor Depreuantt. — Among the internal remedies
already mentioned, gelsemium and jaborandi belong to
this class. Another remedy, more especially recom-
mended in urticaria, is atropia. The good effect of

this drug in urticaria, when used in full doses, such as
are always required to produce this effect (from one-
hundred-and-fiftieth of a grain upward) is probably
due to its secondary action ; in this action the muscles
relax and the vessels are dilated. Hot-water applica-
tions take the first place in local remedies belonging
to this class. Here, also, may perhaps be included
such local sedatives as hydro-cyanic acid, cyanide of
potassium, corrium juice, tincture of arnica and chloro-
form.

Dr. Bronson closes the article by illustrating the
therapeutic principles laid down by means of special
forms of the affection.

Vittvxt ftiteratuce.

AnoMtAetiei and their Adminittralion. A Manual for
Medical and Dental Practitioners and Students.
By Fbbdbriok W. Hkwitt, A.M., M.D. (Cantab.).
With illustrations. London : Charles Griffin & Co.
1893.

We have before alluded to the many advantages of
the system of regularly appointed anaesthetists which
prevails in English hospitals. This work of Mr.
Hewitt is a proof of those advantages. He has put
the careful experience of many years into a book
which will stand easily at the head of all works on
the therapeutic administration of anaesthetics. The
data are well arranged under four parts : Preliminary
Considerations; The Administration of the Selected
Anaesthetic ; The Management and Treatment of the
Difficulties, Accidents and Dangers of General Antes-
thesia ; The Condition of the Patient after Adminis-
tration.

Mr. Hewitt has given the question of " Chloroform
or Ether ? " careful consideration, and makes no hesi-
tancy in advocating ether as the surest, safest and best
anaesthetic for general use. The whole book is worthy
of study by all who have to do with anaesthetics,
either as surgical instructors, pupils or general practi-
tioners.

7%« Johns Hopkins Hospital Reports. Report in Gyn-
ecology, II. Baltfmore. 1894.
This volume of more than 400 pages is very inter-
esting, not only as g;iving an idea of the amoaut of
work done in this department in Johns Hopkins Hos-
pital, but also as illustrating its thoroughness and its
value from an educational standpoint. The material
at baud has been so carefully worked over and utilized
that it is full of suggestions for the practitioner. The
result is a series of monographs, nineteen in all, most
of them by Dr. Kelly, which are of varying importance
and interest, but all of them well worth study. They
are fully illustrated with figures and plates, which add
much to their value.

Of especial interest may be mentioned the articles
on operations for the suspension of the retroflexed
uterus, urinalysis in gynecology, the importance of
employing anaesthesia in the diagnosis of intra-pelvic
gynecological conditions, and one hundred cases of
ovariotomy performed on women over seventy years
of age.

This series of reports would be a valuable addition
to any gynecologist's library.

Digitized by

Google

Vot. CXXX, No. 22.] BOSTON MEDICAL AND SURGICAL JOURNAL.

547

THE BOSTON

iStetilcal ano ^utgCcal journal*

THURSDAY, MAY 31, 1894.

A Jowmal of Medicine, Surgery, and Allied Seie»ee*,p»bUthed at
BotUm, weetljf. Ay the wndenigfud.

SDBgCBiPTiOM TSBMS : 95.00 per year, in advanee, poetage paid,
for (Jk< United 3iate$, Canada €md Mexico ; •6.66 per year for all for-
eign countrie* belonging to the Pottal Union.

All eonuammioatione for the Editor, and tUl booki for r«0{«», ihonU
ie addretted to the Bditor of the Sotton Medical and Snrgieal Journal,
283 Wathington Street, Soeton.

All lettere containing butinet* eommunioaHom, or referring to the
puHieation, tubecription, or advertiting department of tlA* JotunuA,
ehotUd be addreteed to the undenigned,

Jlemittancet should be made by money-order, draft or regittered
letter, payable to

DAMKEIiL A UPHAH,
283 WASHineTOS Stsxet, Bortok, Mass.

ARTERIO-SCLEROSIS AND ARTERITIS : MOD^
ERN VIEWS AS TO ETIOLOGY.

Tbb conception of arterio-sclerosis as a general dis-
ease of the arteries finding expression in interstitial
inflammations of rarious viscera, originated with Lan-
cereaux in 1871, and, independently, a year later with
Gttll and Sutton. The latter designated the condition
as an " arterio-capillary fibrosis," and they snpposed
the capillary net-work to be invaded by a " hyaline
degeneration " ; while Lancereaax more correctly de-
fined the disease as a generalized endarteritis, followed
by renal, cardiac, or other endarterites, and subsequent
interstitial inflammation.

This notion of a general idiopathic arterial disease
with visceral manifestations has since been established
as an irrefragable medical doctrine, has been frnitfal
in practical applications, and it has been shown that
there is perhaps no more common disease of the age
in which we live than arterio-sclerosis. " Longevity,"
says Osier (in quoting from a much (ilder authority),
" is a vascular question, for a man is only as old as
his arteries. To a majority of men death comes
primarily or secondarily through this portal."

Arterio-sclerosis and atheroma designate two distinct
localizations of a slow morbid process, atheroma being
applied to the inflammatory or degenerative changes
as met with in the larger vessels. Arterio-sclerosis,
according to Gull and Sutton, Mahomed, Hnchard, and
others, is the parent of atheroma and of all the fatty,
fibroid and calcareous changes in both large and small
vessels. The primary morbid process is an obliterat-
ing endarteriolitis of the vasa-vasorum or nutrient ves-
sels of the artery ; dystrophy, local infiltration and
degeneration in the media and adventitia follow.
" These lesions lead to a weakening of the wall in the
affected area, at which spot the proliferative changes
commence in the intima, particularly in the subendo-
thelial structares, with gradual thickening and the for-
_ matiou of an atheromatous button or patch. A similar
process goes on in the smaller vessels, and it can be
seen on section that each patch of endarteritis corre-

sponds to a defect in the media, and often to changes
in the adventitia."

According to this view, in this as in other dystrophic
diseases where the nobler elements perish from lack of
their nutritive supply, the counective-tissue- elements
proliferate and form an overgrowth which by its pres-
ence obstructs function and damages or destroys the
surrounding structures ; or, if fragile and of low vital-
ity the new growth becomes necrosed and fatty, and
may eventually be removed or undergo the calcareous
transformation.

The question whether the visceral scleroses (being
connective-tissue inflammations) are always prima-
rily diseases of the arterial system, is answered dif-
ferently. Mahomed, with Gull and Snttoo, taught
that the nephritis is but a manifestation of a diathesis
or poison which affects synchronously the cardio-
vascular system. In all cases, " the blood-poison, of
whatever nature it may be, produces certain changes
in the cardio-vascular system, at first functional and
afterwards organic by inducing high arterial tension
and subsequently hypertrophy of the heart and thick-
ening of the vessels ; and at the same time it af-
fects not only the kidneys but also the other excretory
organs which all alike become congested in their efforts
to excrete the poison ; hence in these organs certain
changes occur — interstitial, if the disease be chronic,
epithelial, if acute." '

There is no doubt that this is a part of the truth,
but it is not all the truth, and pathologists have rec-
ognized the fact that there is an interstitial nephritis
that is primary, and may, at least in its early stages,
be independent of general arterial disease — this is the
case with the senile kidney and saturnine nephritis,
according to Charcot. Certain chronic fibroid pneu-
monias, according to the same authority, may always
remain local ; so also a variety of syphilitic hepatic
sclerosis, hypertrophic cirrhosis, and (according to
Lancereaux) common alcoholic cirrhosis.

As to the nature of the poison, there is not entire
agreement among pathologists respecting a disease
which, according to Mahomed's estimate, affects to a
greater or less extent seventy-five per cent of all per-
sons who pass the age of sixty. Lancereaux, who has
written much on arterio-sclerosis, is sure of but cue
causal agent, which he calls herpetitm, which he re-
gards as a " vaso-trophic neurosis, always manifesting
itself by multiple affections of divers parts and systems
such as hsBmorrhoids, varices, dry and gouty and rheu-
matic arthrites, migraines, eczematoas diseases, etc."
As for alcohol, he denies its causal influence, except so
far as it favors development of the peculiar diathesis ;
that the abuse of this poison causes local fatty lesions
of the heart and arteries he as positively a£Brms.

Gueneau de Mussy also insists on the influence of
herpetism in the production of atheroma, and includes
gout and rheumatism as being the diathetic maladies
par excellence. He prefers the term artkritiitn * to her-

> Leotnrm in Lancet, 1879.

I X>e rAtberome Arterial : LefOng de Cllnique IKcUoale, t, I,

Digitized by

Google

5^8

BOSTON MEDICAL AND SVBGICAL JOVSJUAL.

[Uat 81, 1894.

petiBin. This author, whose cootribation to the sub-
ject of atheroma will always possess great scientific
value, concludes from twenty-five carefully tabulated
clinical observations in which the autopsy was con-
ducted with great care, that " the lesions produced in
the arteries by alcoholic excesses, are earlier, deeper,
more rapid and more pronounced than those produced
under the influence of all other causes." *

It has been disputed whether syphilis is ever a cause
of generalized arteritis; certainly the arterial lesions
which it produces, in the tertiary stage, are frequently
limited to arteries with prominent lymphatic sheaths as
those of the cerebrum. The same may be said of
malarial endarteritis, which always aCects the large
vessels, especially the aorta, taking the form of gelati-
nous or indurated patches (Lancereaux).

Over-eating, overwork of the muscles (by increasing
the peripheral resistance and raising the blood press-
ure), and renal disease (by increasing the toxic quality
of the blood and thus poisoning the vessels) have been
reckoned as causes : and Huchard assigns a consider-
able role to mental emotion (worry and anxiety),
which, he thinks, acts by producing spasm of the arte-
rioles and vascular hypertension.

In senile arterio-sclerosis, complex causal factors
exist which may be principally classed under the heads
of dystrophic and toxic. This is really a diffuse arte-
rio-sclerosis with extreme degeneration of the arterial
coats, with nodular, beady indurations in the smaller
and calcareous patches in the larger arteries. It is
astonishing with what apparent good health many old
persons will live, and to an advanced age, who have
long had calcareous arteries and granular kidneys.

There is a close relationship between plethora and
arterio-sclerosis, as Germain S6e has pointed out.*
Two causes, he says, favors its development : (1) phy-
sical causes, namely, intra-vascular obstacles which
increase vascular pressure and owe their origin to dis-
regard of hygienic laws, excesses or sedentary life;
(2) chemical, autoxic and infectious agents ; alcohol,
gout, diabetes, syphilis. There are two classes of per-
sons who early develop increased vascular tension : (a)
those that take much food and little exercise and de-
velop adipose tissue ; (5) then, sometimes, anemic
individuals who are obliged to lead a sedentary life.
Every copious repast determines a certain temporary
plethora. If more food is ingested before the previ-
ous plethora has been disposed of, there gradually is
established a permanent vascular repletion.

After showing how increased adiposity obstructs
the abdominal circulation and raises the pressure in
the aorta, he points out the fact that a considerable
venous distention is also produced, showing itself in
superficial varices, haemorrhoids, predisposition to pul-
monary catarrh. The development of sclerosis is al-
ways preceded by this stage of increased vascular ten-
sion. This abnormal pressure is the principal cause
of the general endarteritis.

> Oe I'Atherome Arterial : LegoiudeCliulqae MMlcals, t. i.,p. S04.
< Arterial Dlieaae ; Sajoa'i Aimnal, 1890 ; Medical Bulletin, Uarob
17, ISM.

ANNUAL EEPOBT OF THE MASSACHUSETTS
GENERAL HOSPITAL,

The eightieth annual report of the Massachusetu
Greneral Hospital and McLean Asylum for the year
1893, while not showing any marked changes in this
over recent years, describes enlargements and improve-
ments already begun, which will increase the useful-
ness of the two institutions in the near future. The
report opens with a clear and concise summary by a
Committee of the Trustees, of the principal items of
interest.

The year shows a deficit of over $29,000, the largest
in the history of the hospital, a great part of which,
however, is owing to necessary repairs and alterations
connected with the buildings. There was a falling oS
in the receipts in the second six months of f 6,741,
while the increase in disbursements was $8,470. This
falling off is mainly due to the temporary closing of
Ward B, also to the fact that the year has been one
of great and exceptional financial depression.

On December 1st, the new o£Bce of examining phy-
sician to out-patients was made, the previous arrange-
ments for examination and registration not having
proved wholly satisfactory. The usefulness of this
office in preventing the mingling of cases of contagious
diseases with the out-patients in the waiting-rooms has
already been proved.

In the hospital building gome considerable and im-
portant changes have been made. The old Treadwell
Library-room has been adapted to give a much needed
addition to the work-room of the enlarged staff of
house-officers, while the Treadwell Library itself has
been transferred to a new room in the second story.
Additional house-officers' rooms, with suitable bath-
rooms, have been provided. Changes and additions to
the amphitheatre building include an addition of one
story, containing a new sterilizing-room for the prep-
aration of surgical instruments and dressings. A new
dressing-room for the surgeons has also been provided.
A gift of $50,000 has made it possible to erect a new
isolated ward for contagious diseases ; such a ward
has been needed since the foundation of the hospital.
A card catalogue of all the cases at the hospital from
1871 has been started. An appeal is made for a well-
equipped laboratory ; and for funds for the general
expenses both of the hospital and of the asylum. The
percentage of free patients at the hospital is enormous,
while the subscriptions for free beds have diminished.

The buildings of the new McLean Asylum at Wa-
verley have progressed steadily during the year. The
description of four of them, not included in last year's
report, appears in this one. Two interesting reports
are printed ; one upon the occupation of patients at
the asylum, by the Superintendent ; the second by a
special committee on the case of W. H. King, a pa-
tient in the asylum, whose retention has been the
source of much litigation.

In the hospital the total number of patients admitted
was 8,524, an increase of 200 over the previous year.
The number of out-patients was 26,527, with a total

Digitized by

Google

Vot. CXXX, No. 22.] BOSTOJS MEDICAL AND SURGICAL JOVRSAL.

549

attendaDce of 86,579, aboot the same number as in
1892.

In the asylum, although the average number of pa-
tients, 177, was larger than in previous years, the num-
ber of admissions and discharges was less. The com-
ing removal of the asylum from Somerville to Waverley
will be an important epoch in its history ; the build-
ings, roads, and other works at Waverley are now so
far advanced that they may easily be finished before
September 29, 1895, when the estate at Somerville is

to be vacated.

♦

MEDICAL NOTES.

Tbb Nchbbk op Patients at Kino's Collkoe
Hospital. — During the year just closed there were
2,372 patients admitted to King's College Hospital,
London, and 24,000 out-patients treated.

Mb. Gladstone Operated upon foe Cataract.
— Mr. Gladstone was successfully operated upon for
cataract by Mr. Nettleship last week, and has been
making an excellent recovery.

The Medical Societt of the State op Penn-
sylvania. At the annual meeting held May 21st,
Dr. John B. Koberts, of Philadelphia, was elected
president for the ensuing year.

Db. Pepper's SnccEssoR as Protost op the
Universitt of Pennsylvania. — Mr. Charles C.
Harrison has been elected Provost of the University of
Pennsylvania, to succeed Dr. Pepper. He has ac-
cepted provisionally.

Sad Death of a Brooklyn, N. Y., Physician. —
Dr. Charles James, of Brooklyn, died on May 22d
from an accidental dose of tincture of aconite. He was
twenty-seven years old, and a graduate of the Long
Island College Hospital Medical School.

A. ScccEssFCL Splenectohy. — Dr. James Mur-
phy, of Sunderland, England, did a splenectomy upon
a woman forty-five years old, on April 25th. The
operation was undertaken for abscess and hypertrophy.
The wound healed promptly, and at last reports the
patient was making a satisfactory progress.

A Leper Hospital for Louisiana. — At the re-
quest of the Senators and Representatives from Lou-
isiana, the Secretary of War has given New Orleans
and the State of Louisiana the right to use the Gov
ernment military reservation, at Fort Pike, for a hos-
pital for lepers and patients with contagious diseases.

The Thirteenth International Medical Con-
gress. — Dr. Baccelli has written to SeSor San Mar-
tin, the delegate of the Spanish Government to the
International Medical Congress at Rome, that there is
a generally expressed desire that the Thirteenth Con-
gress, the one following that in Russia, should be held
iu Madrid.

Congress of the French Surgical Society. —
The French Surgical Society will hold its annual meet-
ing this year at Lyons, probably in the early part of
October. This is Uie first time the meeting will have

been held outside of Paris. The matter was decided
by ti pUbiicite, and the result is regarded as a victory
for the advocates of decentralization.

Plague at Hong Kong. — A serious epidemic of
disease is reported from Hong Kong. Since the mid-
dle of April over a thousand deaths have occurred.
The disease is said to be similiar to the plague which
decimated the population of Hochow ten years ago ;
but as the cholera is at present reported to be general
in Canton, the disease at Hong Kong is not unlikely
to be of the same character.

BOSTON AND NEW ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon, May 30, 1894, there
were reported to the Board of Health of Boston the
following nnmbers of cases of acnte infectious disease :
diphtheria 37, scarlet fever 65, measles 24, typhoid
fever 12. There were no cases nor deaths from small-
pox during the week. There are no patients at the
Canterbury Street Hospital. The last case of small-
pox was discharged from Gallop's Island this morning.

The Massachusetts Medical Registration
Bill. — The Medical Registration Bill was passed by
the House on Monday May 21st, and now awaits the
Governor's signature before becoming a law.

College op Pharmacy Cohmbncbhbnt. — The
twenty-sixth annual commencement exercises of the
Massachusetts College of Pharmacy was held in Asso-
ciation Hall, Boston, May 23d. Seventeen men re-
ceived degrees.

The Somerville, Mass., Hospital. — The an-
nual report of the Somerville Hospital shows that 325
patients were cared for during the past year, the aver-
age number being 14. The total running expenses
were $9,482.03, the average cost of each patient being
$12.72 per week.

Physical Training at Wellesley College. —
The Committee on Health and Physical Training of
Wellesley College calls attention to the urgent neces-
sity of improved facilities for both in-door and out-door
exercise, and systematic hygiene and physical training
for the young women of the college such as are abun-
dantly provided for colleges for young meu.

The Connecticut School Vaccination Law
Constitutional. — The Superior Court, at Hartford,
Conn., has decided, in a suit brought against the New
Britain School Board to compel them to admit unvao-
cinated children to the public schools, that the law
giving the school board authority to order all school
children vaccinated, and to exclude those not vacci-
nated from the schools, is constitutional.

The New Catalogue of the Massachusetts
Medical Society. — A new and attractive Catalogue
of the Ofiicers, Fellows and Licentiates of the Massa-
chusetts Medical Society from 1781 to the close of
1893 has just been prepared by the Treasurer, Dr. E.
J. Forster, and issued by the Society. A special ef-
fort was made to give full oames and to eliminate all

Digitized by

Google

650

BOSTON MBDIOAL AND SUB6I0AL JOVBNAL.

[Hat 81, 1894.

initiats; and this has been done in nearly every in-
stance, there being bat thirty-fire Fellows whose full
name is not kuown. The total namber of Fellows
siuce the foundation of the Society has been 4,905, of
whom 1,927 are living. In addition to these there
were 178 Licentiates who never became Fellows of
the Society. There have been 145 Honorary Mem-
bers, of whom 7 are now living. In addition to the
statistical tables and lists there is an interesting chap-
ter of historical memoranda.

MBW TOSK.

Nbw York Countt Medical Association and
THE Code. — At a meeting of the New York County
Medical Association held May 21st, a resolution was
unanimously adopted to the effect that the Association
re-affirms its adherence to the code of ethics of the
American Medical Association, and instructs its dele-
gates to the approaching meeting of the latter in San
Francisco to unite with other delegates from the State
of New York in maintaining the code as it now stands.

The Medical Department of the National
Gdabd of New Yoek. — At this meeting Dr. Joseph
D. Bryant, who has been Surgeon-General of the State
for the' last ten years, read a valuable paper on " The
Medical Department of the National Guard : Its Status
in Two Decades." In it he spoke of the general in-
efficiency of this department of the militia up to 1884
and of the radical reforms that have taken place since
that date. It is only due to Dr. Bryant, as was clearly
brought out in the discussion on bis paper by regi-
mental surgeons, that these reforms have been instituted
and carried out by the Surgeon-General himself, who
has devoted much time and attention to the matter.

PoBLic Health. — The reports of the Bureau of
Vital Statistics still continue to show an excellent state
of the public health. In the week ending May 26th
there were reported Til deaths, which represents an
annual death-rate of but 19.28 per thousand of the
estimated population. The mortality from pneumonia
has diminished to a considerable extent, but is still
larger than that from consumption. During the week
the deaths from the former numbered 89 and from the
latter, 82. Diphtheria continues by far the most fatal
of the zymotic diseases, and caused 56 deaths. The
deaths from scarlet fever were 16, from measles, 8,
and from cerebro-spinal meningitis, 5. A considerable
number of cases of small-pox are still reported every
week, and there were four deaths from it daring the
week named. There is but little typhoid fever in the
city, and only three deaths were caused by it.

Tub Tenth Annual Meeting of the Fifth
District Branch. —The tenth annual meeting of
the Fifth District Branch of the New York State
Medical Association was held in Brooklyn on May 22d.
The address of the President, Dr. J. D. Rushmore, of
Brooklyn, was on " The Prevention of the Disagreeable
and Dangerous Symptoms produced by Ether as a
General Anaesthetic." A number of eulogistic addresses
were made on the late Dr. Alfred L. Carroll, and bio-

graphical sketches were read of other members de-
ceased during the past year. Among the papers read
were the following : " The Dietetic Treatment of Con-
sumption," by Dr. T. J. McGillicaddy ; " Report of a
Case of Chronic Peritonitis with Intestinal Fistula

— Celiotomy, Enterorrhaphy, Recovery," by Dr. F. H.
Wiggin ; " The Treatment of Chronic Oophoritis by
Electricity," by Dr. Edward Sanders. The meeting
was closed by a discussion on " Yaccination," which
was opened by Drs. F. A. Jewett, S. E. Jelliffe and
H. H. Morton, of Brooklyn.

PHILADELPHIA.

Resignation of Dr. Edwards. — Dr. .Tos. F.
Edwards has resigned from the State Board of Health.

The Housb-to-House Visitation, which accom-
plished so much good last summer in improving public
health, has again been ordered by the city authorities
on general sanitary grounds.

The Establishment of Sections in the Col-
lege of Phtsicians. — The establishment of Sec-
tions in the College of Physicians has proved very
profitable, the meetings being well attended and the
discussions valuable. A plan is under consideration
whereby the papers and discussions shall appear in
their proper position as contributions to the annual
volume of Transactions of the College.

Non-Vaccinated Children may Attend the
Public Schools. — Owing to a conflict of authority
between the City Board of Health and the Board of
Education, the latter has withdrawn its prohibition
recently issued, against non-vaccinated children attend-
ing public schools. In view of the fact that no epi-
demic is threatened at present, they were not willing
to resort to extreme measures.

Jefferson Medical College Appointments.

— The Trustees of the Jefferson Medical College dis-
cussed the proposed plan of re-organization which in-
cluded the establishment of the office of Provost, and
concluded to postpone further consideration of the sub-
ject until next fall. Dr. S. MacCuen Smith was
elected Clinical Professor of Otology, and Dr. W.
Joseph Hearn, Clinical Professor of Surgery, and Dr.
E. P. Davis, Clinical Professor of Obstetrics.

The American Medico-Pstchological Asso-
ciation. — This Association held its semi-centennial
meeting in Philadelphia at the Continental Hotel May
15th to 19th. Dr. John Curwen of the Pennsylvania
State Hospital for the Insane at Warren, presided and
delivered a very valuable address. Governor Fattison
delivered an Address of Welcome in which he reviewed
the progress of the treatment of the insane in this State
since 1844. An address, by invitation, was delivered
by Dr. Weir Mitchell, who pointed out many flaws
in prevalent methods of treating the insane and
described an ideal hospital. At the closing session
the society elected Dr. Mitchell to honorary member-
ship. Dr. Edward Cowles, of Somerville, Mass., was
elected President and Denver selected as the next
place of m eting.

Digitized by

Google

Vol. CXXX, No. 22.] BOSTOS MEDICAL AND SURGICAL JOUBNAL.

661

99i^cenattp.

DI8-

A CLASSIFICATION FOR INFECTIOUS
EASES.

At b recent meeting of the New York Academy of
Medicine, Dr. W. H. Thomson read a paper on the need
of a more accurate nomenclatare for infections and con-
tagious diseases, and offered the following classification :

(1) Infections diseases are due to the presence of
their respective living micro-organisms in the hody.

(2) Infections diseases are divisible into three classes :
a, communicable, h, non-communicable, c, septic.

(3) The communicable diseases are those whose ori-
gin is from an animal body, examples of which are
small-pox, Asiatic cholera and tuberculosis.

(4) The non-communicable iufectious diseases are
those whose origin is not from an animal body, but
from a place or thing, examples of which are ague,
yellow fever and miasmatic diseases in general.

(5) The communicable diseases are divisible into
two classes, according to the ordinary modes of their
communication : a, into the contagious, h, into the non-
contagious communicable diseases. The contagious
communicable diseases are those in which simple prox-
imity to the sick is sufficient to communicate the in-
fection ; examples of which are scarlet fever, measles,
small-pox, diphtheria, mumps, etc. Isolation of the
sick iu these cases is, therefore, needful to prevent
infection. The non-contagious communicable diseases
are those in which the communication ia not by simple
proximity to the sick, but through intermediate means
of communication. Isolation of the sick with them,
therefore, is neither needful nor effective in compari-
son with measures directed against intermediate means
of infection ; examples are typhoid fever, Asiatic
cholera and tuberculosis.

(6) The septic infections diseases are those in which
infection is introduced through a wound or abrasion ;
examples are erysipelas, hydrophobia, tetanus, etc.

THE SYMPTOMATIC TREATMENT OF DISEASE.

In a recent address before the Harveian Society,
Dr. Samuel West said :

" The treatment of symptoms is often spoken of
with some contempt — not, I think, by clinical physi-
cians, who are not prepared to discard remedies be-
cause they cannot explain their action. It is sufficient
for them that experience proves the value of the drugs
they use. It is true that we have so far no remedies
which will kill disease germs in the body, and there-
fore directly cure any germ disease; but the germs
produce poisons, and these by their action on the body,
in all probability cause the symptoms of the disease.
These poisons we may be able to neutralize or destroy,
if we cannot kill the germ. What the poisonous sub-
stances produced are we do not know, and for anti-
dotes to them we are, and have long been, groping in
great dafkness, it is true ; yet I think it is not un-
likely, when these poisons are isolated and investi-
gated outside the body, that among the old and once-
trusted remedies, which empiricism has discovered and
fashion discarded, will be found some of the true anti-
dotes we want, and thus the symptomatic treatment of
disease, now regarded as so unscientific and irrational,
be discovered to rest upon a truly scientific founda-
tion."

€orreiet])otttieitce.

THE MEDICAL REGISTRATION BILL.

Boston, May 28, 1894.

Mr. Editor : — Is the health of the people of this Com-
monwealth as safe in the hands of ignorant " practisers " of
medicine as it is in the care of educated physicians ? If so,
then our calling is the only profession or vocation of -which
such a statement can truthfully be made.

Granted, that the more knowledge the doctor has, the
better care he will be able to give the sick and wounded,
is it desirable and possible to raise the standard of medical
education ? How shall this be done 7 The various medi-
cal schools, as a rule, are doing what they can in this direc-
tion.

Can anything be done to protect the innocent and igno-
rant sick and wounded from these pretenders, who have
never studied in any school, or anywhere else, and who are
destitute, not only of knowledge and experience, but of
character and good repute ? Is it desirable, that any aid
or protection should be extended to the unfortunate victims
of disease, when seeking for help in their distress, or shall
they be left to the tender mercies of the medical bunco-
steerers of the community ?

It is assumed by the writer, that there are not a few
sensible people in this State, who think and feel strongly,
that some light, as to the qu^ification of doctors, should be
given the people through legislation. This is the object of
ue medical bill. It is designed to benefit the people and
not the doctors. The educated physicians of Massachusetts
ask for no protection and no legislation for themselves, or
for their business against quackery. They are abundantly
able to take care of themselves. But as no class in the
community sees the evil results, the needless suffering, both
mental and physical, and great waste of money, arising
from the unlimited license of quackery, as do the physi-
cians, upon them falls the duty of calling attention to the
matter.

The medical bill undertakes in no way to say who shall
practise medicine, or what " school " or " system " any one
shall practice, or what sort of a physician or doctor or
<< healer " any one may or may not employ. It simply says,
that every one in this State, who puts the title of " Doctor "
to his name in public, shall be possessed of a reasonable
amount of knowledge of his business. That is all. It is
not a great step in the right direction, but it is something.

It is here authoritatively stated that, " the medical mem-
ber of the senate " is the author of the bill, and that, of all
.men, he is the one most responsible for its origin, and pres-
ent status. His great regret is, that it could not have been
made more complete. Very truly yours,

Geor'ok W. Gay, M.D.

METEOBOLOOICAL RECORD,

For the week ending May 19tb, in Boston, according to ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corps:—

Baro-

Thermom-

Relative

Olreetlon

Velooity
of wind.

Wo'th'r.

1

meter

eter.

bnmidlty.

of wind.

•

Oste.

i

s

i

I

§
1

1

i

1

i

■i

*
S

1

1

n

■i

s

*
■i

s

*

0.'

1

*
■i

I

a'
fa

a
1

B..13

30.05

6«

80

02

53

34

44 W.

N.W.

12

22

0.

0.

M..14

30.0H

54162

46

28

39

34IN.W.

N.W.

22

10

O.

0.

T..15

29.86

M,66

44

33

40

361N.W.

N.W.

20

8

<).

0.

W.16

29.80

60 74

46

34 40

37

N.W.

S.E.

12

10

c.

0.

T..17

29.84

61 70

52

75

68

72

N.K.

S.W.

9

11

0.

o.

F..lg

29.80

58 6«

51

97

91

94

E.

S.E.

S

10

0.

o.

001

S..19

29.88

S4

B8

61

97

100

98

N.K.

N.E.

0

9

0.

B.

0.<9

tr

*O.,el0iHl7l CelMti F.,fairi O-.tMi B.,hu7i 8., imokri B.,raliii T.,tlu««t-
I •ninf I M.. MOW. t IndmUin ti«e« of ruDfali. iv- Meas for wock.

Digitized by

Google

562

BOSTOS MSDIOAL AlfJ) 8VS610AL JOVBHAL.

[Mat 81. 1894.

RECORD OF HORTAUTT
Fob thx W>bx ■mdikq Satukdat, Hat 19, 18M.

Be

1

fei

Percentage of deaths from

, .

Ottlm.

Estimate] 1
lation for

1-

ao.4i

11

§3

P

New York . .

1,891, 3M

768

316

14.96

2.47

11.96 1 1.66

Otiieago . . .
Philadelphia .

I,438,UU0

—

—

—

w.

—

^ 1

I.1I6,S62

347

114

14.;0 i 14.2]

2.32

0.22

.68

Brooklfu . .

878,3i)4

369

121

U.12

16.40

.84

6.16

2.24

St. Louli . . .

SUO.UOO

_

—

^

—

—

_

—

Boston . . .

487,397

—

—

—

—

—

—

_—

Baltimore . .

SOO.OOO

—

—

—

—

—

—

...-

WafhiDgton .

308,431

92

21

7.63

8.72

4.36

2.18

UlDolnnatl . .

305,U0U

121

40

11.92

14.94

7.47

1.66

__

GleTeland . .

290,000

123

68

19.44

20.26

2.43

4.16

4.16

Pittsburg . .

263,709

80

33

18.60

13.76

6.00

3.76

3.76

Milwaukee . .

290,0110

■—

—

—

^-

—

.—

__

NashTllle . .

87,764

33

11

18.18

3.03

16.16

3.03

__

Charleston . ,

65,165

43

16

6.99

2.33

4.66

*.

_

Portland . . .

40,000

—

—

—

—

..

Worcester . .

96,217

30

13

10.00

2S.SS

3J3

6.6S

Fall River . .

87,411

31

19

12.92

16.16

12.92

•^

_

Lowell . . .

87,101

22

10

466

4.36

_

Cambridge . .

77,100

34

13

—

—

Ljnn ....

62,6G6

U

0

—

9.09

"^

—

_

Springfield . .

48,684

16

3

—

12.60

_

_

Lawrenee . .

48,36S

.—

—

—

—

—

^

_

New Bedford .

4S,88«

24

13

4.16

16.64

^

—

^

Holjroke . . .

4U78

18

11

22.22

38.88

.—

—

U.II

Salem. . . .

32,233

14

4

—

7.14

—

^

Brockton . .

32,140

8

1

—

37,60

—

—

__

HaTerUU . .

31,396

II

1

—

18.18

—

—

^

Chelsea . . .

30,264

7

0

.-

14J»

.^

•^

_

Maiden . . .

29,394

8

2

—

37 JO

—

~-

^

Newton . . .

27,W6

6

1

—

40.00

.—

...

ntehbnrg . .

27,146

3

0

33.38

Taunton . . .

26,972

7

1

28.06

—

I4.3S

—

Oloneester . .

26,688

—

—

—

—

^

..

Waltham . .

22,068

7

2

28.66

—

—

14.28

14.28

Qolnoy . . .
PitUfleld . .

19,642

_

—

—

—

—

*-

18,802

4

3

20.00

—

—

«-

_

ETsrett . . .

" 16,686

1

0

— .

..

—

—

Northampton .

16,331

4

1

—

2S.00

—

—

—

Newburjport .

14,073

6

0

—

^

—

—

—

Amesbnry , .

10,920

6

2

"~

20.00

^

^

-"

Deaths reported 2,254: tmder five yean of age 849; prlDctpal
infectiona diseases (small-poz, measles, diphtheria and croap,
diarrhosal diseases, whoopiog-ooa^b, erysipelas and fever) 348,
acute lane diseases 327, consumption 211, diphtheria and croup
1B2, diarrhcBftl diseases 63, scarlet fever 36, whooping-cough 25,
measles 23, typhoid fever 17, cerebio-spinal meningitis 13, small-
pox 7, erysipelas ti.

From whooping-cough Brooklyn 7, New York and Pittsburg 4
each, Philadelplila and Cambridge 3 each, Cincinnati 2, Cleve-
land and Nashville 1 each. From measles New York 7, Brook-
lyn and Cleveland 6 each, Philadelphia 4. From typhoid fever
Philadelphia 6, New York 3, Brooklyn 2, Washington, Cincin-
nati, Pittsburg, Lowell, New Bedford and Holyolie 1 each.
From cerebro-spinal meningitis New York 6, Cleveland 4, Hoi-
yoke, Taunton and Fitchburg 1 each. From small-pox New
York 5, Brooklyn 2. From malarial fever New York 8, Brook-
lyn 1. From erysipelas New York and Brooklyn 3 each.

In tbe thirty-three greater towns of Englaitd and Wales with
an estimated population of 10,458,442, for the week ending
May 12th, tbe death-rate was 18.2. Deaths reported 3,649:
acute diseases of tbe respiratory organs (London) 272, measles
232, wbooplng-cough 139, diphtheria 74, scarlet fever 56, diar-
rhoea 40, fever 31, small-poz (Birmingham 6, London 4, Bradford
2, Mancheiiter and Oldham 1 each) 14.

The death-rates ranged from 9.6 in Derby to 26.2 in Birming-
ham; Blackburn 17.0, Bradford 16.4, Cardiff 16.1, Halifax 14.6,
Leeds lti.5, L«icester 14.6, Li verpool 23.8, JL>ondon 18.4, Hanches-
tor 20.6, Newcastle-on-Tyne 17.3, Norwich 16.3, Nottingham
19.4, Portsmouth 12.6, Sheffield 17.9.

OFFICIAL LIbT OF CHANGES IN THE STATIONS AND
DUT1K8 OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. 8. ARMY, FROM MAY 19, 1894, TO
MAY 25, 1894.

Leave of absence (or (oar months, is granted Major Pktih
J. A. Clkabt, sargeon.

Captain Wiluam G. Spiwceb, assistant surgeon, having
been found by an Army retiring board. Incapacitated for active
service, will proceed to his home.

Captain Alonzo R. Chapin, assistant sargeon, is relieved
from dnty at Fort Hancock, Texas, and ordered to new Fort
Bliss, Texas, for duty.

FiBST-LiBUT. Francis A. Wintbb, assistant snrgeon, is re-

lieved (rom duty at new Fort Bliss and (rom temporary dnty
at old Fort Bliss, Texas, and ordered to Fort Hancock, Texas,
(or duty at that post.

Captain Gkokob McCsbkby, assistant snrgeon, will, apon
the abandonment o( Fort Sidney, Nebraska, report in person to
tbe commanding officer. Fort D. A. Russell, Wyoming, for dnty
at that poet.

Captain Robbst R. Ball, assistant surgeon, is relieved
(rom temporary duty at Fort Monroe, Virginia, and ordered to
Fort Adams, Rhode Island, for duty, relieving Captain
William C. Bokden, assistant surgeon.

Captain Bobden, on being thus relieved, is ordered to Fort
Snelling, Minnesota, for duty at that post, relieving Captain
Chaelks F. Mason, assistant surgeon.

Captain Mason, on being thus relieved, will report in person
to the Superintendent of the U. S. Military Academy, West Point,
N. Y., for duty at that post.

Lieut-Col. Francis L. Town, deputy surgeon-general, is re-
lieved from temporary duty in tbe office of the medical director,
Department of the Missouri, and will report in person to tbe
commanding general. Department of Texas, (or duty as medical
director o( that Department.

casualty.

Colonel Joseph C. Bailt, assistant surgeon -general, died
May 16, 1894, while en route from El Paao to San Antonio,
Texas, in tbe line of duty.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. S. NAVY FOR THE WEEK ENDING HAY
28, 1894.

B. R. Ward, assistant sargeon, detached from Bureau of
Medicine and Surgery and to the " Vermont."

C. A. SiBoruKD, surgeon, ordered to the U. S. S. " Cindn-
nati."

MAINE MEDICAL ASSOCIATION.

The forty-second annual meeting will he held in Common
Council Chamber, City Building, Portland, Me., Wednesday,
Thursday and Friday, June 13, 14 and 15, 1894.

Wednesday, June ISth.
"Typhoid Fever, with Some New Notions Regarding its
Treatment." By E. M. Fuller, M.D., Bath. Discussion bv A.
K. P. Meserve, H.D., Portland : S.J. Ba8sford,M.D.,Biddeford.
" An Interesting Obstetrical Case." By Geo. Goodwin, H.D.,
Millbridge. President's Address. " Treatment of Hiemorrhoids
by Clamp and Cautery." By B. B. Foster, M.D., Portland.
Discussion by S. U. Weeks, H.D., Portland. " Puerperal
Eclampsia." By H. B. Palmer, M.D., Phillips. Discussion by
Alfred Mitchell, M.D., Brunswick. " The Artificial Feeding of
Infante." By W. B. Small, H.D., Lewiston. Discusdon by B.
F. Bradbury, M.D., Norway; Geo. H. Brickett, M.D., Augusta.
" The Principles of Antiseptic Surgery." By W. L. Dana, H.D.,
Portland. " Surgery of the Ovary.'' By A. Palmer Dudley,
M.D., New York. Discussloa by Alfred King, M.U., Portland.
" A Unique Case of Urinary Calculi." By S. H. Weeks, M.D.,
Portland. " The Code Question from tbe Standpoint of a Gen-
eral Practitioner." By D. A. Robinson, M D., Bangor.

Thubsday, Jcnb 14th.

"The Surgical Demands of a Country Practice." By W. P.
GIddings, liTD., Gardiner. Clinic at tbe Maine General Hospi-
tal at 11.30 o'clock, with special reference to the illuatrstion of
Surgical Dressings. Election of officers for tbe ensuing year.
"Symphyseotomy with Report of Case." By J. B. O'Nell,
M.D., Portland. Discussion by Stanley P. Warren, M.D., Port-
land ; F. E. Small, M.D., Portland. " The Chemistry of Decom-
position." By Prof. F. C. Robinson, M.D., Brunswick. Report
of Cases: "Csesarian Section," "Extra-Uterine Pregnancy."
By S. C. Gordon, M.D., Portland. Report of " Cases of Abdom-
inal Section." By Wallace K. Oakes, M.D., Auburn. Business.

Annual Oration. By Henry H. Smith, M.D., Maobias, at 8
p. M.

Friday, June 15th.

Reports of delegates to other medical societies. Voluntary
papers or reporte of cases. Report of the Board of Censors.
Unfinished business.

The Business Committee desire that members will come pre-
pared to contribute the resulte of their experience and observa-
tion, by reports of cases, with clinical notes or queries upon
diagnosis, treatment, action of remedies, eto.

Dr. John A. Donovan, President, Lewiston.

Dk. Chas. D. Smith, Recording Secretary, Portland.

RECENT DEATH.

Geobob J. Romanes, Follerian Professor of Physlologv in
the Royal Institution of London and Rosebury Lecturer on Natu-
ral History in tbe University of Edinburgh, died In London,
May 23d, aged thirty-six years.

Digitized by

Google

OL. CXXX, No. 28] BOSTON MBDICAL AND SURGICAL JOVRNAL.

658

mticejEtj^e^.

SCPRAPUBIC HYSTERECTOMY:

HE Addrkss of the Chairman of the Section
ov Obstetrics and Diseases of Women, of the
A.aaKRicAN Medical Asbooiation, San Francisco,
Jtjkk 5, 1894.

BT J08BPH BAgTKAK, M.D., I.t.,D.,

formerly Prt^euor cf Anatomy and Profettor of OyfUKology and
jibaominal Surgerj/, Catlral College of Phytieiant ana
Sttrgeont, Indianapolii, Ind.

1SS.R. Chairman, Ladies and Gentlemen : — It
eems best on this occasion to turn aside from the
isoal caBtom of reporting progress in the department
»f obstetrics and gynecology, a subject which has been
lo often and ably presented by my predecessors, and
»kll your attention to the present status of suprapubic
bysterectomy as viewed from the standpoint of personal
observation and clinical research, with the hope that
I may contribute in some small measure to the
profitable discussion which I am quite sure will fol-
low the reading of the valuable papers on your pro-
gramme.

It is not my intention to report a series of operations
made for the removal of symmetrically formed pear-
shaped tumors, with well-defined broad ligaments ; with
aterine arteries easily accessible and seen pulsating in
their anxiety to be ligated ; tomor ligaments and
arteries dealt with by some definite method; each
operation made in exactly so many minutes, and all
the patients making uneventful recoveries. The litera-
ture of the subject is already cursed with such produc-
tions. Therefore I would rather suggest such means
and methods as experience has taught me will furnish
the best possible results in dealing with tumors by no
means symmetrically formed ; with broad ligaments
displaced and disorganized by nodular masses interfer-
ing with the ligation of arteries and the easy formation
of pedicles.

Despite the efforts of some to name a distinct
method of operating because a flap is made here, or a
ligature placed there, the problems of suprapubic
hysterectomy are rapidly nearing their solution.
Those engaged in the work are divided into two
classes : first, those who have been and are yet satis-
fied with forming a pedicle and fixing the same in the
abdominal wound ; second, those who were not satis-
fied that this method was the best that could be de-
vised, and who have been earnestly endeavoring to
reach some method which shall disregard morphology
of, tumor, of broad ligaments and the location of
nterioe arteries.

Od February 3, 1887, knowing full well that ab-
dominal fixation of the pedicle in suprapubic hysterect-
omy bad at that time given the lowest rate of mortal-
ity, I decided not to operate in that way, bat planned
and ezecDted an operation which in every essential
festare was an extirpation of almost the enUre cervix.
A large cautery passed three times down through the
cervix in reality destroyed a large portion of what
little cervix I had left. A rubber drainage-tube was
iDterted for vaginal drainage. In a recent discussion
in the Nev Tori Journal of Oh*tetric$ and Gynecology,
the operations by Stimson, Krug, Baer and myself are
spoken of as if they were all operations of total ab-
lation of the uterus. If these operations are to be
considered, then the operation by Stimson in Novem-

ber, 1888, was antedated by my determination to secure
something better than the abdominal fixation of the
pedicle on February 8, 1887.

It is not my purpose to occupy time in discussing
questions of priority in making an operation, although
the operation, including the use of my hysterectomy
staff, as I demonstrated it at the International Medical
Congress in Berlin, has since been made many times
by Krobak, of Vienna, and numerous American opera-
tors, with great satisfaction.

I concede the fact that where a given fibroid tumor
has no nodular masses in the region where we would
form a pedicle or imbedded in the broad ligaments,
and where the abdomen is not exceedingly fat, the ab-
dominal fixation has given results, in the hands of
expert operators, in a very high degree satisfactory.
So far as I have been enabled to read the writings of
its warmest advocates, none of them have mentioned
the very strongest point in its favor ; namely, that in
this method we have practically one wound ; whereas,
in the total or partial extirpation method we have two
wounds, the one in the abdomen, the other in the
pelvis, the latter extending through connective-tissne,
rich in lymphatics, down to the vagina — an incubator
for many varieties of bacteria which cannot always be
sterilized and maintained aseptic during an opera-
tion.

I became well convinced a number of years ago that
the use of the clamp of Keith or the serre-neud of
Koeberle for controlling hssmorrhage from the neck
of the uterus was based upon the idea that the spiral
or curling branches given off from the uterine arteries
really penetrated the tissues of the uterus, including
its cervix. Some seven text-books on anatomy which
I have examined state that these branches penetrate
the uterus. I have a number of times, with fingers on
the broad ligaments and their contained vessels, cut
directly through, seizing the spurting vessel and
securing it later. I have also peeled off the uterine
arteries from the sides of the uterus and then cut off
the cervix with little or no haemorrhage.

These studies were for the purpose of reducing the
number of ligatures,' long or short, to become incap-
sulated or slough off, through the vagina, and also to
economize the time for their thorough application.

Here is a nodular mass fed and nourished by a
capsule — a capsule containing the venous and arterial
papillaries. It is well known to every gynecic surgeon
that these nodules can be peeled out of the capsule
withont ligating a single artery. What I have stated
regarding the nourishment of this nodule by its net-
work of capillaries and not by the penetration of the
arteries, for surgical purposes, holds true with refer-
ence to a uterus disorganized by a fibroid tumor or
tumors no matter how large or how small ; not only
of the fibroid uterus, but the normal nterus as well ;
not only of the uterus but its entire cervix down to
the external os.

I here present a specimen (see p. 554) ; and to my
mind it marks a new era in the removal of fibroid
tumors by hysterectomy, for the reason that the uterine
arteries were not ligated at all. I went down between
the uterine arteries and the uterus. The uterine
arteries were absolutely left within the pelvis of the
woman, not a single ligature being ased except those

> A Ugatore to seoora the nterine •rterlei irlU often aeonre a cer-
tain amonnt of masoalar and oonneoUve tlnne, and is one of Uie
noaelbleeourcei of infection of Uie wonnd; hanoe the importance of
navlng aa fev Ugatore* constricting tluue in this work aa poesible.

Digitized by

Google

564

BOSTOJf MEDICAL ABD SURGICAL JOURNAL.

[Jinri 7, lai

which tied off the ovarian arteries and a small section
of the upper portion of the broad ligaments.*

Then in addition to solving the problem as to what
to do with the pedicle, by deciding not to have any,
we also solve the problem as to what to do with the
broad ligaments and especially their contained uterine
arteries by simply leaving them in the pelvis of the
patient.

ptin this case I simply controlled the circulation in
the ovarian artery by ligating the upper portion of the
broad ligaments with a strong ligatnre, then, cutting
the broad ligaments above the ligature, began with this
serrated gouge (see cut) to peel down the broad
ligaments, keeping the gouge close to the tumor, being
especially careful in the interspaces between the nod-
ules not to puncture or tear the uterine artery, or any
of its branches. From time to time nicking the edges
of the peritoneum with these button-pointed scissors,
with the serrated cutting edge, I pushed it forward
under the peritoneum anteriorly and posteriorly so as
to make anterior and posterior flaps. Then pushing
with the serrated gouge, I carefully worked around the
tumor until I had reached the uterine cervix, and then
proceeded with still greater caution not to cut the cer-

' Skater, of Constanttne, Qermany, three-qouterg of a century
ago remoTed the utertw by the raglna without olamp or ligature (See
article by Dr. Ouldo Bell, Indlaiia Medical Jonmal, February, 1894).
Further, the enucleation of the oerrlx by the Tagina waa made by Lang-
beck in 1813. by Reoamier in 1829, ana by Malgaigne at a later date
(See article by Ur. Robert Raybom).

vix nor its capsule, but to push it down, as I oowdf
mv cufi toward my elbow with the fingers of my rigk
hand. The enucleation of the lower portion vS. ike
uterus, including its cervix, reminda me of FroieaK
Sayre's admonition when removing the bead of the
femur for hip-joint disease. He says, " I take tbii
oyster knife and work my way paat the trodiamei
major and minor, then make sure to get beoeatk eke
periosteum close to the bone." " Then," be naed to
say, " d — n the anatomy, stick close to the bone," tak
proceeded in peeling off the periosteam until he U
the entire head of the femur out of the soetabolum.

As I reached this lower part of the cervix, my kw-
terectomy staff was passed up the vagina. I tkes
removed the entire cervix, cutting a little opening m
to the staff, slipping a strip of ganze in the fenestra a(
the suff. When the staff was withdrawn, tfau vh
brought down in the vagina, the upper portion of ik«
gauze being packed into the pocket from whiefa tfa£
cervix had been enucleated. The flaps which I hai
dissected off from the tumor and cervix were broogkt
together by buried suture over the ligatures which kid
included the ovarian arteries, so that their raw endi
also came into the wound. Several rows of binkd
suture were used, so that all raw edges made by peel-
iug out the cervix were deeply buried so as to prefoi
leaking into the peritoneal cavity, the ganze beag
dragged down into the vagina a little each day, fadii-
tating perfect drainage in that direction. This opert-
tion is the realization of the ideal. Heretofore, all of
US had simply been idealizing the real. In a lecture
delivered in July, 1893, I closed with a series of eoa-
elusions. From them I quote the third, to wit:
" Where the neck of the uterus remains small, abdo-
men not too fat after the ovaries and tubes have beea
tied off, the pedicle may be fastened in the lower angle
of the wound and give satisfactory results." To ^ii
conclusion stated at this time 1 have this to add:
Where such anatomical conditions exist, eoncleatiai
of the cervix can be done in less time than the maoit-
facturiug of a pedicle, the adjustment of the serre-nrad
and elastic ligature. Furthermore, abdominal fixation
of the pedicle cannot be accomplished, in all cases.

It is to the class of cases where no pedicle can be
formed to fix in the abdominal wound that I woold
invite the best-directed efforts on the part of those
who have a heartfelt interest in this class of suffering
women.

One's per cent, of recoveries would undoubtedly be
much better if, after making a careful examination
which discloses a tumor deeply imbedded in t-he pelvii,
we would discourage operative procedure ; bat in mj
first 100 hysterectomies I found a number of cases
were gangrenous tumors and tumors containing gan-
grenous nodules, causing slow death in some cases and
rapid death in others from septicemia. Within tbe
last six months I have operated on seven women wbo
bad either gangrenous fibroid tumors or fibroid tumon
with gangrenous nodules. In five of the cases tbe
nodular masses were deeply imbedded in the pelvis,
and two of the cases were operated on within one
week. In each case a nodule as large as a coooaoat
was completely imbedded in the broad ligaments, hav-
ing been developed from low down on the side of tbe
uterus, and in both cases the nodular masses were in
an advanced state of gangrene, they having caused tem-
perature ranging from 100° to 103°. In two other
cases tbe subserous tumors bad become gaogresou

Digitized by

Google

Vol. CXXX, No. 23.] BOSTON MEDWAL AND SURGICAL JOURNAL.

665

from small twisted pedicles. In each case rapid and
well-pronounced septicaemia threatened the life of the
patient. Surely, the technique of suprapubic hysterec-
tomy is not complete until guided by sound surgical
principles. We have methods and means for this class
of cases. I am pleased with the rapidity with which
we can ligate the upper portion of the broad ligaments,
cut the same loose from the tumor, peeling the peri-
toneal covering off from the tissue, leaving a little
subserous tissue beneath it, enucleating nodular masses,
and directly find ourselves down on the uterine cervix
close to the external os, with only an occasional bleed-
ing from some enlarged arterial twig.

The most serious question in my mind in these cases
is how to properly drain the cavities from which these
oodular masses have been enucleated. In a recent
case I packed the cavity in the broad ligament, from
which I had enucleated a gangrenous mass as large as
a cocoanut, with iodoform gauze, bringing the same
out at the side of the pedicle which I bad Axed in the
abdominal wound. In addition to the gauze, I placed
a metallic drainage-tube well down into the pocket.
I wished to be absolutely certain that this cavity was
thoroughly drained, believing that in other cases where
I had trusted to gauze alone for drainage it was not
satisfactory. In the first forty-eight hours we pumped
out of this drainage-tube fully a pint of black blood,
which, ooming from the cavity occnpied by this gan-
grenous nodule, gave a considerable odor, notwith-
standing the thorough washing of the cavity through
the drainage-tube. I believe it would be better in such
cases to secure the most thorough vaginal drainage — not
only through the opening made by the enucleation of
the uterine cervix, the same being packed with gauze
surrounding a drainage-tube, but by making a free
and direct opening from the bottom of the cavity in
the broad ligaments into the vagina. It has been
taught that the danger of removing cysts or fibroids
from the broad ligaments lies in the disturbance of
important plexuses of nerves. My observation leads
me to believe that the shock is not materially great in
such enucleation, and that the bad results following
such operatious are due to the use of drainage which
doos not properly drain. But while I secured the
most perfect drainage in the case referred to by bring-
ing the drainage-tube up to the side of the pedicle, I
would not advise abdominal fixation of pedicle in
cases where nodular masses are enucleated from the
broad ligaments and even imbedded in the region of
the cervix, where we would form a pedicle, believing
that these cases can be treated more successfully by
removal of the entire cervix, with free vaginal drain-
age.

As I suggested at the beginning of the paper, one
of the great objections to the total extirpation of the
cervix and vaginal drainage is that we make an addi-
tional wound and have a possibility of vaginal infec-
tion. I concede, further, that it is not always possible
to render the vagina surgically aseptic. ... Id a
large per cent, of cases, however, a thorough washing
of the uterine cavity, packing the same with iodoform
gauze and then stitching the external os will prevent
any purulent fluid from escaping into the vagina dur-
ing our handling of the tumor. Then, thoroughly
washing and even scrubbing the vagina with a brush
and packing the same (including all its cul-de-sacs)
with iodoform gauze, will give us a reasonable assur-
ance that this tube has been made aseptic and reduces

the dangers of infecting the peritoneal , cavity ]to the
minimum.

In a conversation with Dr. Bantock, of London, I
expressed the hope that in the near future we would
be able to remove fibroid tumors with the same low
rate of mortality which follows oar work in removing
ovarian cysts. He replied : " This can never be done,
for the reason that the anatomical conditions are essen-
tially different." Carefully reflecting over this state-
ment, I have become thoroughly convinced that a
more thorough study of the essential anatomical con-
ditions which exist in an abdomen containing an
ovarian cyst would enable us to bring the rate of mor-
tality of the two operations to something approximat-
ing equality.

I have a number of times left the greater portion t>f
the uterine arteries to remain in the pelvis of the pa-
tient; but from the results I had, I was thinking that
the possibility of infection through the rich chain of
lymphatics at the side of the uterus was greater in
such cases than .where broad ligaments were thoroughly
constricted by ligature all the way down to the open-
ing in the vagina. This led me to prefer cutting
around the cervix to enucleating it. But carefully
reflecting over the statement of Dr. Bantock that the
anatomical conditions were essentially different in
fibroid tumors from what they are in ovarian cysts, I
have become convinced that we often find fault with
the technique which we have used in treating the
pedicle when the cause of death ought to be explained
in some other way. For example, when the parietes
of the abdomen are rendered thin by pressure of an
ovarian cyst, the blood-sopply is reduced so that all
the intra-abdominal viscera are more or less ansemic.
This condition is in marked contrast with the hyper-
nutrition often present in and about the pelvis which
contains a fibroid tumor. I am quite sure that deaths
occur in consequence of our almost losing our heads in
the determination to make the pedicle and all pertain-
ing thereunto as perfect as possible, and neglecting
perfect approximation of the abdominal incision, al-
ways as long as the tumor, including its peritoneum.
I have many times cut through two inches of fat to
reach a fibroid tumor, and unless such a wound be
thoroughly closed by three rows of sutures, the inter-
nal one being fine silk with stitches not more than
one-fourth of an inch apart, and then making absolute
serous approximation, there is danger of infecting the
peritoneal cavity by the wound leaking into the abdo-
men. Too often we take extreme precautions to
nicely adjust the outer integument when it would be
better, if any leakage from the wound is to occur, that
it shall pour outward, and not inward. Again, the
more vascular condition of the peritoneal cavity and
its contained viscera in cases of fibroid tumors, as com-
pared with ovarian cysts, warn us of the greater intol-
erance of rough manipulations, making it necessary to
protect intestines and viscera as much as possible dur-
ing operation by hoi sterilized towels or sponges, by
temporarily bringing the wound together over the in-
testines with a temporary stitch or vulsella, and, above
all and over all, by the most thorough irrigation of the
peritoneal cavity with water at a temperature of not
less than 1 10°, not only after the work has been com-
pleted, but at intervals during the work, so as to undo
the harm we do to the vaso-motor nerves distributed
to the pelvic and abdominal viscera. Half-a-dozen
pitchers full of water are none too many ; and if we

Digitized by

Google

656

BOSTON MEDICAL AUD 8VR01CAL JOVSSAL.

[June 7, 1894.

have prodnced material shock, as evidenced by the
pulse, a few pitchers of water poured through the
drainage-tube and allowed to pour out again has at
times, as I believe (permit me to say, I absolutely
know), saved lives that otherwise would have been
lost. The operator of to-day who seeks to do away
with the "washout" and the drainage-tube on all
occasioua, on theoretical grounds, is rolling the wheels
of progress backward. The skilful management of a
patient during shock is of very great importance in-
deed. The use of opium to put the disturbed tissues
at rest has the genuine ring of surgical wisdom. The
use of strychnia to keep up the tone of the nerves dis-
tributed to the intestinal tract, and thereby counter-
acting the tendency to gaseous distention of the bowels,
is one of the precious comforts to the anxious abdomi-
nal surgeon when his patient is low in shock.

When Ephraim McDowell made bis first ovariotomy,
the citizens surrounded his house threatening his life
because he was about to "butcher a woman." The
sheriff of the county interfered. At first they refused
to listen to his pleadings for the doctor's life. Finally
he struck a compromise, the mob agreeing to let the
doctor alone if the woman recovered, the sheriff agree-
ing not to interfere if the woman died. This was a
crucial test of the doctor's heroism. Other heroic sur-
geons for years did not hesitate to remove ovarian
cysts, but allowed women to pass on to their graves if
the diagnosis convinced them that it was a fibroid tumor.
Still later surgeons removed fibroids if they were pear-
shaped and a pedicle could be easily formed, allowing
women to pass on to their graves if the examination
showed the tumor deeply imbedded in the pelvis by
nodular masses. Even the great and noble Dr. Thomas
Keith, after battling with fibroid tumors with as good
a percentage of recoveries as any one at that date,
finally abandoned fibromectomy, resorting to the use
of electricity, and only wished that he had back from
their graves the patients that had died from his oper-
ations for fibroids. Thank God there were others to
take up the work when he became discouraged. The
old adage that the qualifications of a surgeon were
«< the head of an Apollo, the eye of an eagle, the heart
of a lion and the hand of a woman," is eminently true,
especially as regards him who would seek to be success-
ful in removing fibroid tumors. The head to plan
and to meet the surprises which spring on us during
such work ; an eye to see quickly the exact constric-
tion of every ligature and adjustment of every suture;
the lion heart to forge forward in this aggressive work
when our percentage of recoveries might be better if
we would let fibroids alone, especially bad ones ; the
nimble wit in the end of the fingers, backed by an in-
domitable will to skilfully and speedily perfect the
last suture with the same precision as the first, make a
combination of qualifications suggesting that the sur-
gical type of a man is not to be found thirteen times
in a dozen.

No operation so thoroughly demands that the trinity
of surgery be carried out — thorough preparation of
the patient, thorough operating, and skilful after-treat-
ment. As American surgeons we have a right to be
proud that no other nation leads us in the originality
of methods or successful results in removing fibroid
tumors. Almost every State of our Union has oper-
ators who would venture to give a woman with a fibroid
tumor the chances of life which surgery offers. With
a more thorough and perfect understanding of the

essential anatomical conditions which make an abdomen
containing a fibroid tumor different from one contain-
ing an ovarian cyst, with the realization of the ideal
method applicable alike to all fibroid tumors regardless
of their morphology, a method as successful in the
hands of the many skilled operators as the few, may
we not hope to say with all sincerity that fibroid tumors
can be removed with the same low rate of mortality
which has placed ovariotomy among the brilliant
triumphs of the century ? Then shall the torch lighted
by McDowell in the midnight darkness shine forth
with resplendent glory in this brilliant noonday of
abdominal surgery. The century which in a few years
will have rolled on to the eternal past, has plaoed in
the magnificent temple of medicine many pillars of
surpassing beauty and grandeur, while its surgical
columns have risen high toward Heaven, where as
gilded towers, they fain would vie with the God-given
sunshine in dispelling the chill and gloom of human
agony.

Cbirargia's tower, thy lights resplendent blaze,
Dries woman's tears and leDgthens out her days.
McDowell and Sims, of our Columbia's clime,
Began the work moved onward nigh sublime.
To woman then, these blessings shall be given,
Qaeen of the home and home the type of Heaven.

Abdominal surgery is proud of her past because it
is prophetic of her future. Even now in the vital
present it shall stand forth unchallenged as the crown-
ing glory of all science and of all art.

ABSTRACT OF PRESIDENT'S ADDRESS

Before the American Lastnoological Society,
AT iTB Sixteenth Annual Session, Wash-
ington, D. C, Mat SO, 1894.

BT D. BKTSOH DBIJlVAir, M.D., KKW YORK.

In opening our Sixteenth Annual Congress let me
heartily welcome yon to what gives every promise of
being a most useful and enjoyable meeting. The sup-
port which you have given it, both by your presence
and the scientific contributions provided, has been
spirited and generous ; and I am assured that you will
still further co-operate with me in carrying it through
to a harmonious and successful close. Surely the ex-
periences in sixteen years should give light to illuminate
for us the present and enable us to look forward some-
what into the future. In trying to forecast the future
it is eminently right that we should indulge in retro-
spect, particularly for the benefit of many who may
have but recently come among us and to whom our
early history may be unknown. I shall aim therefore
to go back with you to the early history of this Asso-
ciation.

[The President then gave a detailed account of the
various factors which led to the formation of the As-
sociation. Special houor was paid to the preceding
work of Horace Greene, who was the pioneer special-
ist in this country in diseases of the throat, and whose
works now prove that he led the world. He died,
however, before this Association came into existence ;
but he left behind an able and brilliant successor in
Elsberg, under whose presidency the Association was
formed at Buffalo in June, 1878.J

the socibtt's aih.

The labors of Elsberg and his contemporaries in the
formation of this Society were a preooooeived move-

Digitized by

Google

Vol. GXXX, No. 2«.] BOSTON MEDICAL AND SUS6J0AL JOURNAL,

557

ment id the direction of a higher and broader edacation,
and were an iotelligent and vigoroas effort to advance
and disseminate the knowledge of our special work.
How faithfully this primal aim has been carried out
onr history attests by its annual meetings, publication
of transactions, encouragement of special literature of
our department by the bringing forward of youthful
aspirants for laryngological fame, and by the practical
study of the best methods of instruction in our schools.
New York city was the place, the autumn of 1873 the
time, and Dr. Clinton Wagner the promoter of the
first society ever founded for the exclusive study of
laryngology and rbinology.

[Attention was directed by the President to the for-
mation of various special foreign societies and the vast
increase in the number of organizations in this country
whose attention is entirely devoted to these branches.]

It is a great satisfaction that this strong onward
movement should have been headed, and at so great a
distance in advance, by this country ; and it is surely
not unpardonable that we should in the enthusiasm of
the time express ourselves as the occasion warrants.
But if we are still to be an example to the world, we
mast still strive for superiority. The place which we
have won must be held, not through vain-glory, but
through increased diligence on onr own part and an
ever-broadening receptivity to the ideas of others.

GROWTH OF SPECIAL LITBBATUBB.

Our Association is intimately related also to another
important educational factor. Special journals have
now become quite numerous, and our own work re-
ceives a generous and constantly growing appreciation
in the columns of our general medical journals. The
establishment of the bibliography of the earlier laryn-
gology was largely the work of several of our Fellows.

THE association's MOTTO.
"Docendo digcimiu —hj teaching we learn."

If we are to reach the higher usefulness, we must
ourselves be teachers. The question of education as
related to onr own department is by far the most op-
portune by which onr attention could possibly be en-
gaged. Therein lies the hope of the future as to oar
own reputations, and, what is still more, as to the
beneficent ends to which we fondly hope our specialty
may attain. The problem of instructing undergradu-
ates may be said, in this country at least, to fiave been
squarely met and fairly solved. One of our institu-
tions particularly is of conceded superiority, both as to
its plan of instruction, equipment and general disci-
pline. But other schools as well are doing creditable
work. All the problems, however, can never be
solved by undergraduate institutions, and to meet the
new needs there have sprung up the various so-called
post-graduate schools. The task of the teacher in this
field is more difficult, for the needs of his classes are
far more varying than is the case with the uudergrad-
uate. His students are men of some experience in
general practice, of a wide diversity of preliminary
education ; and they are frequently hampered by pre-
conceived ideas. They often have much to unlearn
before they can grasp fully the salient points as to
what the science of laryngology really is ; hence the
greater difficulties of the teacher's task. But the the-
ory of graduate instruction in this country is an estab-
lished and triumphant success, and it may well be the
province of this Association to discuss how we can best

infuse the ferment of sound learning into the unleav-
ened but well-promising mass of students who come to
our graduate schools. Three things seem demanded to
bring about this desired result: first, a higher and more
thorough general medical education on the part of the
student ; second, more careful selection in the choice
of instructors ; third, a modification of the best under-
graduate methods to satisfy the needs of the older men.

A FINAL WOBD.

When this Society was formed laryngology was in
the hands of a few men, who, under the stimulating
influence of the earliest enthusiasts, formed a veritable
aristocracy of learning. Now it is changed. The
spirit of socialism has been among us ; that noble and
generous socialism of science which, having acquired a
rich and rare possession, desires to spread it broadcast
and with lavish hand to the four quarters of the earth.
The old order of things under which our specialty was
held in the hands of a few has passed away.

Original '^xtitlt^,

THE OBSCURE ORIGIN AND INDETERMINATE
COURSE OF ACUTE INFECTION, AS ILLUS-
TRATED BY A CASE OF MALIGNANT ENDO-
CARDITIS.'

BT J. 8. OBBKME, M.D., OF DOBCHBSTEB, MASS.

In the near past, when the theory of infection now
in vogue was first authoritatively set forth in its full
and fascinating proportions, it seemed as if there could
no longer arise cases of doubtful nature or uncertain
origin. The so-called spontaneous development of in-
fectious maladies in man apart from any ruling epi-
demic was artificially paralleled by Bouchard when he
provoked in healthy animals, without wounding, the
rapid appearance of microbes in the blood, by the ap-
plication of depressing causes such as cold, fright, fa-
tigue.*

By the action of such commonplace influences the
pathogenic bacteria which inhabit our cavities, and
which ordinarily remain harmless, are enabled to
penetrate into and multiply in the fluids. It is thus
that infectious diseases become generalized or aggra-
vated in the system, and set up the phenomena of sep-
tic fever.

Some of these phenomena are headache, pain in the
back and limbs, secretory disturbances, coma, convul-
sions, delirium ; and perhaps there must be added to
this already formidable train, paralyses, both of peri-
pheral nerves and of nerves proceeding from the bulbar
centres on the integrity of which the instant life depends.

We are no longer permitted, as in the beatific past,
when bacteria were not in sight and ptomaines were
not even suspected, to talk of brain fever when the
septic process is chiefly determined to the cerebral
functions, nor of rheumatic fever when the back and
limbs receive the rebound from the shock of poison
dealt to the trophic nerve centres. Still traces of
what was our state of blissful ignorance remain, and in
the light of later knowledge show as black spots on
our sunshine. Cases yet arise where a disease ulti-
mately determined to be of infectious origin masks

' Bead before the Boston Society for Medloal ObeerTattou, March
S, 18M.

> Tbeorle de I'lnfeotlon, verbiMidluagea des z Intematloualen eou-
greaaei, a. t. 48.

Digitized by

Google

658

BOSTON MEDIO AL AND SUBGIOAL JOUBNAL.

[JcNB 7, 1894.

itself behind groaps of gymptomg capable of being
qnite otherwise interpreted. The infections agent,
whatever microscopic form it takes, indaces a septic
fever, which acts with varying intensity and by multi-
form combinations on the nervous system and on differ-
ent organs and functions. Soon or late, the integrity
of some important organ may be steadily invaded, or
an acute inflammatory process may be localized in
some tissue ; and whether these complications occur
or not, the phenomena of septicaemia, pure and simple,
may dominate to the end. Again, the infection rather
than the localization may have had the minor rdle,
proceeding without the ranges of temperature com-
monly associated with septic processes. Nervous dis-
turbances apparently or manifestly functional may
prevail over either thermic or adynamic, to that degree
that when the disease finally becomes localized by signs
or symptoms ordinarily unmistakable, these signs and
symptoms are misinterpreted because disconnected from
their customary relationship.

Material for cultures is not always attainable daring
the course of the disease ; and when a fatal issue has
not been averted, and when the pecuniary or vital
wants of survivors combine with the scientific interest
of the physician to seek what of verity autopsy may
reveal, the early solicitude of the funeral undertaker
to preserve the integrity of the mortal remains by the
injection of poisonous chemicals will probably have
interposed an effectual barrier to the inquiries of the
bacteriologist and the microscopist.

A fatal case of disease of infectious origin simulating
multiple neuritis, but proven by autopsy to have been
acute endocarditis, supplies the clinical material to
illustrate the foregoing remarks.

The case was that of a man thirty-foor years of age,
by occupation a letter-carrier, and thus exposed to the
influences of cold and fatigue. His father died of ty-
phoid fever ; his mother survives in impaired health,
with signs of cardiac trouble. There is no family his-
tory of rheumatism. The patient was about five feet
four inches in height, spare in flesh, nervous tempera-
ment, good habits. At the age of thirteen, after the
shock of a fall and exposure to wet, he had a prolonged
attack of inflammatory rheumatism with cardiac and
pleuritic complications ; but recovery, though slow,
was complete, and for twenty years thereafter he had
no illness requiring medical attention. A less satisfac-
tory state of health dates from about a year ago, when
he yielded for part of a week only to an attack of grip-
pal influenza. Following that came annoyances of
nasal catarrh and anal fissure, for which troubles he
sought relief as a hospital out-patient. These ailments,
and a cold pain, as he termed it, above the left hip,
accompanied noticeable diminution of strength. Early
last November a widowed sister living with him died
after a brief illness, leaving two orphan children to his
charge. Soon after this event, prodromic symptoms
began, and for two months continued to accumulate.
These symptoms were lessened appetite; frequent
perspirations ; pains in shoulders, legs and soles of
feet ; cold throat ; stiff and tired ankles, worse in morn-
ing. His urine had been remarked habitually thick.

During the week previous to the final yielding to
illness, his nights were marked by sweats, and by cold,
restlessly-moving feet; and he remained in bed two
days before going again upon his route. In the night
of Sunday, January 14th, he aroused the family by a
scream of pain, and said it was as if his two feet were

cut off. Pain lasted all night, yet he went to work
Monday, but ate no dinner. While delivering, pains
caught him, first in chest from side to side, passing to
back of legs below knees ; and he returned home with
stooping shoulders and limping gait. Nevertheless,
that evening he walked half a mile and back to coDsolt
a doctor, and got a tonic. Tuesday, the 16tb, he put
his last day's work between two restless nights.
Wednesday morning, the 17th, at 3 o'clock, he arose
and went down stairs, unable to rest from pains in sides
and chest, in legs and in feet. That day a physician
was summoned. The patient complained of stiff cords
around ankles and numbness of soles. Thursday, red
streaks were seen on the feet. The hands and ariDs
had become painful, and the abdomen was hard. Fri-
day, the jaws and the back of the neck were involved
in the suffering. The history to this point is gathered
from patient and his mother.

I first saw him on the evening of Saturday, January
20th, in consultation ; and at the joint request of phy-
sician and patient, I became associated with the former
in the guidance of the case. The patient was lying on
his back, with an aspect of helpless unrest, talkative
and moaning ; his countenance expressive of anxiety.
The pulse was 104, fair quality ; respiration 26 ; tem-
perature 101.2° ; tongue clean, but dryish ; thirst.
He complained of shooting pains down the thighs and
legs, of burning tenderness of the outer and inner
aspects of thighs, and of numbness of the soles just
anterior to the heels — all dating from Wednesday;
of pains in the arms (especially about the elbows), with
numbness of the two outer fingers of each hand — from
Thursday ; of pain in the lower jaw, below articulatioD
on each side — since Friday : of concurrent pain about
the region of the lower ribs on each side, especially
the right. On examination, there was no redness nor
swelling of joints nor elsewhere. The tenderness elic-
ited by touch was regional, not following the course
of large nerves nor in joints ; especially noted at the
upper portion of the calves and at the anterior surface
of the soles, including toes, especially of right foot.
Other points or patches of tenderness to touch were
over the ramus of the jaw on each side. Moving or
flexing the toes caused pain. There was a degree of
rigidity of the lower limbs, and of resistance to passive
motion, and such motion caused pain ; but the pain
was vaguely localized, and not in joints. Hands and
arms showed less rigidity and little tenderness, ile
moved the jaw with difficulty, complaining of pain be-
low articulations. It was noted that the apex beat of
the heart was in the mammary line in the sixth inter-
space ; but there was no diffused nor heaving impulse,
and the heart sounds were dear, unaccompanied by
murmurand of normal rhythm, and so remained through-
out. The plantar and patellar reflexes were absent.
Albumen was absent from the urine, which was heavy
with amorphous urates. The patient lived for ten days
longer, and died the 30th of January.

iSnring this period of daily observation, there was
gradual abatement of numbness, of localized tender-
ness, and of muscular rigidity ; no restoration of ten-
don reflexes ; muscular wasting rapid and extreme.

On the 24th, it was noted that pains had appreciably
abated within two days, and none remained in sides of
chest. Patient could move limbs more easily, and
open jaws more readily. He still shrank from touch
at the plantar surface of the toes and adjacent part of
the soles, and still kept the limbs rather rigid, espe-

Digitized by

Google

Vol. CXXX, No. 28. J BOSTON MEDIO AL AJSD SURGICAL JOURNAL.

659

cially his hands and arms, with fingers spread apart,
moving and flexing like one slowly scratching.

On the 25th, he sat on the edge of the bed a few
minutes after passing urine.

Od the 26th, there were painful and ansuccessfol
attempts at micturition, a resort to the catheter, and
(later) successful voluntary effort. This day tender-
ness to touch and numbness were all gone. A few
petechial spots were seen on the legs. He still kept
a certain rigidity of joints on passive movements, as if
fearful of hurt, but could relax and move painlessly.
The type of fever became more and more distinctly
typhoidal, the tongue more dry and furred ; no sordes.
Delirium of sufferings and of travel, active at first, be-
came somewhat more quiet. He wandered all over
the country and encountered all kinds of trouble ; he
never knew where he was, but was sure he was not at
home, though he got almost there ; yet he knew every
one about him. He had occasional " wild spells,"
when he wanted to get up and off, but had little
strength to exert. There were moments of quick,
labored respiration, but not often ; scarcely any cough.

His temperature had no regular oscillations, but
ranged oftenest from 100.5° to 101.5° ; but the morn-
ing of the 23d it reached 103.5°, and the evening of
the 24th and the following morning it was 103°. The
pulse generally went with the temperature, though not
invariably ; it varied between 104 and 120, reaching
(exceptionally) .130.

The last day I did not see him ; but there was chok-
ing on attempts to swallow, collapse with cold sweat,
and he died with gradual heart-failure.

Dr. Wm. T. Councilman performed an autopsy,
Thursday, February 1, 1894 : " Anatomical diagnosis,
acute endocarditis of aortic and mitral valves. Body
of medium size, slightly built, somewhat emaciated.
The body had been injected by an undertaker, so that
little could be told of the degree of congestion, etc., of
internal organs. The peritoneum was smooth, and
there were no lesions in any of the abdominal organs.
The spleen was large and rather soft. Both lungs
slightly adherent. On section, a slight mnco-purnlent
secretion in some of the smaller bronchi. The heart
was of ordinary size, the cavity of the pericardium
obliterated by adhesive pericarditis. Myocardium
pale and easily torn. The valves of the right heart
were normal. On the aortic valves, just along the line
of closure, there were numerous projecting granulations.
The valve about the seat of these vegetations was
thickened. Similar vegetations were along the free
edge of the mitral valve, and in one place extended
over the auricular surface of the valve up to the auricle.
The tissue here was thickened, infiltrated, and small
ecchymoses were here and there visible. The nerves
of the lower extremities were removed for examination.
Owing to the injection of the undertaker, bacterial
cultures which would probably have thrown much
light on the case could not be made. I think there is
little doubt from the character of the lesions in the
heart that there has been an infection with either the
dipplococcus pneumonisB or the streptococcus."

The result of this autopsy was the revelation of an
unsuspected seat and form of localized inflammation.
True, the chief signs and symptoms on which a diag-
nosis of infectious neuritis was founded had gradually
abated during the week which followed my introduc-
tion to the case. On the other hand, the group of
symptoms representing septic infection had kept their

unrelenting sway, dominating and supplanting, while
no signs were detected nor symptoms intruded to draw
attention to a lesion of cardiac valves.

Thus, prior to the autopsy, there still remained the
possible alternative that death was wholly due lo the
effect of the toxines of infection acting on the higher
nerve centres. The inference that such was partly
the case, that the cardiac lesions were in fact subordi-
nate in determining the manner of death, derives sup-
port from the symptom of occasional rapid, labored
breathing, and from the paralysis of muscles of degluti-
tion noted some hours before death.

The temptation is here presented to follow to their
natural conclusion these observations on the uncertainty
attending the origin and course of acute infection, by
some reference to like uncertainties in the fatal ending.

This final point can be illustrated by a case of possi-
ble multiple neuritis comparable to the foregoiug one,
but introduced here only in synopsis. It was the case
of a young man of remarkably neurotic constitution by
inheritance, whose father and two paternal relatives
bad died suddenly in acute agony — two of them with
precordial pain, the third (a girl of sixteen) of tooth-
ache, so-called. An autopsy on the father showed no
disease of brain, heart nor kidneys. The son had been
pushed to the verge of nervous break-down by over-
work and use of tobacco ; still further depressed in his
vitality by two illnesses supposed to be la grippe —
one marked by semi-stupor, numbness and bad head,
the other by vomiting, headache, pain of back and
limbs, and rigidity.

He is out for an evening's enjoyment, perhaps gets
chilled, has next morning a convulsive seizure, nearly
or quite unconscious, some fever and transient albumi-
nuria ; five days of disability with spinal and lumbar
pains. Another seizure ; nine more days of suffering,
involving legs as well as back. Another seizure;
pains more torturing, and involving arms and some-
what chest, as well as back and legs. After six more
days an agonizing pain in head aroused by a trivial
cause ; a distressful, restless, but not usually painful
head throughout; and fiuallya sadden snap, and death
after twenty-two days' illness.

No autopsy was permitted. The outset of the ill-
ness was very peculiar, some of the indications during
its course equivocal, one period reassuring and thereby
misleading — > other periods absorbingly distressing, and
the termination unexpectedly sudden.

It was undoubtedly a case of acute infection, and its
phenomena can perhaps be explained either on the
theory of multiple neuritis or through the action of
toxines on the nerve centres, without the existence of
localized microscopic lesions. What concerns us here
is the question how death was induced.

In the Rewe de Medecine of February 10, 1891,
Dr. Havage, of Paris, reports a case of alleged acute
infectious neuritis, in the course of which, and follow-
ing the abatement of fever, there occurred numbness
and prickling, and then extensive paralyses involving
not only the limbs but the facial muscles and some of
those concerned in articulate speech, and finally the
right external muscle of the left eye, inducing stra-
bismus and diplopia. Nevertheless, in a mouth from
the onset of the disease recovery from these paralyses
was nearly complete, and the entire restoration to
health was not delayed to the end of the second month.
Those who cannot share the sanguine belief of Dr.
Havage that the case was one of multiple neuritis —

Digitized by

Google

660

BOSTON MEDICAL AND SURGICAL JOVBNAL.

[Jt»E 7, 1894.

a belief that seems scarcely coniistent with the general
observation of the length of time needed to effect repair
and restoration of function in nerve tracts which have
been the seat of an inflammatory process — must neces-
sarily regard these formidable paralyses as transitory
effects of the tozines of infection.

If, then, such toxines can cause extensive paralyses
of peripheral nerves without the aid of inflammation,
there is little difficulty in perceiving how they may
also, by their depressing, irritating, or paralyzing in-
fluence on nerve centres, determine death in various
forms, by heart- failure, by asphyxia, and even by pain
and shock. Also it is obvious bow important must be
the influence of family constitution and personal idio-
syncrasy in shaping the fatal issue. A single sharp
agony sometimes ushers in an attack of localized neuri-
tis ; and pain in the head or chest or elsewhere was a
notable feature at the critical points in the history of
the family to which I have referred. Was there a
correlation between these two facts, or did ptomaines
alone cause pain enough to kill ? What changes do
toxines effect in the nerve elements, to induce now
lingering, and again sudden, death ?

The questions may not be answered ; but the asking
serves its purpose of illustrating the obscurities still so
often attending the termination, as well as the origin
and course, of acute infection.

CRYSTALLINE DEPOSITS IN THE URINE:
THEIR CAUSATION AND RELATION TO
RENAL DISEASES.1

BY BO-WABD K. OBBBKB, A.M., II.D.
(Oonelnded from Mo. IX, p. 641.)

Cases of oxalnria and uric-acid crystals, associated
with more or less dull pain in the lumbar regioo, are
familiar to all, and require no further comment other
than to emphasize the importance of a microscopical
examination of urine, in order to differentiate them
from lumbago, muscular strain or uterine disease.
There are rare cases, however, in which there occurs
a sudden precipitation in the kidneys of a large
amount of crystals, causing agonizing pain fully as
severe as that produced by calculus. In these cases it
has been supposed that a stone was actually passed,
but was not found on account of careless observation.
This, I am convinced, is not always the case. I have
ha<l an opportunity to study this interesting condition
in two cases, whidi I will relate.

Mr. R. F., a chemist, age thirty-one — pale, of a
nervous temperament, rather below medium weight,
but of good muscular development, of good habits,
family history negative — had previously passed two
life-insurance examinations, but recently had been
under considerable mental strain from family troubles,
and suffered considerably with dyspeptic symptoms.
In August, 1891, he had been taken suddenly, for the
first time, with severe pain in the abdomen and lumbar
region, but recovered after one day's treatment with
morphine and cathartics.

The physician who had charge of him at that time
did not examine the urine, but thought that the colic
was connected with constipation. In the next two
months he had similar, but not very severe attacks.

I saw him first on November 19, 1891, three months

> Bead before the Bocton Sootetrfor Medloftl Obserration, March
0,1694.

after the beginning of this trouble. The pain in this
attack begau while he was at work in his laboratory,
and rapidly increased in severity, so that be had barely
time 10 get home and into bed before calling me. I
found him groaning apparently in intense agony, and
at once gave him one-quarter of a grain of morphiDe
hypodermically, repeating it about an hour later.
Pain was most severe in the right lumbar region, ex-
tended down the abdomen in the direction of the ureter
to the bladder. There was considerable paiu also in
the left lumbar region, and tenderness on pressure on
both sides. The skin was moist and pale, and the
pulse about 60. Expression was worn and anxious,
and he was constantly nauseated and had severe
vomiting. Morphia was continued as necessary, and
the pain gradually wore off and disappeared entirely
in four days. There was no increased frequency of
micturition. The first urine passed after the pain
began was of a high, slightly smoky color; acid;
specific gravity 1,028; one-tenth per cent, of albamen;
sediment considerable in amount, and consisted of con-
siderable altered blood, excess of mucus and leucocytes,
and numerous calcio-oxalate crystals. Under the use
of alkalies and a large amount of water the calcic oxa-
late disappeared in a few hours, and the blood and
albumen two or three days later.

On November 28tb the urine was alkaline ; specific
gravity 1,025 ; free from albumen, blood or casts, bnt
there was a slight increase of leucocytes and mucus.
December 2d, urine was high-eoloreid, strongly acid,
specific gravity 1,027, no albumen, but a considerable
sediment consisting of calcic oxalate and mucus shreds.
December 5th, there was no albumen, and a few
leucocytes only in the sediment. The urine was all
saved and examined before being thrown away, and
never contained calculi or even gravel large enough )o
be seen by the naked eye.

December 29ifa, I was summoned by a carriage to
come at once to his place of business, and found him
in another severe attack. He had not had time to get
home, but was lying on the floor in great pain, vomit-
ing, and almost dazed. I injected morphine subcuta-
neously, and drove at once with him to the Massachu-
setts General Hospital, where he arrived almost in a
state of collapse, rolling about with the pain, in spite
of one-half a grain of morphia given subcutaneously.
Pain was located principally in the back, just below
the twelfth rib on the right side, from which it would
shoot occasionally down to the right testicle in a line
corresponding with the ureter. There was less severe
pain in the left loin, but both sides were tender on
palpation. There was no evidence of floating kidney.
Pulse was 50, small and weak, but regular. He was
given one-eighth of a grain of morphia every two
hours and a poultice applied. The pain became grad-
ually less, and almost disappeared after two days.
Unfortunately, the first urine passed was not preserved,
and in the hospital history there is no record of the
urine, except that on December 31st it is stated that
the " urine shows no constant crystalline sediment."
On January 9th, an examination of the urine was
made by Prof. £. S. Wood, as follows : " Color nor-
mal, acid, 1,019, urea and uric acid normal, albumen
very slight trace, sediment slight, and showed a few
hyaliue and finely granular casts, some of large diame-
ter, probably from the straight tubules." Duriog his
stay in the hospital no calculus was found, nor any
gall-stones in the stools. The pulse ranged from 50

Digitized by

Google

Vol. CXXX, No. 23. J BOSTON MEDIOAL ASD SUR610AL JOURNAL.

661

to 60, but daring the last four days from 60 to 70, and
the temperature from 98*^ to 99°.

As there was no evidence of stone in the kidney, he
was discharged well January 9th.

I did not know the secret of the patient's mental
and physical condition nntil he asked me to testify in
divorce proceedings on July 1, 1893.

It seems that some six months before these attacks
began he had married a young woman on only two
weeks' acquaintance. She was a public singer, and,
according to her own admission, she never once allowed
her husband any sexual connection, on the ground
that pregnancy would spoil her fignre and hurt her
voice. She slept with her husband constantly. 1
testified that this state of affairs had brought on neu-
rasthenia, melancholia and dyspepsia, which predis-
posed to the formation of calcic oxalate, and that his
constant ungratified sexual desire tended to increase
the hypersemiaof the kidneys. No contest was made,
and the judge granted absolute divorce.

He did not return to his wife after leaving the hos-
pital, and never had another attack. He has- also
gained ten or fifteen pounds in weight, and now feels
perfectly well.

The second case I had a good opportunity to watch,
as he was under observation at my own house during
two of his attacks. The patient was a yonng business
man, aged tweuty-nine, married, of good family and
personal history, strong and well-developed, of average
weight.

His first attack occurred without any previous warn-
ing at 6.30 A. M. on July 3, 1891. This pain, which
was severe, was in the left lumbar region, and lasted
all day. The treatment was morphia injections.

The second attack was milder, lasting only a few
hours, and occurred some six or eight months later.
The physician then in charge was said to have been
puzzled how to account for the attacks. The third
attack occurred under my observation Decembers, 1892.
The patient had been at work as well as usual during
the day, but about the middle of the afternoon began
to have a dull pain in the lumbar region. The pain
gradually increased in the course of an hour, when the
patient came to consult me about it.

Almost as soon as he reached the oflSce the pain be-
came severe, and I gave him one-eighth of a grain of
morphia by the mouth. In a few minutes the pain
was so severe that I gave him one-quarter of a grain
of morphia subcutaneously.

This had no effect, and be was soon shrieking with
pain and tossing about io agony. The skin was
blanched and covered with perspiration, the pulse was
62. Pain was referred mostly to the right lumbar
region over the kidney, and, to a less extent, to the
region of the left kidney. The pain did not especially
follow the course of the ureter, and there was no
desire to micturate.

Both flanks were tender on pressure. Ether was
then given and pushed to complete ansesthesia. On
removing the ether after a few minutes the patient
complained again, and more ether was given. In
about half an hour the ether was again removed. The
patient was very hilarious and happy in coming out of
the ether, and said he had no pain at all.

He soon began to pass urine in large amounts.
The first specimen passed after the attack was pale,
acid, 1,018, albumen a slight trace (one-fifteenth per
cent.), lediment considerable, And coosisted of clumps

of small calcic-oxalate crystals imbedded in mucous
shreds, a little blood, epithelial cells (probably from
the pelvis of the kidney), and a few hyaline casts,
some of which contained small calcic-oxalate crystals.
The urine passed the next forenoon was perfectly nor-
mal, except for a few blood-globules.

Specimens examined occasionally for several weeks
showed nothing abnormal. The entire amount of
urine passed for several days after the attack was
saved and examined by me, but no trace of calculus
was found. Io the previous attacks the patient is
positive that he never passed a stone, although he
watched for one constantly. There was apparently
no exciting cause in this case, such as exposure to
cold, over-exertion or over-eating. He never ate
rhubarb.

On September 22, 1893, this patient had another
similar attack. He suffered severely for nearly two
hours before I could get to him and give him ether.
The ether was kept up most of the time for four hours,
when the pain entirely disappeared. During the next
night the pain returned in a mild form for about an
hour. The next forenoon he went to business at
about ten o'clock, although he " felt as though he had
been on a spree." The first urine passed after the
pain was high-colored; specific gravity of 1,020; very
slight trace of albumen ; a considerable sediment, con-
sisting of a large amount of calcic-oxalate crystals,
singly and in microscopical concretions ; considerable
blood ; and a moderate number of hyaline casts. No
stone was passed, and a day or two later the urine was
normal. The only cause I can find for oxalnria in
this case is an habitually concentrated urine from
drinking too little water. There was no evidence of
floating kidney.

The treatment of these two cases during the parox-
ysms suggests to me the almost uselessness of mor-
phine injections, in addition to their danger, and the
remarkable success of ether in reHeving the pain en-
tirely and cutting short the attacks. The attacks in
which morphine had been used were prolonged and
painful.

The secret, it seems to me, is this : opium, accord-
ing to Lauder Brunton, frequently lessens the quantity
of urine ; while, according to H. C. Wood and Brun-
ton, ether stimulates the heart at the same time that
it dilates the blood-vessels, increases very markedly
the blood-pressure, and thus renders the peripheral
circulation very vigorous. The abundance of urine
and its low specific gravity after ether, in the second
case just reported, indicate that by this means a large
amount of water is at once poured through the renal
tubules. Thus we get instant relief of pain and re-
move its cause at the same time.

The remarkable thing about these cases is the sud-
denness with which the crystals are precipitated and
their rapid disappearance, together with albumen and
blood. I have not been able to find any good account
of similar cases. Dr. G. W. Allen read before the
Soffolk District Medical Society in April, 1891,' a re-
port of three cases of renal colic in which the pain
exactly simulated that caused by calculi, but none were
found. In his first and third cases no report as to the
urine was made, and, in the second case, the urine was
said to have been passed in very small amount during
the attack, " not enough in all to furnish a specimen
for examination, but it looked perfectly norntftlt"

« Pocton Medical snd Snrglwl Jonmal, Jone JS, tWt,

Digitized by

Google

5(i2

BOSTON MEDICAL AND SURGICAL JOURNAL.

[JcNE 7, 1894.

DuriDg the next two week« the urine was carefully
ezamined, but nothing found to account for the attack.
He was unable to make an exact diagnosis, but raised
the question whether the symptoms might not be due
simply to renal neuralgia.

Edes, in an article in " Pepper's System of Medicine,"
recognizes the possibility of the occurrence of renal
colic not caused by calculi. He says : " Most physi-
cians have seen cases when the same set of symptoms
has not been followed either by the discbarge of the
stone per urethram or by the evidence of its continued
sojourn anywhere in the urinary organs. They may
occur in persons of a neuralgic tendency in connection
with the uric or oxalic diathesis. If, after careful
watching, no stone appears, and, on the other hand,
the pain does not continue, and no pus gives evidence
of pyelitis, it is highly probable that no stone is, or
has been, present. A true neuralgia may undoubtedly
exist."

My own opinion is that while neuralgia of the kid-
ney is possible, that it is not a sufficient explanation for
the very severe cases of sudden onset, short duration,
and sudden termination. The five cases reported by
myself and Dr. Allen were all in men, while it is in
women that we are most likely to get neuralgia and
hysterical pain. These cases I believe to be more
commonly due, as Edes hints above, to irritation by
crystals. In my cases it was only the first specimen
passed that gave the clue to the true condition. The
pain in these cases is usually in both kidneys, rather
than in one, as is usually the case with calculi. It can
be distinguished from the pain due to sudden obstruc-
tion of the ureter, as in movable kidney, by the fact
that we get no evidence of movable kidney by palpa-
tion, by the presence of the crystals and by the occur-
rence of more or less pain in both kidneys. In gall-
stones the pain is not exactly in the same position, and
we soon get a jaundiced urine. It is a singular fact
that in jaundice «alcic oxalate is likely to be very
largely increased. Fagge quotes Schultzeu as having
found as much as seven and a half grains of calcic
oxalate in twenty-four hours in cases of jaundice. In
other conditions which might be confounded with renal
colic the onset of pain is not sufficiently sudden.

TREATMENT.

Bearing in mind the etiological factors considered
above, the treatment required to prevent these crystal-
line deposits obviously consists in preventing the for-
mation of uric acid and calcic oxalate in the system,
and, secondly, in preventing their precipitation in the
kidneys. The first result is to be gained by hygienic
and dietetic measures, while the second requires medi-
cinal treatment.

The hygienic measures consist of an out-of-door life,
as far as practicable, exercise, and baths. The plethoric,
high living, uric-acid victim, with his tissues crowded
with waste material, evidently requires all the outrof-
door exercise he can stand and warm baths to stimulate
the eliminative action of the skin. The other class of
debilitated, antemic, neurasthenic subjects of uric acid
or calcic oxalate are equally in need of fresh air to
assist their feeble oxidizing powers, but we must be
careful not to overtax their weak constitutions with
too much exercise and bathing. In the consideration
of diet it is especially necessary that digestion should
be perfectly performed, failure in this respect causing
more defective metabolism than could possibly arise

from a little more or a little less of some particular
article of food.

Most persons are able to digest lean meat more
easily than starchy, saccharine, or fatty substances. In
the three latter classes of foods, if digestion is slow,
fermentation is sure to occur and the resulting acids
are taken into the blood, thus lessening its alkalinity and
solvent power and interfering with all the metabolic
processes. In the majority of cases, therefore, a diet
containing a considerable proportion of albumiooas
material, supplemented by succulent vegetables, will
be more easily digested than one in which the starchy
and saccharine elements predominate. The diet must
be carefully suited to each individual case. Stimnlants
of all kinds must be avoided. In cases of oxaluriawe
must avoid the ingestion of vegetable substances con-
taining oxalic acid, such as tomatoes, sorrel, rhubarb,
onions, turnips, canliflower, and asparagus. The free
use of pure water and of milk is extremely important.
As we have already seen the urine containing crystal-
line deposits is almost always concentrated and highly
acid. Water at the same time dilutee the urine and
renders it relatively less acid.

Drinking hot water at bedtime acta very beneScislly
as a diuretic and gives a copious flow of urine in the
morning — a point of importance, as Roberts and
others have shown that uric acid is largely precipitated
in the urine in tlie early morning hours.

The medicinal treatment to prevent the formation
of crystalline deposits of uric acid differs from that
required in oxaloria and will be considered separately.

We can, as pointed out by Roberts in his recent
Croomiau lectures, effectually prevent by medicinal
treatment the occurrence of those coaditions of the
urine under which alone the formation of uric-acid
crystals is possible. The immediate determining caase
of the precipitation is excessive acidity of the nrine
and the essential indication of preventive treatment is
to diminish the acidity.

Chemically it is impossible for uric acid to be de-
posited from an alkaline urine and not at all likely in a
neutral or feebly acid urine. A study of the normal
variation of the urioe at different periods of the day
and night leads to the inference that the liability to
uric-acid gravel rises to a dangerous intensity only dur-
ing certain limited portions of the twenty-four hours.
The character of the urine has been shown by Roberts
to be most affected by the digestion of food, by pro-
longed fasting and by sleep.

A meal, whether composed of ordinary mixed food,
or of purely animal, or purely vegetable substances,
produces two constant effects. It lowers the acidity of
the urine and increases its volume. Conversely, pro-
longed fasting raises the acidity and diminishes the
flow of urine. During the hours of sleep which are
also hours of fasting, the acidity of the urine reaches
its highest point and the flow of urine reaches its low-
est point. The proportion of uric acid in the urioe is
highest during the time of sleep, but the hourly excre-
tion is highest during the hours following a meal.

Obviously, therefore, the period when there is most
risk of precipitation in the kidneys is during the time
of sleep, and especially in the early morning, during
the two or three hours before breakfast. Jn sleep,
also, the horizontal position and the bodily repose make
the urinary stream more sluggish and predispose to
crystalline precipitation. Ou the other hand, during
the day and the waking hours the recurrence of (he

Digitized by

Google

Vol. CXXX No. 23.] BOSTOif MEDICAL JjfD SUSGIOAL JOURNAL.

mt

meals keeps the urine at a low degree of acidity, or
eveu renders it for a time nentral or alkaline, while the
renal stream is comparatively full and rapid, and its
descent from the kidneys is favored by the force of
gravity . It is, therefore, only daring the critical period
of the latter part of the night that medicinal treatment
is required. In the milder cases a single full dose of
one of the alkalies taken at bedtime suflSces to prevent
the formation of uric-acid concretions. For this
purpose the citrate of potash is, perhaps, the best prep-
aration to employ. The dose for an adult is from
forty to sixty grains, dissolved in a few ounces of water.
In severer cases a second but smaller dose should be
taken during the night.

Haig has shown also that salicylate of soda has a
decided influence in increasing the excretion of uric
acid. Phosphate of soda is at the same time a good
alkalizing and laxative agent. It is also, as we have
seen above, the principal natural solvent of uric acid
in the urine. Roberts also points out that salines ex-
ercise a protective influence against the precipitation
of oric acid. People who take very large quantities
of common salt with their food experience a practical
immunity from stone. On the other hand, it is very
frequent among the children of the poor who are fed
very largely on farinaceous articles and among the
natives of India who feed on rice. Acids and iron in-
terfere with the solubility of uric acid and with its
elimination.

A fact of great practical importance mentioned by
Haig and quoted by Osier, is that " lithia, although a
beautiful solvent of uric acid in a test-tube, yet when
given by mouth never reaches the uric acid at all be-
cause it at once forms an insoluble compound with the
phosphate of soda in the blood, thus removing from
that fluid one of the natural solvents of uric acid and
diminishing its power of holding uric acid in solution."
Lithia waters, then, have been found useful because
the beneficial e£Pect of the water itself exceeds the harm-
ful effect of the lithia contained in it. This is directly
opposed to the prevalent idea of the value of the lithia
compounds in the uric-acid diathesis.

For a plethoric habit the free use of alkaline mineral
waters, such as Carlsbad and Vichy, is important.

in the treatment of oxaluria much less is accom-
plished by chemical agents. The usual tonics suitable
for cases of debility are often required. Dilute mineral
acids, especially nitro-muriatic acid, are considered by
many as almost specifics. Their beneficial action is
probably accounted for by their power to correct diges-
tive disturbances. Phosphate and chloride of sodium
have a distinct solvent action on oxalate of lime. It
has also seemed to me, in a few cases, that sodium
salicylate has caused the crystals to disappear.

The treatment of calcalus in the kidney will not be
considered here, as the so-called "solvent" remedies
have been found entirely unreliable, and the final resort
must be to surgical methods.

LOSD ROSEBERBT ON La.NDSOAPK AdTERTISINQ.

— Lord Roseberry, amid the cares of office, has yet
been moved to ask : " What is to become of our Eng-
lish landscape if it is to be simply a sanitary or adver-
tising appliance ? Think of the feelings of the illus-
trious Turner, if he returned to life, to see the luggers
and the coasting ships which he made so glorious in
his paintings converted into a simple vehicle for the
advertisement of a quack medicine."

iUport^ of 4bocietie^.

BOSTON SOCIETY FOB MEDICAL OBSERVA-
TION.

J. O. XDMrOBD, M.D., SBCBBTABT.

Reoclas Meeting, Monday, March 5, 1894, Da.
J. Foster Bosh in the chair.

Dr. J. S. Greene read a paper on

THE OBSOCRK ORIGIN AND INDETERMINATE COURSE
OP ACCTE INFECTION, AS ILLUSTRATED BT A
CASE OF HALIONANT ENDOCARDITIS.*

Dr. Pctnau : I have been very much interested in
Dr. Greene's case. It is a very striking one, and the
account he gives opens a great many questions which
we all wish with him we were better able to discuss.
Some years ago I had a case similar to this in some
respects. It was a case of infection causing death in
one week or a little more and with lesions of paren-
chymatous neuritis. The patiept had difficulty in swal-
lowing and then difficulty in breathing, before his
death. The patient was a man of nervous temperament,
otherwise in good health, but had weakened himself
very much by excessive sexual intercourse. Other-
wise there was no apparent cause for the disease, ex-
cept that he rode home one night in a open horse-car
and was exposed to a severe wetting and chilling. The
symptoms came on that night, and he died at the end
of ten days. It is rather unfortunate that the discoveries
which we make in pathology sometimes chain our
knowledge and even cur imagination to a considerable
degree. We felt we had learned a great deal when
multiple neuritis was first discovered, and when the
cases began to pour in they seemed to be covered by that
term ; but, as a matter of fact, as Dr. Greene has
pointed out, I think when it comes to a case of rapid
death of that sort, the term multiple neuritis, even
where we can establish the existence of manifest
changes in the peripheral nerves, is often inadequate
to cover the whole condition which is present. In my
case there was a considerable amount of parenchyma-
tous degeneration, swelling of axis cylinders, and great
injection, with escape of leucocytes into the surround-
ing tissue in the nerves, and a few changes of the mus-
cle. I examined the diaphragm and the phrenic nerve
with considerable care ; and although changes were
present there, it did not seem as if that could have
been sufficient for death. It seems more probable that
death was due to poisoning of the nervous centres;
and in my case that was in a measure borne out by the
discovery of changes at the root of the vagus nerve,
although there was nothing in the actual nucleus of
the vagus which could be called pathological as far as
I could tell. I should think it might be still open to
doubt whether in Dr. Greene's case there may not
possibly have been alterations in the peripheral nerves,
for the reason that these alterations sometimes occur
at the very extremity of the nerve and not in their
course or at the roots. The question of the cause of
death in these casus is very interesting ; and, as far as
I know, the bacteriologists do not pretend to say why
patients with diphtheria die, or why patients with tu-
bercular meningitis die. The information at our dis-
posal seems inadequate to account for the resulL In
an interesting disease more or less allied to one of
the many forms of multiple nearitis, — acute ascending
> See page of the 807 Jonmal.

Digitized by

Google

664

BOSTON MEDICAL ASJ> SVROWAL JOVRSAL.

[Jtjnb 7, 1894.

paralytis — the patients apparently die from some poi-
son before the changes are established in any portion
of the nervous centres, so far as we are able to detect
them.

Da. Ernst : I have but little to say. Of course,
from the scientific point of view it would be well for
some protest to be entered against the immediate injec-
tion of cases where autopsy is likely to be held, because
it is not uncommon that the ultimate examination is
very much injured by the preparations of undertakers.

Dr. £. M. Greene read a paper entitled,

OBTSTALLINB DEPOSITS IN THE URINE, THEIR OC-
ODRRENCB AND SIGNIFICANCE.'

Dr. Putnam : I should like to ask whether the
high specific gravity generally indicates increase of the
total solids, and also whether Dr. Greene can throw
any light on the controversy with regard to the symp-
toms of the uric-acid diathesis ?

Dr. Greene: The high specific gravity was indica-
tive of diminution in the amount of water. I did not
consider the subject of * uric-acid diathesis, on account
of the length of the paper. Uric acid has been injected
into animals without doing harm. I have seen the ex-
planation where there were severe headache and uric
acid, that it was similar to precipitation in the joint,
precipitation in the meninges of the brain — a mechani-
cal cause and not uric acid in solution.

Dr. Ater: 1 should like to ask Dr. Greene in
regard to the effect of irritation of oxalate of lime or
aric acid upon the kidneys, as he states that some au-
thors are of the opinion that it may cause chronic
nephritis of serious character. I wonder if he has fol-
lowed along cases to be certain of that. I have been
following five or six years a case where the irritation
of the kidneys was probably started by a renal calculus,
and since then the urine has generally contained quite
a trace of albumen, with casts of different kinds, and
almost always oxalate of lime. The patient is no
worse. 1 have been puzzled to know whether it was
chronic nephritis or a persistent irritation from oxalate
of lime and uric-acid crystals, which might continue
many years and be of no consequence.

Dr. Greene : The points I brought out in my paper
were chiefly these, that constant irritation of the kid-
ney, producing hyperaemia with blood in the urine and
albumen, must do harm if kept up long. I have not
been able to follow any case long enough to see it ran
into a chronic interstitial nephritis. That is a condi-
tion which may go on years and years. I know of
one case in which a considerable amount of albumen
and casts has been present ten or twelve years, and the
woman has had several children without bad effect.

AMERICAN SURGICAL ASSOCIATION.

Annual Meeting, Washington, D. C, Mat 29, SO,
31 AND June 1, 1894.

FIRST DAT. TDESDAT.

The Association was called to order by the Presi-
dent, Dr. J. EwiNO, of Philadelphia, who delivered the

president's address.

In this was considered only matter of interest to the
Fellows of the Association, referring to the previous
work of the Association, and the method of best carry-
* See page 560 of vbe Journal.

ing on the work of the Society. The Secretary, Dr.
J. R. Weist, presented, for the President, the Associ-
ation with a gavel which had been made from a por-
tion of the office chair of Prof. S. D. Gross, the founder
of the Association. This was accepted with the thanks
of the Association.

The first paper was entitled

THE SURGICAL TREATMENT OF EHPTEMA,

by John Ashhurst, Jr., M.D., of Philadelphia.
The following summary was presented :

(1) No operation is justifiable unless the presence
of pus is certain ; unless thorough treatment by medi-
cinal agents, blisters, etc., has failed ; or unless the
symptoms, dyspnoea, etc., are so urgent as to demand
immediate relief.

(2) The first operation should consist of simple
aspiration, with antiseptic precautions.

(3) When the fluid has partially reaccumulated, as
it almost certainly will do, if purulent, incision and
drainage should be practised.

(4) Drainage is best effected by making two open-
ings, one at the lowest point, and carrying a large
drainage-tube through the cavity from one opening to
the other.

(5) Drainage should be supplemented by washing
out the cavity with mild antiseptic fluids ; when the
lung has expanded and the discharge has nearly ceased,
the tube should be shortened, the upper opening being
allowed to heal, and the tube then being gradually
withdrawn through the lower opening.

(6) When the lung is so bound down by adbesioni
that it cannot expand, resection of two or more ribs
should be practised (Estlander's operation, so-called),
in order to allow collapse of the chest-wall and to
promote healing by bringing the costal and visceral
layers of the pleura into contact.

(7) The more extensive operations of Schede and
Tilhuans, while probably justifiable in exceptional
cases, are not to be recommended for general employ-
ment.

Dr. Chas. B. Nancrede, of Ann Arbor, did not
see the advisability in cases where pus was shown to
be present by aspiration, of limiting the treatment to
this operation. It is held that in a few cases this will
be followed by cure, but he had never seen such a case.
Where pus is present, he preferred to immediately
provide for its permanent evacuation. He called at-
tention to the danger of the drainage-tube becoming
occlnded by the pressure of the ribs, and he believed that
in empyema of long standing some form of excision of
the ribs should be employed.

In irrigation, if the pus is not too much contaminated,
sterilized water is sufficient ; but, if necessary, an ef-
ficient antiseptic solution may be used, and if there is
fear of absorption, the chest can afterwards be flushed
with sterilized water.

If provision is made for the free escape of pus, he
bad seen no necessity for the removal of large segments
of ribs.

Dr. T. F. Prewitt, of St. Louis, thought that the
rule that no operation is justifiable unless the presence
of pus is certain, needed modification. As a rule, we
can determine only that fluid is present and cannot be
sure that it is pas. He thought it advisable to aspirate
even when serous fluid is present. If thorough anti-
sepsis is maintained, this can do no harm. He had
never seen it result in the formation of pus, and this

Digitized by

Google

Vol. CXXX, No. 28.] BOSTON MSDIOAL AND SVMGIOAL JOVttNAL.

666

method greatly shortens the daration of the disease.
In empyema in children he had seen several recoveries
follow aspiration, but never in adults. In children
the pus does not seem to possess that thick clotting
character so common in adults, and which requires a
free opening. In empyema in adults he invariably re-
sects a rib, sometimes two ribs.

Attention was called to the great necessity of caution
in the administration of anaesthetics in cases of this
affection.

As to washing out the cavity, he always does that,
using a weak solution of bichloride of mercury.

Dr. DeForebt Willard, of Philadelphia: It
seemed to him that the whole question was one of
thorough drainage of an abscess cavity. Whether or
not the ribs should be excised was to be determined
by the question of securing free drainage. In children
the ribs were so close together that removal of a por-
tion of the ribs was usually required.

In the early treatment he favored the use of a clean
aspirator rather than to compel nature to cause the
absorption of a large quantity of fluid. Such operation
did DO harm and saved several weeks in time.

He believed that washing, as a routine measure, did
more harm than good. If the pus was decomposed it
indicated that freer drainage was needed. If strong
antiseptic solutions were employed there was danger
of renewed inflammation.

Dr. John E. Owens, of Chicago, called attention
to the necessity, when evacuating pus from the chest
or washing out the pleural cavity, of changing the
position of the patient during the proceos, in order that
all the pus might be removed.

Dr. Christian Fenoer, of Chicago, considered
that there were certain cases in which Schede's oper-
ation was required. Its place was after milder meas-
ures such as incision, drainage, and Estlander's oper-
ation. He reported a successful cure where this oper-
ation was performed after other measures had been
resorted to during seven years.

Dr. BoawKLL Park, of Buffalo, N. Y., thought
that the treatment of empyema should be based upon
the same principles as are applicable to other abscesses.
In acute cases, where we have to deal with streptococ-
cus and staphylococcus forms of suppuration, it may be
sufficient in a few instances to simply aspirate. A
large proportion of cases of empyema, however, are
essentially cold abscesses, — tubercular abscesses. In
these cases free incision, free drainage and excision of
a rib is required. In certain cases be had resorted to
scraping with the sharp spoon, and in some had cau-
terized the diseased surface with a fifty-per-cent. solu-
tion of chloride of zinc He reported several cases
where death would have occurred had it not been for
some such radical operation.

Dr. W. H. Carmalt, of New Haven, Conn., asked
how far it was justifiable to go in the way of resection
of ribs in these cases. He reported a recent case in
which he had removed portions of five ribs, the longer
piece exsected being four and a half inches. In these
cases it was necessary to remove enough of the chest
wall to permit of obliteration of the cavity. He had
also used the sharp spoon in order to secure a fresh
surface.

Dr. M. H. Richardson, of Boston, Mass., said
that the questions that arose in the treatment of empy-
ema were different from those in ordinary abscess, for
io the former we have an abscess with rigid walls.

With regard to drainage, he had used double tubes
provided with valves, but considered them inapplica-
ble and liable to cause increased trouble, for when air
or pus is forced out through the tubes by coughing, a
vacuum is established and the valve is held against the
chest wall, preventing drainage- He believed that
Estlander's operation was applicable only to certain
forms of cavity, and that there were certain cases where
the cavity involved a large portion of the thorax.
The operation of Schede is the only one applicable
after a failure of Estlander's operation.

Dr. Stephen F. Weeks, of Portland, Me., thought
that the rule of Dr. Ashhurst, to aspirate, especially in
children, was a good one. Sometimes that will result
in cure. The tuberculous cavity is to be treated dif-
ferently from the cavity where this condition does not
exist. Thorough drainage is sufficient in many cases.
He called especial attention to drainage by packing the
cavity with sterilized gauze. In twenty-four hours he
removed the gauze and washed out the cavity.

Dr. L. McLane Tiffant, of Baltimore, Md., con-
sidered that the treatment of acute empyema was of
more importance than that of the chronic form as it
was the more common. The most important point as
bearing upon treatment and prognosis was the character
of the pus and its bacterial cause. The reason that
the child's empyema often yields to aspiration was
that in many of these cases the pus was simply a pure
culture of the pneumococcus. In the adult we rarely
have the pneumococcus form. Here we had a
mixed infection. If the empyema was of the amoebic
form the patient died. If empyema was due to the
streptococcus, the odor was offensive and the cavity
needed to be carefully washed out. If empyema was
due to the staphylococcus, washing out was not required.
Where there was time he preferred to withdraw some
of the fluid with the hypodermic syringe and have it
submitted to bacteriological examination.

While he used ether in general work, in these cases
be preferred the use of a few whiffs of chloroform
which appeared in these cases to have a peculiarly
happy effect. Only a very small quantity was employed.

The employment of respiratory gymnastics was of
much benefit in favoring the expansion of the con-
tracted laog.

Dr. James MoFadden Gaston, of Atlanta, Ga.,
referred to the natural tendency of the empyemic
cavity to open spontaneously in the anterior part of the
chest. He reported two cases in which this spontane-
ous opening had occurred, followed by recovery.

W. W. Keen, M.D., of Philadelphia, read a paper
on

amputation of the entire upper bxtrbmitt

(including the scapula and CLATICLB) AMD
OF THE arm at THE SHOULDER-JOINT,

with especial reference to methods of controlling hiem-
orrhage, with the report of one case of the former am-
putation and four of the latter.

In this paper were considered, first, those amputa-
tions which allow of simple disarticulation at the shoul-
der-joint itself ; second, those cases in which the axilla
is invaded, yet only to such an extent as to allow of its
being thoroughly cleaned out, followed by amputation
at the shoulder ; and, third, those in which removal of
the entire upper extremity, including the scapula and
clavicle, is required.

Simple amputation at the thoulder-joirU. — Here the

Digitized by

Google

666

BOSTOJf itMDlCAL AUD SVSGJCAL JOVBHAL.

[June 7. 1894.

control of hsemorrhage is the key to the situation. Tho
methods for the prevention of haemorrhage are, first,
those applicable to the subclavian vessels ; and, second,
those applicable to the axillary.

Most text-books recommend compression of the sub-
clavian by the thumb or a well-padded key. Dr. Allis
ha* modified this method by substituting a stick eigh-
teen inches in length, with a pad of sterilized gauze at
its extremity. This pad obviates the danger of slipping,
and can be applied without fatigue on the part of the
operator. The author had suggested compression by
means of a solid pad held in position by an Esmarch
bandage passing over the perineum ; but on trial in
the case of a child, this had proven unsatisfactory. A
third plan consists in ligation of the subclavian artery.
This is objectionable on account of the prolongation of
the operation, also on account of the necessity of re-
secting the clavicle in order to ligate the vein, and if
the vein is not ligated there is danger of the entrance
of air.

The axillary methods are, first, those in use prior to
the introduction of Esmarch's tubing, and, second, the
different methods of using Esmarch's tubing.

Under the first bead we have : (a) compression of
the inferior flap by the fingers, which seize the vessels
before they are cut ; (i) Harvey's method, by compres-
sion of the vessels by means of a padded ruler thrust
into the axilla ; (e) ligation or seizure of the vessels
with heemostatic forceps before they are cut; (d)
Gross's compressor (but practically this is never used ) ;
(«) Furneaux Jordan's method, by making a circular
amputation at the surgical neck, securing the vessels
as in a hip-joint amputation, the blood-vessels having
been compressed by an Esmarch band or other method,
followed by disarticulation of the upper end of the
humerus.

Under the second head are :

(a) After making the antero-exterual flap, a stout
pin is passed through the postero-iuternftl flap between
the vessels and the bone, and elastic tubing wound
over the ends of the pin. In this method there is dan-
ger of the vessels retracting above the constricting
band.

{h) Esmarch's method, in which an elastic tube is
placed in the axilla and drawn tight over the shoulder,
where it is grasped by the hand of an assistant. This
is open to the danger of slipping of the bandage after
disarticulation of the bone.

(c) Morre's method. In this method the tubing is
applied as in the Esmarch method, but is held in place
by a bandage passing around the chest and under the
tubing in front and behind.

{d) Wyeth's method, by pins and elastic tubing. In
this method the operation is performed as follows :
The arm is held at a right angle to the body. The
sharp-pointed cylindrical pins, eleven inches long and
one-fourth of an inch in diameter, are used. The
anterior pin is introduced through the middle of the
anterior axillary fold at a point a little nearer the body
than what may be called the centre of the fold trans-
versely. The point of emergence is of much greater
importance than the point of insertion ; this should be
one inch within the tip of the acromion. The second
pin is introduced at a corresponding point through the
posterior-axillary fold, emerging an inch within the
tip of the acromion. The point of emergence is of
importance, for if the pin emerges near or at the tip
of the acromion, the moment the head of the humerus

is removed, the tubing is apt to slip downward and
compress the two flaps against each other, thus hiding
the cavity and permitting the vessels to retract The
pins being in position, a piece of rubber tubing is
wound around the axilla and shoulder on the hither
side of the pins. The disarticulation having been
effected, the main vessels and all visible vessels are
tied and the tubing removed, the vessels spurting being
grasped with hasmostatic forceps. The author con-
sidered this the most satisfactory method of controlling
btemorrhage, and he felt confident that any one who
adopted it would abandon all other methods in its favor,
except possibly in emergency cases.

AmjnUation at the $hoidder-joint in catet in which the
axilla it invaded to high that Wyeth't pint cannot he
uted, — In 1812, Dalpech proposed to make "an ob-
lique incision extending from the external third of the
clavicle to an inch above the inferior border of the
great pectoral muscle. We thus discover, and can cut
near to its origin on the coracoid process of the scapula,
the lesser pectoral. The index finger is then carried
through the cellular tissue along the serratus magnus,
then the subscapular, and is used as a hook in order to
draw outward the mass of vessels and nerves. The
artery is found in the anterior portion of this mass."
The artery and vein are then ligated. The advantages
of this method are that it gives wide access to the
axilla ; that we can determine with ease how far and
how great is the invasion of the axilla, and if thought
advisable, the operation can be abandoned at this point,
or if it is decided to proceed with the operation, the
incision already made serves as the inner part of the
deltoid incision. The author had employed this method
with great satisfaction in a case where a sarcoma of
great size had invaded the axilla nearly to the clavicle.

Control ofhamotrheye in catet in which it it neeet-
tary to remove the arm, the teapula and the clavicle. —
The methods which have been employed in these cases
have been the following: (1) Simple compression of
the subclavian artery. (2) Compression of the artery
after resection of the clavicle. (3) Ligation of the
subclavian prior to beginning the amputation. (4)
Resection of the middle half of the clavicle and ligation
of the subclavian. (5) Wyetb first tied the artery,
then formed his flaps { and when the arm, clavicle and
scapula were only connected with the trunk by the
veins and nerves, secured the veins and cut the nerves.
(6) The artery and vein have both been tied after re-
section of the middle portion of the clavicle. This
seems to be by far the preferable method. The ad-
vantages of this method are that it prevents haemor-
rhage from division of the axillary and its branches,
diminishes the amount of blood lost during the oper-
ation, prevents the- entrance of air into the veins,
permits of a large opening of the space between the
upper extremity and the chest, and enables us to divide
the posterior attachments of the upper extremity, where
the arterial circulation is still going on, at the end of
the operation.

As a rule, recovery from this operation follows in
from two to three weeks. The mortality in the more
recent operations has been extremely low, one in four-
teen. Again, by this method we can often amputate
wide of the disease, in consequence of the relative
smallness of the flaps required. In view of these facts,
the aathor urged that in all cases of malignant disease
of the upper end of the humerus, or even of the lower
end when it is already diffused, we should not content

Digitized by

Google

Vol. CXXX, No. 28.] BOSTON MBDIOAL AND 8UR0I0AL /OUSNAL.^

667

ourselves with mere amputation at the shonlder-joint,
bat should at the same time extirpate the scapula and
clavicle.

The author reported a case io which the arm, scapula
and clavicle wern removed for myeloid sarcoma, occur-
ring in a woman aged twenty years. The operation
was done November 20, 1893. The patient recovered,
and is still perfectly well.

Db. Roswell Park, of Buffalo, N. Y., said that
he bad bad two cases of total removal of the upper
extremity, both which had been successful. One was
for railroad injury and the other for extensive epitbe-
liomatous ulcer. In the first case the clavicle was
already broken, and the subclavian vessels were secured
at the point of fracture. Id the second case the clavi-
cle was divided and the vessels tied.

Db. Chables B. Portbr, of Boston, Mass., as an
illustration of the rapidity with which a malignant dis-
ease may advance, reported the case of a patient with
sarcoma of the radius where the arm was amputated
above the elbow. The disease soon recurred, and
amputation at the shoulder-joint was made ; and again
the disease (sarcoma) recurred so high up that no oper-
ation could be employed. The whole history of the
case extended over only one year after the first oper-
ation. A case was also reported where the arm had
been torn off in a railroad accident, where he had sub-
sequently removed the scapula and outer portion of
the clavicle by an osteoplastic resection, and the wound
was closed by skin grafts. Three mouths later a hard
plate of bone bad formed, very similar in shape to the
scapula.

Dr. John AaaHCRST, Jr., of Philadelphia, said
that he had once used the Wyetb pins satisfactorily in
an amputation at the shoulder-joint. Another device
to which he had resorted in several cases was to make
the incision in the lower flap from without inwards,
and secure the vessels in the wound.
{To be oontimtied.)

CONGRESS OF AMERICAN PHYSICIANS AND
SURGEONS.

Third Triennial Meeting, Washington, D. C,
May 29, 30, SI and June 1, 1894.

GENERAL SESSIONS.

TUESDAY AFTERNOON, HAT 29tH.

The Congress was opened with a bri<f address by
Db. Landon Carter Gbat, of New York, Chairman
of the Executive Committee. Dr. Gray then intro-
duced the President of the Congress, Dr. Alfred L.
LoOHis, of New York, who in a few remarks thanked
the Congress for the honor that it had conferred upon
him by electing him to the presidency ; but as the time
allotted to the session was so short, he refrained from
making any extensive address.

This session was under the direction of the Associ-
ation of American Anatomists, and the subject selected
for consideration was

MOBPHOLOGT AS A FACTOR IN THE STDDT OF DISEASE.

The discussion was opened by Dr. Harrison
Allen, of Philadelphia.

It has often been asserted that anatomy is a finished
subject, that nothing new can be said of it; but no
true anatomist would be content for a moment with a

science thus limited. The science of anatomy is await-
ing important advances to be brought about by new
readings in the infinite book of Nature. The anatomi-
cal teztrbook assumes an ideal which is properly de-
scribed. The facts that exceed this ideal or otherwise
disturb it are ignored unless they are needed by the
surgeon. Three sciences have appeared since the days
of Vesalius and of Hunter, sciences so vast as to com-
mand the time and energy of distinct bands of workers.
These are histology, embryology and general morphol-
ogy, the most important of the tbree. Morphology is
anatomy writ large. Within it is to be placed the sub-
ject of descriptive anatomy as a conventional and unim-
portant part. The author regretted that anatomy was
still taught pretty much as it was a century ago. The
demands of the surgeon still dominate the lecture-hall.
The forces for the education of the medical scholar are
unused ; the powers of observation of the practising phy-
sician are not stimulated ; the outlines of methods by
which the science of morphology can be extended, un-
ihougbt of; while the opportunities of accumulating
at the hands of physicians, materials to be used in the
explanation of phenomena of organic structure acting
perversely, or serving as the causes of diseased action,
are neglected. While such knowledge is in the posses-
sion of advanced clinical workers it has been obtained
after their academic education has been completed.
Is it not entirely proper that tbey should be carefully
educated in these points before graduation ? Empiri-
cal knowledge never leads to true conceptions. Dis-
eases are not related to one another but to their causes.
Etiology is the single factor that yields conditions
which can correlate. Tissue changes furnish truer
guides than function changes. In medicine, elaborate
experimentation combined with anatomical observations
on the dead, are worth all that is possible from empiri-
cal observations on the living. The physician should
refer more problems than he is inclined to do to the
morphologist.

Reference was then made to the chemical conditions
that underlie texture and this was illustrated by the
growth of the teeth particularly as influenced by gout.

In like manner the nails show the effect of the
gouty diathesis. If among wild animals varieties were
found to vary as much among themselves as do gouty
and non-gouty persons, zoologists would be justified in
defining therefrom subspecies. Why should not gout
be defined as well by the results of the chemical com-
positions of the fiuids as by these compositions them-
selves. Morphological data are the most reliable.

So long as we study diseases as distinguished from
their causes and effects, we are empirical. The theories
of the humorists, the solidists, or any one of the many
theories which have agitated the profession would have
been impossible had the system of medicine been
broadly based on morphological data.

The changes in the shape and composition of a part
of an organism constitute a variation, and the detection
of these variations and the propositions on which they
are based, constitute one of the chief occupations of the
morphologist.

The value of minute knowledge of muscle fibres was
illustrated by reference to the causation of oesophageal
pouch and heart-failure.

In an exact sense, the structure of an animal may
be said to express the resultants of certain forces. In
a sense less exact, the work of the anatomist can be
said to be that of analyzing the results of these forces.

Digitized by

Google

568

BOSIOS MEDICAL ASD SVBGJCAL J0VBJ9AL.

[JcNE 7, 1894.

Disease in a morphological sense is the expression of
forces operating inordinately or eccentrically, but yet
our systems completely fail when we attempt to ex-
plain them by the tests of nutrition or of heredity.
The reason of this lies in the inadeqaacy of knowledge
of the causes of which stractures are simply the effects.
In the study of anatomy it is not so much the fact as
the import of the fact that is essential.

The author called attention to the fact that the
anatomical material coming under our observation is
almost always that of a highly domesticated nature
and that in order to study it with advantage we must
recall what is in common between man and the animals
(both in a wild and domesticated state) about him.
Our acquaintance with man as a domesticated animal,
as a degenerate animal, and our ignorance of him as a
wild and primitive animal, causes the morphologist to
regard human structure with the same sort of interest
as the botanist entertains for those plants which have
been cultivated so long that he has lost knowledge of
the typical form of the species. Can the anatomy of
such an animal be said to be closed ?

Degeneration while a phase of specialisation, is one
which portrays structures that fail to subserve the
highest possible use in the economy. Illustrations
were drawn from alterations in the shape of the crown
of the teeth and also from the phenomena of polycos-
pidation in the molars. Reference was also made to
the proportionate size of the face as compared with the
brain-case. The short-faced specimens of the skull of
civilized man are the result of some profound impres-
sion on the nutritive forces rather than a reversion
brought about by natural selection.

To what extent structures which are degenerate be-
come on that account predisposed to disease it is dif-
ficult to say, but taken as a whole the animal economy
resists the inroads of disease in proportion as its vital-
ities are maintained at high levels of eflBciency. It
may be asserted without fear of contradiction that the
skeleton of civilized man differs from the skeleton of
uncivilized man. In the crania of the wilder types of
man, there is usually a disposition for one part of the
skull to be in harmony with another part. This is
largely absent in civilized types.

Perhaps the best single conclusion to be drawn from
the study of morphology as a factor in the study of
disease, is its value to humanity. The scientific study
of race in connection with diseased action is almost an
unbroken field. When this comparative phase of
anatomy shall have been formulated, we shall for the
first time have a reasonable hope that the subject of
human acclimatization, the geographical study of dis-
eases, the causes and motives of migration, and thus
indirectly, the history and destiny of man himself, may
be in shape for elucidation.

He was followed by Db. Thos. Dwigbt, of Boston.

Dr. Allen defines morphology as anatomy writ large.
The underlying idea of his paper is to plead for a longer,
broader, deeper course in anatomy. The tendinous
heart-strings of every anatomist will vibrate in sym-
pathy, producing a chorus of musical murmurs. Per-
chance in some of us one of the factors will be the
moderator band of the ruminant which has left its
normal place near the apex of the human heart to
cross near the middle of the right ventricle. The ex-
pert auscultator can recognize this cord. It is good
for his patient that he should know from anatomy that
have these things pointed oat rather than pursued, I

such a baud may be present and that its sound is no
sign of even functional disturbance. The ophthalmol-
ogist is none the worse that embryology teaches him
the whereabouts of the hyaloid artery which may per-
sist throughout life. Anomalies, therefore, as well ss
slighter variations are of practical importance. The
surgeon needs to know of the fibrous or muscular band
which may cross the axillary artery, that the brachial
artery may divide high up the arm (very rarely in the
lower third), and that the diverging artery, be it radial
or ulnar, almost always runs superficially. A third
trochanter, which seems much larger than it is, when
felt through the soft parts, must not be mistaken for
an exostosis, nor a deltoid tubercle of the clavicle for
an old fracture.

Before removing the kidney, the surgeon will do
well to be sure that it is not the only one. I, myself,
within a few months have seen a case of complete ab-
sence of one kidney, the other being of about the usual
size and in its proper place.

But it is not necessary to turn to anomalies to sup-
port the need of a deeper knowledge of anatomy for
the practitioner. The statics and naechanics of the
skeleton, the action of the muscles are becoming daily
more important to the orthoptedic surgeon and to the
neurologist.

The anatomy of childhood is still almost in its in-
fancy. Though not quite helpless it has not yet made
its way into text-books, but hides itself bashfully in
scattered papers and monographs. A more thorough
knowledge would be of great value to the practitiouer
in children's diseases. How interesting and how prac-
tical in view of infant feeding is the story of the rate
of growth of the stomach in the first months of life,
and how few know it.

My views of the esteem in which anatomy is held
are far less pessimistic than Dr. Allen's. It is but too
true that we have many in high places absolutely igno-
rant of anatomy themselves, who look on its progress
with a jealous aversion, but they are mostly on the
wrong side of fifty, and they belong to a school of
thought that is doomed. On the other hand, I look
with confidence to the rising lights. I see in the bet-
ter class of our young practitioners, a great respect for
anatomy. They have a clearer vision of its sphere.
One of the most gratifying incidents of my professional
life is the constantly increasing number of those who
come to me for information on anatomical problems or
for the meaqs of solving them.

Surely, from what I have said, I shall not be sus-
pected of indifference to the cause if I do not quite
agree with Dr. Allen as to the remedy. He would
have students thoroughly instructed in the highest
anatomy before graduation. I reply that there is no
time. As a practitioner myself of twenty-five years'
standing, I am appalled at the amount of knowledge
of all kinds which is now necessary for the simplest
practice of the profession by any one who would not
fall behind his colleagues. I heartily agree with Bux-
ley's saying, that any one who adds one tittle that is
unnecessary to medical education, is guilty of a very
grave offence. I would leave the matter to the good
judgment and tact of the professor of anatomy. While
his teaching should be eminently practical in the ordi-
nary sense of the word, I would have him incidentally
point out the explanations of stractures from compara-
tive anatomy and embryology, and still more insist upon
the application of morpholoj^ to disease. But I would

Digitized by

Google

Vol. CXXX, No. 23.] BOSTON MEDICAL AND SURGICAL JOURNAL.

569

would bare him show the poggibilities of anatomy which
nafortanately are impossibilities in the regular coarse.
Thas he will enlarge the student's horizon. It is not
necessary to have followed a certain line of research
to know that it gives promise of great resalts. The
mind of a stadent so trained will be in a very different
state from that of his comrade who has been crammed
with facta from a compendium. Advanced students
and graduates are those to whom the highest anatomy
will be most profitable, and the more so that they can
see for thexselves its value, which the beginner must
take on trust.

Dr. F. Bakkb, of Georgetown, D. C, spoke next

The study of the human organism, of its structure,
its functions, its diseases, of the effects that various
agents have upon it, therapeutically and otherwise,
mast necessarily be a study of life and 'U» manifesta-
UoDs; it is a biological science. The study of mor>
phology as a preliminary to the study of disease is a
necessity. The great impulse given to the study of
anatomy by Vesalius and his followers in the 16th
century has not yet exhausted itself. The error in
the Vesalian anatomy which has prevailed up to the
present time consists in considering the body as an
essentially fixed organism. From this view arises the
notion that anatomy is a fixed science, but even a cur-
sory view of the history of the science shows this as-
sumption to be baseless. To the modern biologist the
human body is by no means fixed and invariable.

The human body has been studied far more than any
other organic form. There is no lack of knowledge of
details, but for the ordinary student these details are
not classified and arranged as the results and sequences
of morphological laws. It may even be said that in-
flammation itself cannot be properly understood with-
out a knowledge of the morphological character of the
tissues involved. The whole subject of tumors has,
since the investigations of Virchow, been studied from
a morphological standpoint, and it has become evident
that in order to understand their causes and their his-
tory, we must know more about the laws that control
cell formation and the growth of tissues.

The human body is built up of cells, and the gross
variations in form must depend upon these minute cell
activities. These variations may be ot ail grades. The
morphologist studies these variations as indicating slow
modifications of the form of the human body. It is
well known that the body of man is slowly changing,
that adaptations are going on within slowly fitting it
more and more to its euvironipent. In this process
there are constantly left structures which have ceased
to be of value and may properly be termed vestigial.
Among such may be noted the vermiform appendix,
Meckel's diverticulum of the intestine, the thyreoglos-
sal duct, hypospadias and the persistence of the cho-
roidal fissure of the eye producing coloboma.

The erect position of the human body was gradually
acquired, and in many respects the body has not yet
become perfectly adapted to this posture. The shape
of the pelvis has necessarily become modified that it
may support the weight of the viscera, yet with all
this, that weight is often a cause of hernia. As a re-
snltof these changes the pelvis of the civilized woman is
less adapted for easy parturition than that of her savage
grandmother of the Stone Age. Many of the abdomi-
nal viscera show signs of maladaptation. The cecum
and ascending colon are not favorably situated. The
liver, instead of being supported from the spine, is

slung from the diaphragm, which to support the weight
must receive strong connections from the pericardium
and the fascia which supports the heart. This must
interfere with the growth and expansion of the lungs.
The heart itself works at great mechanical disadvan-
tage. The valves of the veins are not adapted to the
erect posture.

As the science progresses there is no doubt that
many important generalizations will be made. Some,
already, seem almost ready for statement. Among
those may be mentioned what may be called the law
of stability. It is this : that the stability of a struct-
ure varies directly according to the time it has been
functionally active in the ascending series of animal
life. The structures most readily attacked by disease
are those at either end of the scale of activity. The
original elementary tissues, epithelium and connective-
tissue are the most stable, their derivations, nerve-tis-
sue, muBcle-tissne, glandular-tissue are the least stable.

Morphology is throwing light upon a vast variety
of subjects connected with the domain of medicine, not
only upon the causes of disease, but upon the action of
cells, the problems of therapeutics, the very springs of
life that underlie heredity, development, training and
education. It is a growing science, one that is des-
tined to a great future, promising much for the eluci-
dation of the highest problems of medicine.

Dr. Burt G. Wilder, of Ithaca, N. Y., regretted
that he had been unable to prepare a formal paper,
but he wished to express his agreement with the state-
ment of Dr. Baker, that the human body is not to be
regarded as a completed structure. It is by no means
completed. The physician should consider very seri-
ously whether it is not his duty to improve the human
body in the direction in which it has been moving,
namely, by the obliteration of that most frequent
source of trouble, the appendix of the intestine. It is
the unanimous consensus of opinion among surgeons
that the removal of the appendix, if not gangrenous,
presents no great likelihood of mortality. It is now
four years since he proposed that we should not only
do vaccination but also de-appendicize the child at a
period of life when time was not very valuable, and
thus improve his chances of existence.

Dr. Dwight had alluded to the impossibility of put-
ting more into the curriculum of the schools, and to
this the speaker partly agreed ; but he held that
there should be more morphology taught in the pre-
liminary school education, and he predicted that it
would not be many years before' most children prior
to leaving the ordinary college will know as much
anatomy, physiology and morphology in the broad
sense as can now be obtained by the average physic! in.

WEDNESDAY AFTERNOON, HAT SOtH.

The first portion of the session was under the charge
of the Americin Climatological Association. The sub-
ject discussed was

SBVTEB OA8.

Dr. Alexander C. Abbott, of Philadelphia, pre-
sented the first paper, entitled,

CHEMICAL, PBTSICAL AND BACTBRIOLOOICAL STUDIES
OF AIR OTER DECOMPOSING BCRFACE8, WITH ESPE-
CIAL REFERENCE TO THEIR APPLICATION TO THE
AIR OF SEWERS.

A Study of the literature of this subject leaves the
impression that many of the opinions advaooed are not

Digitized by

Google

670

BOSTON MEDICAL AND SURGICAL JOURNAL.

[JcKE 7, 1894.

based on exact methods of invegtigation. We are now
tolerably well acquainted with the nature of the air of
sewers, and we know that as ordinarily found it does
not differ conspicuously from the air that we are ac-
customed to breathe. Studies in bacteriology demon*
strate the comparative poverty of sower gas in bacte-
ria. The general impression is that the air of sewers
is under an active pressure and tends to force its way
into houses, but numerous experiments witb pressure
gauges show that such is not the case. The studies
upon the chemical, bacteriological and physical side of
the subject, together with observations on the health
of those constantly exposed to the emanations of sew-
age, are not of a nature to warrant the opinion that
sewer air is the dangerous factor that some believe it
to be. There does not seem to be a single conclusive
demonstration that the air of sewers stand in causal
relation to the diseases for which it has been held
accountable.

Among the problems which the author bad endeav-
ored to solve experimentally in the laboratory was
whether or not it was possible to demonstrate oo ani-
mals that the gases arising from sewage or from other
decomposing substances, have any direct effect upon
the health of the animal or its ability to resist infection.
The method of experimentation was given in detail.
The teaching that because materials containing organ-
isms capable of producing disease are constantly gain-
ing access to the sewers, the air of these sewers must
of necessity also contain such organisms is simply an
opinion. It is not supported by observations that lead
as to accept it as a fact. The more conservative of
those who believe in a causal relation between the air
of sewers and pathological conditions are coming to
the opinion that it is not directly concerned in the
production of disease, but that its continuous respira-
tion in some way interferes with the normal vital re-
sistance of the tissues, and thus renders them more
susceptible to infections to which they may be exposed.

The author detailed his experiments on animals, and
concluded that if experiments upon animals are of any
value in demonstrating the positive or negative effect
of air saturated with the gaseous products of decompo-
sition, it does not seem reasonable to suppose that the
air of a sewer or cesspool, in the enormous dilution in
which it exists at the time that it reaches an individual
in a house to which it has access, can be of much im-
portance either in the direct production of the diseased
conditions or in influencing the vital powers of the
resistance of the individual who inhales it.

THE KFFECT OF SEWER GAS IN THE PBODUCTION OF
DISEASE,

by Dr. A. Jacobi, of New York.

The author presented the followiag conclusions :

The atmosphere contains specific germs both living
and dead. They are frequently found in places which
were infected with specific disease.

In sewers, fewer such germs have been found than
in the air of houses and school-rooms.

Moist surfaces, such as the contents of sewers and
cesspools and the walls of sewers, while emitting odors,
do not give ofi specific germs even in a moderate cur-
rent of air.

Splashing of the sewer contents may separate some

germs, and then the air of sewers may become tempo-

arily infected, but the germs will sink to the ground

gain.

Choking of the sewer, the introduction of hot fac-
tory refuse, leaky house drains and the absence of
traps may be causes of sewer air ascending or being
forced back into bouses, bat this complication of cir-
cumstances certainly will be rare.

Whatever arises from the sewer under these circum-
stances is offensive and irritating. A namber of ail-
ments, such perhaps as sore throat, may originate from
this cause, bat no specific disease will be generated by
it except under the rarest of conditions ; for spcclBc
germs are destroyed by the process of putrefaction in
the sewers, and the worse the odor the less is the dan-
ger, particularly from diphtheria. The causes of the
latter disease are very numerous and the search for
the origin in an individual case is often unsuccessful.
Irritation of the throat and naso-pharynx is a frequent
scarce of local catarrh. This creates a resting-place
for the diphtheria germs, which are ubiquitous during
an epidemic, and thus an opportunity for diphtheria is
furnished.

Of the specific germs, those of typhoid and dysen-
tery appear to be the least subject to destruction by
cesspools and sewers. These diseases appear to be
sometimes referable to direct exhalations from privies
and cesspools. Fewer cases, if any, are attributable to
sewer air.

A simple outlet from the sewer would be dangerous
to the general health because of the density of the
odors (not germs) arising therefrom. Therefore a
very thorough and multiple ventilation is required.

The impossibility or great improbability of specific
diseases arising from sewers into our bouses protected
by good draius and efficient traps mast, however, not
lull our citizens and authorities into indolence or care-
lessness ; for the general health is suffering from the
chemical exhalations, and the vitality of cell-life and
thi) power of resistanca arj undermined.

SEWER OA8 A CAUSE OF THROAT DISEASE, OR THE
EFFECT OF BAD DRAINAGE ON THE THROAT.

by Dr. Beterlt Robinson, of New York.

Defective sewage may produce a sore throat of a
benign character, which affords a soil suitable for inoc-
ulation by the diphtheria germ when present in the
air. it is an admitted fact that the throat swarms
with bacteria at all times ; and possibly the Loffler
bacillus is among these occasionally, but they are in-
capable of doing much harm if the iudividaal is in good
health. Through the depressing influence brought
about by bad drainage, etc., they are capable of multi-
plying and increasiug In virulence, and finally causing
infections sore throats. It is therefore clear how im-
portant it is to keep up an excellent condition of general
health to avoid contracting throat disease. Proper
disinfecting washes and gargles are also of value.
While the connection between effluvia from sewers and
drains and the condition of the throat caunot always
be determined, yet in many cases it is clearly demon-
strated. That many cases of tonsillitis are immedi-
ately caused by the air of sewers and fsecal emanations
scarcely admits of doubt. In some cases the sore throats
have been confined to particular parts of houses ; and
when the bad sewage has been remedied, they have
ceased to recur. When cases of diphtheria, tonsillitis
or erythematous sore throat occur in houses where the
plumbing is found to be defective, we should be care-
ful not to ascribe these diseases necessarily to this
cause. While throat affections often occur where the

Digitized by

Google

Vol. CXXX, No. 28.] BOSTON MEDICAL AND SURGICAL JOURNAL.

571

drainage is bad, they may occar where the sewage is
in perfect coadition or where there is no sewage at all.
The second part of the Session was under the direc-
tion of the American Dermatological AssociatioD. The
subject for discagsion was

LEPROST.

Jaues Nbtins Htde, M.D., of Chicago, read the
openiog paper, which was on

TBE DISTRIBUTION OF LEPROST IN NORTH AMERICA.

Reference was first made to the different ways in
which the disease could gain entrance into the United
States. The northern part of the country has suffered
far less than the southern, and even in the latter por-
tion the disease is more common in the southern than
in the northern provinces. The United States is ex-
posed to the entrance of leprosy from the four princi-
pal pcMuta of the meridian, north, south, east and west.
That the total res alt up to the present time is insignifi-
cant, has been due, not tO'wisely-directed vigilance, but
rather to the general excellence of the habits of the
people, and to their resources and enviroBments.

At the present time the distribution of leprosy in
the United States cannot be determined with any accu-
racy. The credit of being the first to collect statistics
as to the number and location of lepers is due to the
American Dermatological Association. According to
these statistics and those of others, it may be said that
the cases of leprosy in the United States have been
distributed as follows : Arkansas 3, California 158,
Dakota 2, Florida 6, Georgia 1, Idaho 2, Illinois 13,
Indiana 2, Iowa 20, Louisiana 83, Maryland 4, Massa-
chnsetta 5, Minnesota 120, Missouri 2, Mississippi 2,
New York 100, New Jersey 1, Oregon 3, Pennsylva-
nia 6, Utah 3, Wisconsin 20, making a total of 560.
The accumulation of cases is found to be principally
at points of commercial activity. The number of
lepers in this country at the present time cannot be
definitely stated.

These facts call for intelligent discussion and for
wise provision looking after the needs of the unfortu-
nate leper, and for the safety of the community in
which the infected are now living. Tuberculosis
alone, at the present time, exposes the health of our
population to a greater danger than leprosy. The
presence of leprosy in this country offers a constant
menace to its inhabitants, and proposes a problem in
State and sanitary science which I believe the general
government alone can readily solve.

THE CONTAOI008NE8S, PROPHTLAXIS AND CONTROL
OF LEPROST,

by Dr. James C. White, of Boston.

The establishment of the proof of the contagious-
ness of a disease should be based upon the following
points :

(1) The history of its action upon communities or
nations.

(2) The study of its action upon individuals.

(3) Its resemblance to other affections generally
regarded as contagious.

(4) The establishment of a satisfactory cause for
such contagion.

(5) The influence of control upon its history and
course.

These tests were then applied to the disease under
contideration :

(1) The history of its action upon communities and
nations. Reference was made to its coarse in medi-
aeval Europe, where, introduced from the East, it
became a pestilence of such overwhelming proportions
that no influences of heredity alone could account for
its spread. Belief in its contagious nature was then
universal. In uur own day, the extraordinary rapidity
of the spread of the disease in the Hawaiian Islands
can be accounted for on no other grounds than its in-
fectious nature. The same is true of its introduction
and spread in British Guinea, Trinidad and other
places.

(2) The study of its action bpon individuals. Great
difficulty is here met with on account of the long
period of incubation of leprosy, which may be of two,
five or even ten years' duration. Such a retardation
of the tangible effects of the contagion renders direct
historical proof in individual cases almost an impossi-
bility. Again, the tissues of animals other than man
thus far studied show themselves indifferent to inocu-
lation experiments. The possibility of using human
tissues for such demonstration in satisfactory suflScieiicy
is too remote for serious consideration. In one case a
condemned criminal was inoculated, and three years
later leprosy appeared. Reliance must therefore be
laid upon a careful study of the beginning of endemics
in small communities. Another class of evidence is
the acquisition of the disease by immigrants of non-
leprous nationality into leprous countries. Of this
there are many instances on record. Another impor-
tant fact is the development of leprosy among the per-
sonal attendants of lepers. Of this several instances
were cited.

(3) Resemblance to other affections generally re-
garded as contagious. Under this head, reference was
made to the many points of resemblance between
leprosy and syphilis and tuberculosis, and the speaker
held that these strong resemblances suggested an inti-
mate relationship in etiology and pathology.

(4) Establishment of a satisfactory explanation of
its contagiousness. With the discovery of the bacillus
lepree, the cause of its contagious nature was demon-
strated as clearly aa was that of tuberculosis by the
discovery of the bacillus tuberculosis. Leprosy is pre-
eminently a bacillus disease, for this organism is found
in rich abundance in the tissues.

(5) Influence of control upon its history and course.
In mediwval Europe, when the disease was regarded
aa infections, the leper was segregated and placed in
lazarettos. In later centuries, when the disease bad
been thus controlled and confined to a few districts,
the belief grew up that the disease was not contagious,
but was hereditary, and scarcely any one thought of
questioning this dictum. At the International Medi-
cal Congress in 1876, the author had called attention
to the prevalence of the disease in the United States.
In 1882 he again called attention to the subject in a
paper presented to the American Dermatological Asso-
ciation. His conclusions that the disease was increas-
ing to an alarming extent, and that it was contagious,
at that time found few supporters, but since then pro-
fessional opinion has greatly changed. A study of the
disease in other countries shows that where laws for
its control have been enacted there has been a great
decrease in the number of cases, and that where it has
been given free license the number of cases has
rapidly increased.

While not denying the possibility of the transmis-

Digitized by

Google

672

BOSTON MEDICAL AND SUBGICAL JOURNAL.

[JcMB 7, 1894.

sion of leprosy by heredity, the author held that its
apparent occurrence in any instance shonld not be ac-
cepted without the absolute demonstration of the im-
possibility of inoculation after birth. He believed the
theory of heredity to be a dangerous one, and that the
sterner judgment of the Middle Ages, which made
the leper individually the responsible agent rather
than the progenitor, must again be adopted before the
affection can be exterminated.

With regard to the prevention and control of leprosy
in the United States, the consideration of the follow-
ing propositions was recommended :

(1) Every physician should I>e compelled by State
law to report to the nearest board of health the exist-
ence of a case of the disease, and the neglect to do so
on the part of the medical attendant or a member of
the leper's family should be a penal offence.

(2) immigrants affected with the disease should be
arrested at ports of entry and along our border, and
turned bacic to their previous homes by the authority
df the National Board of Health.

(3) Graded hospitals should be established by the
national government, in insular localities where pos-
sible, within which both suspected and confirmed cases
should be confined, and to which all access should be
prevented excepting under proper restrictions.

Such compulsory isolation may be considered cruel
to the few, but its longer neglect on our part is cer-
tainly a greater cruelty to the many, for in no other
way shall we exterminate this most miserable disease.

In the general discussion of the subject, Db. George
H. Fox, of New Yorit, said, that whatever might be
the result of inoculation experiments, he was sure that
those who had given special attention to the study of
leprosy would agree that the disease was communi-
cable, but that the danger of infection from association
with the leper is extremely slight. In the United
States, the disease has never shown any tendency to
spread among those brought in contact with communi-
ties of lepers. He thought that there was no neces-
sity for the segregation of the lepers to be found in
the United States. To forcibly take these individuals
from their homes would be an injustice which the
slight menace to the general health would not warrant.
Syphilis and tuberculosis are much more liable to be
communicated to others than is leprosy. He believed
that many cases of leprosy are amenable to treatment
and capable of being cured, and he would be in favor
of the establishment of hospitals for leprosy where
these cases could be studied.

Db. Joseph B. Brtant, of New York, advocated
the institution of active measures, because such a
course would be a humane one as far as the leper
was concerned; it would conduce to public security
and confidence ; and it would secure good sanitation
and better therapy. He offered the following propo-
sitions :

(1) That a wise public policy and humane consid-
erations demand that lepers be not permitted to asso-
ciate with the unaffected.

(2) That the exercise of local authority for their
segregation is unwise and unsanitary, as establishing
innumerable abiding-places for the disease at great
expense, and without the assurance of proper surveil-
lance.

(3i) That a safe, prudent and humane policy de-
mands that lepers be properly segregated under the
care and control of the general government.

Db. Walter G. Wtman, Surgeon-General, United
States Marine-Hospital Service, descrilied the effect of
the quarantine laws which had been promulgated with
the object of preventing the entrance of lepers into
the United States. He then considered the reasons
in favor of and against the national control of leprosy,
and presented the draft of a bill relating to this object
He also suggested that, as a preliminary measure, a
leprosy commission should be appointed to study (he
disease and report upon the best methods of control-
ling the disease in this country. For himself, he be-
lieved that leprosy should be under national control.

Db. Arthub Van Harlinoen, of Philadelphia,
dwelt upon the importance of all physicians studying
leprosy so as to be able to recognize its earlier mani-
festations, which were frequently overlooked. He
had good reason for saying that, notwithstanding the
rigid quarantine laws, many cases of leprosy had
gained access to the country, although they had been
subjected to some sort of an examination. This was
due to a failure to recognize the early manifestations
of the disease.

THB DIAONO8TI0 FEATURES AND TREATMENT OF
LEPBOST,

was the subject of a paper by Db. P. A. Mobrow, of
New York, which was read by title.

THUBSDAT AFTERNOON, HAT 31 ST.

The first portion of the session was under the direc-
tion of the American Association of Grenito-Urinary
Surgeons.

Db. Edward L. Eetks, of New York, read the
first paper which was on

NKPHBITIS IN ITS SCRQICAL ASPECTS.

In opening the discussion on this subject, Dr. Keyes
announced his intention of confining himself to a con-
sideration of that form of surgical nephritis in which
suppuration occurs, either spontaneously in the course
of suppurative disease of the urinary tract below
(ascending pyelo-nephritis), or originating below as a
result of infection by the surgeon, or in the blood (the
descending variety) — all the various forois of so-called
surgical kidney.

He divided his paper into three parts : (1) introduc-
tory, (2) practical, (3) bacteriological. The introduc-
tory section demonstrated by a plentiful citation of
authority, mainly French and German, the following
points :

(1) Without microbic infection, suppuration in the
kidney is impossible.

(2) The bacilli found most often are, notably, the
bacterium coli communis, less often (alone or in com-
pany with the bacterium coli) the staphylococcus
pyogenes aureus and the streptococcus pyogenes.

(3) These bacilli find entrance in a variety of alleged
ways.

(4) The introduction alone of these bacilli does not
occasion ascending pyelitis, or even necessarily cystitis.
It is as much a question of soil as it is of seed.

(5) The soil is made receptive for microbic invasion
by a variety of local physical maladies — by anything
that interferes with free, urinary outflow; by ovei^
distention or tension; and also by traumatism, and
failure of the general vitality of the individual. The
kidney is especially prepared for invasion by dilatation
of the ureters, a dilatation always occurring from above

Digitized by

Google

Vol. CXXX, So. iS.] BOSTOlf MBDtOAl AND SUttOlOAL JOURNAL.

m

downwards, always doe to a moderate obstraction of
urinary outflow below, never to enddeu stoppage of
the ariDary drainage nor to back-pressnre of the urine.

The practical part of the paper contained Dr. Keyes's
personal views upon urinary asepsis and antisepsis, and
detailed the methods wbich he employed in everyday
clinical work and the solutions he used, together with
his method of instituting catheter life upon an old sub-
ject with clear urine atony, retention, thin-walled blad-
der, dilated ureter and damaged kidney (as regards its
vitality).

The bacteriological study was conducted by Professor
Dunham of Bellevue Hospital Medical College, under
Dr. Keyes's direction, to determine the destructive or
inhibitive power over the three bacilli under consider-
ation, of a great variety of medical substances often
used for local antiseptic purposes in the treatment of
vesical suppuration, and of a variety of urines medicated
by the ingestion of a number of different drags. About
five thousand tubes were examined and the conclusions
generalized and tabulated, with the result of showing
theoretically wbich drugs possessed the greatest value
under varying conditions — those of direct infection
by the surgeon, the tissues not being involved ; and
those in which, chronic suppuration already existing,
the bacilli were protected from the actio.n of the ami.
septic. These conditions were reproduced in the lab-
oratory, a method of investigation apparently novel
and yielding suggestive results. The experiments
consisted in comparing the action of the same drug
upon bacteria in Group I, where direct infection im-
mediately created was simulated, with its effect on
bacteria in Group II, where chronic inflammation was
simulated, the bacteria being more or less protected.

This investigation showed that nitrate of silver was
by far the most reliable agent we possess in counter-
acting the effects of local contamination, while corrosive
sublimate was more reliable in Group II, where the
tissues were involved. Salicylic acid was shown to be
a very reliable antiseptic, and Dr. Keyes proposes a
new solution for greater convenience of use. Boracic
acid has little or no value, common salt being about as
good. Many other agents were experimented with.
The various medicated urines showed little or no in-
hibitive power over bacterial growth.

The following general conclusions were presented :

(1) Healthy urine is sterile.

(2) Purulent urine is always microbic.

(3) Microbic infection takes place from within the
body by a number of methods in the course of disease ;
it is often brought about by instrumental mauoeuvres
on the part of the surgeon.

(4) A healthy organism and vigorous bladder can
cope successfully with microbic invasion, and rid itself
spontaneously or with a little aid of all damage arising
therefrom, showing little or even no inflammatory
response.

(5) A. suitable condition of the patient's soil is
essential to the propagation and perpetuation of the
inflammatory phenomena upon the urinary tract, after
microbic invasion.

(6) This condition, intensified by traumatism and
physical weakness, notably of the degenerative variety,
is most intense when there is vesical distention with
atony, and when the ureters are dilated and the kidneys
involved in the changes incident to tension below,
namely, atrophy and sclerosis above, with or without
surface catai*rh.

(7) Under these circumstances surgical pyelonephri-
tis is most likely to declare itself as a result of microbic
infection from below (occasionally from above) in the
course of suppurative disease.

(8) Asepsis, antisepsis and sterilization of urine are
ends to be aimed at in genito-urinary surgery, but like
all other greatest goods not yet attained in perfection.
Much, however, can be done by local means in a pro-
phylactic and curative way, little by internal medica-
tion, and possibly as much or more than by any other
means by flushing the urinary passages with natural
mineral waters.

Dr. Geo. M. Steenbbbg followed, with a paper on

THE BACTERIOLOGY 07 NEPHRITIS.

Ascending nephritis or pyelonephritis is very com-
monly secondary to cystitis of long standing.

Recent researches show that the bacillus coli com-
munis is found more frequently than any other micro-
organism in the so-called " surgical kidney." This
bacillus is now known to be the usual cause of perito-
nitis, it has been obtained in pure cultures in some
cases of abscess of the liver, from urinary abscess
and from the pleural cavity in certain cases of pleurisy.

Injections of a pure culture made into the ureter,
after tying it below the point of injection, have been
shown by Schmidt and Aschoff to give rise to pyelo-
nephritis, and the changes induced are said to corre-
spond with those seen in the "surgical kidney" of
man. Clado in 1887, Albarran and Halle in 1888,
and fiovsing in 1890, have described non-liquefying
bacilli found by them in the urine of cases of chronic
cystitis and of pyelonephritis, which appear to be
identical with the bacillus coli communis, which has
been shown by the subsequent researches of Schmidt
and Aschoff and of others, to be very variable in its
growth on various culture media — upon gelatine the
growth is sometimes transparent and sometimes opaque.

Krugius in 18itl, first identified the bacillus de-
scribed by Clado (his " bacterie septiqne " ) and by
Albarran and Halle ( " bacille pyogene " ) with the
bacillus coli communis, and this identification is verified
by the researches of Achard and Renault, Schmidt
4nd Aschoff, and others. In 22 cases of cystitis studied
by him (1892) Krugius obtained the bacillus coli com-
munis 14 times in pure cultures. Reblaub (1892)
obtained the same bacillus in pure culture in 6 cases
out of 16 cases of cystitis examined.

The number of cases of pyelonephritis reported by
various authors since 1889, in which the bacillus coli
communis was found, and was probably the cause of
the ascending nephritis, is 29, and in 20 of these it was
found in pure culture.

The etiological relation of this bacillus to ascending
nephritis seems extremely probable in view of the facts
referred to. Certain cases appear to be due also to
the presence of one or more species of protons, and
possibly to other micro-orgauisms.

The general discussion was participated in by Dr.
George Chismore, of San Francisco, Cal., and Dr.
Francis S. Watson, of Boston.

The second portion of the session was under the
charge of the American Gynecological Association.

The first paper by Db. Wm. M. Polk, of New York,
was entitled

THE CONSERVATIVE SURaERT Or THE FEMALE
PELVIC ORGANS.

Digitized by

Google

574

BOSTOS MEDICAL AHl) hlRGlCAL JOthhAL.

[JrKE 7, 1894.

The data from which the author drew his deductions
have been furnished by a study of 164 cases on which
he had done abdominal section for disease of the ap-
pendages. Of these, 64 were operated on by the radi-
cal method, and lOU by so-called conservative measures.
By the term conservative he meant to indicate the
retention of all tissues which have a reasonable chance
of adding to the local or general well-being of the in-
dividual. Conservative surgeiy is applicable to trau-
matisms, non-malignant disorders and the early stages
of infectious disorders of the female pelvic organs.

The advisability of conservative operations on the
perineum, vagina and cervix has long been recognized
and accepted. The author then went ou to speak of
myomectomy. Where the tumor has a pedicle or a
distinct capsule and the tumors are not too numerous,
operations for the removal of the tumors themselves
may be indicated. Ligation of the broad ligament has
been suggested in order to check the growth and lessen
the heemorrhage. This operation seems to be capable
of filling a valuable place for these indications. It
seems to be better than the operation of oophorectomy,
but as yet our knowledge is insufficient to enable a
more definite statement to be made.

One of the most conservative operations is curetting,
with the drainage and depletion to be obtained by
packing. This is applicable in all forms of endo-
metritis and metritis, whether acute or chronic In
acute or subacute infiammation after abortion or labor,
it is of great service if done at once.

It may be that in afllections of the appendages,
efficient depletion can be secured by the cavity of the
uterus, and will do much toward effecting a cure.
The results should be best in the early stages of
salpingitis and odphoritis, but the chronic cases are
not beyond its influence, if done properly, it is harm-
less and renders the secondary operation safer. The
more the speaker had employed this method of treat-
ment, the better was he pleased with it. Women are
the better mentally and physically for the maintain-
ance of menstruation and ovulation. Until recently
many conditions of the tube or ovary were considered
adequate causes for their removal. Such is not now
the case. The functions of menstruation and ovula-
tion should be preserved when it can be done without
sacrificing the patient's health or life. In cases of
destructive inflammation of the appendages, the opera-
tion is best done after the salMidence of the acute in-
flammation. The tendency of these inflammations is
in the direction of resolution. There are many cases
of occluded adherent tube in which the ovary is in
good condition. The same statement applies to some
cases of pyosalpinx and many cases of hsematosalpinx.
The author's proposition was to remove such tubes
and leave such ovaries. The nearer the patient is to
nature's menopause the less is the necessity for such
conservatism. In early life it is urgently necessary.
He had operated on 46 cases in this way ; and in their
ability to work and enjoy life they are in as good con-
dition as any equal number of cases of odphorectomy.
Mentally they are far better.

In 36 cases he had resected ovaries the seat of simple
or blood cysts. In all but five coses the results were
entirely satisfactory. In two cases there was fresh
development; and in three suppuration in the cyst
occurred due to infection from the catgut. Where the
tubes have been simply adherent, they are released
and allowed to remain. Twelve such cases have done

well with the exception of one where gooorrhaeal in-
fection spoiled the work. Where the abdomiDal open-
ing is closed, this is opened and the fimbriated ring
stitched back.

As demonstrating the possibility of pregnancy after
operations of this character, he reported five cases from
his own practice where women had become pregnant
after such procedures. The precise question is, how-
ever, not so much the possibility of pregnancy but the
mental, moral and physical influences of allowing
the ovary or a portion of it to remain.

Db. Williah Goodkll, of Philadelphia, said that
he had taken the liberty of changing the title of hii
remarks to

THE CONSERVATIVIC TBEATMKNT OF THE FEKALK
PELVIC OBOAN8,

preferring to use the word " treatment " instead of
"surgery." This enlarged the scope of the subject,
and was more in keeping with his views ; for he held
that besides strictly surgical ones, there were other
kinds of conservative treatment which are especially
adapted to the ailing female organs. He considered
the whole question of the proper treatment of these'
disorders to hinge on the effect of castration in
women. These effects are prolonged and distressing
vaso-motor disturbances (often very hard to bear) and
a tendency to morbid brooding, low spirits, melan-
choly, suicidal impulses, and even to insanity. Then,
again, castrated women are liable to become unsexed
to that extent as to lose all sexual feeling, or to have
it greatly blunted. In some cases senile atrophy of
the- genitalia takes place, or in its place a hypertrophic
condition of the vulva occurs, which forbids coition
and causes much domestic unhappiness. An inevitable
and deplorable result is sterility, which is often a
cause of great sorrow. The author laid stress apon
the prevalent lay opinion that women deprived of
their ovaries are thereby wholly unsexed. Castration
in the male or in the female is alike regarded as a
sexual mutilation to which is attached a stigma. No
woman would marry a eunuch, and few men would
wed a woman without ovaries. It is then manifest
that during the period of woman's menstrual life her
mental, physical and social welfare depends largely
upon the continuance of the catamenial and reproduc-
tive functions. Hence the conservation of those organs
which preside over these functions is of the utmost im-
portance.

The speaker reprehended that hasty operative inter-
ference based on the plea that chronically diseased ap-
pendages are dangerous to life, for in his experience
few women perish from chronic disorder of these
organs even when pus is present. More women die
from the radical operation than from the disease itself.
To restore such women to health, abdominal section is
by no means always necessary. Many have been
cured by curetting and draining the womb. Others
he had seen get well under the use of rest, massage,
electricity, alteratives and local applications, although
they had been sent to his private hospital to have
their appendages removed. In a few instances among
his own patients this treatment was followed by con-
ception and pregnancy.

The possibility of a closed-up Fallopian tube regain-
ing its lumen is warmly disputed; but since uterine
fibroids of large size spontaneously disappear through
retrogressive metamorphosis, why may not the thio

Digitized by

Google

Vol. CXXX, No. 2H.-\ BOSTON MBDIOAL AND SURGIOAL JOURNAL.

676

tobal septa of inflaniinatory origin also melt away and
reatore the bore of the tube ? He cited examples in
which great disorganization of the tobes and ovaries
did not prevent conception. Cases were also related
in which, after a small fragment of an ovary and a
short stamp of a tabe were left behind, pregnancy
took place.

Id view of these interesting facts, he advised that
when therapeutic measures failed and the final appeal
was made to the knife, as little as possible of the ap-
pendages should be taken away. If the tubes and
ovaries are simply adherent and not otherwise dam-
aged, they should merely be freed from these adhe-
sions, and not extirpated ; if they are diseased, only
the unhealthy portions should be removed. He had
fonnd that a piece of ovary not larger than a small
bean was quite ample to maintain intact menstruation
and the sexual feelings.

He contended tliat the aim of modern surgery is
conservation. Limbs, members and organs are now
saved which formerly would have been sacrificed.
This is its glory, and this has been brought about by
antisepsis. On the other hand, antisepsis, by the
glamor of success, so dazzled modern gynecology as
to make it a spoiler rather than a conservator. Re-
form here is greatly needed, the reform of conserva-
tive gynecology.

The general discussion was participated in by Dr.
Lutaad of Paris, Dr. Matthew D. Mann of Buffalo,
Dr. Joseph Taber Johnson of Washington, Dr. Howard
Kelly of Baltimore and Dr. Florian Eragg of New
York.

lEtecent Eiteratuce.

Treatise on Rupture*. By Jonathan F. C. H. Mac-
react, F.R.C.S., Surgeon to the Great Northern
Central Hospital ; to the City of London Hospital
for Diseases of the Chest, Victoria Park; to the
Cheyne Hospital for Sick and Incurable Children ;
to the City of London Truss Society ; and Surgeon
in London to the Merchant Taylors' Company's
Convalescent Homes at Bognor. Philadelphia: P.
Blakiston, Son & Co. 18i»3.
The author divides this book into two parts. Part
first is on raptures when the function of the bowel is
undisturbed. Part second is on ruptures where the
function of the bowel is interrupted.

As surgeon to the City of London Trass Society,
Mr. Macready has had an exceptional opportunity to
study herniae, particularly from the non-operative point
of view. Statistics are presented in this work in a
thorooghly judicial way ; they are so misleading at
times that it is a pleasure to read the unbiassed pres-
entation of this interesting subject by Mr. Macready.

The forms of hernise are clearly described, and at-
tention is called to the changes which occur in the
shape of the abdomen, especially in long-standing
cases of hernia.

The trusses which are shown in the illustrations are
not models of lightness; they suggest clumsiness.

The subject of hernia is presented in a clear and
scholarly manner. The list of references at the end
of each chapter is especially to be commended. The
book's value is added to by an admirable index. It is
weii illustrated, printed and bound.

THE BOSTON

iSteDfcal ant) Surgical ^ountal*

THURSDAY, JUNE 7, 1894.

A Journal ofMedieime, Swrgerf. and Allied Seieneet.publUhed at
Botton, teeetly, fty the undenigned.

SUBSCBIPTIOH Tbshs: $6.00 per ytar.in advance, po§tagepaid,
for the United StateM, Canada and Mexico ; fS.SS per year for all for-
ev" eowifriet belonging to the Poital Union.

All commnnicationt for the Editor, and all books for review, $hotUd
be addreeied to the Editor of the Boiton Medical and Surgical Journal,
283 Waehington Street, Botton.

All letter! eontaming butineu ccmmunicationt, or referring to the
publieation, nbtcription, or adverOting department of thit Journal,
ihotUd be addretied to the mtder$igned.

Remittanoes thould be made by money-order, draft or registered
letter, payable to

OAMSELL A UPHAM,
283 WASBISerOH 8TBBET, BOSTON, MASS.

THIRD TRIENNIAL CONGRESS OF AMERICAN
PHYSICIANS AND SURGEONS.

The Third Triennial Congress in Washington of
the fourteen special national associations and societies
has furnished additional proof, if any were needed, of
the distinct and increasing value of such an organiza-
tion to medical science and medical practice and to
the higher aspirations of the medical profession in our
country. It is a comparatively short time — only
thirty years — since the first of these associations be-
gan to be started amid some misgiving and against
some opposition. The older associations soon proved
their usefulness to the profession, and successive years
have witnessed the formation of others in new fields
until the present number has been reached, and all
departments of medicine are represented from anat-
omy and physiology, through general medicine and
general surgery to climatology, pediatrics and genito-
urinary surgery. All of these associations are flourish-
ing ; tiieir annual meetings are well attended ; good
work is presented and intelligently discussed ; and
membership is prized and sought for by the best men
— teachers and practitioners — in the profession.

It would seem, however, as if the division of subjects
had gone quite far enough, and we see no good reason
for the further multiplication of separate societies.
But there is every reason for the continuance and per-
fection of these triennial gatherings of all the separate
societies at one time and one place. The very sub-
division and specialization of professional interest and
work is the strongest argument in their favor. The
opportunity afforded for the discussion of such subjects
as those appointed for consideration in the General
Sessions of this Congress, by representative members
of the special societies from their different points of
view, is of great value if availed of, and might be of
much greater value if made more available.

Whilst appreciating the force of the reasons which
led to the adoption of the acrangement of this year, we
still think it a mistake to attempt the presentation and
discussion of two important and debatable subjects in

Digitized by

Google

676

BOSTOH MEDICAL ASD SVBGICAL JOISHAL.

[June 7, 1894.

one afternoon, allotting to each only an hour and a
half. The result must inevitably be that which ob-
tained this year. We shall have a presentation of the
subjects, an excellent one it is true, but still such as
might be had at an annual meeting of the special so-
ciety of the day ; but the discussion, and such a dis
cussion as is only possible under the conditions of the
triennial congress, is conspicuous by its absence. It
would be better to have one subject treated as it might
and should be treated by such a body of men, than to
give each association more frequently the empty honor
of selecting and presenting the topic of the day. We
hope the Executive Committee will see its way to
putting the Congress in a position to do for the pro-
fession in this respect what may reasonably be ex-
pected of it.

The best papers presented, as a rule, were the short
ones, and the presiding officers would do well to be
more rigorous with those readers who have not learned
to appreciate the merit and the possibilities of conden-
sation.

Under any management, the great advantage of
meeting distinguished and rising colaborers in con-
genial pursuits is inherent in such a reunion. Men
from different parts of the country make new profes-
sional acquaintances and cement old friendships.
Junketing is happily absent, the only general festivi-
ties being the gracious reception by the President and
Mrs. Cleveland of the members of the Congress, and
a subscription dinner at the Arlington Hotel.

The weather was all that could be desired, and
Washington looked its best; under such conditions it
is a national capital of which no American need be
ashamed, especially if he avoids the so-called debates
in the Senate and House of Representatives. No
wonder the " industrials " (we refer to Coxey armies,
not to the " trusts " or " industrials " of the Stock Ex-
change) were tempted to look upon it as a place of
hope and promise !

The Oongreitisti registering numbered four hundred
and ten, and of these comparatively few had cause to
regret their visit. The sufferings experienced three
years ago were not repeated, and, with few exceptions,
the gastro-intestinal tract made no protest. Notwith-
standing this amelioration, the Executive Committee
was empowered to name the place of meeting of the
next Congress, Washington not being specifically
designated.

At the business meeting held Friday afternoon,
June Ist, at the instance of the Dermatological Asso-
ciation, it was voted to memorialize the Congress of
the United States with the view to the appointment of
a commission of five to investigate the prevalence of
leprosy in the United States and in the countries upon
its borders and to suggest means for its control.

A resolution was passed entering the most earnest
protest of the Congress against any legislation tending
to interfere with the adv'ancement of medicine by
means of experimoiUntion upon animals conducted by
properly qualified persons.

A resolution was passed that, in the opinion of the
Congress, the proposed reductions in the number of
medical officers in the army and in the appropriation
for the Library of the Surgeon-General's office, are
unwise and are contrary to the best interests, not only
of the army, but of the medical profession of this
country and of all who depend upon its members for
skilled professional services.

THE CONVEYANCE OF SCARLET FEVER AND
DIPHTHERIA BY PUBLIC CARRIAGES.

It has not infrequently been noted that a ready
source of infection with scarlet fever and diphtheria
exists in the public hackney vehicles of a large city —
inasmuch as they are use<l without regard to contagion
by patients with such diseases. Even among physi-
cians it is not, however, generally known that such a
source for contagion has no legal right to exist, aud
that with a little energetic cooperation it might prac-
tically be done away with.

The great majority of all cases of these contagious
diseases carried in public vehicles in Boston are pa-
tients taken to its City Hospital. A large number of
these patients are sent to the hospital by their physi-
cian, who is probably in most cases ignorant of the
police regulation forbidding such procedure, which
reads : " No person having charge of any hackuey
carriage shall receive or permit to be placed therein,
nor convey in or upon the same, any person sick or
infected with any contagious disease, or the body of
any person deceased from such disease."

The drivers of herdics and cabs are, of course,
aware of this regulation, but are too often willing to
take their chance of escaping conviction and fine.
Convictions have not been many, fines have not been
large aud have involved no loss of license, so that
financially the risk is a good one. The sense of moral
responsibility toward the public is not highly devel-
oped in the average cabman, nor is his diagnostic
knowledge of disease acute. Heavier penalties would
doubtless improve both faculties.

It is by the physician, however, that much may be
done towards abolishing this dangerous practice. In
the past many have sent their contagious patients to
the hospital in cabs through ignorance of this rule or
through thoughtlessness.

The City Hospital sends its ambulance, free of
charge, for any and every case of scarlet fever or
diphtheria which it can admit. The transfer from the
house to the hospital can be made with as much speed
and more comfort in an ambulance than in a cab, and
without subsequent exposure of other people. Now
that attention has been called to this easily remediable
evil, it is hoped that all physicians will cooperate in
suppressing it by refusing to sanction carriage-transfer
of patients, and insisting that cases which they send to
the hospital be taken only in the proper ambulance.

If physicians are to be firm in requirinir th"!"" |«-
tients to make use of a hospital ambulance they have

Digitized by

Google

oi.. CXXX, No. 28.] BOSTOH MEDICAL ASD SVRGICAL JOVBHAl.

677

right to expect that, on their side, the hospitals will
i.lce all precaudoDB to have no secondary infection
rsMseable to the use of the same ambulance for cou-
'eying both scarlet fever and diphtheria patients.
Chere are many cases in which, either from an unde-
ermined diagnosis or from personal feelings of the pa-
ient or the family, the physician's line of duty to his
>atient and to the general public is not an easy or
»iinple one to follow. In such cases his position of
Lxtsistiug on the use of a hospital ambulance will be
Euade much easier and more secure if he can assure
Ills patient that the ambulance is not used indiscrimi-
nately for both scarlet fever and diphtheria. In this
city he cannot make this statement, as there is but
one ambulance for contagious diseases at the City
Hospital. He should, at least, be able to state that the
same blankets, pillows and mattress are never used
'without precautions for more than one patient, and that
the ambuance is thoroughly disinfected after every trip.

BECENT SANITARY IMPROVEMENTS IN
HAMBURG.

The great Hamburg fire, half a century ago, pre-
pared the way for the broad streets, the great water
park made by damming the Elbe and flowing exten-
sive flats, the excellent water-supply and the admirable
system of sewers which made the city the pioneer,
under the distinguished English engineer Lindley, in
modem sanitation. Paris, and next London, but in a
far inferior way, followed with their improved sewer-
age, and then came the filtration system of the London
water-supply. The exemption from cholera in Ham-
burg in subsequent epidemics, furnished the most
powerful argument in Europe, and especially in Ger-
many, for cleaning up their cities and for establishing
the theory that cholera comes chiefly from drinking
water contaminated by human excrement.

It is rather curious that, in the growth of the city
and in the subsequent contamination by human excre-
ment of the river providing their drinking water,
Hamburg should have suffered so from cholera in
1892, as to be the great lesson to the few remaining
doubting Thomases who held to Pettenkofer's ground-
water theory of the origin of that disease.

Under the title of " Hamburg's New Sanitary Im'
pulse," in the June number of the Atlantic Monthly
Magazine, Mr. Albert Shaw has admirably described
the methods of sewage-discharge, of a new intake from
the river and of a vast system of water-filtration which
had been planned before the last epidemic.

Under an American, Dr. Dunbar, the hygienic lab-
oratory makes frequent and minute bacteriological
examinations of the drinking water, and carefully
notes the results of filtration. It would be curious to
know whether the very valuable original work in that
direction done in recent years by the Massachusetts
State Board of Health had given any hint or had
famithed any knowledge as to the efiicacy of efiicient
filtration iu making safe water which had contained

the specific germs of disease. The fact had been
demonstrated practically by the London and Altona
filter-beds, but the scientific investigations made have
provided the explanation of the fact and ehowed the
degree to which filter-beds could be depended upon.

MEDICAL NOTES.

An Honor to Db. Goodell. — Dr. William
Qoodell, of Philadelphia, has received the honorary
degree of LL.D. from JeSerfon Medical College.

Billkoth's Sccoessor at Vienna. — Professor
Dr. Czerny, of Heidelberg, is reported to have been
officially called to be Billroth's successor at the Uni-
versity of Vienna.

Cholera in Pbdssia. — Cases of cholera were re-
ported lately from Upper Silesia and the city of Stet-
tin. Dr. Fairfax Irwin, of the Marine-Hospital Ser-
vice, Sanitary Inspector at Berlin, was immediately
ordered to Stettin to make an investigation.

A Soroical Operation upon Kaiser Wilhelk
11. — It has been ofiicially reported from Berlin that
a small encysted tumor was removed from the Em-
peror's cheek last week by Drs. Bergmann, Leuthold
and Scblange. It is stated that the operation was
done without anaesthetics.

Small-Pox in Chicago. — The Health Depart-
ment of Chicago is having great difficulty in prevent-
ing the spread of small-pox, owing to the opposition
of the Polish and Bohemian population, among whom
it ia chiefly epidemic. In the house-to-house investi-
gation which they have been forced to make, the
Board is obliged often to have police protection, and
in many cases to break down the doors of houses with
sledge-hammers. On June 1st fourteen cases were
found in this manner, concealed in tenement-houses.

A Dissatisfied Patient. — The cable announces
that Prince Bismarck's left leg is so feeble he can
only stand on it a few minutes at a time. He ex-
plained to a friend that upon the recommendation
of a Russian Grand Duchess he consulted a Russian
doctor some time ago. He has since learned that this
doctor was an idle and ignorant fellow — the head of
a children's hospital in St. Petersburg, where he killed
oS 3,000 patients annually ! " He ruined my leg, aud
I have suffered the consequences ever since."

Individual Communion-Cdps. — The opposition
to the common use of one communion-cup is increas-
ing rapidly among the laity, as well as among physi-
cians, for the laity nowadays are by no means ignorant
of bacteriology. The fruit of the tree of knowledge is
bitter indeed, and is now found to be infected with
bacilli. Kissing, the world old expression of bodily
love, has been found scientifically dangerous and is
going out of use, so it is said ; »iid now even a spiritual
love must not manifest itself by the use of a common
cup. As one advocate of bacterial individuality has
recently written, "Let us mingle our tears in sym-

Digitized by

Google

678

BOSTON MBDIOAL ABD SURGICAL JOURNAL.

[JoMK 7, 1894.

patbj, oar prayers in sapplication, oar songa in praiae,
bat permit each one to pouesi in solitude his individ-
aal bacteria."

A New English " Specialist." — According to
the Brititk Medical Journal, a new specialist has
made hia appearance in England, and at present is
basilj engaged in sending his circulars to his expected
patrons. As this new operator is a "circumcision
apecialiat," his notices are sent to newly-made fathers
of finely-formed bat too preputially endowed sons.
The following are extracts from one of these ciroa-
lara : " Every Circumcised person have always been
so hardy and thereby escaping obscure nervous disor-
ders, the facts of which are acknowledged by highest
medical authorities." " Every invalid or victim of
some obscure nervous disorder should not neglect this,
as it will materially assist in restoring him to health."
" What are the benefits derived therefrom ? Predis-
position to and Exemption and Immunity from dis-
ease."

BOSTON A.N1> NEW KNaLAND.

Acute Infectious Diseases in Boston. — Dar-
ing the week ending at noon June 1, 1894, there
were reported to the Board of Health, of Boston, the
following numbers of cases of acute infectious disease :
diphtheria 37, scarlet fever 55, measles 25, typhoid
fever 1.

A Case of Skall-Pox in Rutland, Vt. — Last
week a traveller from Chicago was taken ill at a hotel
in Ratland, Vt., with what proved to be small-pox.
The hotel was at once quarantined by the health
aathorities.

AWABD OF THE BOTLSTON MeDICAL PbIZE. —

The Boylston Medical Prize for 1894 has been
awarded to Dr. Norman Walker, of Edinburgh, Scot-
land, for an essay entitled " The Histological Varieties
of Cutaneous Cancer."

Db. Walcott's Smoke-Talk at the Unitersitt
Club. — Dr. Henry P. Walcott, Chairman of the
State Board of Health, gave a smoke-talk at the
University Club last Wednesday upon the proposed
changes in the Charles River Basin.

The Massachusetts Cremation Society's In-
vitation TO Physicians. — In connection with the
annual meeting of the Massachusetts Medical Society,
the building of the Massachusetts Cremation Society
at Forest Hills will be open for inspection from two
to four p. H. on Tuesday, June 12th, when the heat
will be applied to the retorts and the process carefully
explained.

NEW TOBK.

Small-Pox Quabantinb at Sino Sino Re-
moved. — On June 2d, Warden Durston removed the
quarantine from Sing Sing prison, which had been
closed to visitors for nearly two months on account of
several of the convicts having had small-pox. All of
the patients have now recovered and are at work again.

The Dead Fisn in the Water-Scpply. — Con-
side rable alarm was occasioned a short time since by

the publication io the newspapers of the report of Dr.
J. G. Wood, health-officer at Brewster's, in the Croton
water-shed, that there were large numbers of dead fish
in Haines' Pood, a part of the Croton system, near
Sodom Reservoir, and that he was led to believe that
some epidemic was prevailing among the fish which
might pollute the water. The gills of the dead fish,
he claimed, had a diphtheritic appearance. The matter
was at once investigated, although the officials of the
New York Board of Health, recognizing the fact that
diphtheria is a disease confined exclusively to warm-
blooded animals, felt that the only danger that could
arise from the presence of dead fish in the water was
from decomposition, and that that was very slight. It
is stated by Dr. Biggs, bacteriologist to the Board,
that chubs, or suckers, are susceptible to a peculiar dis-
ease every spring, which develops a fungus-like growth
about the bead, and which carries them off in great
numbers. At the meeting of the Board of Health held
May 28th, reports were submitted by Dr. Biggs and
by Dr. Lederie, chemist to the Board, which showed
that there was no contamination of the water from the
cause mentioned. It is interesting to note that while,
according to Dr. Biggs's examinations, the water
taken from Haines' Pond, where the presence of the
dead fish first excited alarm, showed 182 colonies of
bacteria, and the water from Sodom Reservoir, 384
colonies, a sample of water drawn from a hydrant
just outside the Board of Health Bailding, on Mul-
berry Street, showed no less than 520 oolonies of
bacteria.

RETROGRESSIVE LEGISLATION IN REGARD
TO MASSACHUSETTS BOARDS OF HEALTH.

The following comments appeared in the Botton
Beratd, of May 25th :

"In the year 1797 a law was enacted in Massachu-
setts providing for the election of boards of health Id
towns. By an amendment which was made twenty
years later it was further provided, that, if any town
failed to elect such a board, ' the selectmen shall be the
board of health.'

"By this wise enactment, towns in Massachusetts
have, for nearly a century, had some provision for
boards of health ; and, for nearly eighty years of that
period, such a board has been in actual existence in
every town in the Commonwealth, to which the people
had the right to look for sanitary protection.

" Let us now examine the legislation of 1894 upon
this subject. By the provisions of Chapter 218 of the
Acts of the present year, the Acts of 1797 and 1817
are repealed so far as all towns having more than 2.000
inhabitants in each are concerned, and a board of health
may or may not exist, in accordance with the varying
whims of the voters of such towns. If the town does
not elect a board of health, then, under the present
law, such town is entirely without any local sanitary
protection — a condition of affairs which has not existed
for at least three-quarters of a century.

" In Section 2 of the same Act, provision is made

Digitized by

Google

Vot. CXXX, No. 28.] BOSTOS M&DWAL AND SVSGICAL JOURNAL.

579

for the election of a board of health in every town
having a population of Itu than 2,000, the old provi-
sion being here retained, that if a board is not chosen,
' the selectmen shall constitute such board of health.'
By this provision it appears that each one of the small
towns mu*t have a board of health of some sort, while
in the large towns the law is permissive only.

" Now it is nothing less than a sanitary axiom that
increasing density of population requires the enactment
of better sanitary laws for the protection of the people ;
and since the population of the State has increased
from about 400,000 in 1797 and a half million in 1817
(the date of enactment of the early laws upon the sub-
ject) to two and one-half millions at the present time,
and, since this increase has been mainly in those towns
which have populations of more than 2,000 in each
and not in the small towns, the legislation iu this direc-
tion ought to be in the line of improvement and not of
retrogression. Measures ought, therefore, to be taken
to remedy this defect before the close of the present
session."

MB. GLADSTONE'S TRIBUTE TO SIR ANDREW
CLARK AND THE MEDICAL PROFESSION.

A LAROELT attended public meeting was held in
London recently to take definite action npoo the
memorial to Sir Andrew Clark. The chief address
was made by Mr. Gladstone, who paid a most eloquent
tribute to his late physician and to the whole medical
profession as well. He said:

" The profession itself, is one with regard to which
it is impossible, I think, not to be conscioas that
its position in our generation, and in some generations
previous, has been a position continually advancing
au.d continually widening. The other learned profes-
sions undoubtedly had a start of the medical profession.
Fear or five hundred years ago property was of more
worth than human life and physicians were little heard
of. But the position of the medical profession to-day
is becoming one of vital and commanding interest to
the whole of society, and I anticipate that that interest
must continue. While wealth increases, while inven-
tions and discoveries increase, wants will increase and
enjoyments will increase ; and, in connection with
those wants and enjoyments there will, I fear, be a
corresponding increase of infirmity and disease, and
the medical profession braces itself to grapple with the
situation which has been created, and continually ad-
vances in knowledge, credit and importance. My own
life has been long enough to enable me to witness, and
in some degree to measure, the change that has taken
place. I have had ihe good fortune of knowing many
eminent and distinguished men in the profession during
the last threescore years, and I have seen also a great
change in capacity, in attainments, and in competency
to deal with the difficult, the almost insoluble, problems
that are continually presenting themselves to the mind
of the medical man.

" It appears to me that it was eminently desirable
that, in a time like this, a man such as Sir Andrew
Clark should rise to the head of his profession. For,
after all, we require something more than knowledge,
something more than skill. We require great devotion
to the purposes of the profession ; and that devotion
never, I think was exemplified in a more remarkable
manner than in the career of Sir Andrew Clark. He
loved his profession with his whole heart and soul.

While engaged in that profession he loved it not only
with sincere and cordial but with chivalrous devotion.
We need not say that the age of chivalry is altogether
passed so -long as we have among us men of the type
of Sir Andrew Clark.

" I think the profession has done well in taking by
common consent Sir Andrew Clark as the typical
man, the representative of all that is best and noblest
in the profession and its purposes. Others may judge
better than I can of his scientific ability. What I
have seen is his patience, his thoroughness, and his
absorption in the care of his patient as if that one case
was all with which he had to occupy his mind. I have
had to note in my own instance a warmth of friendship
and assiduous prosecution of the task of watching my
health which I know not how adequately to describe.
Although he was a much younger man than I, yet he
followed me from month to month and week to week
with something that resembled paternal affection. I
am sure that whatever happens ; whatever may have
been the past advances of the medical profession, and
they are great ; whatever may be the future advances
of that profession, and they will be greater still, —
there will never come a time when the profession will
not be justly satisfied, and glad to have recorded upon
its annals, a name such as the name of Sir Andrew
Clark."

CoccejeijponDence.

"RESERVING THE CLAIM OF EXEMPTION
FROM REGISTRATION."

Boston, June 4, 1894.

Mr. Editor: — In the Boston Medical and Surgical
Journal of May 24th, a correspondent suggests correctly,
that members of our State Society, by its act of incorpora-
tion. Lave a complete license to practice without registering
under the proposed new law. Incomplete as this law may
be, a refusal to register might, by some, be construed as
showing a disposition to obstruct an]/ legal regulation.

I win mention a way of registering, and at the same
time of reaffirming the old corporate right. It was sug-
gested by an eminent attorney, and adopted by several
physicians in resard to a law tor regulating a specialty, a
few years ago. It is to write before or over the signature,
the phrase : " Reserving the claim of exemption from regis-
tration." Very truly yours,

J. L. W.

METEOBOLOGICAL RECORD,

For the week ending May 26th, in Boston, according to ob-
geryatlons furnished by Sergeant J. W. Smith, of the United
States Signal Corps:—

Baro-

Tfaennom-

BelatlTe

Direetton

Velocity
of wind.

Wo'th'r.

meter

star.

humldltT.

of wind.

•

Oat«.

i

a

S

S

i

a

a

f

a

a

ri

i

a*

S

a

^

>.

a

■<

h

>>

■*

h

•<

b

M

«•

C

2

a

si

^

«

s

s

s

s

g

1

5

s

a

44

<£

«

C

w

<£

20

CO

21

X

B.

R.

S..20

30.26

46 148

96

96

96

N.E.

N.E.

.M

M..21

30.34

46

48

43

92

86

89

£.

E.

24

9

O.

0.

T..22

30.16

m

62

39

72

62

67

N.W.

8.W.

3

13

0.

0.

W.23

29.93

60

70

BO

68

84

76

W.

E.

7

4

O.

F.

.03

T..24

29.74

49

A2

46

100

97

98

JS.K.

N.K.

13

22

K.

K.

1.10

F..26

29.64

B4 S9

48

80

90

8i

S.W.

N.

4

7

T.

O.

.06

S..26

29.85

M

61

47

70

78

74

H.W.

S.E.

10

»

O.

0.

w

•ColoodTi Celtari F.,f*iri 0..fO(i H.,b*i7i S.,iliiokjri R.,ntiii T.,tlirMl-
dngiM.,inow. tlndlcatei trace of nwfall. ar- Mtu (orweek.

•nlngi

Digitized by

Google

680

£0ST02f MSDJOAl ASD SVUGICAL JOVRHaL.

[JtNE 1, 1894.

BECOBO OF MOBTAUTT
For tbb Wbbz »n>uia 8atou>at, Mat 28, 18M.

|i

t.

A

1

Pereentage of death! from

OltlM.

i

^3

•Q K

r

6.
fl

5'

P

¥

New York . .

l,«gi,306

721

272

16.94 1 14.84

.98

9.66

2.10

CUoago . . .
PhlUdelpbta .

1,438,000

—

—

— ! —

—

—

— .

1.116,6«2

363

100

9.62, 7.28

I.M

6.46

.78

BrooklTU . .
St. Louis . . .

»78,3M

344

128

14.70 14.70

1.60

7.80

.90

S60,000

—

^

—.

—

—

Boton . . .

4X7,397

226

66

14.08

13.64

1.16

6.16

aio

Baltimore . .

80U.000

—

^

_

^

—

Wafhington

808,131

9B

22

IIJSB

ilis

4.20

2.10

_

CIneinnaa . .

SOS.OOO

103

39

7.76 1 14.6S

2.01

2.91

—

GlaTeland . .

290,000

139

72

14.40 1 :3.76

2.16

2.16

1.44

Flttaburg . .

263,709

—

—

— 1 .m.

—

^

Milwaukee . .

260,0u0

—

—

— «-

—

—

—.

NaahTllle . .

87,7M

3S

12

8.68 1 17.16

—

2.86

2.86

Gharleaton . .

65,U>5

29

IB

13.80: 8.4S

6.00

—

Portland . . .

40,000

—

—

^ 1 ^

«_

—

_

Woroetter . .

96,217

22

12

16.20 i —

^

13.66

4.E6

FallBlTer . .

87,411

41

22

— ^

—

^

Lowell . . .

87,191

28

7

_

—

—

X

^

Cambridge . .

77,100

21

6

33^

._

—

4.;6

23.80

Lynn ....

62,6(6

13

6

10.38

7.68

—

7.69

Spriagfleld . .

48,684

13

3

—

15.38

—

—

-^

Lawrenee . .

48,3M

—

—

—

—

^

—

»

New Bedford .

48,886

19

10

—

21.0i

—

—

^

Holyoke . . .

41,ii78

—

—

—

._

^

—

_

Salem ....

32,1283

13

6

38.45

7.89

—

16.38

1B.38

Brockton . .

32,140

9

1

11.11

22.22

—

—

HaTerUn . .

31,386

6

2

—

20.00

^

—

Cheliea . . .

30,264

13

1

2SJ8

44.76

^

7.69

7.6S

Maiden . . .

29,394

9

1

22.22

—

—

Newton . . .

27,M6

4

1

—

_

^

—

^

Fitehburg , .

27,146

4

1

—

—

Taunton . . ,

26,972

6

1

—

_

—

—

^

Glonceeter . .

26,688

_

—

_

—

— .

^

^

Waltbam . .

22.068

6

2

~—

16.66

—

—

^

Qnino; . . .
Pittafleld . .

19,642

—

—

—

^

—

^

—

18,802

2

0

^

^

—

^

—

ETerett . . .

16,68fi

2

0

^

— .

—

—

_

Northampton .

16,331

4

0

25.00

—

—

_

Newbnryport .

14,073

2

1

—

^

—

^

_

Ameibury . .

10,920

S

1

^

20.00

~*

^

—

Deaths reported 2,339: under five years of age 829; principal
infections diseases (small-pox, measles, diphUieria and croi^,
diarrbosal diseases, whoopmg-coaeh, erysipelas and fever) 3!S,
acnte long diseases 307, coDsumption 282, diphtheria and cronp
102, scarlet fever 41, diarrhcsal diseases 34, measles 30, whooping-
congh 27, typhoid fever 19, cerebro-spinal meningitis 9, erysipelas
6, small-pox 6, malarial fever 4.

From measles Brooklyn 10, New York 8, Cleveland 6, Phila-
delphia 3, Fall River 2, Nashville 1. From whooping-coagh
New York U, Boston 5, Brooklyn 3, Washington and Cleveland
2 each, Cincinnati, Charleston, Fall Uver and Salem 1 each.
From typhoid fever Philadelphia 6, New York 3, Washington
2, Brooklyn, Boston, Cincinnati, Cleveland, Charleston, Lowell,
North Adams and Wobnrn 1 each. From cerebro-spinal menin-
gitis New York 6, Cleveland 2, Lynn and Brockton 1 each.
From erysipelas Philadelphia, Boston, Cleveland, Lowell, Haver^
hill and Northampton 1 each. From small-pox New York 4,
Washington 1.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,4S8,442, for the week ending
Hay lyth, the death-rate was 17.1. Deaths reported 3,426:
acute diseases of the respiratory organs (London) 234, measles
2fi7, whooping-cough 112, diphtheria 72, scarlet fever 37, diar-
rhoea 37, fever 22, small-i)ox (London, West Ham and Birming-
ham 3 each, Manchester 2, Wolverhampton and Oldham 1 each)
13.

The death-rates ranged from 7.9 in Croydon to 22.2 in Nor-
wich ' Birmingham 18.6, Bolton 1S.4, Cardiff 15.6, Gateshead
16.6, Hull 16.9, Leeds 16.2, Leicester 13.0, Liverpool 21.8, London
17.S, Manchester 17.4, Newcastle-on-Tynel6.8, NoUingham 20.1,
Portsmouth 9.6.

Ol-FICIAL LIM- OF CBANOB8 IN THE STATIONS AND
DUTIKS OF OFFICERS SERVING IN THE MEDICAL
UKPAKTiMENT, U. S. ARMY, FROM MAY 26, 1894, TO
JUNE 1, 1894.

FissT-LiBUT. William H. Wiuoh, assistant surgeon, now
on duty at Fort Leavenworth, Kansas, will proceed at once to
Camp Herritt, Montana, and report for assignment to temporary
duty at that post.

NEW HAMPSHIRE MEDICAL SOCIETY.

The one hundred and third anoiversary meeting will be held
at G. A. B. Hall, Conoord, Monday and Tuesday, June 18 and
19. 1894.

Monday, Juxk 18th.

Medical papers and communications: " On the Prevention of
Communicable Diseases," D. Edward Sullivan, M.D., Concord.
Discussion opened by Wm. Child, M.D., New Hampton.
" Sleep, How Best Induced in Certain Pathological CoDditions/'
J. B. Raynes, M.D., Lebanon. Dlscoasion opened by W. T.
Smith, M.D., Hanover. " On Puerperal Infection," J. Elizabeth
Hoyt, M.D., Concord. Discussion opened by John W. Parsons,
M.D., Portsmouth. " Betrospective Glances," A. G. Straw,
M.D., Manchester. "Beport on Bone Surgery," D. 8. Adams,
M.D., Manchester. Discussion opened by Robert Bums, M.D.,
Plymouth, who will also report a case of " Exsection of the
Astnualus." " Beport on Empyema," William H. Lyons, M.D.,
Manchester. Discussion opened by G. C. Blaisdell, UJ).. .
Contoooook. " On the Differential Therapeutics of Stro|riianthiis
and Digitalis," W. K. Wadleigh, M.D., Hopkinton. Discussion
opened by Henry Dodge, M.D., Webster.

There will be a meeting of the Council at 7.80 p. x.

After the meeting of the Council (probably about 8.80 p. M.),
the members of the association residents of Concord will welcome
the Society in the G. A. R. Hall, and will entertain the memben
and their friends with a lectnre on " Potable Water," by Prof.
E. J. Bartlett, of Hanover, after which there will be a meeting
of the alumni of Dartmouth Medical College.

TcBSDAT, Jena 19th.

" On the Pathology and Methods of Treatment of Hypertrophic
and Atrophic BhinMs - with Especial Beference to the Work of
the General Practitioner," Albert Pick, M.D., Boston, Mass.
" On Laceration of the Cervix Uteri," F. A. Stillings, M.D.,
Concord. Discussion opened by M. W. Russell, M.D., Concord.
" Glimpses of Fifty Years in the Medical Profession," Cyrus K.
Kelley, M.D., Plymouth. " On Sanitation in Mexioo,'^ G. P.
Conn, H.D. , Concord . "On the Importance of the Early Becoc-
nition of Certain Diseases of the Eye by the General Practi-
tioner, with Suggestions Begurding Management," U. W. D.
Carvel le, M.D., Manchester. Discussion opened by Geo. Cook,
H.D., Concord. President's Address, Samuel P. Carbee, M.D.
Introduction of officers.

The Anniversary Dinner will be served at the New Eagle
Hotel at 1 p. M.

Exhibit. — Exhibitors will use the banquet-room adjoining
the assembly-hall, which will be in charge of Dr. Day, of the
Committee of Arrangements.

GBAHVU.I.B P. CoNH, M.D., Secretary, Concord, N. H.

SOCIETY NOTICE.

Massacbusbtts Mbdico-Lkqal Socibtt.— The annual meet-
ing of the Society will be held on Tuesday, June 12, 1894, at 1
o'clock, p. M., In the hall at 19 Boylston Place, Boston.

The usual business of the annual meeting will be transacted,
and the following communications will be presented :

1. " What Cases Shall the Medical Examiner View? " J. A.
Mead, M.D.

2. " Suicide or Homicide? A Medioo-Legal Diagnosis." C.
S. Holden, M.D.

3. " Comments on a Case of Homicide." A. H. Hodgdon, M.D.
Fellows of the Massachusetts Medical Society are invited to

be present.

Z. B. Asaxs, M.D., President.

F. W. Dbapbb, M.D., Beeording Secretary.

BOOKS AND PAMPHLETS RECEIVED.

Home Dumb Bell Drill. Bobert J. Roberts. Springfield,
Mass. : Triangle Publishing Co.

Measurements of the Chest and Lung-Capacity. By Edward
O. Otis, M.D. Reprint. 1894.

Nenratrophia, Neurasthenia and Neurlatria. By C. H.
Hughes, H.I>., St. Louis. Mo. Reprint. 1894.

Self-inflicted Injury in a Case of Chronic Mania. By Chas.
B. Mayberry, A.M., M.D. Beprint. 1894.

Tenorrhaphy by Means of the Suture & Distance of Catgut,
with Beport of Case. By Emanuel J. Senn, M.D., Chicago.
Beprint. 1891.

Treasury Department, Quarantine Laws and Regulations of
the United States, April 26, 1894. Washington: Government
Printing Office. 1894.

Beport of the Rnsh Hospital for Consumption and Allied Dis-
eases, from February 1, 1892, to February 1, 1894, with the
Second Beport of the Women's Board of the Buah Hoqtltal,
PhiladelphU.

Digitized by

Google

Vol. CX:XX, No. 24] BOSTON MSDIOAL AHJ) SURGICAL JOURNAL.

681

%Vttt^^tf^.

THE LEGISLATIVE CONTROL OF MEDICAL
PRACTICE.*

BT KBQIKALD H. FITZ, If.D., BOSTON.

Mb. Pbesident and Fellows of the Massa-
cansETTS Medical Society : — With the advance-
ment of learning, and the progress of civilization, it
has been found ueceMary for those in authority to ex-
ercise more and more control and restraint upon sach
as are engaged in the practice of medicine.

As it became evident that the name of physician or
surgeon was offered in excuse for the grossest igno-
rance or neglect, or to iiicite the actual destruction of
human life, laws were passed to aid the victim of mal-
practice, and to punish the criminal abortionist.

When it appeared that sane persons were sometimes,
and perhaps for the worst of motives, placed under
restraint, justified only in the case of lunatics, a physi-
cian's certificate became necessary for the commitment
of the insane.

The public has learned that the surest way of con-
trolling the ravages of contagious disease is by the
isolation of the earliest cases, and that for the protec-
tion of the well, even arbitrary measures of isolation
may be found necessary. It, therefore, makes it the
duty of the physician to notify immediately the proper
authorities when he knows that he has seen a case of
cholera or small-pox, diphtheria or scarlet fever, that
the community may rest assured that suitable measures
are being taken to protect the healthy. Elaborate and
costly quarantine methods, useless without the services
of intelligent, skilful and especially trained physicians,
are established for the same purpose. In addition,
vaccination, compulsory if need be, must be guaranteed
by the physician to promote the same object.

He must make a return of the birth at which he
assists, and must furnish a certificate of the cause of
death. When there is reason to suppose that the lat-
ter has occurred under suspicious circumstances, the
community orders that these shall be satisfactorily
investigated by physicians of its own choice, if it sees
fit

The people thus demand, and submit with more or
less eagerness or readiness to certain attempts at regu-
lating the practice of medicine. They admit the nec-
essity of the control, and they require qualifications,
which only combined intelligence, education and
honesty can provide. They seek for them in physi-
cians, and expect the latter to possess them.

It is well recognized among those possessing the best
opportunities for judging that patients are at times
treated with reckless ignorance or negligence, and die
in consequence ; but no verdict of homicide is rendered.
Ignorant and unskilful persons have often assumed to
treat patients in a medical way, have caused injury,
and have not suffered civil damages. Equally igno-
rant and unskilful pretenders to practice do not know
the symptoms of contagious disease, do not suspect its
presence, make no report to the proper authorities,
suggest no isolation, and are the direct cause of the
spread of diphtheria, of scarlet fever and the like from
house to house and from district to district. The phy-
sician's record of the cause of death not infrequently
conceals criminal abortion, sometimes manslaughter,

'The Annual DJaooorse before the HaSMObuMtU Mediesl Soolet;,
dellTered June 13, 1894.

and is often indicative of such ignorance as to be wholly
worthless.

Nowhere in the Union is the possibility of these
evils greater than in Massachusetts. In this State
any one who chooses may practise medicine. He has
but to announce himself a physician and he becomes
one. He may assume a title to which he has no claim,
and may place a forged certificate upon his walls. He
He may advertise himself a graduate of any institution
he prefers ; may claim to have accomplished any num-
ber of cures of what have been pronounced incurable
disease. He may promise preventives and specifics
against any and all maladies ; he may publicly announce
the most glaring untruths — all for the sake of deceiv-
ing and fleecing a credulous public — and the law can-
not interfere with his actions. We are repeatedly told
that our law makes no distinction between the various
schools of medicine, or between the various kinds of
practitioners. Members of this Society, homoeopathists,
electrics, clairvoyants, faith-curers, mind-healers. Christ-
ian scientists, are alike legally qualified as physicians.
Since the people demand, at times under penalty,
services from physicians which only intelligence, edu-
cation and honesty can supply, and since it is a matter
of common knowledge that many stupid, ignorant, and
dishonest pretenders to practise exist, it is clearly the
duty of the State to discriminate between the two, to
legally qualify those who deserve the confidence of
the people, and to disqualify those who are often the
abettors of crime, the victimizers of youth and the
constant source of danger to every member of the com-
munity.

The object of such legislation is unmistakable. It
is for the protection of the entire community, but es-
pecially for that portion of it less favored by education
or fortune, by experience or knowledge. Its design
is to promote their health, happiness and prosperity
by giving them a means of deciding to whom they
shall apply for intelligent, skilful and honorable aid in
the time of need, often so sudden and unexpected in its
coming. It enables them to determine by the only
feasible means who is educated and who is not, what
physicians are deserving of esteem and consideration,
and what practitioners are pretenders, sometimes honest,
perhaps, usually specious and presumptuous, and gen-
erally wofuUy ignorant.

To license the physician does not imply that he is
not to treat his patients in any way he or they may
prefer. It should mean that he is to show, before
being allowed to treat disease, that he can discriminate
between those which are dangerous to the individual
and those which are a source of peril to the public.
The former may, perhaps, ta]ce his life in his own
hands, but he should not be allowed to imperil that of
his neighbors.

Such a law offers no protection to the licensed
physician, who can take care of himself. His educa-
tion and opportunities have taught him to whom he is
to go for suitable advice. Nor does it favor his occu-
pation, since the more unskilful or negligent treatment
in the community the more the demand for the ser-
vices of the skilled and upright physician.

The many who ask for this protection and appreci-
ate its need, suffer from the few, who, ignorant of the
necessity, are deceived by false pretences, or are
blindly devoted to a theory.

The numerous attempu at the legislative control of
medical practice which have been made in the past

Digitized by

Google

682

BOSTOK MEDICAL AND 8VBGICAL JOURNAL.

[JcMK U, 1894.

twenty-five years show that these aims may be accom-
plished to a certain extent. Every effort meets with
opposition, and it is to the nature of the latter and
the arguments it offers that your attention is now re-
quested.

Such opposition is diverse and its motives extremely
mixed.

On the one hand is to be found the entire class of
those likely to be shown ignorant, unskilful, dishonest
or corrupt. These are encouraged and supported by
those whose occupation it is to systematically oppose
all antagonistic legislation — for a consideration. On
the other hand -we see intelligent theorists and educa-
tors, at times leaders in thought and morals, who ob-
ject to the infringement of personal rights, or the ex-
ercise of paternal care by the government. With
these are associated respected leaders of the profession
who have vigorously and persistently struggled for
the highest possible standard of medical qualification,
and oppose or discourage all measures which fall
short of it. Thorough supporters of some medical
legislation, they are determined opponents of all plans
of which they cannot approve. These leaders of the
opposition are followed by a considerable number of
citizens, insnSBciently educated, often ill-balanced, and
frequently influenced by arguments of the most
specious and superficial character.

In general the grounds for the opposition to the
legislative control of the practice of medicine are the
following assertions :

It invades personal liberty.

It legislates for a class.

It tends to obstruct the progress of therapeutics.

It is unnecessary.

It is not wanted.

It has proven a failure.

Let us consider these somewhat in detail :

it is claimed to be a violation of personal liberty,
since it denies to some their right to pursue the occu-
pation they desire and to others the right to select as
medical adviser any person they please.

Herbert Spencer is usually quoted as the leading
exponent of this view. He says : '

" If it is meant that to Kuard people against empirical
treatment, the State should forbid all unlicensed persons
from prescribing, then the reply is, that to do so is directly
to violate the moral law. . . .

" The invalid is at liberty to buy medicine and advice
from whomsoever lie pleases ; the unlicensed practitioner
is at liberty to sell to whomsoever will buy. On no pretext
whatever can a barrier be set up between them without the
law of equal freedom being broken ; and least of all may
the government, whose office it is to uphold that law, be-
come a transgressor of it..

" Moreover this doctrine, that it is the duty of the State
to protect the health of its subjects, cannot be established,
for the same reason that its kindred doctrines cannot,
namely, the impossibility of saying how far the alleged
duty shall be carried out. Health depends upon the fulfil-
ment of numerous conditions — can be ' protected ' only by
ensuring that fulfilment; if, therefore, it is the duty of
the State to protect the health of its subjects, it is its duty
to see that all the conditions of health are fulfiled by
them . . . eaact a national dietary ; prescribe so many
meals a day for each individual; fix the quantities and
qualities of food, both for men and women ; state the pro-
portions of fluids, when to be taken, and of what kind;
specify the amount of exercise, and define its character ;
describe the clothing to be employed ; determine the hours

SoeUl Statics 1851,373.

of sleep, allowing for the difference of age and sex . . .
and to enforce these regnlations it must employ a safficiency
of duly qualified officials, empowered to direct every one t
domestic arrangements."

It is to be remembered that this argument of Mr.
Spencer is directed against placing restrictions upon
" empirical treatment," which is regarded as a viola-
tion of the moral law. But let us quote further : '

" Let it be conceded that very many of the poorer classes
are injured by druggists' prescriptions and quack medi-
cines. . . .

" Inconvenience, suffering and death are the penalties at-
tached by nature to ignorance, as well as to incompetence
— are also the means of remedying these. ... Alt means
which tend to put ignorance upon a par with wisdom,
inevitably check the growth of wisdom. Acts of parliv
ment to save silly people from the evils which putting
faith in empirics may entail upon them, do this, and are
therefore bad. Unpitying as it looks, it is best to let the
foolish man suffer the appointed penalty of bis foolishness.
For the pain — he must bear it, as well as he can ; for the
experience — he must treasure it up, and act more ration-
ally in the future."

This argument of more than forty years ago is per-
sistently brought forward whenever the question is
raised of the control of medical practice by the State.
It is usually overlooked that it relates especially to
prescribing, whereas the practice of medicine includes
other considerations than that of providing means of
treatment.

Despite the reasoning of Mr. Spencer the govern-
ment finds it necessary to take certain steps, theoretic-
ally objectionable, for the protection of the health of
the individual. It does not prescribe the number of
meals per day, or the proportion of fluids and solids,
the amount and character of the exercise, the kind of
clothing and the hours of sleep. It does, however, in-
sist that food offered for sale shall be unadulterated
and wholesome ; that water-supplies shall be ancon-
taminated ; that noxious trades shall be rendered, as
far as possible, harmless ; that clothing shall be made
under certain conditions. The State cannot protect
the health of its subjects in every respect; but it
everywhere endeavors to accomplish something. Even
Mr. Spencer may be quoted in approval : *

" He who contaminates the atmosphere breathed by his
neighbor, is infringing his neighbor's rights . . . and in
the discharge of its functions as protector, a government is
obviously called upon to afford redress to those so tres-
passed against."

Professor Huxley's name is usually coupled with
that of Mr. Spencer as an opponent to placing re-
strictions upon the practice of medicine. His words
are as follows : *

« In my judgment the intervention of the State in the
affairs of the medical profession is to be justified . ■ •
simply and solely upon the ground that the State employs
medical men for certain purposes, and as employer, has a
right to define the conditions on which it will accept service.
It is for the interest of the community that no person shall
die without there being some official recognition of the
cause of his death. It is a matter of the highest importance
to the community that in civil and criminal cases, the law
shall be able to have recourse to persons whose evidence
may be taken as that of experts ; and it will not be doubted
that the State has a right to dictate the conditions under
which it will appoint persons to the vast number of naval,

> Social StaUw, 1861, 877.

< Op. eit., 372.

• Nineteenth Century, 1884, xv, 228.

Digitized by

Google

Vol. CXXX, No. 24.] BOSTON MBDIOAL AND SURGICAL JOURNAL.

583

military and civil medical offices held directly or indirectly
ander tlie government. Here, and here only, it appears to
me, lies the justification for the intervention of the State in
medical affairs."

Although this plea that the regalation of the prac-
tice of medicine is a violation of human rights has
regularly been brought forward for the purpose of ex-
citing sympathy, it has repeatedly been declared by
the courts, except in New Hampshire, to be invalid.

It is best answered in the words of Judge Williams : *

" In a certain sense it is true that every man has a natu-
ral right to follow out the bent of bis inclination, and be a
clergyman, a lawyer, a doctor, a scavenger, a peddler, an
auctioneer, just as he may choose. But, it is not true that
a man can practise any one of these professions or occupa-
tions except he does it upon such terms as the law imposes,
and the law can impose just such terms upon any one of
these professions or employments as tbe legislators in their
discretion deem best for the interest of the community. . . .

" The right to ])ractice medicine is a mere statutory
privilege, subject to be changed at any time by the legis-
lature."

It is claimed to be class-legislation, producing a
monopoly, and, therefore, unconstitutional. We have
again a statement, which is offered to excite sympathy,
although its illegality has been demonstrated. It is
everywhere recognized that legislation designed for
the welfare of the people is the duty of the State, and
is approved, if not demanded, by tbe public. The
only question is to what extent shall such class-legisla-
tion be carried. The people alone are to decide.
Licenses are given to peddlers, plumbers and apothe-
caries, to dealers in liquor, milk and oleomargarine.
Pilots must show a familiarity with the dangers to
navigation in the waters through which they under-
take to guide vessels, before they can be permitted to
take charge of them. Surgeons must be examined
as to their medical and surgical knowledge before they
can be appointed to the service of the militia. These
are but a few of the illustrations that such class-legis-
lation as is contemplated in the licensing of physicians
is taking place constantly and with uniform approval.
It does not create a monopoly, since it does not limit
the practice of medicine to any particular sect or
school. Any person can still become a physician by
taking the necessary steps to secure a proper prepara-
tion for an occupation which is generally conceded to
be one of great responsibility, and one demanding a
various training. What is open to 1(11 is no monopoly.
But this objection, too, has been definitely settled by
the decision of the Supreme Court of the United States,
given by Mr. Justice Field in the case of Dent v. West
Virginia.'' According to him

" there is no arbitrary deprivation of such right where its
exercise is not permitted because of a failure to comply
with the conditions imposed by the State for the protection
of society. The power of the State to provide for the
general welfare of its people authorizes it to prescribe all
such regulations as, in its judgment, will secure or tend to
secure them against the consequences of ignorance and in-
capacity at well as of deception and fraud. . . . The
nature and extent of the qualifications required must de-
pend primarily upon the judgment of the State as to their
necessity. . . .

" We perceive nothing in the statute which indicates
an intention of the legislature to deprive any one of bis
righL No one has a right to practice medicine without
having the necessary qualifications of learning and skill ;

• Rep. III. State Bowrd o( Health, 1885, Tit, 433.
' 12> United SUtes, 114.

and the statute only requires that whoever assumes, by
offering to the community bis services as a physician, that
he possesses such learning and skill, shall present evidence
of it by a certificate or hcense from a body designated by
the State as competent to judge of his qualificaticms.

" There is nothing of an arbitrary character in the pro-
visions of the statute in question ; it applies to all physi-
cians, except those who may be called for a special cause
from another State ; it imposes no conditions wnich cannot
l>e readily met."

We are told that a law to license medical practi-
tioners will obstruct the progress of therapeutic knowl-
edge, since certain so-called healers and curers will
refuse to be examined for a license. This class is
likely to include the hydropaths, psychopaths, nature-
paths, omnipaths, mind-healers and faith curers, spirit-
ualists, mesmerists and Christian scientists, botanic,
hygienic and Indian physicians, the seventh son of a
seventh son, and the retired clergyman whose sands of
life have nearly run out, and tbe like.

They will refute to be examined, since they are
conscious of their inability to pass an examination, or
they may claim that they will suffer a loss of therapeu-
tic power by acquiring knowledge of the anatomy and
physiology of the body or of the symptoms and diag-
nosis of disease. These people should not be licensed
unless they sabmit to the requirements which are
deemed sufficient to test the qualifications of physicians.
There need, then, be no interference with such thera-
peutical experiments as they and their patients see fit
to carry on, at their own exclusive risk.

The demand for such persons, ander some title or
other, will always exist. There are many worthy
citizens, some of a high degree of intelligence in many
things, who firmly believe that most remarkable and
wonderful cures have been accomplished by such
" healers." They are told, and are willing to believe,
that the latter possess the gift of healing, and have
" divined " the successful treatment of disease. Such
miraculous cures have been reported in all ages, but
the methods of their accomplishment have proven no
commendable additions to therapeutic knowledge.
They are recognized as dependent upon mental peculi-
arities, by no means to be encouraged, of tbe patient,
and equally striking and frequently objectionable char-
acteristics of the practitioner.

We are told that the latter will refuse to be exam-
ined because he may lose his power. It is to be re-
membered that Christian scientists are not the only
practitioners who have obtained successful results by
the use of faith. Dishonest charlatans have been as
fortunate as religious enthusiasts, and eminent physi-
cians have proven quite as successful as either. Men-
tal therapeutics may accomplish wonderful results in
certain instances, but the ability to use them is in no re-
spect limited to persons ignorant of any claim to medi-
cal knowledge. It may well be admitted that there
are some patients who will recover under certain ther-
apeutists, but not when licensed physicians attempt
their treatment. It is unfair to deprive such individ-
uals of this possibility unless there is a risk to others.

Even Mr. Spencer recognizes the importance of re-
straining those " who contaminate the atmosphere,"
and no person should be allowed to undertake the
treatment of the sick without previously having given
evidence of a suflBcient knowledge of the means of
recognizing contagious diseases and the measures to be
adopted to check their diBseminatioQ.

Digitized by

Google

684

BOSTOS MEDICAL ABD SURGICAL JO'DRHAL.

[JuMK 14, 1894.

There are those who claim that were there no other
oVjection to the further control of medical practice it
ii> unneceggary, since it would add but an infinitesimal
degree of security to the citizen's chance of being
faultlessly treated when sick, and the people are al-
ready protected by the existing laws against malprac-
tice and manslaughter.

No honest and intelligent physician of practical
experience claims to treat faultlessly a sick person.
No sensible physician, familiar with the seats and
causes of diseases, believes that it ever will be pos-
sible to always treat faultlessly the sick person, pro-
vided it is meant by this phrase to cure him of his
disease. But the treatment of the sick person is but
a part of the doctor's duty. To enable his patients to
avoid disease, to prevent them from becoming danger-
ous to others, are not the least important parts of his
occupation. Edncation alone, in addition to intelli-
gence and honesty, can enable him to promote these
aims.

The practise of Massachusetts courts in medical
cases during the greater part of the present centary
was based on the decision of Chief Justice Parsons in
1809,' that if the patient's death is the result of treat-
ment honestly administered, the person prescribing is
not guilty of manslaughter. It is only within the
past ten years that this decision has been reversed *
by the declaration of Judge Holmes that one who
practises with reckless ignorance or negligence is
liable for homicide, and for civil damages if he causes
injnry by ignorant or unskilful practice.

The number of cases of death due to the gross igno-
rance or negligence of the charlatan is nnknown.
Some are probably familiar to many members of this
Society. I merely allude to the statement of the conrt
that Thomson, who gave his name to Thomsonianism,
without reasonable doubt caused the death of his pa-
tient by unskilfnl treatment. That Franklin Pierce
was the cause of his patient's death by ordering the
application of flannels saturated with kerosene oil for
some three days. That a barber in Illinois, by the
unscrupulous methods of the quack, obtained a con-
siderable practice, and caused " the brutal butchery of
a mother in labor and her unborn offspring." "

Other instances, occurring in his own experience,
are mentioned by the medical examiner for Suffolk
County, Dr. F. W. Draper, in his argument before
the Public Health Committee of the Legislature,
February 14, 1894.

Dr. F. B. Harrington, of Boston, informs me of a
poor woman who was suffering from copious and con-
tinuous htemorrhages from uterine cancer. These
were controlled in accordance with his advice. She
later came under the care of a Christian scientist,
who told her there was nothing the matter, and that
she might go out and pursue her daily occupation.
The bleeding returned, but the advice to go about was
persisted in. A haemorrhage took place while she
was away from her home and caused her death shortly
after her return. Similar illustrations of death follow-
ing the gross ignorance of persons claiming to cure
disease might be produced almost without limit, and
the existing laws fail to prevent them.

But it is claimed, if the person is injured as a re-
sult of negligence or lack of skill, a suit for damages

• Commonwealtb t>. Samuel Thom«OD, 6 Man. Rep., 134.
> CominoDwealth r. Franklin Pierce, 138 Maa«. Kep., I6S.
"> Kep. State Board of Health, 111., 1884, vi, 10.

may be brought As a rule such cases do not come
to trial. Those which are brought before a jury are
usually directed against educated physicians of means
for various motives. The hospitals of every large city
are constantly resorted to by unfortunates who have
been induced to apply to ignorant and pretentious
charlatans for medical or surgical aid, and have suf-
fered grievous injury from following their advice. If
the sufferer realizes the cause of his misfortunes, he
may be unable to secure the services of counsel. If
he should be successful in this effort he usually re-
covers nothing, since the charlatan either has no
visible means, or leaves the State in time to escape an
unfavorable verdict. Much more often he suffers io
ignorance of the cause of his suffering.

Not only are the laws against manslaughter snd
malpractice insufficient to protect the community, but
those intended to guard against the spread of conta-
gious diseases are alike ineffective. The ignorant pre-
tender, under whatever title he or she may appear,
often does not recognize the nature of the contagious
disease. No suggestion is made of isolation. Well
children are allowed to play with the sick. All are
permitted to go to school, and the outbreak of scarlet
fever or diphtheria is thus promoted, which could have
been avoided by the intelligent precautions of an edu-
cated physician. I have before me the advertisement
of a person employed in a street-car, announcing
'< Diphtheria cured in all stages." Cases were taken
to him for treatment and were not reported to the
Board of Health. The law concerning the notifica-
tion of contagious diseases could not apply to this
person, since he did not call himself a physician;
neither was he a householder, and be could have
pleaded ignorance of the nature of the malady. The
cases under his treatment which were about to die
were referred, at the last moment, to physicians who
were then called upon to give such aid as was possible.
Existing laws do not protect the community from such
persons as these.

We are told that the legislation is not wanted,
since the people do not ask for it. The history of
medical legislation in the various States of the Union
furnish direct evidence to the contrary. Appeals are
made by clergymen, lawyers, authors, physicians and
public-spirited men of every degree. Physicians, it is
true, as a rule, take the initiative, since the evils re-
sulting from the ignorance or lack of skill of the pre-
tender are usually first brought to their notice. The
grievously sick or dying victims of the abortionist,
the moribund patient deceived by the promises, or
injured by the statement of the charlatan, eventoally
seek aid from the educated physician in good standing,
often at a time when death is but a few hours re-
moved, or permanent deformity has been made a
necessity, or conditions often bordering upon insanity
have been reached.

It is this experience of the doctors which has
opened the eyes of the people, and it is the en-
lightened common - sense of the latter which has
decided upon the need of the regulation of the prac-
tice of medicine throughout nearly all the United
States.

Finally, we are told that the State control of medi-
cal practice has proven a failure. At the present
time some sort of law intended to regulate the prac-
tice of medicine exists in nearly every State and
Territory of the Union. These laws differ widely in

Digitized by

Google

►1.. CXXX, No. 24.] BOSTOS MEDICAL AND SURGICAL JOURNAL.

585

sir scope and in their regulte, bat all have the same
d in vievr — the protection of the people. As some
iVe failed to produce the desired resalt, suitable
aendments have been made. Some of the most re-
nt laws are those which promise to be the most
Bcient, and it would indeed be astounding were a
iries of failures likely to act in favor of a renewal of
le same undertaking. On the contrary, the failure
! tbe earlier attempts at medical legislation has led
> tbe avoidance of the causes of failure, and the re-
orts from various States give encouraging evidence
f what has been accomplished.

(2*0 6«con<(n««d.)

THE INFLUENCE OF ANIMAL EXPERIMEN-
TATION ON MEDICAL SCIENCE:

Abstract or thb Presidbmt's Address before the
Congress of American Physicians and Surgeons,
AT ITS Third Triennial Meeting, Washington,
D. C, May 81, 1894.

BT ALFBBD I.. LOOMIS, II.D., OF KKW TOBK.

Tbk specific problems with which medical science
deals are questions of the relative influence of multiple
forces ou the production of given results. Only the
deepest ignorance can fail to recognize that the forces
concerned in the simplest change of inorganic nature
are so numerous and their relations so complex that
they defy recognition under uncontrollable conditions,
while in the organic world the task is even more hope-
less. Eixperimeutation, therefore, in which one or
more of the involved forces can be controlled, becomes
an absolute necessity in all scientific investigation.
However clear the mental analysis, however accurate
the logical demonstration from cause to effect, it is
possible by experiment alone to prove that no involved
force has been overlooked. Is it not strange that
medicine should be denied the right to follow those
imperative methods of scientific reaeach which are so
unquestionably accorded to every other science? It
is not a little surprising that men with an appreciation
of the necessity of experimentation should for so long
have preferred to be its subjects, and that even to-day
so many refuse to yield the place to animals. For ex-
ample, in widespread epidemics we note the effects of
an infection on perhaps half a million of human beings,
with a great sacrifice of human life. On the other
hand, we study in laboratories the cause of tbe epidem-
ics with a comparatively small sacrifice of animal life.

In entering upon the consideration of this subject
the author fearlessly laid down this proposition :
Every distinct advance, every established principle,
and every universally accepted law of medical science
has been in the past and will be in the future the direct,
if not the immediate result of animal experimentation.
He then passed to a review of some of the obvious and
coDcIuaive proofs of this proposition.

It is not too much to claim that during the latter
half of the present century the results obtained from
experiments on animals have done more than all the
observations of the preceding centuries to raise medi-
cine from conditions of vagueness to conditions of ex-
actness. From the time of Aristotle, who proved that
tbe blood, brain and spinal marrow in animals have no
lensation, down to the present day, animal experimen-
tation has been practised by all investigators who have

gained any definite knowledge of the more important
phenomena of animal life.

Gralen must be regarded as the pioneer in this line
of investigation. By his experiments on living animals
he showed that arteries contain blood, that the lungs
passively follow the movements of the chest, and that
the diaphragm although the most important is not the
only muscle of respiration. Further, by section of
the spinal-cord and of the recurreot laryngeal nerve,
he demonstrated the nervous control of tbe voice and
explained the mechanics of respiration. He also ad-
vanced the knowledge of the functions and movements
of the alimentary canal and laid the foundation of our
knowledge of the functions of the brain and spinal-
cord. The results of his experimental work are now
as conclusive as when first made, and are tbe only
part of his vast labors which have stood the test of
modern investigation.

From Galen's time to Harvey's great discovery,
little experimental work was done ; and during this
time medicine ceased to advance. Harvey's demon-
stration of the circulation of the blood in 1620 rests
entirely on animal experimentation, as is shown by his
writings.

The next series of important investigations on ani-
mals were applied by Galvani and Volta to the nervous
system.

In 1664 Robert Hook, by inflating the lungs of ani-
mals by means of a bellows, demonstrated artificial
respiration. The experiments of Boyle and of Priestly
in tbe seventeenth century laid tbe foundation of our
knowledge of the respiratory process.

The injection of fluids into the blood-vessels of ani-
mals was first done by Dr. Christopher Wren. In
1666 Richard Lower performed the first tranfusion, and
the following year Dr. Denis performed the same ex-
periment on man.

Haller, in the middle of the eighteenth oentary,
proved that all motion in the human body proceeds in
great measure from the brain and spinal-cord. He
also demonstrated that irritation of the peripheral end
of a severed nerve produced contraction in the muscle
to which it was distributed. This was followed by the
experiments of Sir Charles Bell. At the beginning
of the present century Magendie demonstrated the
difference between the anterior and posterior roots of
the spinal-cord. His experiments on animals by the
injection of various medicinal substances enabled him
to lay the foundation of the doctrine that remedies
exert their action upon special structures and organs.
In this line of work he was followed by Claude
Bernard. It is perhaps a conservative statement, that,
excluding the medicinal foods, ninety per cent of all
our medication is made definite and valuable by this
principle alone. Magendie, Bernard and Loget estab-
lished by their experiments the doctrine of recurrent
sensibility, which was followed by the discovery of
Marshall Hall of reflex action of the spinal-cord. Tbe
doctrine of vaso-motor action was practically demon-
strated by Bernard's experiments.

John Hunter, in 1785, by his experiments on dogs,
established the fact that injuries to healthy arteries
were soon repaired, and that ulceration after ligature
occurred only when the vessel was diseased. The ex-
periments led him to apply ligatures for the cure of
aneurism to healthy portions of the arteries. Hunter
first learned by experiment on pigeons and young pigs
that the growth of bona was from the periosteum.

Digitized by

Google

586

BOSTON MBDIOAL AND SURGICAL JOURNAL.

[June 14, 1894.

As we witness some capital operation performed at
the pre!<eut day without pain, almost bloodless, followed
neither by fever nor suppuration, we may ask how far
these results are due to experimentation on animals.
The effect of chloroform was discovered through ex-
perimentation on the ant. Simpson practised and per-
fected his use of chloroform on animals before he
placed his first patient in a state of ansesthesia. That
other great alleviator of pain was first practised on dogs.

These results are sofficient to exalt animal experi-
mentation to the first place, as a means of scientific
advancement.

The first important step in the field of etiology based
on animal experimentation was made in 1850, when it
was proven that splenic fever could be communicated
from animal to animal by inoculation, and the first hint
of bacteriological study was given by the discovery
constantly in the blood of these animals of little thread-
like bodies.

About the same time Virchow made bis observations
on trichinosis. M. Viyaman inaugurated an important
era when he established the fact that tuberculosis was
an infections disease. The invaluable studies of
Pasteur introduced us into a new world of knowledge.
He not only obtained pare cultures of organisms, but
also studied their life-history and placed bacteriological
science on a firm basis. The crowning glory of Pasteur's
work came with the discovery of the attenuation of
bacterial toxic products. It is not possible to point to
a work of richer or grander promise, yet it is a work
that was possible only by experiments on living ani-
mals. The application of Pasteur's doctrine by Mr.
Lister to the antiseptic treatment of wonnds has been
a full confirmation of this principle.

The discovery of the bacillus tuberculosis by Koch
marks another brilliant epoch in medical science.

Within the past two decades animal experimentation
has accomplished more in the field of cerebral localiza-
tion than all the preceding centuries of carefully re-
corded cerebral symptoms studied in the light of post-
mortem investigation. It has opened a new field of
operation.

From this history, it seems evident that most if not
all of the real advances in medicine have been made
possible through experimentation. This review of
what our profession has done is not a plea for mercy —
it is a cause for pride. So long as the moral and
spiritual development of mankind remains the supreme
purpose of creation, medical science can claim equal
honor with the science of God, and in the conflict with
physical evil mast be the first to meet the foe. Until
Infinity repeals the edict which gave man power over
all created things, the right to claim the services of
the brute can never be denied him who devotes his life
to the service of mankind. We glory in our experi-
mental work because we know the tenderness of cruelty,
the balm of pain, the life whose birth is only in the
throes of death. From the ignorant we expect to re-
ceive only censure ; but from those who in the valley
of the shadow of death have learned to know what
manner of men we are, I have faith to believe that the
reply will come, " We have trusted you with the lives
of our loved ones, we entrust to you Grod's dumb
creatures."

Tbb Pope has decided that cremation, while heretical
in principle, ntay be allowed under special conditions.

Original %ttit\t^,

STRANGULATION OF MECKEL'S DIVERTIC-
ULUM CAUSED BY VOLVULUS OF THE
ILEUM.I

By J. W, KLLIOT, M.D., BOSTON,

Burgeen to the M<u$aehmetU Oentral HoipUal,

Thb patient, a man about thirty years old, was
brought to the accident room of the Hassacbusetu
General Hospital, October 17, 1893. He bad been
sick for four days, with vomiting, chills and abdomiual
pain. The bowels had moved twice in the previoas
forty-eight hours. The temperature was 103.6°, poise
160, respiration 35.

The abdomen was distended, tympanitic and exquis-
itely tender, especially to the right of, and below the
umbilicus. Free fluid was evidently present in the
peritoneal cavity. Under ether, a large hard mass
was plainly felt in about the middle of the abdomen,
just below and slightly to the right of the ambilicus.
Both Dr. M. H. Richardson and I considered it a se-
vere case of appendicitis. Dr. Richardson also kindly
assisted me with the operation, which proved to be the
most difiicult and perplexing operation I ever saw.

The abdomen was opened by a vertical incision two
inches inside the anterior superior spine of the ileam.
A quantity of turbid fluid escaped. The appendix wss
examined, and found to be normal. On exposing the
mass near the middle of the abdomen by extending the
incision, it looked like a large dilated and gangrenous
knuckle of intestine, but without a mesentery. It
sprang from the lower part of the convex surface of
the ileum, and was tightly twisted at its point of at-
tachment to the bowel. It extended upwards into a
dense mass of adhesions, and when dissected free was
found to be attached to the under surface of the um-
bilicus. It was then evident that we were dealing
with a Meckel's diverticulum in a strangulated and
gangrenous condition. It was seven inches long, and
about the same sise as the ileum. During the dissec-
tion, the gangrenous diverticulum was ruptured, allow-
ing the escape of a quantity of fsecal-smelling fluid into
the peritoneal cavity. The diverticulum was removed,
and the opening in the ileum was closed with several
Lembert sutures. The ileum at this point was found
twisted on itself and held in this abnormal position by
adhesions. The gut was not wholly obstructed by the
twist. On untwisting the bowel old adhesions were
found extending deep into the mesentery so as to
shorten it at one point. This contraction of the mes-
entery seemed to have caused the volvulus of the il-
eum. The diverticulum having its outer end fixed at
the umbilicus, was twisted and strangulated at its base
by the turning over of this coil of the ileum. The
gangrene of the diverticulum was most intense near
the ileum, the end at the umbilicus being only moder-
ately inflamed. This is explained by the fact that the
diverticulum has its blood-supply from the mesenteric
artery of the ileum.

The operation was severe, causing the pulse to rise
to 180 at the end. The patient, already septic at the
time of operation (unfortunately the cultures of the
turbid fluid found in the abdomen were lost), died of
septic peritonitis on the second day.

As is well known, Meckel's diverticulum is due to
the persistence or incomplete obliteration of the vitel-

1 RMid at the Congress of American Physiciuu aod Snrgaoiii at
WMtilngtoD, Maj 31, IBM.

Digitized by

Google

Vol. CXXX, No. 24.] BOSTON MBDIOAL AND SURGICAL JOURNAL.

687

line duct. It is nsually small, and has its principal in*
terest in the fact that it not infrequently acts as a band
and causes intestinal obstraction.

Dr. R. H. Fitz,' in a very valuable paper on this
subject, quotes Roth ' as calling attention to the origin
of retention cysts from Meckel's diverticulum. " Such
cysts are divided into two classes, according as their
cavity is continuous or discontinuous with that of the
intestine. The wall is composed of the various layers
found in the intestine." Both describes a cyst of this
kind occurring in a child one year and four months
old. " It was connected with the concave surface of
the ileum, near the mesenteric insertion twenty-six
inches above the ileo-ceecal valve. The pedicle hav-
ing •become twisted, a hsemorrbagic infiltration and
necrosis of the mucous membrane had occurred, also
acute peritonitis."

The case here reported
is unique, but this case
of Roth's resembles it
in several important par-
ticulars. In both cases
the diverticulum was
strangulated by twisting
of the pedicle, and acute
peritonitis followed.

These cases are suf-
ficient to establish the
fact that strangulation
of Meckel's diverticu-
lum is one of the causes
of acu te peritonitis. This
fact has an additional
interest at the present
moment in that the diver-
ticulum resembles the
vermiform a p p e n d ix,
and the two lesions may
easily be confounded,
clinically, as in the pres-
ent case. While the di-
verticulum is often with-
out a mesentery and is
therefore freer and more
likely to suffer from
strangulation by twisting
of its pedicle, yet it not
infrequently has a me- ' '

sentery ; in which' case

it must be liable to the same pathological processes
(though evidently much less frequent) as the appen-
dix. Such cases are not wanting. Fitz mentions
a case reported by Dr. Beale,* where acute peri-
tonitis followed perforation of a diverticulum, in the
cavity of which were a cherry-stone, the coriaceous
covering of several orange-pips and other substances ;
and also a case of adherent diverticulum described by
Houston.* This diverticulum was filled with a hard
matter, apparently inspissated faeces. " The omentum
and intestines in the neighborhood were closely joined
to the tumor by adhesions, the result of former inflam-
matory attacks, and the woman had complained for
many years before her death of occasional severe pun
in the abdomen."

* Amerlean Jonmal of Medical ScIenoM, Jnly, 1884.
> Tlrobow't ArohiT, 1881, Ixxzrl, 377.

* Beport of ProcMdingB of the Fsthologloal Society of London,
1881-J2.

' DeeariptlTe Catalogue of the prepantlona in the Mofenm of the
Koyal College of Surgeons In Ireland, 1834, 1, 38.

The symptoms of inflammation of these two intes>
tinal pockets are the same, as they both cause perito-
nitis. The only points in the differential diagnosis
which the writer is able to suggest, are that a history
of a discharge from the umbilicus (this occurred in a
case of intestinal obstruction due to diverticulum in the
practice of Dr. Jobn Homans) would suggest the pres-
ence of a diverticulum, while a history of previous at-
tacks of pain would be significant of either an inflamed
appendix or diverticulum, as, according to Fitz, " In
nearly one-half the cases of vitelline remains previous
attacks of pain were recorded." The presence of a
tumor or tenderness near the umbilicus should favor
the theory of inflamed diverticulum as against the ap-
pendix. It will be remembered that in the case here
reported a distinct tumor could be felt just below and
slightly to the right of the umbilicus.

The only treatment to be thought of in such cases
is prompt laparotomy and the removal of the inflamed
or strangulated diverticulum. The special points to
be observed in the operation are the careful stitch-
ing of the pedicle, as it often opens directly into the
intestinal canal ; also the careful ligature of the ves-
sels, because the diverticulum is supplied by a branch
of the mesenteric artery, which is the persistent om-
phalo-mesenteric artery, and may be of considerable
size.

SUICIDAL GUNSHOT WOUND OF THE ABDO-
MEN; YMCA^L FISTULA; COMPLETE RE-
COVERY WITHOUT OPERATION.!

BT P. KiiLPH BOAN, M.D.,

At*Mant-Swgem, United States Army.

The older surgeons looked on gunshot wounds of
the abdomen with feelings akin to despair. The mor-
tality from these injuries under the most favorable cir-
cumstances amounted to over eighty per cent. In less
fortunate cases it reached a hundred per cent.

Need we wonder that after the successful cases of
Kocher and Bull, ten years ago, the motto became,
" Laparotomy for diagnosis and treatment." It was the
inevitable enthusiasm following a new and successful
method of treatment. It is now, however, beginning
to be modified before the tests of experience.

In military practice the difficulty of diagnosing a
perforation, and the frequent necessity for immediately
transporting the patient from the seat of action, gener-
ally caused laparotomy to be deferred. It will further
be necessary to differentiate as far as possible between
wounds of the various parts of the intestines.

It has always been a well-known fact that wounds
of the large intestine were less fatal than those of the
stomach and small intestine. Even wounds of the
different divisions of the large bowel give different re-
sults. Assistant-Surgeon Otis, United States Army,
writes : ' " While few instances are observed of recov-
ery from gunshot wounds of the transverse colon,
many were seen of survival after perforation of the
ceecum and ascending portion of the bowel, and a still
larger proportion of recoveries was observed in wounds
of the sigmoid flexure and other parts of the descend-
ing colon. . . . Nearly all were attended by sterco-
ral fistulse which commonly closed after a time, with-
out operative interference, reopening at intervals, and

■ Read for the anthor at the April (WM) meeting of the Society of
the Alumni of Charity Hoepltal, Nev York, by Dr. Walter Leater
Carr.

> Medical History of the War of the Rebellion.

Digitized by

Google

688

BOSTON MEDICAL AND SURGICAL JOUBNAL.

[June U, 1894.

then healing permanently." He then gives a history
of 59 recoveries, in 50 of which the stercoral fistulse
had completely closed.

In 1886, during the discussion of gunshot wounds
of the intestines, Dr. W. T. Bull ' spoke as follows :
" In conclusion, let me make one exception to the rule
of treatment I have advocated, namely, to explore
bullet wounds. It is in cases where the wound is sit-
uated in the posterior part of the abdomen, or in the
lateral wall covered by the lower ribs, and there is no
evidence of any wound anteriorly."

In the same debate, Dr. Parks, of Chicago, thought
that sufficient data had not been offered on which to
form a correct diagnosis. He thought the size of the
firearm must be taken into consideration, as also the
distance, shape of the bullet, its calibre, and that the
result of the injury might be afiected by the obliquity
with which the missile entered the body. He then
detailed the remarkable case of a thief who was shot
while running away from his pursuers. The bullet
was of 44 calibre, and struck him in the back. The
next morning be went to the hospital, where it was
found the ball bad entered the back aboat four inches
from the spinal column, and came out near the umbil-
icus. He never developed any serious symptoms, and
left the hospital on the second day.

Dr. Bryant,* believed laparotomy was a justifiable
operation, but that it should not be attempted even in
so-called favorable cases, unless the operator could
avail himself of many of the recognized means of pro-
cedure necessary to combat the shock of the operation,
and was snflBciently familiar with its steps to operate
with accuracy and despatch.

Dr. Weir said : " Clinically, it is found that every
case of such a wound (that is, penetrating,) does not
justify laparotomy. When such a case comes under
the eye of a surgeon, the collapse which he or she is in
may, and too often does, prohibit utterly surgical in-
terference. In only one condition is there an opera-
tion justifiable, and that is for the arrest of hsemor-
rhage which may be the cause of shock."

Before the International Medical Congress in 1887,
fsecal extravasation was considered the only clear in-
dication for operation (Hingston). The same year
Sir William McCormac wrote : " Some degree of doubt
mast always exist on account of the necessary obscur-
ity of the symptoms, except in the rare event of pro-
lapse of the injured gut, ftecal extravasation appearing
externally ; or very free bsemorrhage from the wound."
Operation, he thought, was practically useless after
twenty-four hours had elapsed, or when general peri-
tonitis and great collapse had set in.

In 1888, BecluB reported the recovery of three cases
of perforation of the abdomen. He claimed as the
result of experiment that perforation was not necessa-
rily present in cases of penetration, and that therefore
laparotomy need not be performed unless ihe sigus
were unmistakable. He advised firm compression of
the abdomen and large doses of opium ; and only when
this treatment had failed was laparotomy to be per-
formed.

Two years later, Dr. Lewis A. Stimson showed that
the integral statistics of the principal hospitals in New
York City to that date were as follows : * without op-
eration, 23 cases (15 deaths, mortality 65 per cent.) ;

> Hedioal Kem.

< Medical Beoord.

• New Tork Medleal Jonroal.

with operation, 16 cases (13 deaths, mortality 81.2 per
cent.). He thought perforation occurred in tXX cases of
penetration save when a small bullet has entered so
that its course must lie through the liver, and those in
which the ball has traversed the abdominal wall very
obliquely. He condudes that in the present state of
our knowledge it cannot be said that either interfer-
ence or non-interference should be the rule of prac-
tice, and the surgeon may be guided by his own con-
victions and feelings, whether they lead him to seek
to do as much good, or only as little harm as possible.

In the discussion. Dr. Wyeth thought the question
of operation was then involved in as much obscurity
as it had been nine years before. ^

In 1892,* Luhe concluded, from 324 cases, iuclad-
ing those of McCormac, Coley and Morton, that lapa-
rotomy was indicated in nudoubted cases of perfora-
tion. He fouud the mortality in 152 cases of shot
wounds was 62.9 per cent. ; while for other forms of
wounds it was 34 per cent In those cases in which
laparotomy was performed within the first twelve hours,
the mortality was 58.2 per cent. ; but in those cases in
which it was delayed for a longer period, the mortality
reached 79.5 per cent. ; while the mortality in those
cases in which the length of time was unknown was
82.4 per cent.

This shows that delay increases the mortality in op-
erations after these wounds. The rule that immediate
laparotomy is necessary, must, of course, have some
exceptions, as in military practice where antiseptic
precautions and the time necessary for the proper per-
formance of the operation are wanting. He believes
the formation of artificial ani will be often necessary,
and that transportation should be prohibited during
the first few days at least.

In the above papers the difference in the mortality
according to the part of the intestine injured, as shown
by Assistant-Surgeon Otis, seems to have been over-
looked. The following case is cited in support of the
correctness of his views :

F. W., colored, age twenty-four, was admitted to
hospital on May 31, 1893, about 10.22 a. m. A num-
ber of petty robberies had been committed in the place.
He was accused by his companions of being the thief.
This so preyed on his mind that he tried to commit
suicide. With this object he placed the muzzle of a
45-calibre Springfield carbine to the front of his abdo-
men. The stock he rested on a box about two feet
high, then bending forward he pulled the trigger.
The bullet entered in the mammary line just a little to
the right and immediately below the lower edge of the
false ribs on the right side. It made its exit just over
the highest point of the innominate bone and about
one-fourth of an inch external to the line of the outer
border of the axilla. He was seen inside one-fourth
of an hour after the accident. A slight amount of
pallor existed. He had no hemorrhage and no blood
in his stools. The only sensation he ezperieoced
around the wound was one of numbness. There was
nothing to indicate that a perforation of the intestines
had occurred. It was concluded that if any portioo
of the intestines had been injured it was the ascending
colon, and in view of the favorable results given by
Assistant-Surgeon Otis, laparotomy did not seem justi-
fiable. His wounds were dressed aseptically. He was
given a liquid diet, and placed on his hack. His tem-
perature was sub-febrile in the evening, and thereafter

« OentTKlbt. fttr CUr.

Digitized by

Google

Vol. CXXX, No. 24.J BOSTON MBDIOAL AUD 3UBG10AL JOURNAL.

689

as shown iu the accompanying chart. On the third
day he began to lie with his knees drawn up. This
position be explained was to relieve pain which had
developed round the wound. At the same time a

slight odor was noticed in changing the dressing. It
came from the posterior opening. During the night a
quantity of faecal matter came out; and on the follow-
ing day it amoanted to over a pint, and necessitated
frequent dressings. For the next tea days it decreased
in quantity, and on the twelfth had completely ceased.
The photograph was taken a little after this period
when both wounds had closed.

As he suffered from pains oo exertion, he was kept
under treatment until July 20th, when he was dis
charG^ed. The wounds never reopened ; and he has
continued to ride horseback and do ordinary work with-
out any inconvenience. His general health remains
excellent.

From the above citations, we may safely reach the
following conclusions :

(1) That wounds of the large intestine are more
liable to spontaneous cure than those of any of the
other abdominal viscera.

(2) That antero-posterior perforation of the abdo-
men, though nearly always followed by perforation of
the bowel, is not necessarily so, as shown by the re-
markable case of Dr. Parks.

(3) That prolapse of the wounded intestine or fsecal
extravasation is alone diagnostic of a perforation.

(4) That if operation is indicated, it must be per-
formed as soon as possible, and with the withdrawal
and examination of only a small portion of the intes-
tine at a time. The examined portion to be replaced
and another section examined in the same way until a
thorough search has been completed.

(5) That if the case is not seen for several hours
after the accident, drainage by iodoform gauze should
be alone attempted, as fibrinous adhesions have been
found to occlude the wound and wall off the peritoneal
cavity in a few hours.''

(6) That in military practice the impossibility of
always taking antiseptic precautions, and the urgent
necessity for Transporting the patient to a base hospi-
tal, will often prevent the performance of laparotomy.

The introduction into warfare of the small jacketed
bullet, projected with great velocity, will probably not
modify the status of abdominal wounds in any material
degree. The wounds will be more like a puncbed-out
hole, with little, if any, contusion of the neighboring
parts. Fatal hsemorrbage will be more prevalent, and
there will be about four times more dead than wounded.'
There will also be more men killed and wounded iu a
given time by the new rifle. The wounds produced,
if not immediately fatal, will, however, be more amen- •
able to surgical skill, and much more promptly recov-
ered from.' More penetratiug wouuds of the abdo-
men will be liable to spontaneous recovery, while those
that come to operation will show an increased percent-
age of recovery. The general opinion of military sur-
geons seems to be favorable to the new weapon, so far
as experiment and its limited employment in actual
warfare enable them to judge.

lEt.e)ioitie( of Jbntistit^,

CONGRESS OF AMERICAN PHYSICIANS AND
SURGEONS.

Third Tribnniai- Meeting, Washington, D. C,
May 29, 30, 31 and June 1, 1894.

QENERAL SESSIONS.

(Oonoluded from No. 23, p. S7S.)

FRIDAY AFTEBNOON. — JDNK IST.

The business meeting of the Congress was held at
1.30 p. H., the President, Alfred L. Loohis, in the
Chair.

Dr. Netins B. Htdb presented, on behalf of the
American Dermatological Association, the following
resolution :

Whereas, The American Dermatological Association re-
cognizes the importance of the undoubted existence of
leprosy in North America, therefore

Resolved, That the Congress of American Physicians and
Surgeons be requested to memorialize the Congress of the
United States of America, with the view to the appoint-
ment of a commission of five to investigate the prevalence
of leprosy in the United States of America and in the
countries upon its borders, and to suggest means for the
control of the disease.

Db. William H. Welch, of Baltimore, stated that

' Abbe and MoOraw.

• Colonel Boonen-Birera on the War In CblU.

• Thornvald, In Austria, as the resalt of experiment, baa oome to
this same ooneloslon.

Digitized by

Google

590

BOSTOJf MBDIOAL AND SURGICAL JOVBSAL.

[JcME 14, 1894.

a bill had beeo presented in Congress prohibiting ex-
periments on animals in the District of Golambia, and
presented and moved the adoption of the following
resolution :

Whereax, The attempts in other countries to regulate by
legislation the practice of experimentation upon animals
have proven most disastrous to the progress of medical
science and art,

^ Resolved, That the Congress of American Physicians and
Surgeons enters its most earnest protest against any legis-
lation tending to interfere with the advancement of medi-
cine by means of experimentation upon animals, conducted
by properly-qualified persons.

D&. L. McLank Tifpant, of Baltimore, offered the
following resolution :

Whereas, The army appropriation bill reduces the num-
ber of medical officers in the srmy by twenty-five, and also
reduces the appropriation for the library of the surgeon-
general's office from ten thousaud dollars to seven thousand
dollars,

Resolved, That it is the opinion of this Congress that
these proposed reductions are unwise and are contrary to
the best interests, not only of the army, but of tlie medical
profession of this country, and of all who depend upon them
for skilled professional services, and that we respectfully
request our representatives and senators to so amend this
bill as to prevent the reductions above referred to.

These three resolutions were adopted.

The question of amendment of the by-law relating
to the place of meeting was brought np, and its con-
sideration postponed until the next meeting, when it
should be made the special order for the first day's
sessioD.

The Congress then proceeded to the scientific work.
The first portion of the afternoon was under the direc-
tion of the American Laryngological Association, and
the subject for consideration was

THS SnBGKBT OF THE A00BS80BT SINDBE8 OF THE
NOSE.

Dr. F. H. Boswobth, of New York, read the first
paper, which was on

DISEASED conditions OF THE ETHMOIDAL SINUSES.

Diseases of these sinuses differ from diseases of the
other sinuses in their anatomical peculiarities and in
their symptoms. In the other sinuses there is one
large single cavity ; in the ethmoid we have a mass
of small cells more or less completely separated from
each other. In order to establish a radical cure, it
would be necessary to open each one of these cells. This
is impossible, and therefore the separating walls must
be broken down and a single cavity formed.

Whereas, in the other sinuses the principal symp-
tom is the occurrence of a purulent discharge, eth-
moidal disease sets up a train of symptoms more or
less neurotic in character, sach as headache, intra-
orbital pressure, sneezing, asthma, and interference
with the action of the brain. Ethmoidal disease is
more frequent than is commonly supposed. In the
last five years 97 cases of ethmoidal disease had been
under his care. There are three varieties of disease
of the ethmoid, the extra-cellular myxomatous, intra-
cellular myxomatous and purulent ethmoiditis. These
varieties are really simply successive stages of one and
the same affection. As the disease progresses, the mu-
cous membrane may project into the nasal cavity in
the form of small polypi. Another result may be
crowding out of the middle turbinated bone, from ex-

tension of the ethmoid cells. The final result is suppu-
ration, and the pus may be discharged through the
anterior or through the posterior cells.

Treatment in these conditions should be instituted
early, if possible, before the occurrence of suppuration.
In acute ethmoiditis, the ordinary measures employed
in acute rhinitis are indicated. Of all measures, be
regarded the douche as the most valuable. One or
two gallons of water, rendered saline and as hot as can
be borne, should be passed through the nose twice
daily. This is devoid of danger provided the patency
of the nostrils is determined beforehand and the water
is passed in the narrower nostril so as to obviate any
interference with its discharge.

In the chronic stage, surgical treatment is demanded
when other measures have failed. The object of the
treatment is to relieve the intra-cellular pressure. To
remove the projecting portions, the snare answers the
purpose best. In operating on the ethmoid cells a
small burr attached to a dental engine is the best in-
strument. The operation usually requires several sit-
tings, and care must be taken on account of the thin
bone separating the cavity from the orbit and from the
brain. The operation is not especially painful and can
be done under the application of cocaine.

Ninety-seven cases had been treated. Of this num-
ber three were cases of carcinoma, and one was a case
of sarcoma. Excluding these, there were 93 cases.
Of the simple inflammatory cases, 15 in number, 9
were cured, 3 improved, and 3 disappeared. There
were 29 cases of myxomatous degeneration, of which
12 were cured, 10 improved, and 7 were seen but once
or twice. There were 22 cases of myxomatous change
with polypi ; 9 were cured, 10 improved, and 3 disap-
peared. There were 27 suppurative cases ; 8 were
cured, 12 improved, and 7 disappeared. In nearly all
of these cases radical measures were employed.

8DR6EBT OF THE HAXILLART SINUS.

Dr. J. H. Brtan, of Washington, read a paper on
this subject.

Of the surgical affections of the antrum, empyema is
the most important, and the principal question Uiat has
arisen in regard to its treatment has been as to the
method of opening the cavity. The washing out of
the cavity through the natural opening has been
strongly advised. This is applicable to acute, but not
to chronic cases, and the results are uncertain. In the
majority of cases, an artificial opening is necessary. If
there is a carious tooth present, it should be extracted,
and frequently in this way the cavity will be opened.
If not, it will be necessary to establish connection by
a trocar or small trephine propelled by an engine. The
opening should be large, and a metallic drainage-tube
introduced. If the anterior wall of the antrum shows
signs of weakening, it may be opened at this point. If
it is desired to enter the cavity from the nose, it may
be done through the inferior meatus by a spear-shaped
knife, but it is better to use the trocar or drill. After
the cavity has been opened, it should be washed out
with mild antiseptic solutions.

Where the case is an obstinate one, the opening
should be enlarged so that the cavity may be thor-
oughly explored with a probe, the little finger or the
endoscope. This will often show the presence of
spots of ulceration, necrosis, snpernumary teeth, etc.,
as the cause of the trouble.

Dr. J. N. Mackenzie, of Baltimore, also called

Digitized by

Google

'oi~ CXXX, No. 24. j BOSTON MEDICAL AND SUSGWAL JOURNAL.

591

ttentioQ to the varioag methods of opening the au-
rum. Washing oot through the natural opening is
ot applicable to many cases, for it is often difficult to
ind the opening, and this is so even after death. In
rder to obviate this difficulty, it has been proposed to
emove the inferior turbinated bone; but that does
lot seem justifiable in the majority of cases. It has
lIbo been proposed to make an artificial opening below
.he nataral opening. This is rather difficult to carry
>nt, and the hssmorrhage is sometimes great. The
>peratiou of entering the antrum through the canine
fossa should only be done in cases of growths, or
irhere the antrum wall is so thin that it is an easy
matter to pierce it, and where, if the surgeon does not
open the antrum, it will discharge itself. By far the
best operation for gaining access to the antrum is that
through the mouth, by the extraction of a tooth,
whether sound or decayed, or by going through the
alveolar process without the extraction of a tooth.
The speaker considered this method far superior to
any other. This opening furnishes drainage from a
dependent point; and when injections are made
through the opening, most of the fluid escapes through
the nose. The objections that have been urged against
the operation are that it involves the loss of a tooth
(perhaps sound), that food may enter through the
tube, and that there is danger of microbes finding en-
trance from the mouth. These objections are, how-
ever, without weight. There is only one contraindi-
cation, and that is the presence of an edentulous
alveolar process. In these cases the operation had
better be done through the nose.

Dk. John O. Bok, of Rochester, read a third paper
on this subject.

The treatment of these cases is largely surgical, on
account of the fact that they are largely out of reach
of ordinary medicinal treatment. Most cases of ozoena
are in all probability due to discharge from some of
the sinuses of the nose. In cases where the discharge
does not rapidly subside under treatment, a free open-
ing should be made. If there is no history of long-
standing disease, the treatment should be begun with
injections through the natural passage, if the case is
recent, the discharge persisting after an acute inflam-
mation, this may biing about a healthy condition.
When such treatment cannot be employed, an artificial
opening should be made. When the teeth are sound,
the opening can be made through the zygomatic region
or through the meatus. If the disease does not rapidly
subside, it is probable that there are conditions of the
cavity which must be dealt with radically. Then a
free opening should be made and the diseased condi-
tions removed. The opening should be maintained
until we are sure that the disease is entirely cured,
wheu the opening can be safely allowed to close.
The following conclusions were presented :
The old idea of considering drainage and cleanliness
as the treatment, regardless of the exciting cause,
should be abandoned.

lu all cases where the purulent discharge does not
cease after a reasonable time, the cavity should be
freely laid open, so that the exact pathological condi-
UoD can be determined.

The opening should be maintained for inspection
sod treatment until the diaease has been cured.

The second portion of the session was under the
charge of the American Neurological Association.

Dr. Jakes J. Putnam, of Boston, read a paper on

THE INFLUENCE OP INFECTIOUS PROCESSES ON THE
NERVOUS 8T8TEM, PATHOLOGT AND ETIOLOOT.

The relation of nervous diseases to infectious proc-
esses may be studied from the point of view of the
bacteriologist or that of the neurologist ; it is the lat-
ter which mainly concerns us now. The nervous
system may suffer from local bacterial action, from the
effects of toxic products, or from the effects of a lower
vitality of the nervous system, making it prone to
show signs of constitutional weakness or fall a prey to
new causes of disease. The term " infection " is here
used for convenience (somewhat loosely) to denote
the action of specific virus as well as that of specific
organisms.

The infectious diseases which would be admitted by
every one to cause nervous affections are tetanus,
rabies, syphilis, tuberculosis, diphtheria, lepra, gonor-
rhoea, typhoid, erysipelas, influenza, mumps, the acute
exanthemata, the pyogenic organisms, the diplococcus
lanceolatus, malaria, actinomycosis. The nervous af-
fections which follow acute infectious diseases are not
always due to that primary infection, but to a second-
ary infection, or they may be only an indirect result.

The diseases of the nervous system which are sus-
pected (but not fully proved) to be of infectious origin
are, especially, beri-beri, poliomyelitis, Landry's dis-
ease ; certain forms of myositis, neuritis and myelitis ;
some of the cerebral palsies of children ; chorea ; dis-
seminated sclerosis and other cerebro-spinal and spinal
scleroses ; amputation neuritis ; herpes zoster.

Finally, we find a number of affections following in
the wake of infections processes, but hardly to be
classed as indicating the action of specific virus. Such
are the constitutional neuroses and psychoses, the
adynamic cerebral affections, the results of cedema or
of arterio-scleroses ; various forms of scleroses of the
spinal cord, to which the nervous system is always
prone, and which any one of various poisons will help
to bring out ; subacute forms of multiple neuritis of
the ordinary type, such as arise from manifold causes.

A disease may be suspected to be of infectious
origin when bacteria are found in the tissues; when
the outbreaks occur in epidemics or are related to
seasons or locality ; when it exhibits vascular and his-
tological changes characteristic of the infection, or
specific toxicity of the blood and urine ; or it has be-
come much less frequent since the introduction of anti-
septics. The discovery of bacteria is by no means con-
clusive, since they are often only incidentally present.
We should suspect a disease of not standing in a very
close relation to infection if it was of a kind devel-
oping under other influences ; and it is therefore im-
portant to study what are the morbid conditions which
occur most easily as a consequence of various general
strains and as a result of heredity. The French
school has done much in this direction. The argu-
ments are strong in favor of the infectious origin of
the different forms of acute (often hasmorrhagic) myelo-
neuritis or polymyositis, including beri-beri (the epi-
demic disease of Northern fishermen), Landry's dis-
ease, poliomyelitis. We can at least say that they are
due to some poison acting powerfully for short periods
and in the manner characteristic of bacterial toxines.
Bacteria have been found in Landry's disease, but are
not yet accepted as specific. Chorea is probably of
infections origin (Pianese, Dana, Berkley). Bacteria

Digitized by

Google

692

BOSTON MEDICAL AND SVBOICAL JOVSNAL.

[JcBK 14, 1894.

have been found which may or may not be specific
Myelitis (acute, focal or transverse,) may be produced
experimentally by injection of cultures. It also may
follow gonorrhoea, and may occur in a manner sugges-
tive of other infectious causes. Amputation neuritis
is said to have become less common since the introduc-
tion of better methods of asepsis. Tliere is little to
be said for the infections origin of zoster.

Acute multiple neuritis may follow almost any one
of the infections processes, but it is difficult to say just
what relation it bears to them. The lesions observed
have more of the vascular and interstitial character
than is ordinarily met with in neuritis of inorganic
origin, but are doubtless often due to the products of
metabolism. Sometimes, as in diphtheria of rapidly
fatal course, no obvious lesions are produced, but
modern research is continually widening our resoarce
in this direction ; witness the recent observations of
Golgi in rabies, and the investigations of Nischl and
others into the pathology of the nerve cell. The
meningitis which follows the exanthemata is probably
due to secondary infection. It cannot, however, be
affirmed that the absence of bacteria indicates the
absence of specific local action in diphtheria and other
affections ; the virus seems to be almost the equiva-
lent of the organism in its power of exciting local re-
action. The meningitis which complicates typhoid,
pneumonia, and perhaps influenza, is generally due to
the primary infection, at least in part. Epidemic
cerebro spinal meningitis and sporadic forms are gener-
ally due to the diplococcus lanceolatus, the same germ
which causes pneumonia ; sometimes also to other
organisms. Recent research has accentuated the im-
portance of purulent and even simple catarrhal affec-
tions of the naso-pharynx and the ear as starting-
points for meningeal affeccions. The specific organisms
liable under favorable conditions to cause meningitis
are often present in even the healthy pharynx.

Sometimes the infective agent seems to make its
way in from the intestinal tract.

If we except the cerebro-spinal membranes, which
are a great breeding-place for many bacteria, we may
■ay that the instances of local bacterial action upon
the nervous system are few, while, on the other hand,
the nervous system is especially prone to suffer from
toxic agents circulating in the blood. These poisons
are sometimes separable into several definite constitu-
ents, which vary as regards their volatility, their solu-
bility in alcohol and their physiological action. Several
of them have a strong tendency to attack the vaso-
motor system in various ways ; and the disturbance of
the circulation thus produced is liable to prevent the
normal vascular dilatation which is so necessary for
the protection of the body against tbe invasion of pa-
thogenic organisms. These poisons affect tbe nervous
system in various characteristic ways, thoagh it is not
improbable that they are capable of acting as universal
neurotic poisons, in tetanus (Brunner) the irritability
of the spinal cord is heightened as in strychnia poison ;
iu diphtheria, the cardiac centres are sometimes strongly
involved, though gross lesions may be absent; in influ-
enza the tendency of tbe poison is towards the brain
more than in the case of some of the analogous diseases.
Besides the psychoses which are common, acute haem-
orrhagic encephalitis occurs.

As regards chronic poisoning or its results, we find
disseminated sclerosis after various acute infections
diseases, and especially after malaria; but it is not

probable that they are due to the action of the specific
virus of this antecedent malady.

The causes which contribute to increase the liability
of the nervous system to suffer from the effects of in-
fectious disease may be divided into two classes :

(1) Those which increase the liability to invasion
of the body by pathof^euic organisms ;

(t) Those which lower the resistance of the nervous
system.

Of tbe latter class are hereditary weaknesses in special
directions, the presence of other poisons in the ner-
vous system, tbe effects of trauma, a poorly acting
vaso-motor system.

Debility of the nervous system may contribute to
increase the liability of the body to invasion by impair-
ing the vitality of the tissues which should resist the
germs of disease, besides impairing the efficiency of
the vaso-motor reaction.

The most important lines of research for the fntore
are in the direction of classifying the special liabilitiea
on the part of the nervous system to disease independ-
ently of infectious causes, the refinement of our methods
of histological research, the more widespread and thor-
ough study of bacteriology and of the means of deter-
mining the toxic condition of the blood and urine.

RELATION OF INFECTIOUS PROCESSES TO HKNTAL
DISEASE,

by Charles K. Mills, M.D., of Philadelphia.

Nearly a century ago. Rush declared that certain
causes as gout, dropsy, consumptiou, pregnancy, and
fevers of all kinds produced madness by acting on tbe
brain in common with the whole body ; and before the
time of Rush and since, this subject has claimed the at-
tention of the medical profession. It is, indeed, only
one aspect of the old humoral doctrine, to which we
now recur with the important aid furnished by experi-
mental research.

Among the questions to be considered are, Whether
the mental disorders of well-known forms of infectious
disease are toxemic, or are due to anssmia, exhaustion
or other causes, and whether particular types of insan-
ity are due to the action of special micro-organisms?
In endeavoring to answer these and similar questions,
we are naturally led to consider inferences and conclu-
sions drawn from, first, clinical and clinico-patbological
observations ; second, from analogies with affections of
the nervous system not psychoses, but which are known
or believed to be of microbic origin ; and third, from
the consideration of the combined clinical, pathological
and bacterial observations and investigations.

Under clinical and clinico-patbological observations
are included the so-called febrile and post-febrile in-
sanities. Regis and Chevalier-Lavaure, in a report at
the Congress of French Alienists iu 189S, and Hurd,
iu a paper published in 1892, have furnished valuable
summaries of the literature of infectious processes in
their relations to mental disorders, and have considered
the subject from various points of view. The former
distinguished mental disorders due, first, to infectioa«
diseases ; second, to visceral disturbances ; and, third,
those associated with diathetic maladies.

While not denying the origin of mental manifesta-
tions and even special types of insanity from other
causes, such as traumatism, anaemia, exhaastion, and
emotional shock, these are sometimes due to tbe action
of infectious intoxication and probably to specific micro-
organisms, although the last cannot he regarded as

Digitized by

Google

Vol. CXXX, No. 24.] BOSTON MEDICAL AND SURGICAL JOURNAL.

593

abaolntely proved. The qaeation of febrile deliriam
and febrile and post-febrile insauity has been especially
considered by numerous observers. A special type of
confusional insanity has been suggested as following
infectious and diathetic disorders. Hurd, Korsakoff
and Tuke and Woodhead favor the idea that this type
of insanity is essentially a toxaemia, and due to a special
poison such as is developed in multiple neuritis, influ-
enza and other infectious disorders. Numerous cases
have been reported by Chomel, Esqnirol, Simon, Hard,
Cbaslin, Lloyd and TuU, Frantzel and Strube, and
Liebermeister. Much negative evidence in favor of
the infectious origin of acute mania or acute delirium
has been furnished by clinico-pathological observations.
In the case of Lloyd and Tull (one of severe acute
delirium or mania), the autopsy revealed nothing posi-
tive, unless it was an uncertain incipient meningitis.

Several similar cases have fallen under the author's
observation. In one case of acute delirious mania
(with hypereesthesia, active contractions and petechial
eruption), the symptoms were highly suggestive of
cerebro-spinHl meningitis, but the autopsy revealed
nothing and the case was apparently one of toxeemia
associated with anaemia. Many other such cases might
be cited.

An argument in favor of the view that the mental
disorders of the infectious diseases are due to toxaemia
rather than to anaemia, exhaustion or other causes, is
furnished by the well-known fact, that such diseases
are sometimes ushered in by violent mental manifesta-
tions, or that such manifestations are the chief features
of the disease which pursues a course largely afebrile.

In considering the analogies with mental affections,
not psychoses or insanities, but which are known or
believed to be of microbic origin, it is only necessary
to briefly refer to such diseases as multiple neuritis,
some forms of myelitis and chorea. The mental dis-
orders of multiple neuritis have now been frequently
recorded ; as also have chronic insanities with mental
manifestations equal in violence to the motor disorder.
The teachings of the recent epidemic of influenza are
important in this connection. Of great interest are
the views of Marie, with reference to the poliomyelitis
origin of the lesions of the white medullary fasciculi
io pellagra. Pellagra is a disease doubtless of infec-
tious origin, with marked nervous and mental mani-
festations associated with the lesions of the skin, and
in which pathological and microscopical investigations
show combined lesions in the lateral and posterior
regions of the spinal cord. Comparing lesions of this
affection with those of general paralysis, and the forms
of sclerosis, it is fair to argue in favor of the possibly
infectious origin of all.

As yet, literature has afforded but few combined
bacteriological, clinical and pathological investigations.
The most valuable contribution thus far is that of
Basori, on the etiology and pathogenesis of acute de-
lirium. Rasori describes in detail a case of acute
delirium, with autopsy, and the results of a careful
bacteriological examination. The autopsy was con-
ducted with the strictest bacteriological precautions.
Two inoculations with subdural fluid led to the devel-
opment of the same micro-organism, a small bacillus
with rounded ends three times as long as its width.
Rasori made numerous experiments, and found that
the micro-organism grew well in different culture media.
He made a series of four inoculation experiments upon
rabbits. The experiments demonstrated that the ba-

cillus obtained from the subdural fluid of the patient
grew and multiplied in the body of a rabbit, and pro-
duced a toxic substance which destroyed the animal,
with symptoms of septicaemia, at a period varying from
one and a half to six days.

In 1893, in consultation with C. S. Potu, of Phila-
delphia, the author saw a case of acute delirious mania
— also taking part in the autopsy on the case — a re-
port of which has since been made by Dr. Potts. Cult-
ures were made from the cerebro-spinal fluid by Dr.
D. Bradeu Kyle, and demonstrated the presence of the
so-called streptococcus lanceolatus, or pneumococcus
of Frankel and Weichselbaum, and also the staphy-
lococcus pyogenes aureus and albas. Microscopical
examination of the cortex showed peri-vascular exuda-
tion and leacocytes in the lymph sheaths and perigang-
liar spaces. Dr. Potts, in reporting the case, sug-
gested that as the germs isolated were those usually
found in meningitis, the lack of microscopic findings
was probably due to the fact that the toxtemia was so
violent as to cause the death of the patient before
naked-eye appearances had time to develop.

Through the kindness of Dr. N. P. Ball, of Phila-
delphia, the author was able to present the report of a
case of acute delirium, with autopsy and the results of
a careful bacteriological examination. The patient was
suddenly attacked with delirium, having previously
been to all intents and purposes in the best of health.
He had marked delusions with hallucinations, and be-
lieved that people were coming to attack him. He com-
mitted suicide. The autopsy revealed under the dura
several fresh patches of exudation ; the pia was glassy,
and covered with two or three spots of a greenish-
white exudate ; the ventricles did not contain the
usual amount of serum. Three small round cysts filled
with a milkish-colored gelatinous fluid were found in
the choroid plexus on each side. Cultures were ob-
tained from the ventricle serum and the contents of
the cysts. The following is an extract from Dr. Ball's
bacteriological report : " In both cases in two days a
fine growth occurred along the needle tracts in a gela-
tine agar tube ; a sparse, whitish growth on the sur-
face of the tube not liquefying. The germ obtained
was a very small bacterium arranged in twos and threes,
resembling micrococci very much, and plainly larger
in one diameter than the other."

Dr. James R. Hunt, of Philadelphia, had furnished
the author with the notes of another unpublished case.
The patient was under the care of Dr. John Ashhurst,
Jr., in the surgical wards of the University Hospital.
He was a German laborer, twenty-six years of age,
who presented a history of obscure renal disease ex-
tending over a period of six years. A distinct resist-
ance was felt in the region of the right kidney, which
was quite tender on pressure. The urine contained
numerous pus ceils, but no blood and no crystals. An
exploratory operation was performed. The man was
irrational immediately after the operation ; and this
state gradually merged into one of moderate delirium,
which on the seventh day actually amounted to mania ;
this lasting until death, which occurred ten days after
the operation. The autopsy was made by Dr. H. W.
Cattell. The right kidney lay in a bed of foul-smell-
ing, somewhat greenish pus resembling tubercular spu-
tum. On section, the renal substance was found infil-
trated with pus, with great destruction of its upper
portion. Examination of the brain and meninges was
negative, with the exception of a slight haziness of the

Digitized by

Google

694

BOSTON MJBDJCJL JJfD SVBGJCJL JOVBUJL.

[JuMK 14, 1894.

pia and some turbidity of the fluid in the lateral ren-
tricle*. Caltures made from the meninges were nega-
tive, bat from the flaid found in the lateral ventricles
a pnre culture of the bacillus pyocyaneas was obtained.
Cultures from the pas in and about the kidney con-
tained yeast and pus organisms, bat not the bacillus or
bluish-green pus obtained from the ventricular fluid.

Interestiug studies sbowiug the toxic and bactericide
action of the blood of the insane have been made by
D'Abnndo, and have yielded interesting results. The
toxaemias of pregnancy and the puerperal state some-
times result in a mental disorder, and are important in
the discussion of this subject. A certain number of
the cases point strongly to an acute intoxication with
the producto of bacteria. In one of a series of cases
reported by Davis, a condition of marked toissmia
(with restlessness, melancholia and other grave symp-
toms) was noted, but in which examination of the
urine failed to reveal casts, albumin or marked defi-
ciency in the urea. Take and Woodhead believe that
in puerperal insanity a considerable proportion of the
cases are due to toxic influences without reference
primarily to childbirth. Olshausen has observed psy-
choses eleven times following eclampsia in two hun-
dred cases. He suggests classifying these cases as
psychoses directly due to febrile puerperal processes,
idiopathic psychoses without bodily or febrile disease,
intoxication psychoses following eclampsia or, excep-
tionally, urtemia without eclampsia.

While, so far as the author has been able to learn,
no satisfactory bacteriological examination has been
made in a case of puerperal mania, Kaltenbaob, or
rather Gerdes under the direction of Kaltenbacb, made
an exact and exhaustive bacteriological examination of
the organs of a woman who died of puerperal convul-
sions ; and the results obtained in this investigation
would have equal significance in the explanation of
fatal puerperal mania. Cultures were made from the
lungs, kidneys, liver and the aortic blood j and in all
cases a growth developed which consisted entirely of a
pure culture of a very short, thick bacillus. Its cult-
ure showed certain characteristic peculiarities. In a
later article Gerdes declared that the eclampsia bacil-
lus is the sole cause of puerperal eclampsia, and is
found in no other disease, and that there can be no
eclampsia without its presence. The infection proceeds
from the uterus, probably from an endometritis ex-
isting prior to conception. The bacteria of puerperal
infection as summarized by Williams, are, however,
the streptococcus pyogenes, the staphylococcus albus
and aureus, the gonococcus and the colon bacillus. He
holds that it is also quite probable that some of the
putrefactive organisms play an imporUut part in what
Matthews Duncan has designated as saprxmia.

Conclusions may be drawn as follows :

(1) Specific infection must be included among the
causes of the mental symptoms, in diseases which pre-
cede, accompany or follow febrile and other infectious
disorders.

(2) Much negative evidence can be adduced to show
that acute delirium or acute mania is doe to toxsemia.
Such evidence is afforded by autopsies which reveal
neither gross or histological lesions ; in these cases the
toxeemia probably overwhelms the patient before the
production of meningitis or other diseases with recog-
nizable structural lesions.

(3) Analogies with nervous affections which are
known or believed to be of microbic origin — such dis-

eases as multiple neuritis, myelitis and chorea — favor
the view that insanities with similar or related phe-
nomena and lesions are also microbic in origin.

(4) The evidence afforded by careful bacteriological
investigation of cases of acute insanity is thus far
meagre ami shows that various micro-organisms may
induce the same or similar types of mental disease.

(5) The mental disorders of pregnaucy and the
puerperal state are in a considerable proportion of the
cases toxasmic without reference primarily to child-
birth ; but it cannot be regarded as proved that a
bacillus of either eclampsia or puerperal mania is the
sole cause of these affections.

THE TBERAPBUTIOS OF INFECTIOUS PBOCE88E8 OF
TBI NEBV008 STSTBM,

by Fbancis X. Debcum, M.D., of Philadelphia.

The consideration of the treatment of infectious ner-
vous processes involves not only the treatment after
infection, but also its prevention. From much that
we know, we have reason to believe that the occurrence
of infection is markedly influenced by the nervoas
system. The ability to resist infection depends largely
upon the maintenance of normal nervous tone. We
have also learned that the nerve cells undergo certain
changes in the course of their fnnctional activity, and
these changes can only be interpreted as those of fa-
tigue. The first problem is the proTention of undue
waste of nervous substance from undue or excessive
fatigue. The necessity for a proper proportion of
sleep and exercise, and suitable food, must be borne
in mind as an important element in prophylaxis.

Are there any means of special prophylaxis against
this or that infectious disease ? Here the answer is
uncertain. The preventive inoculation of Pasteur,
Bebring, Tizzoni and Catanni suggest themselves, but
at the same time doubts as to the advisability and the
applicability of the methods arise.

Again, is there anything that can be done in the
various infectious fevers, in general pysemia, to prevent
nervous infection ? Where the nervous system is
threatened by the existence in other structares of foci
of infection, the indications to remove these foci of
infection is clear.

In regard to treatment, the general indication is to
arrest or limit the infectious process, and to bring
about elimination of the morbid products. To meet
the first indication is not as yet possible ; but the field
of chemistry and of the biological laboratory may in
the future yield great discoveries.-

The attempts to combat infectious microbes by
means of the toxines which they produce was then
considered ; but with the possible exception of tuber-
culosis and lepra, the symptoms produced by infections
micro-organisms appear to be due, not so much to the
germ, as to these very toxines.

With regard to tuberculosis of the nervous system,
the use of the lymph of Koch has been shown to be
not only useless but dangeroas.

in the treatment of leprosy by the use of lymph,
the failure appears to have been almost equally marked.

With regard to hydrophobia, the literature was re-
viewed at length, and the conclusion reached that it
was vain to deny the truth of Pasteur's experimental
researches on animals, while the evidence as regards
human beings in specific instances is strong and con-
vincing.

In reference to tetanus, the condition is still more

Digitized by

Google

Vol. CXXX, No. 24.] BOSTON MBDICAL AND SURGICAL JOURNAL.

695

interesting. A full review of the literature of the
subject was given by the author, who had himself
collected reports of 84 cases treated either by the pow-
der of Tizzoni or by the serum. Of these, 20 cases
were successful, but in some of these cases other meas-
ures such as amputation or early active treatment of
the wound were employed. There is no contra-iodica-
tion to the employment of these antitoxines, as it ap-
pears to be in no way injurious.

The other means at our disposal for combating the
infectious nervous processes resolve themselves into
general remedies, drags and surgical procedures. Cold
has been applied with varying success. It is not im-
probable that baths of suitable temperature might prove
of service in the treatment of infectious nervous dis-
eases. Whether or not by this means the elimination
of toxines would be favored, is a matter that at present
can only be conjectured.

With regard to drugs, we meet little that is encourag-
ing or gratifying. In leprosy, especially, much has
been claimed for gurjon, oil of chaulmoogra. In
chorea, which is probably infectious. Dr. H. C. Wood
has advanced quinine as of considerable value. Anti-
pyrine also has its advocates.

Surgical procedures enable us occasionally to accom-
plish definite and often brilliant rusults. This is espe-
cially true with regard to the evacuation of pus in
positions formerly considered inaccessible, as in brain
abscess.

In conclusion, the author offered a suggestion in
regard to the treatment of tetanus which he thought
might prove of value. It has been observed that the
tetanus bacillus while growing iu thymus iufusiou did
not develop spores, and that animals injected with such
cultures were highly immune to the cultures of tetanus
£rown in other media. If thymus-juice possesses such
■remarkable properties, it should be tested with a view
to its possible therapeutic effect. Its administration,
in a case of tetanus, beneath the skin, could certainly
do no harm, and might do good ; and it might also be
administered by the mouth. If successful, it would
prove far more valuable than the anti-toxiue, because
so readily procured.

This completed the scientific work of the Congress.

The President Da. Alfbed L. Looms, in adjourn-
ing the Congress, congratulated the members on the
fact that registration had been larger at this than at
any other of the previous meetings. The attendance
at the sessions of the various constituent associations
had also been larger, and the work of a high degree
of merit. There had been a united feeling and action
among the different societies in support of the Con-
gress, and the different associations had become more
closely united than ever before. He considered the
Congress to be one of the most important medical
bodies in this country, as it brings together skilled
workers in all the departments of medicine and sur-
gery, and brings about unity of thought and action
among medical men. If there is one body more than
another in this country that is to raise our profession
from the position which it has occupied so long, it is
such a body as has been assembled here for the last
four days.

Cost of tbk Small-Pox Epidemic in Boston.
— The recent epidemic of small-pox cost the City of
Boston nearly $25,000, of which $19,000 was spent for
providing free vaccination.

amebican surgical association.

Annual Mektimo, Washington, D. C, Mat 29, SO,
81 AND June l, 1894.

(Conolndad from No. 23, p. SOT.)
SECOND DAT. — WEDNESDAT.

The first paper read was that of Ds. John S. Bil-
lings, of Washington, on

methods of teaching sdroert.'

This was followed by a paper sent by John Chibnb,
M.D., of Edinburgh, on

the teaching of scroeby.

In discussing this subject one must begin with a
warning. The personal equation relating to himself
and the traditional equation relating to his school must
be allowed for and discounted. The teaching of sur-
gery resolves itself into two heads:

(1) Systematic consideration of general principles
illustrated by clinical examples.

(2) A clinical (bedside) opportunity given to ob-
.serve, to use, and to educate all the faculties, physical
and psychical.

Under either head the teacher must be a learner,
the student must be a teacher. The teacher has con-
stantly to warn the student against a blind belief, and
at the same time he has to speak most decidedly in
giving his opinion. The practice of surgery to be suc-
cessful must be dogmatic.

It has been objected to systematic lectures, that
now that we have books there is no need of a hundred
lectures on any subject. Those who hold these views
can never have known the stimulus of speech ; can
never have felt the electrical impulses passing be-
tween hearer and speaker.

The method of teaching surgery in Eidinburgh was
then described. -

In conclusion, the writer wished to add a word with
reference to the teacher of surgery. He believed in a
fallow time, in a time of rest from mental activity.
The best rest is change of scene. He suggested the
advantages that would accrue from an interchange of
chairs in the great English-speaking educational cen-
tres. In this way once in seven years a teacher would
for a session leave bis alma mater and speak to the
students of another school. Or the fallow might take
another aspect ; give a teacher a session off every seven
years, and let him do in it what seems to him good.

The discussion of these papers was participated in
by Dr. J. Collins Warren, of Boston ; Dr. W. W.
Keen, of Philadelphia; Dr. Hunter McGuire, of Rich-
mond, Va ; Dr. Chas. B. Nancrede, Ann Arbor, Mich. ;
Dr. P. S. Conner, Cincinnati, Ohio ; Dr. W. S. Forbes,
Philadelphia, Penn. ; Dr. Robert F. Weir, New York,
N. Y.; Dr. T. F. Prewitt, St. Louis, Mo.; Dr. John
£. Owens, of Chicago, 111.

THE SDBOEBT OF THE KIDNST,

by L. McLane Tiffant, M.D., of Baltimore, Md.

The subject was such a large one that the author
considered only those points which offers opportunity
for difference of opinion. In the human body bilateral
organs are more than sufficient for the carrying on of
life ; not only may one such organ be removed with-
out impairing existence, but even the remaining organ
may 1)e more or less damaged and yet life be carried
> See Joarml, No. 22, page 636.

Digitized by

Google

596

B0S20N MEDICAL ASD SURGICAL JOVRJUAL.

IJcNE 14, 1894-

ou. Any paper on rargery of the kidney at the pres-
ent day mast take into coDsideration the inflaence of
the disease of the kidney on varions operations of gen-
eral surgery. The influence of anesthesia on the
healthy kidney should be considered. In 150 cases of
operation where healthy kidneys were present, albu-
min was found only in two per cent, of the cases after
operation. Every case of railway accident, and some
other cases where the patient had been exposed for a
certain time, showed albuminous urine ou admission to
the hospital. In these cases operation has not been
deferred on this account. Cases of advanced diabetes
have not been operated on. In cases with healthy
kidneys the amount of urine passed in the twenty-foar
hours following operation is diminished in quantity,
the specific gravity usually being a little higher.

As to wounds of the kidney, there was no good
reason why the kidney should be separated from the
rest of the body and require different surgical treat-
ment. A kidney wound should be exposed, sutured,
drained, tamponed with gauze, or a piece of it excised
in injury beyond repair, or drained, as the case may
be, and not the whole kidney sacriflced. '

Nephritis and pyelo-nephritis, so-called surgical kid-
ney, is generally met with by the surgeon — a process
(organic) resulting from extension upwards of inflam-
mation from the urethra or bladder due to the pres-
ence of bacteria. The bacteriology of the trouble in
question is yet to be written. In so-called pyelo-
nephritis beginning in the kidney, the most frequent
cause is stone. The surgeon has especially to deal
with the ascending inflammation from the uriuary
channel below, more often obstructive. The diagno-
sis is usually not difficult when the disease is advanced.
In the early stages the difficulty of diagnosis is great,
especially is it difficult to recognize whether the trouble
affects one kidney or both. Here it is that the cysto-
scope offers great opportunity. A moderate amount
of urine, with a low specific gravity, and an habitual
low temperature independent of the conditions of the
pulse are danger signals more important than any
others. In the recognition of the kidney affected, we
have to rely on pain, pressure and the cystoscope.
The treatment before operation consists in exciting
the kidneys to secrete by means of infusion of digitalis,
acetate of potassium and infusion of bucbu. Acid
urine and pus suggest pyelo-nephritis very strongly.
It is the author's habit not to operate until the patient's
kidneys are acting well. After operation, strychnine
hypodermically is a useful addition to the previous
treatment. The hot-air bath has proven unsatisfactory
in chronic cases. In acute cases it is beneficial. Free
purgation is of advantage.

Where an operation on the bladder is called for, and
there is evidence of disease of one kidney or decided
pain in one kidney suggesting disease, that kidney
should be operated on at the same time as the bladder.
Twice the speaker had done lithotomy for stone in the
bladder, the lithotomy being done and the kidney opened
at one and the same sitting. All went well. In an-
other stone case, within two weeks, acute suppurative
inflammation took place and was followed by death.
In a second case there was a similar occurrence.

THE SDBOICAL TREATUEMT OF SUBOIOAL KIDNBT,

by EoBEET F. Weib, M.D., of New York.

Suppurative pyelo-nephritis, suppurative interstitial
nephritis and surgical kidney are the ordinary names

given to a disease which originating, as a rule, in the
bladder, generally affects both kidneys. In this
affection the kidneys are congested and studded with
foci of pus. Dr. Delafield states, that so far as be
knows all cases die. While this may be the general
result, a case reported by the speaker shows that some
modification of this prognosis must be made.

H. W., age twenty-five years, was admitted to the
surgical wards of the New York Hospital on April
2, 1894. Four years previously he had scarlet fe-
ver followed by nephritis. About one year ago he
had a mild attack of urethritis. Three months ago
he had a severe attack of urethritis which invaded
the bladder ; gonococci were present in the discharge.
This gradually subsided under treatment. Twelve
days prior to admission to the hospital he had, withoat
assignable cause, a chill followed by fever. The fol-
lowing day there was pain in the loins, with subsidence
of the fever, but the next day the temperature reached
108° F. There was no increase in frequency of uri-
nation. The lumbar tendency gradually increased.
H&was admitted to the medical wards of the New
York Hospital March 28th. During the next seven
days he had four chills, the temperature ranging be-
tween 103° and 105°.

The patient was seen by Dr. Weir April 8d. His
condition was a most serious one. The urine con-
tained pus, and was fifty or sixty ounces in amount.
There was pain in the right lumbar region, with ten-
derness on pressure. It was thought that some en-
largement of the right kidney could be made out The
impression of the speaker was that there was an abscess
of the kidney, or possibly several such of considerable
size. He did not think that it was the " surgical kid-
ney," on account of its one-sided character. On April
4th the kidney was exposed in the usual manner.
Puncture in two or three places gave no evidence of
pus. An incision was made into the kidney, disclosing
numerous miliary abscesses, and showing that we had
to do with ordinary surgical kidney. It was then de-
cided to extirpate the infected organ. Immediately
after the operation the temperature fell from 105° to
99°. The patient made an uninterrupted and rapid
recovery, being discharged on April 2!0th.

It is difficult to say how often the affection is lim-
ited to one kidney, but this may not be infrequent.
Even where both organs are involved, it may he that
something may be done for the relief of tension and
the egress of pus by means of free incision made- into
the kidney substance.

With the happy experience of this case, the reader
considered it hereafter justifiable, if the patient's gen-
eral condition would warrant it, in a case of acute sep-
tic invasion of the kidneys, to make ou one or both
sides an exploratory incision, not only in the hope of
relieving the acute interstitial invasion, but also of
perhaps encountering a larger and well-defined focus
of pus — which pathological condition cannot always
be readily discriminated from the more dangerous le-
sions of the veritable surgical kidney. Should the
symptoms point, as in the case narrated, to one kidney
only, or should a double exploratory incision show
the same result, a nephrectomy may with some hope
be resorted to.

BCRGEBT OF THE DRKTBBS,

by CHBISTIA.N Fenoeb, M.D., of Chicago.

Accidental wounds and subcutaneous ruptures of the

Digitized by

Google

Vol. CXXX, No. 24.] BOSTON MEDIOAL AND SURGICAL JOURNAL.

697

nreter bare not as yet been objects of direct sargical
procedure upon the nreter at the seat of lesion.

Catheterization of the ureters from the bladder for
the purpose of diagnosis has given valuable informa-
tion. The procedure is reasonably practicable in the
female. In man, catheterization is practicable only
through epicystotomy.

Catheterization of the ureter from the bladder as a
curative measure for the evacuation of hydro- or pyo-
nephrosis, has occasionally been performed. This is
more difficult and uncertain than nephrotomy and the
attempt to find and remedy the stenosis of the ureter
from the pelvis of the kidney.

Dilatation of strictures of the female ureter by elas-
tic bougies has been tried from the bladder with tem-
porary success, and from the pelvis of the kidney suc-
cessfally.

Permanent catheterization of the ureter from the
bladder, a fistula or an implanted ureter is often toler-
ated only for a limited time, and must be. employed
with caution.

Uretero-lilhotomy is a safe operation by the extra-
peritoneal method.

Intra-peritoneal ureterostomy should be done only
when access outside of the peritoneal cavity is impossi-
ble, and should be completed by careful suturing, cov-
ering with omental or peritoneal flap, and drainage.

Opening of the peritoneal cavity to locate the seat
of stone may occasionally be necessary ; but when the
diagnosis is once made, ureterostomy should be done by
the extra-peritoneal method.

In valve formation or stricture of ureter causing
pyo- or hydro-nephrosis or a permanent renal fistula,
nephrotomy should be followed by exploration of the
nreter. This is to be done by a long, flexible, silver
probe or an elastic bougie. The size of a bougie that
will pass a healthy ureter is from No. 9 to No. 10,
French scale.

Operation for valve formation should be done through
the wound in the pelvis. A stricture in the ureter, if
not extensive, can be treated by a plastic operation.
Resection of the upper end of the ureter and implanta-
tion of the distal end into the pelvis has been per-
formed with success.

Utero-uterine fistulas can be treated satisfactorily
by plastic closure of the vagina, or nephrectomy. Im-
plantation of the ureter iuto the bladder is, under
favorable circumstances, the operation of the future
for this condition.

Uretero-vsginal fistulas should be treated by vaginal
plastic operation for displacement of the distal end of
the oreter into the bladder.

Complete transverse wounds in the continuity of the
nreter should be treated by uretero-ureterostomy after
the method of lateral implantation if possible. Com-
plete transverse wounds of the upper end of the ureter
should be treated by implantation of the ureter iuto
the pelvis of the kidney. Complete transverse wound
of the ureter near the bladder should be treated by
implantation into the bladder.

Loss of substance of the ureter too extensive to per-
mit of uretero-ureterostomy, or too high up to permit
of implantation into the bladder, may be treated by
implantation on the skin or into the bowel. Implan-
tation into the bowel is objectionable. Implantation
on the skin in the lumbar region may hi^ve to be fol-
lowed by secondary nephrectomy, which, however, is
mach less dangerous thau the primary operation.

THIRD DAT. — THURSDAY.
EXECUTIVE SESSION.

The following officers were elected : President, Dr.
F. S. Dennis, of New York ; Vice-Presidents, Drs. J.
R. Weist, of Richmond, Ind., and J. B. Roberts, of
Philadelphia. Secretary, Dr. M. H. Richardson, of
Boston. Treasurer, Dr. N. P. Dandridge, of Cincin-
nati, 0. Recorder, Dr. DeForest Willard, of Philadel-
phia. Member of Council, Dr. T. F. Prewitt of St.
Louis, Mo.

The next meeting is to be held in New York City.

Dr. Dudley P. Allen, of Cleveland, 0., was elected
to membership.

The following were elected to honorary membership :
Sir Spencer Wells, F.R.C.S., London ; Dr. William
MacEwen, Glasgow ; Dr. M. H. E. W. Schede, Ham-
burg ; Prof. Ernst V. Bergman, Berlin ; Prof. Karl
Thiersch, Leipzig ; Prof. Theodor Kocher, Berne ;
Prof. Jules E. P^an, Paris.

BEGCLAR SESSION.

DISCUSSION ON BENAL AND UBETERAL SUROERT.

(Postponed from Wednesday.)

Dr. M. H. Richardson, of Boston, emphasized the
importance of examination of the urine prior to all
operations. In regard to the method of performing
nephrectomy, he dwelt upon the abdominal method,
the incision being made in front laterally. This en-
abled the operator to control bleeding which was the
chief source of danger in the operation. In this method
the surgeon was able to determine the presence or
absence of the other kidney. He believed that by this
method the mortality of nephrectomy would be greatly
reduced by so providing for haemorrhage that it could
not be an element in the mortality.

Dr. H. H. Mudd, of St. Louis, Mo., agreed with
Dr. Tiffany that in traumatic lesions of the kidney
(even gunshot and stab wound), it is not always neces-
sary to do nephrectomy. He had seen such cases re-
cover. He had also met with a number of cases of
extensive laceration of the kidney from contusion, in
which there was no external evidence of such injury.
Many of these cases recovered without operation.
When operation was needed, he believed that partial
nephrectomy was justifiable. If necessary, a second-
ary operation could be done as a primary operation ;
the removal of kidneys so injured was apt to be disas-
trous.

In pyelo-nephritis and renal lithotomy the first oper-
ation should be tentative, consisting of incision and
evacuation, the kidney being allowed to remain; a
secondary operation being performed if necessary.

He did not favor the abdominal incision for the re-
moval of the kidney, on account of the risk of infect-
ing the abdominal cavity in suppurative conditions of
the kidney, and because the lumbar incision was usu-
ally sufficient, and if necessary it could be extended
and the abdomen opened.

Dr. T. F. Pbewitt, of St. Louis, called attention
to several cases of renal stone, laceration, etc, coming
under his observation. One of these cases was that of.
a man who had passed scales of stone by the urethra,
and in whom operation showed a stone in the pelvis of
the kidney, with several small detached particles. He
was unable to offer an explanation of this separation.
With regard to diagnosis, he held that a large amount

Digitized by

Google

598

BOSTON MEDICAL AND SURGICAL JOURNAL.

[JrNK 14, 1894.

of pug with a small amount of mucus \n the urioe ia-
dicated that the trouble was in the kidney rather than
in the bladder.

Dr. W. S. Fobbes, of Philadelphia, called atten-
tion to the tolerance of the kidney to the presence of
stone. He related a case where autopsy revealed the
presence of a stone iu the pelvis of the kidney, and in
which during life there were no indications of stone.
The character of the stone was peculiar, in that it was
what is known as indigo stone.

Dr. Chas. B. Nancredb, of Ann Arbor, Mich.,
had used the abdominal method of nephrectomy in
four cases, but he did not favor it in suppurative con-
ditions of the kidney. In order to avoid hsemorrhage
he had used an elastic ligature, gradually slipping it
down and removing the kidney piecemeal until the
pedicle was reached. In the treatment of suppression
of urine that may follow these operations he recom-
mended the use of nitro-glycerine, which he had used
with advantage.

Dr. John B. Deayer, of Philadelphia, added his tes-
timony in favor of the anterior incision in nephrectomy.
He felt certain that with proper precautions the dan-
ger of infection of the peritoneal cavity could be avoided.

Dr. Stephen H. Weeks, of Portland, Me., reported
the case of a man who developed an abscess in the
gcoin after having had symptoms of renal colic some
months before. On opening this abscess, pus was dis-
charged, and subsequently a small calculus was passed.
No urine was discharged throngh the abscess at any
time. The sinus has since almost healed.

Dr. William H. Carualt, of New Haven, Conn.,
reported the case of a woman ou whom it was thought
that nephrectomy might be required. Ou preliminary
examination through an abdominal incision, only one
kidney could be discovered. The patient died three
years later, and autopsy showed that the second kidney
was located in the pelvis.

THE treatment OF INOPERABLE KALIONANT TD-
MORS BT THE TOXINE8 OF ERTSIPELAS AND PRO-
DI0I08US,

by Dr. William B. Colet, of New York.

Dr. Goley began the treatment of inoperable sar-
coma by repeated injections of living cultures of ery-
sipelas streptococci, in May, 1891, and continued this
method of treatment in ten cases- (six sarcoma and
four carcinoma) a report of which was published in the
American Journal of Medical Seiencet, May, 1893.

In but four of these ten cases was he able to pro-
duce erysipelas; yet the marked improvement which
in several cases followed the repeated injections where
no erysipelas was produced, led him to believe that
the greater portion, if not all, of the curative action
of the erysipelas, was due to the toxic products rather
than to the germ itself.

The first experiments with the toxines were made
in 1892, with bouillon cultures prepared by heating to
100° C. The effect on the tumors was slightly less
than when living cultures were used.

Early in 1893, he began to use bouillon cultures
filtered through porcelain, without having been sub-
jected to heat. The toxines of bacillus prodigiosus,
prepared in the same way, were used in conjunction
with the toxines of erysipelas. This was done with
the idea of intensifying the action of the erysipelas
upon sarcoma, it having been proven by bacteriolo-
gists that the virulence of the erysipelas germ could be

increased by combining it with the bacilins prodigio-
sus.

The action of the combined toxines has been proven,
to the writer's satisfaction, very much more effective
than that of the erysipelas toxines alone, and to this
combination he attributes the successful results.

The toxines, to be of value, must come from very
virulent cultures, and must be freshly prepared. All
of the successful cases were treated by toxines derived
from cultures from a fatal case of erysipelas.

Twenty-five cases of sarcoma, eight cases of carci-
noma, and two cases of sarcoma or carcinoma, were
treated with the combined toxines. Including one
case treated by the injections of fluid living cultures,
there were five cases in which it was reasonable to
hope for permanent cure.

The first, sarcoma of the neck and tonsil, twice re-
current Has gone nearly three years without treat
ment.

A second, sarcoma of the back and groin, is pep.
fectly well and free from recurrence fourteen months
after cessation of treatment.

A third, sarcoma of the abdomen and pelvis, is in
perfect health one year after leaving the hospital, and
the very small portion of the tumor which had not
been wholly absorbed has remained dormant.

A fourth, sarcoma of the abdominal wall, which bad
entirely disappeared under two and a half months'
treatment with the toxines, is perfectly well and with-
out recurrence three months after treatment was dis-
continued.

A fifth, sarcoma of iliac fossa, is well one year since
beginning of treatment, with the tumor one-third the
original size, and the element of malignancy appar-
ently destroyed.

A sixth, recurrent sarcoma of leg and thigh, is still
under treatment. The sarcoma of the stump, the size
of a hen's egg, has entirely disappeared.

Of the remaining nineteen cases of sarcoma treated,
nine others showed marked improvement, while in
eight the improvement was very slight, and in two no
improvement was noted.

Of the eight cases of carcinoma, all but one showed
more or less improvement, and in three cases it was
very marked.

All of the cases treated were inoperable and hope-
less. In all, the diagnosis was not only established by
eminent surgeons, but confirmed by expert patholo-
gists.

No rational explanation of the action of the toxines
upon malignant tumors could be offered, except on the
assumption that such tumors were of micro-parasitic
origin. Admitting this theory, evidence in favor of
which is steadily increasing, explanation would be
easy, namely, antagonistic bacterial action.

The conclusions drawn from the cases treated, were
as follows :

(1) The curative action of erysipelas upon malig-
nant tumors is an established fact.

(2) This action is much more powerful on sarcoma
than carcinoma.

(3) This action is chiefly due to the soluble toxines
of the erysipelas streptococcus, which toxines may be
isolated and used with safety and accuracy.

(4) This action is greatly increased by the addition
of the toxine; of bacillus prodigiosus.

(5) The toxines, to be of value, most come from
very virulent cultures and most be freshly prepared.

Digitized by

Google

Vol. CXXX, No. 24.] BOSTON MEDICAL AND SURGICAL JOURNAL.

599

(6) The resalts obtained from the use of the toxines,
without danger, are 80 nearly, if not quite, equal to
those obtained from an attack of erysipelaa, that inoo-
nlation should rarely be resorted to.

VENOUS TCMOR OP THE DIPLOfi,

by Dr. Lewis S. Pilchee, of Brooklyn.

The case reported differed from others which bad
been described, in that the tumor did not communicate
with the longitudinal sinus, but was essentially a large
venous cavity into which numerous diploic veins
opened. The patient was a girl, aged fifteen years.
\Vhen five years of age she fell and struck the top of
her head. Within a few days a small, soft swelling
was noticed at the site of injury, without pain or ten-
derness. This gradually increased in size. At the
end of five years, it was lanced and a small quantity
of clotted blood extruded. It immediately refilled.
It was repeatedly opened, with the same result. She
came under the observation of the author in 1894.
At this time there was a prominent tumor over the
sit« of the anterior fontanelle, about two-and-one-half
inches in its largest diameter. Over the convexity of
the tumor the skin was thin and without hair. In the
right anterior quadrant of the base an elevated plate
of bone could be felt. The tumor was soft, and could
be diminished very slightly in size. It was gradually
enlarging. On March 1 4th the author operated for
the relief of this condition. The tumor was opened.
In the anterior part of the base the cranial bone was
wanting and over a space of two-and-onehalf by one-
and-one-half centimetres the dura mater was exposed.
Certain venous channels of the diploe were seen to be
opened, and from these free bleeding took place. The
overhanging bone edge was cut away with bone for-
ceps, the base of the cavity was well curetted, the
cavity packed with iodoform ganze, and as far as pos-
sible the wound was sutured. No complication dis-
turbed the after-course of the case.

8TBANODLATION OF MECKEL'S DIVERTICULUM CAUSED
BY VOLVULUS OP THE ILEUM.*

J. W. Elliot, M.D., of Boston, read a paper on
the above subject.

fourth DAT. — FRIDAT.

mooted points as to fractures of tqb arm,
with notiob of an improved splint,

by J. McFadden Gaston, M.D., of Atlanta, Ga.

The purpose of the paper was to ask attention to
practical considerations touching the treatment of
fractures near the articulations of the arm. In cases
of fracture complicated with dislocation, the author saw
DO advantage in first setting the fracture, but preferred
to reduce the dislocation before treating the fracture,
and efficient means should be taken to prevent the re-
currence of the dislocation.

With regard to fractures at the wrist, the only one
in which there is any notable diversity of opinion is
Colles' fracture, which occurs from half an inch to one
inch from the carpal articulating surface. In most
cases the adjustment can be effected by extension upon
the hand and pressure over the projecting lower frag-
ment, but there is usually difficulty in maintaining ap-
position. The apparatus for Colles' fracture should
control any movement of the wrist or of the fingers.
This is effectually accomplished by the splint originally
> See page 186 of tbe JoamaL

adopted by Nelaton. The dorsal and palmar Nelaton
splints keep the fragments in their proper position, and
with the extension effected by the pistol-handle-shaped
splint, all the requirements are met. Tbe injunction
to leave the fingers exposed, that movements of these
and of the carpal bones may accompany the treatment,
is more likely to increase tbe local inflammation than
tbe rule to maintain complete rest. Early movement
of the fingers and of tbe carpal joint must increase the
tendency to subsequent stiffness. After considerable
experience wit& the double pistol-handle-shaped splint
in the treatment of Colles' fracture, tbe author had
never seen a case in which there has remained any
permanent impairment of the use of the fingers or the
wrist-joint, nor had any material deformity followed
the treatment.

Dislocation of the head of the radius or the upper
part of the ulna is frequently observed in connection
with fractures of tbe lower extremity of the bumeru<>.
These require correction before the fracture is treated.
In considering whether tbe arm should be dressed in
the extended or flexed position, we should investigate
thoroughly the bearings of the different modes of treat-
ment when there is likely to be such inflammatory in-
volvement as so induce anchylosis. A stiff arm in the
extended position is practically useless, while in a
flexed position it is of much service. While it is held
that with proper precautions anchylosis should not oc-
cur, yet there are cases with such complications that
anchylosis will ensue in spite of tbe best treatment.
Where the surgeon cannot reasonably expect to avoid
anchylosis, there is no question as to the necessity of
treating the arm in an angular position. Tbe prac-
tivability of maintaining the fragments in position
where the fracture involves the articulation, is favored
by the relaxed rather than by the extended position.
The rather fanciful claim in favor of the extended
position being favorable to tbe preservation of the out-
ward angularity of the forearm upon the arm is not
entitled to any special consideration, as there is noth-
ing in the flexed position to interfere with tbe relation
of the radius and ulna to the humerus. The comfort
and convenience of dressing the arm in the flexed posi-
tion also commend themselves. The author considered
the use of a straight splint applicable only in fractures
of the olecranon.

In the treatment of fractures near the elbow, the
author applies a roller bandage from tbe fingers to
above tbe seat of injury, and with tbe arm in a flexed
position pasteboard splints are moulded to its inner
aud outer surfaces. These splints extend from tbe
wrist to the shoulder. An internal angular splint
is applied to the outside of tbe dressing until the paste-
board has become thoroughly dry. This dressing has
all the advantages of plaster-of-Paris aud can be re-
moved daily if it is so desired. The results of this
method have been entirely satisfactory.

Fractures near the head of the humerus may be in-
tercapsular or may only implicate the tubercle outside
of the capsule. The most frequent seat is through the
surgical neck. It is for this class of cases that a special
splint has been devised by the author, the object being
to effect extension and counter-extension and keep the
fragments in place and at rest. The splint is formed
with a right angle in the plane of the board at the
elbow, tbe upper branch extending into the axilla with
a crutch-iike termination, and tbe lower branch reach-
ing the wrist. When fitted to the inner face of the

Digitized by

Google

600

BOSTON MEDICAL AND SURGICAL JOURNAL.

[JcKB U, 1894.

arm and secured with a bandage, with a light board
splint moolded to the outer aspect of th'o arm, alt the
conditions are met for retaining the fragmenU accu-
rately in apposition. The arm is to be kept close to
the body. The crutch-shaped branch is the special
feature of this splint. Several case* were reported in
which the splint had been used with success.

THE HEUOVAL OP STONE IN TBB BLA.DDER, WITH
TBB PRESENTATION OF A. NEW LITUOTRITE,

by Dr. W. S. Forbes, of PhiladelpbiaT
The points considered were :

(1) The measured crushing resistance of vesical
calculi.

(2) The litfaotrite from a mechanical point of view.

(3) The measured strength of the lithotrite.

(4) A new lithotrite.

A table was given of the size, displacement, specific
gravity and measured crushing resistance in pounds
and ounces of 183 human vesical calculi. The strong-
est calculus in this group took, on the testing machine,
four hundred and six pounds to crack it. Several took
upward of three hundred pounds to crack them. In
testing the strength of the lithotrites on the testing
machine, the strongest lithotrite (No. 83 F., made by
Tiemann & Co.) had the female blade bent at six hun-
dred and fifty pounds. A Thompson lithotrite (No.
29 F., made by Weiss, London), bent badly at three
hundred and thirty-three pounds, on the same testing
machine. The practical bearing of these observations
is, that the strength of the lithotrite may be tested and
stamped on it, before it leaves the instrument maker's
shop, thus enabling the surgeon to begin his operation
knowing the strength of the lithotrite.

The testing apparatus for determining the force re-
quired to crush the stone and the strength of the
lithotrite was exhibited and demonstrated. The appa-
ratus was the invention of Mr. John S. Forbes, son of
the author. Mr. Forbes has also devised a new lithotrite
designed to furnish a stronger instrument and obviate
some of the defects of former instruments.

extirpation of the lartnx,

by Wh. H. Carmalt, M.D., of New Haven, Conn.

In this case the operation was done in such a way
as to permanently close the opening into the mouth,
BO that there should be no communication with the
lungs. He was induced to do this by his knowledge
of a case in which the larynx was extirpated and the
opening to the mouth subsequently closed. The oper-
ation was done two and a half years ago by Dr. J.
Soils Cohen, of Philadelphia, and the man gained the
power of speaking loud enough to be heard in a large
room. This was preceded by swallowing or drawing
air into the pharynx.

Dr. Carmali's case was that of a man forty-four
years old. The patient came under observation with
severe attacks of dyspnoea due to the presence of an
ulcerated nodule in the larynx, which had been first
discovered two years ago. The dyspnoea necessitated
the performance of tracheotomy. The larynx was ex-
tirpated March, 1894. The upper portion of the
oesophagus was stitched to the epiglottis. On the
second day he was able to swallow fluids, and made
an uneventful recovery. The patient is now able to
speak in a whispered voice.

Dr. Jasvis S. Wight, of Brooklyn, exhibited a
number of instruments, including needle forceps, self-

threading needle, aneurism needle forceps, and a new
form of knife provided with a beak substituting the
use of a grooved director.

The following papers were read by title: "The
Effect of Erysipelatous Attacks on Tuberculosis," by
Dr. DeForest Willard, of Philadelphia; "Hernia,"
by Dr. W. T. Bull, of New York ; '• Cases of Extra-
Uterine Pregnancy, with Remarks," by Dr. M. H.
Richardson, of Boston ; " Treatment of Urethral
Vegetations by a Circular-cutting Curette," by Dr.
John B. Deaver, of Philadelphia ; '* Report of Surgical
Cases," by Dr. Chas. B. Porter, of Boston.

STATE MEDICAL SOCIETY OF PENNSYL-
VANIA.

The Forty-fourth Annual Meeting of this Society
convened in Philadelphia, May 15th to I7th inclusive,
the sessions being held in a vacant church building at
Twelfth and Walnut StreeU. Dr. H. 6. McCormick,
of Williamsport, was President. There were 520
names of delegates and members enrolled upon the
register, making it the largest meeting in the history
of the organization. It may also be said that the pro-
gramme, under the efficient management of the Com-
mittee on Arrangements, Dr. E. E. Montgomery,
Chairman, was the best ever presented to the Society.
Unfortunately, so many papers had been prepared that
more than half bad to be read by title only, and there
was but scanty time to discuss others, even on most
important topics. As the rule, the contributions were
on practical clinical subjects and in quality were excel-
lent; in consequence, the forthcoming volume of trans-
actions will be of more than usual value.

Addresses of Welcome were delivered by Hon. Ed-
win S. Stuart, Mayor of Philadelphia, and by Dr. E.
E. Montgomery.

The Secretary of the Society reported a total mem-
bership of 2,500, with an increase greater than the
average during the past year. The Treasurer, Dr.
Geo. B. Dunmire, reported a balance on hand of nearly
two thousand dollars, all expenses for the year having
been met.

Dr. H. G. McCormick, Chairman of the Legislative
Committee, reported the enactment of a law establish-
ing a State Medical Council and three State Boards of
Examiners and Licensers. The first examination of
physicians for authorization to practice in Pennsylva-
nia, will be held in Philadelphia and Pittsburgh on
June 11, 1894. In order to aid the State Board in
its work, the following resolutions, prepared by a com-
mittee, were submitted and adopted :

Resolved, That the Secretary of each county society is
requested to forward at once to the Secretary of the' State
Board of Medical Examiners a correct list of registration
of doctors under the last Act, on and from the 1st day of
March last, and quarterly thereafter; and in commanuies
where there are no county societies, the President of this
Society shall appoint a member of this Society living in
such county to procure such list, and in any case of neg-
lect by either the officers aforesaid or the appointee to
send such a list, the Secretary of the State Board of Med-
ical Examiners of this Society shall be empowered to pro-
cure the same ; and further be it

Resolved, That we recommend that $500 of the moneys
of the Society, or so much thereof as may be necessarv, be
appropriated for the examination of the registration m
physicians in this State, with the view of enforcing the

Digitized by

Google

Vol. CXXX, No. 24.1 BOSTON MEDWAL AND SURGICAL JOURNAL.

601

Medical EzaminerB* Act lately passed, said moDey to be
expended only under the direction of the State Board of
Medical Examiners representing this Society, and that
they shall approve all billa before being paid. Further,
that the said Board of Examiners report at the annual
meeting of this Society their action and expenditures
under uiis resolution.

A resolution was also unanimoDsly passed calliug
upou the Medical Council and State Boards in all their
publications to refrain from applying any sectarian
designations to members of this Society or candidates
from regolar colleges applying for examination. The
Luzerne County Medical Society also entered a formal
protest at this meeting against the use of the word
" alopath " in the public prints, to designate non-
sectarian physicians.

The Trustees of the Journal of the American Medi-
cal Association were criticised severely for permitting
quack advertisements and other nnethical matter to
appear in the Journal. With regard to the proposal
to alter the Code of Ethics (which will come up at the
San Francisco meeting) this Society unanimously voted
to instruct its delegates to oppose any alteration in the
National Code.

The subject of " The Care and Treatment of the
Insane and the Organization and Construction of Hos-
pitals for the Insane " was brought up by Dr. Hiram
Corson, and was referred to the Committee on Legisla-
tion. At its last session, a committee had been ap-
pointed to memorialize the Legislature on this subject,
and the Senate had passed the bill proposed by this
comnaittee, but it had been lost in the House of Rep-
resentatives. This committee reported as above stated,
and was discharged.

Dr. J. A. Lippincott, of Pittsburgh, Chairman of
Committee on Contagious Ophthalmia, reported that
circulars bad been sent to prominent ophthalmic sur-
geons throughout the State soliciting co-operation.
The committee urged the careful inspection of immi-
grants at ports of entry, for trachoma, and proper
treatment of all such cases. The great danger lies in
the general ignorance of the gravity of the disease.
Dr. George M. Gould offered resolutions with regard
to the legal restriction of ophthalmia neonatorum,
which was adopted.

Resolutions were also adopted deprecating the crip-
pling of the army medical service by the proposed re-
duction of appropriations, which would not only greatly
impair its efficiency, but would seriously imperil the
very existence of the Army Medical School in Wash-
ington.

Oa the third day of the session considerable time
was devoted to a discussion on Tuberculosis, which
was the principal medical feature of the session. It
was really opened by the Address in Hygiene, de-
livered by Dr. J. H. Wilson of Beaver, in which
special attention was directed to the means recently
proposed for restricting the communication of the dis-
ease by means of disinfection and isolation under the
control of State and County Boards of Health.

Papers were read by A. M. Cooper on " Psychical
Phases of Tubercular Folk " ; by Lawrence M. Flick
on " Prophylaxis " ; by Thomas J. Mays on " Strych-
nine Treatment " ; by Daniel Longaker on " Tuber-
cular Meningitis " ; by S. S. Cohen on the " Cura-
bility and Treatment of Pulmonary Tuberculosis."
Dr. Wm. P. Munn, a delegate from Denver, read a
valuable paper on "Colorado Climate" extolling its

comparative dryness, amount of sunshine, and free-
dom from infection. In the general discussion, Drs.
J. S. Cohen, J. C. Wilson, J. M. Andus and others
participated. No less than six papers upon allied
topics had to be read by title on account of the expira-
tion of the time.

The paper that attracted most attention at this
meeting (and the only one published in exlenso in the
newspapers), was read by Dr. Hildegarde H. Longs-
dorf, of Carlisle ; it was on " Christian Science in its
Relation to the Medical Profession," and accounted
for the existence of this mirage of modern medicine as
a psychical manifestation, growing out of the love of
mystery and the revolt from materialistic character of
modern science. It is a "fad" especially liable to
spread among a hyperaesthetic and ignorant leisure
class, whose ills are largely neurasthenic, or entirely
imaginary. On motion, a thousand copies of the
address were directed to be printed for distribution to
the laity, under authority of this Society.

A very interesting lecture on " Leprosy and the
Leper Settlement in the Sandwich Islands " was de-
livered, by invitation, by Prof. Benjamin Sharp, M.D.,
of the Academy of Natural Sciences of Philadelphia.
It was illustrated by photographs and lantern slides
thrown upon the screen, which Dr. Sharp had made
while on a visit last year to Hawaii. It forms a valu-
able contribution to the subject.

The Address in Surgery was delivered by Dr. G.
D. Nutt, of Williamsport ; that in Medicine, by Dr.
W. F. Foster, of Pitteburgh ; in Mental Diseases, by
Dr. T. M. T. McKennan, of Pittsburgh ; in Obstetrics,
by Dr. E. E. Montgomery, of Philadelphia ; and on
Ophthalmology, by Dr. Geo. E. De Schweinitz, of
Philadelphia.

The President's Address, by Dr. McCormick, was
delivered in the evening, and was followed by a re-
ception by the Faculty of the Jefferson Medical Col-
lege at the Academy of the Fine Arts. Other enter-
tainments were given by the Medico-Cbirurgica)
College, the University of Pennsylvania, the Medical
Club, and by the Philadelphia County Medical Society,
the latter being a Theatre Party followed by a recep-
tion.

The following oiScers were elected for the year:
President, Dr. John B. Roberts, of Philadelphia;
First Vice-President, Dr. S. C. Stewart, of Clearfield ;
Second Vice-President, Dr. J. A. Lippincott, of Pitts-
burgh ; Third Vice-President, Dr. J. H. Wilson, of
Beaver ; Fourth Vice-President, Dr. R. Armstrong, of
Clinton ; Secretary, Dr. Wm. B. Atkinson, of Phila-
delphia ; Treasurer, Dr. Geo. B. Dunmire, of Phila-
delphia.

Next place of meeting, Chambersburg, Dr. George
S. Hall, Secretary of Committee on Arrangements.

Tdbercdlosis in Domestic Pets. — Professor
Frohner, of the Berlin Veterinary School, has recently
made some investigations as to the prevalence of tuber-
culosis among small domestic animals, the results of
which are as important as they are interesting. He
finds it rare among dogs, somewhat more frequent
among cats, and quite common in parrots. At the
latter usually live in rooms constantly used by mem-
bers of the family, their liability to tuberculosis makes
them rather dangerous pets.

Digitized by

Google

602

BOSTOS MEDICAL AS J) SURGICAL JOVRJSAL.

[JdNB 14, 1894.

THE BOSTON

iReDtoal ann Surgical 3|oumal.

THURSDAY, JUNE 14. 1894.

A j:amrnal i^MttHektt, Bmrgtrf. amd Allied aetmen.ptMlthtd at
Boikm, wttklp, bp ih* tmdtnigned.

Sumckiptioh Txkms : 96.00 ptr year, to euivaiMC, pottage paid,
far the United Sfatet, Canada and Mexico f9t.t»per year for all for-
eign eomUriet belonging to the Poetal Union.

All eommmnioatiene for the Bdtter, amd eUl hooke for mri«w, ehonU
beaddreeeedtothe Bd%lor<^the BotlonMeMealamd awrgtealJoamal,
283 Wathingtoin Street, Boeton.

All letter! oontaiming tiutaeM eommtmioationt, or referring to the
fnUieation, tuteeripUon, or adt/erUetnt d^fm imtnl of Ud* Joamal,
thouU be addrtteed to the wndereigned.

Jtemittaneee tkould be made bg noMy-order, draft or rtgiettred
letter,pagaNt to

DAMRKT.I. * UPHAH,
188 WABRmoTOH Stuxt, BoiTOH, Mass.

THE TWENTY-SECOND ANNUAL REPORT OF
THE BOSTON BOABD OF HEALTH.

The annual report of the Boston Board of Health
for the year ending January 81, 1894, contains, in addi-
tion to the usual valuable tables and charts, some in-
teresting statements and some important recommenda-
tions. The death-rate per 1,000 inhabitants for the
year was 24.02. Inflaenza b still held responsible in
a great measure for the large increase in respiratory
diseases. The prevalence of pneumonia during the
year is reported as having assumed a character un-
equalled in the registration of vital statistics in thi-
city.

In 1851, its percentage to the total mortality was
7.75; in 1898 it was 13.15 per cent., or a total of
1,540 deaths from this cause alone. On the other
hand, the percentage of the total mortality from zy-
motic causes is less by .49 per cent, than for the year
1892, or 17.43 per cent, of the total number of deaths.
The deaths from diphtheria increased 62, while the
deaths from scarlatina decreased 1 4, as compared with
the preceding year.

The Board finds that it is with the diseases over
which control cannot be exercised that death claim.s
the largest number of victims. The diseases of a con
stitutional character numbered 2,469, or 21.08 per
cent, of the total mortality, and those of a local char-
acter, as pneumonia, bronchitis and heart disease, and
the like, amounted to 5,712 deaths, or 48.77 per cent,
of the whole number of deaths. There were also 572
deaths due to violent causes.

The number of children who died under five years
of age was 8,987, or .80 per cent, higher than in 1892,
but 1.15 per cent, less than the average for the pre-
vious ten years.

There was no epidemic during the year.

Some interesting items are given concerning the
cases of small-pox which have occurred during the
winter, exhibiting in a striking manner the value of
vaccination. From October 30, 1898, to January 31,

1894, there were in all 36 cases. The percentage of
deaths among the un vaccinated was 29.62. No vacci-
nated person died, and no vaccinated person was
seriously ill. A mother nursed her infant, who had
the disease, during the whole course of the attack, bat
the mother had two perfectly characteristic scars
and did not contract tiie disease. Two vaccinated
children, relatives of a patient, were constantly ex-
posed from three to four weeks to the disease, and did
not become ill. Of the 19 cases occurring in Ward
19, which were trace<l to an unrecognized attack of
the disease, only one vaccinated person contracted it ;
and this patient, who had been vaccinated forty-five
years ago, had such an extremely mild attack that, if
it had not been for the existence of the other cases,
the disease would probably not have been recognized.

The city of Boston made an extra appropriation of
$25,000 for free vaccination, and, in round numbers,
about 100,000 persons were vaccinated under direc-
tion of the Board of Health. If one compares the
condition of Boston to-day with that of Chicago in
regard to small-pox, any candid person must recognize
that the energetic action of the Board and the sum of
money have been well spent, to the great advanti^
of this city and its inhabitants.

Under the head of '* Contagious Diseases," the re-
port draws a sharp and instructive contrast between
wliat the Board has been enabled to do during the last
twenty years in restraining and suppressing small-pox,
and its enforced comparative helplessness in its rela-
tion to such diseases as diphtheria, scarlet fever and
typhoid fever. During that period small-pox has di-
minished to almost nothing, whilst the other diseases
have continued practically endemic, as during the pre-
ceding period of twenty years. During the last twenty
years there have been only 34 deaths from small-pox,
and during the same time there have been 8,245 deaths
from diphtheria, 8,281 deaths from scarlet fever, and
3,376 deaths from typhoid fever. Against these dis-
eases the're is, as yet, no prophylactic treatment such
as we possess in vaccination against small-pox. Early
recognition and report of cases, isolation untU all
power to impart the disease is lost, and timely disin-
fection, are the means by which these diseases may be
controlled. The proper application of these means
involves expense.

The Board of Health has repeatedly asked for an
appropriation with which to increase its care for the
uncontrolled cases of diphtheria and scarlet fever, and
it has as often been refused. " The Board would like
to have all cases seen by its own physicians or agents,
held under proper surveillance while at home, and
released from isolation only on the certificates from
the same physicians or agents. It would like to aid
in having all doubtful cases of sore throat decided by
expert bacteriological examinations, and have all cases
of diphtheria discharged from isolation by mejins of
the same tests, or after a prolonged isolation when all
local and general symptoms of the disease have dis-
appeared. To do this the department must have more

Digitized by

Google

t. CXXX, No. 24.] BOSTON MBDIOAL ASD SURGICAL JOURSAL.

603

dical &gent8, and have its present medical officers
leved from daties now performed for other depart-
nts of the city."

1 n regard to diphtheria, the Physician of the Board,
". J. H. McCoUom, emphasizes his conviction, as the
suit of careful personal study of the subject, that the
»nifest importance of a bacteriological investigation
' a means of diagnosis iu doubtful cases of diphtheria
becoming more and more evident, and of no less
aY>ortance, as far as the well-being of the community
concerned, is the bacteriological investigation of
jses after apparent recovery from diphiheria.

In an endeavor to diminislf the prevalence of this
isease, tlie two most important factors, in Dr. Mc-
IJollom's judgment, are : first, the recognition of mild
ind doubtful cases ; second, the actual disappearance
>f the special germs of the disease, which can only be
'ecosnized by means of a bacteriological investigation.
In New York this conviction has reached the stage of
practical application.

An appropriation of money for protection against
the spread of infectious diseases does not fnmbh places
ior " workers " or work for voters ; but there is abso-
lutely no object through which an intelligent and
faithful application of a sum of money, and that of
moderate amount, can be made to yield such valuable
returns to a community like that of Boston. Few will
be found to deny this, and yet such an appropriation
is not to he had. The city might even better be with-
out a park or two, or at least without some of the
very costly elaborations of a Park System !

SUNSHINE AND MICROBES.

Prop. Pekct Fbankland has written an article in
the May number of the Nineteenth Century, on " Sun-
shine and Microbes," which is interesting as a summary
of what has been discovered on the influence of the
sun's rays on bacteria. The first and most important
step in revealing the cleansing and disinfecting proper-
ties of sunshine was made sixteen years ago by two
Englishmen, Downes and Blunt. They established
the remarkable fact that if certain liquids capable of
undergoing putrefaction were exposed to the direct
rays of the sun, they remained perfectly sweet, whilst
exactly similar liquids kept iu the dark became tainted
and exhibited innumerable bacteria under the micro-
scope.

They also ascertained that the oxygen of the air is
a powerful adjuvant to the bactericidal power of the
sun's rays. Recently, M. Moment in Pasteur's In-
stitute, has obtained more exact information confirming
these experiments by e'xposing anthrax-bacilli to sun-
shine in the presence of and in the absence of air, with
the result that while the anthrax-bacilli exposed to the
sun and air were killed in two and a halt hours,
similar bacilli placed in a vacuum were still alive after
fifty hours' exposure to sunshine.

The next problem to be attacked was to ascertain
whether all the solar rays were equally responsible for

this important result, or whether the different colored
rays composing the sun's beams produced different
effects, as is known to be the case in those important
vital processes which go on in green plants.

Geisler, of St. Petersburg, has given especial atten-
tion to this question. He decomposed the white sun-
beams by means of the prism and then exposed typhoid
bacilli to the light of the various parts of the spectrum.
The rays of the red end be found had little or no
effect at all on the growth of the bacilli, whilst the
most powerfully deleterious tuition was obtained in
the ultra-violet, the effect becoming less and less
marked in passing from this to the red. The rays
which exert this destructive or inhibitory effect on
bacterial life are precisely those which also exert the
most powerful acdon on the ordinary photographic
plate.

Of much interest also is the comparison made by
Dr. Geisler of the potency of the sun and the electric
lights respectively in destroying bacterial life. His
experiments have proved the striking inferiority in
this respect of the most dazzling of artificial lights in
comparison with sunshine.

Even if exposure to the solar rays is not sufficient
to actually destroy the bacteria, it may yet profoundly
modify fheir character, and bring about the most im-
portant changes in their subsequent behavior. Thus,
while many bacteria can produce the most wonderful
colors — yellow, orange, scarlet, crimson, indigo-blue,
etc., it has been found that exposure to sunshine for a
short time is able to rob them of this beautiful
property.

Much hygienic importance and interest attaches to
some recent investigations of Dr. Palermo, of Naples.
The microbe selected for experiment was Koch's
cholera bacillus. These bacilli are fatal to guinea-pigs
in about eighteen hours. Dr. Palermo placed some
of these bacilli iu the sunshine for various periods of
time, and found that whilst, when he protected them
from the sun, they killed guinea-pigs in eighteen hours
as usual, after they had been " sunned " for from three-
and-a-half to four-and-a-half hours, they were perfectly
harmless, and the animals experienced no evil results
whatever from inoculation with them.

The cholera bacilli which refused to kill the guinea-
pigs had not been destroyed, nor had their total num-
ber suffered any diminution, but their inability to work
mischief was directly due to the removal during this
exposure to sunshine of their virulence or disease-pro-
ducing powers. More than this, it was found that
those guinea-pigs which had survived the inoculation
with these sunshine-exposed bacteria had acquired im-
munity toward the disease. Thus, when eight days
later they were inoculated with virulent cholera bacilli,
they were unaffected by doses which to ordinary
guinea-pigs proved rapidly fatal.

Dr. Frankland has experimented to ascertain the
action of sunshine on the spores of anthrax suspended
in water, and has found that in this medium they are
able to survive as much as one hundred hours or more

Digitized by

Google

604

BOSTON MBDICAL AND SVBGJCAL JOCBXAL.

[Jink 14, 1894.

of full sunshine, whilst in ordinary culture materials,
like broth and jelly, they are generally killed by a few
hours exposure to the sun's rays. He has also found
that the addition of common salt greatly increases the
destructive action of sunshine on anthrax s|)ore8.

In order to ascertain the effect of daylight on the
bacteria of a running stream, two young German
bacteriologists lately carried on an interesting experi-
ment on the river Isar near Munich. They sat a
whole night by the river bank, from six in the evening
till six on the following morning, determining the num-
ber of microbes in the water at various intervals of
time. The experiments were made towards the end
of September, and they commenced their watch about
sunset at a quarter past six in the evening. At this
time, one hundred and sixty bacteria were found in
twenty drops of water ; but at three and four o'clock
in the morning, when the water had therefore been
for several hours in darkness, there were more than
twice and even three times that number of germs pres-
ent, indicating that in the absence of their deadly foe,
the sunshine, they had multiplied with great freedom
— only, however, as was found when morning ap-
protushed and day wore on, to be kept once more in
subjection and reduced in number.

"These experiments were, of course, made with water
taken from the superficial layers only, but it is ob-
viously of particular interest to ascertain whether this
destruction of bacteria can take place also beneath the
surface of the water, and if so, to what depth the sun's
rays can exercise this inhibitive power.

MEDICAL NOTES.

A New Mobour fob Philadelphia. — The De-
partment of Public Safety of Philadelphia has com-
pleted the new city morgue on Wood Street, Phila-
delphia, and the building was open to physicians'
inspection on Jane 1st.

A RoTAL Method of Paying the Doctor. — A
correspondent of the Medical Record sends the follow-
ing anecdote, which the late Prof. Edward Jiiger, of
Vienna, related of bis father (at that time the first
oculist in Europe), and of Milosh Obreuovicb, who
then was the first Prince of Servia: "Milosh had
cataract of both eyes. Jager operated for him on one
eye with good result. Milosh paid for this operation
6,000 ducats (nearly $10,000). When Jager had
operated on the second eye, and the result was happy
again, Milosh sent him this time 8,000 ducats. Later
they met at the table of Prince Mettemicb, and were
seated one next to the other. Jager asked his neigh-
bor why he had only given him 3,000 ducats for the
second operation. Milosh, with the cunning smile of a
savage or a peasant, answered : ' If I bad had a third
eye to be operated on, I would no doubt have paid
you again 6,000 ducats for the second operation.'
May not his sublime Highness, the Shah of Persia,
feel inclined to play a similar trick on Dr. Galezow-
sky?"

"What Shoold a Doctor bb Paid?" — This
is the subject discussed by Dr. W. A. Hammond in the
June number of the North American Review. Our
readers will be glad to learn that, under certain circum-
stances, $500,000 would be a moderate fee. The
Lancet (June 2d) publishes an address by Dr. Dickin-
son, on " Professional Remuneration." Dr. Dickin-
son's treatment of this topic is less exhilarating.

BOSTON AND NEW ENOLAND.

Acute Impkctiods Diseases in Boston. — Dur-
ing the week ending at noon June IS, 1894, there
were reported to the Board of Health, of Boston, the
following numbers of cases of acute infectious disease:
diphtheria 89, scarlet fever 56, measles 15, typhoid
fever 5.

BoTINE TdBEBCULOSIS at the MASSAOBCSETTg

State Industrial School. — A second herd of im-
ported cattle at the State Industrial School at Lancaster
has been found affected with tuberculosis and the cattle
have all been killed.

Medical Registration Law. — The Medical
Registration Bill has passed both branches of the Mas-
sachusetts Legislature and received the Governor's
signature. The full text of the bill has already been
published in the Journal.

The Rockland, Me., Shall-Pox Hospital
Burned. — The house selected by the Rockland,
Me., Board of Health for a small-pox hospital was
burned June 8tfa. It is supposed that the fire was set
by some one opposed to a quarantine hospital in that
locality as the neighbors had already made much com-
plaint of the selection.

Suffolk District Board op Censors. — The
Board of Censors of the Suffolk District Medical
Society will hold an adjourned meeting for the exami-
nation of candidates for the Massachusetts Medical
Society on June 26th. -This meeting is held for the
convenience of students now taking their final exami-
nations in the Medical School.

The Boston Citt Hospital Club. — The Execu-
tive Committee of the City Hospital Club has voted
that in future the annual dinner of the Club be held
some time during the winter months, instead of in
June, as has been the c&se heretofore. It has been
decided to hold the next dinner on the first Wednes-
day in February, 1895. It is proposed to make the
annual meeting of the Club coincident with the dinner.
No quorum being present at the annual meeting called
for Tuesday, June 12tb, an adjournment was voted to
the first Wednesday in February, or subject to the
call of the Executive Committee.

Mrs. Ahort's Bequests to Hospitals. — The
will of the lata Mrs. Jeanne P. Amory of Braintree
directs the executors to sell within two years all her
right, title and interest in the real estate at 1 1 1 West
57th St., New York City, and to divide the net proceeds
equally between the Massachusetts General Hospital

Digitized by.

.Google

Vol. GXXX, No. 24.] BOSTON MEDICAL AND SURGICAL JOURNAL.

605

in Boston, the City Hospital in Quincy, Mass., the
Woman's Hospital and the Skin and Cancer Hospital,
both in the city of New York.

Thb New Contagiods Hospital at Waltham,
Mass., not Accbpted bt tbb Board or Health.
— At its recent meeting the Waltham Board of Health
refused to make use of the new contagious hospital on
the ground that there are serious defects in its construc-
tion which render it unserviceable. The reasons they
give are : first, that there is no cellar ; second, there is
no adequate method of heating; third, no provision
has been made for proper venlilation ; fourth, that the
diphtheria and scarlet fever wards are too near each
other; fifth, that there is no satisfactory method of
procuring hot water. The desired alterations are esti-
mated to cost over three thousand dollars.

The Massachdsetts Dental Society. — The
Massachusetts Dental Society held its annual meeting
in Boston on June 7th, 8th and 9th. The following-
named officers were elected for the ensuing year :
President, J. King Knights, D.D.S., of Hyde Park;
First Vice-President, George A. Maxfield, D.D.S., of
Holyoke; Second Vice-President, Waldo E. Broad-
man, D.M.D., of Boston ; Secretary, Edgar O. Kins-
man, D.D.S., of Cambridge ; Treasurer, Edward Page,
M.D., D.M.D., of Charlestown ; Librarian, Thomas
W. Clements, D.D.S., of Brookline ; Executive Com-
mittee, Harry S. Draper, D.D.S., George C. Ains-
worth, D.D.S., Joseph T. Paul, D.M.D., all of Bos-
ton ; H. P. Cooke, D.M.D., of Worcester, and Robert
T. Horn, D.D.S., of Brookline.

NEIir TOKK.

Fatal Poisoning kboh Water Hemlock. — Five
lads were fatally poisoned and six others made seri-
ously ill at the Institute of the Sisters of Mercy, at
Tarrytown on the Hudson, on June 4th, by eating
what they supposed to be sweet-fiag root. The root,
which was dug up by laborers engaged in laying some
drain pipes in the grounds of the institution, has been
pronounced by Dr. N. L. Britton, Professor of Botany
in Columbia College, and Dr. H. R. Rusby, Professor
of Botany in the New York College of Pharmacy, to
be that of the water hemlock. In most of the fatal
cases death resulted within half an hour after the poi-
sonons herb was eaten.

Reported Death from Vaccination proves to
BE Untrde. — A short time since the announcement
was made in the newspapers that a child three years of
age had died from the effects of vaccination by one of
the Board of Health's corps of vaccinators. The case
was referred to the coroner's office for the death-certif-
icate, as the attending physician had seen the child too
short a time before its death to feel justified in making
a certificate. The deputy coroner reported that death
was due to tetanus induced by septicemia which was
the result of vaccination. The Board of Health felt
satisfied that death was due to other causes, and
ordered an investigation. On inquiring of other phy-
sicians who had seen the child, it appeared that the

cause of death was most probably a traumatic meningi-
tis. An autopsy confirmed this diagnosis, and the
coroner filed a new certificate of death from " Exhaus-
tion resulting from convulsions from acute meningitis
due to a fall."

OPERATIVE SURGERY UNDER DIFFICULTIES.

The recent death of Mr. Dickinson Crompton re-
calls the following story ^of a surgical operation which
he performed in bis earlier years under great diificulty.
He told the anecdote as follows :

" Some years ago I was called in the night to go to

M to an accident, prepared to amputate. I found

a poor laborer lying on his cottage bed, his left arm
hanging over the edge of the bed, dropping blood into
a chamber pot. The arm was black, as if it had
already mortified. I heard that the man's arm had
been caught in the cog-wheel of one of the agricultural
machines, and was drawn in up to the shoulder. There
was nothing for it but amputation above the injured
part — in fact either close to the head of the humerus
or by disarticulation of the whole. There was no room
for a tourniquet, and I requested Mr. C, the surgeon
of the village, to press upon the artery against the
head of the bone.

" There was a boy in the room — an apprentice, I
was told — but he declined to come near the patient
to hold out the arm. I was therefore obliged to bold
the artery against the head of the bone with my left
hand, while Mr. C. held the arm out at full length by
the hand ; but he told me he always ' fainted at the
sight of blood ' ; so turning his face and body away as
far as possible, he held on till I had made my incision
and sawn through the bone as high as I could.

" There was only a cottage candle in the room, and
therefore I asked Mr. C. to hold it, so that I could
look for the arteries, but he had had enough.

" The poor patient was sitting on a chair making no
complaint ; in fact I think there could not have been
much pain felt, from the appearance of the parts; so
he himself said, ' Sir, if you will give me the candle, I
think I can hold it.' This he did, bringing his right hand
round with the candle in it, so that I had a good view
of the face of the stump. I was delighted to get my
tired thumb and hand free, when I saw the orifice of
the brachial and could pull it out by the tenaculum,
and left it hanging till I could tie the artery, and so
with the smaller vessels. After that I had no further
difficulty, as only one or two small arteries seemed
inclined to bleed.

" The man recovered, but I heard he died of phthisis
six months afterwards."

THE FIRST EPIDEMIC OF MEASLES IN SAMOA.

The virulence of a first epidemic of measles among
a new race is well known, but actual occurrences un-
der medical observation are not so common as to be
uninteresting. Dr. S. H. Davies of Savaii, Samoa,
publishes a brief account of the first epidemic of measles
in that group of Islands.*

" It was brought first to Tonga in June, 1898, where

'■ Birmingham Medical BeTleir, Mhj, tft94.
> Aiutraflan Medical Gazette, Aprtl,;18M.

Digitized by

Google

606

BOSTON MBDIOAL ASD SURGICAL JODRNAL.

[JoNE 14, 1894.

it nearly decimated the population. Three moDthg
later the same vegBel brought the disease to Samoa.
The entire population of the ten inhabited islands of
the Samoa group is about 34,500; and bj the first of
this present year folly one thousand persons had died
from measles, nearly half being adults. The epidemic
was mild in its onset, and comparatively few died dur-
ing the period of fever and eruption.

" The mortality from measles has arisen principally
from the complications of gastritis, enteritis, diarrhoea
and dysentery. A few died from suppressed measles.
But the craving the natives have for raw fish, unripe
or over-ripe fruit, and e*/><eta%half-cookedyrMA/>or£,
became morbid during the period of convalescence.
Many, lest they should be told to abstain from these,
avoided foreign medicine. Nine-tenths of the deaths
might have been prevented by care in diet. The worst
cases of diarrhoea and dysentery yielded to treatment,
and there were no deaths among those who followed
instructions, and who were under one's own personal
supervision. Since measles arrived, an unusually large
number of these people including many adults, with
their usual predisposition to scrofula, have suffered
from the suppurating glands in the neck, submaxillary
region and groin. Not a few had parotitis, going on
to suppuration. During period of fever and rash there
were numerous abortions. Single and multiple ab-
scesses are very common at all times, bat cases have
been multiplied tenfold of late. Now that nearly three
months have elapsed since last cases of fever and rash,
a mild form of remittent fever is exceedingly common."

"The two epidemics of influenza in 1891 and 1898
increased the natural tendency of the Samoans to chest
affections, and the measles has still further intensified
their susceptibility. During the past two months two
hundred persons, at the very least, have died from the
effects of the measles epidemic which will be long re-
membered, as not one of the whole population seems
to have escaped."

THERAPEUTIC NOTES.

The Internal Tbbatubnt of Yebicdlar Ec-
zema. — Dr. Leslie Phillips writes to the British
Medical Journal the results of observations made dur-
ing the last two years on the effect of certain remedies
given in the hope of obtaining some specific or direct
action in modifying the morbid tendency of vesicular
eczema in adults. Calcium sulphate was perseveringly
employed in a large number of cases, always with a
disappointing result. Ichtbyol in pills seemed to have
a slight modifying influence in one or two cases.
Calcium chloride and thyroid glands both gave nega-
tive results. The hypophospbites appeared to be oc-
casionally useful. Tartarated antimony was very
helpful in not a small proportion of cases. It was
given in sensible doses ; namely, one-tenth to one-sixth
of a grain thrice daily, and continued for long periods,
it being seldom found needful to discontinue it on ac-
count of ill-effects.

Tkeatment of Diphtheria at the Hospital
Troubbead.' — The staff at the Hospital Trousseau in
Paris, after trying various methods of treating diphthe-
ria, has settled upon the following routine practice for
exclusive use in all cases of diphtheria or doubtful
angina, which is treated as diphtheria pending bacterio-
> L'tTnlon HMloale.

logical cultures. The local treatment consists in large
irrigations with solutions of carbolic acid in the strength
of 1 to 150 or 200, and in the application of an anti-
septic varnish. These are used in all CMses and stages
of the disease. The douches are especially insisted on
in septic cases. The false membrane is wiped away
as much as possible by pledgets of absorbent cotton.
The carbolic solution, tepid, is thrown from an irrigator
directly upon the denuded area, and is afterwards mn
through each nostril until it returns clear. The var-
nish is applied by swabs of absorbent cotton upon the
false membrane which is not detached, or the place it
once occupied. The formula is :

K Onm lao. (pnrifled, wholly lolabla in aloohol) Z70grusni«s

Benroin (parlfled, wholljr lolnbl* in akotaol) 10 "

Balum tola 10 "

Crygtelixed carbolio aeid . . . : 100 "

Emomo of eiDDamon 6 "

Saoebarlne 6 "

Aloohol to mftka one litre.

The varnishing is repeated, according to the gravity
of the case, every two or four hours during the day
and every three or six during the night. In all cases
the douching is repeated every two hours during the
day and every three or four at night. " The applies-
Uon is naturally opposed by the child, but in view of
the seriousness of the disease force is to be used if
necessary. Accordingly, two or three persons are
needed to immobilize the patient and hold the mouth
open. On the first sign in the urine of carbolic in-
toxication the solution is to be changed for one of
thymol or salicylic acid." The general treatment
consists in (1) tonics (alcohol and quinine) ; (2) diu-
retics, to aid in the elimination of the diphtheria
toxine ; (3) caffeine or sparteine, for cardiac weakness ;
(4) a diet of milk, eggs or broth.

Trba^ent of Whoopino-Codoh bt Quinine.
— Baron ' recommends the use of quinine in pertussis,
and from a study of some fifty cases draws the follow-
ing conclusions. In a small number of cases a favora-
ble effect is obtained very early, even as soon as the
second or third day. In most cases the result is doabt-
ful for the first few days because the larger number of
the children have a tendency to vomit and an uncertain
amount of the drug is retained. From the fifth or
sixth day a decided improvement, both as regards the
number and severity of the paroxysms, is noticed.
This improvement advances rapidly and continuously
even though the quinine is given in gradually smaller
and less frequent doses. The time required for a cure
by this -method is given as not over three weeks, and
in some cases is so short as to almost warrant calling
the treatment abortive. The administration is advised
after the following manner : Each single dose of the
hydrochlorate of quinine is estimated at 0.01 gm. for
each month and 0.1 gm. for each year of the child's
age. This is to be given three times a day, preferably
at 6 A. M. and 2 and 10 p. h. Strong babies, as a
rule, require a somewhat larger dose than that scheduled
for their age, while even children over four years of
age rarely need more than 0.4 gm. t. i. d. Upon a
manifest amelioration of the symptoms two doses daily
only are needed with a gradual lessening of each dose.
A single dose at uight-time should be given for some
time after apparent full recovery. The quinine may
be given in solution (not advised, owing to the vary-
ing size of spoons used), in capsule or in sugar pellets.

1 Berlin kiln. Wochensehrtft, 48, 1893 ; Denteche Med. Zeltsnf .M,
1894.

Digitized by

Google

Vol. CXXX, No. 24.] BOSTOS MEDICAL AND SVBGICAL JOURNAL.

607

The chocolate and qoinine candies might seem to be
of ase. Especial importance is attached to a continu-
ance of the treatment for a few daja beyond apparent
cure, to lessen any chance of too early omisBion of
treatment.

HETEOBOLOOICAL BECOBD,

For the week ending June 2d, in Boston, according to ob-
servations famished by Sergeant J. W. Smith, of the United
States Signal Corps: —

Baro-
meter

€onrejl)iott&ence.

WEIGHT AS A SYMPTOM IN PHTHISIS.

Denver, Col., June 4, 1894.

Mr. Editor : — I wish to offer a few suggestions as to
the method of treatment of phthisis discussed by Dr.
Boardman in your issue of May 1 7th.

To me it seems that not sufficient stress has been placed
upon one sign in the summary of the condition of the pa-
tient after tne treatment mentioned. I refer to the gain or
loss of weight. I believe that physicians are coming more
and more to the belief that this one factor is of infinitely
more importance than all others together in estimating a
patient's progress, and a fatal objection to the method of
treatment mentioned is, as I see it, that in only one of the
ten cases given in detail was there any gain of weight, and
in that one this gain amounted to only three pounds. One
case held his own, and the other eight cases lost an aggre-
gate of thirty-two and three-fourths pounds, or an average
of more than four pounds each, in a treatment averaging a
little over two months. The temporary gain which was
lost before the end of the treatment, is not considered in
this computation.

In an experience of more than a decade in the treat-
ment of this disease in Colorado, I have become more and
more impressed with the fact that those patients in whom
a gain in weight is observed, generally do well, while those
cases in which a loss occurs, no matter how gradual, do
badly in the end. It is my custom to inform patients who
complain of this or that symptom, that, so long as the gain
in weight, which we generally see in incipient cases here,
continues, I do not care very much alx>ut the other symp-
toms.

In our anxiety to establish the bacillary origin of this
disease and to found a treatment upon this discovery, we
have been in danger of losing sight of the one fundamental
fact which underlies the whole matter, namely, that this
disease is one in which the patient is on the road to physi-
cal bankraj)tcy. We all recognize the fact that, in the
absence of this essential condition, the bacillus does not
thrive in the human organism. Practically, the patient's
salvation, when attacked, lies in an improved assimilation
of food. When placed under such conditions «s enable
him to hold his own, and then to begin to gain in weight,
we have, in this gain, a form of evidence that he is over-
coming bis bacillary antagonists, which is infinitely better
than any which can be obtained in the laboratory. As
well assume that a suspected bank must be all right because
of the acquisition of a new set of office furniture,-in spite
of the known fact that its cash account is running behind,
as to consider a case of phthisis improving because of im-
provement in certun symptoms when the weight is de-
creasing.

I do not mean to intimate that the writer has, by any
means, attempted to lead us to believe that this treatment
is better than other recognized methods, but merely wish
to point out the fact that an important factor in estimating
the true value of this or any other means of treatment uf
phthisis has been passed over too lightly in this contribu-
tion. To those of us who have repeatedly seen patients
gain twenty-five or even fifty pounds of flesh in this climate,
coincidently with the recovery of health, the idea of im-
provement without decided gain in weight in tuberculosis
seems preposterous.

We are all under obligations to Dr. Boardman, however,
for his careful record of the cases he has presented.

Yours very truly,

1517 State St. J. N. Hall, M.D.

Date.

S..2;

M..28
T..29
W.30
T..31
F.. 1

niermom-' Kelattve
eter. humiditT.

29.96
29.33
29.85
30.0-J
29.81
29.84
29.73

68 66
64 175
S6i69
58 70
60 ,54
68 66

■i 1 fc

43 46

93 1 97
76 68

Direction
of wind.

VeloeitT
of wind.

S.W.
S.W.
S.E.
N.W.

E.
S.W.
S.W.

S.E.

S.

E.
S.W.

N.
S.W.

s.

We'th'r.

s s

F. I B.

0.8S

0.62
0.17
0.04

•U., cloudy; C.elMrt F.,f*(rt ti..fogt U..h«sy; S..imokyt R.,rMll; T.,thrMl-
enlnxi N.,»ow. t Indieatei Cram of ralnf All. ar* Meaa forwook.

BECOBD OF HOBTAUTT
FoK THK Wbkk aMDiNa Satdbdat, Jcnb 2, 1894.

Oitles.

Estimated popn^
latton for 1898.

1-9
|i

§1

f

Foroentage of deaths from

** m P O

1^ |-

li

■Si

New York . .
Chleago . . .
Philadelphia .
Brooklyu . .
St. Louis . . .
Boston . . .
Baltimore . .
Washington .
Clnolnnati . .
Cleveland . .
Pittsburg . .
Milwaukee . .
NashTllle . .
Charleston . .
Portland . . .
Worcester . .
KallKlver . .
LoweU . . .
Cambridge . .
Lynn ....
Springfield . .
Lawrence . .
New Bedford .
Holyoke . . .
Salem ....
Brockton , .
Haverhill . .
Chelsea . . .
Maiden . . .
Newton . . .
Pitobbnrg , .
Taunton . . .
Oloueeater . .

Qninoy . . ,
Fittafield . .
Everett . . .

Newbnryport .
Amesbnry . .

1,891,306

1,438,000

1.116,662

978,39*

etiO.OOO

487,397

600,000

808,431

306,000

290,000

263,709

260,000

87,764

66,U>5

40,000

96,217

87,411

87,191

77.100

62,666

48,684

48,366

43,886

41.278

32,283

82,140

81,896

30,264

29;394

27,666

27.146

26,972

26,688

22,068

19,642

18,802

16,686

16,331

14,073

111,920

764

363
186
130

81

41

33
33

26
18
8
18
22

9
4
9
13
6
6
6
6

6

6
6
6
4
6

280

12~6
148

et

68

43

12
16

11
IS

10

4
1
6
7

6
0
0

4
1
2
0

1

2

"o

1
0
0
0

17.94

16.96
17.28

12.42

13.86

23.37

6.06
17.08

21.21
2l.'Jl

11.66
22.22

u.ii

9.10

60.00
7.69

16.66
20.00
20.00

13.91

13.16

9.99

14.04
16.40

6.16

21.21
9.76

16.15
9.09

11.66
11.11

9.10

11.11

22.22
30.76
20.00

20.00

20.00
16.66

2.73

3.08
2.16

M

6.16

6.16

14.64

12.12

6.66

11.11
4.66

26.00

9.88

7.28
9.72

e.«
.77

3.68

2.44

6.06
4.66

16.66

1.60

.66
1.33

3.78

3.03
3.^
7.70

20.00
20.00

Deaths repor
infectious (fise
diarrhoeal disc
consumption 28
161, diarrhoeal
typhoid fever 1(
pox 7, erysipeli

From whoop
d each, Philade
bridge, Lynn
Philadelphia 7,
ter 2 each, N
New York 6, 1
From cerebro-
Lynn 2 each, B
pox New York

ted 2,227:
ises (sma
ases, whoo
13, acute 1
diseases 6
i, measles
18 6, mala
ing-cough
Iphia 5, ]S
and Som
Washingl
ew York
Philadelph
spinal me
DSton, Bra
6, Brool

nnde
1-poj
ping
angc
3, set
17, c
rialf
Bro<
ew ^
jrvill
on 3
and
la a
ning
ickto
dyn

r fiv
I, mi

-COUj

iseai
irlet
ereb
ever
oklyi
fork
e 1
Bro.
Nasti
3d B
itis I
D anc
1. 1

9 yean
sasles,
;h,erj
3es27)j
fever
ro-spin
5.

1, Wai
3, Fal
each,
oklyn,
ville
rookly
<ew 1
1 Cbele
from

9 of a
diph
sipela
, aipl
36, wl
al me

shingt
IRive
Froi
Pitts
1 ead
n 4 e
fork I
leal e
erysip

ge 81(
theria
a and
Itherii
loopin
ningit

on an
r2, B
n typ
>urg »
1. Fr
ach, ]
!, Wo
ach, ]
elas f

5; pri
and (
fevet

I and

ffi

d Pitt
DSton,
hoid
nd W
om m
Pittsbi
rceste
from f
lewY

icipal

r^;

croup
;h 32,
imall-

sburg
Cam-
fever
orces-
easles
irg 3.
r and
imall-.
orkS,

Digitized by

Google

608

BOSTOS MBDJCAL ASD SVSGWAL JOVBHAL.

[JcKE 14, 1894.

Philadelphia, Brooklyn and Boston 1 each. From malarial
fever New York 2, Philadelphia, Brooklyn and Fall River 1
each.

In the thirty-three greater towns of EngUmd and Wales with
an estimated popnlation of 10,488,442, Tot the week ending
May 26th, the death-rate was 17.7. Deaths reported 3,543:
acute diseases of the respiratory organs (London) 248, measles
248, whooping-congh 128, diphtheria 62, scarlet fever 41,diar-
Thcea 88, fever 31, small-poz ^/>ndon7, West Ham and Birming-
ham 2 each) 11.

The death-rates ranged from 10.1 in Plymouth to 28.4 in Sal-
ford; Birmingham 18.6, Bolton 16.7, Croydon 11.2, Hnll 14.2,
Leicester 16.2, Liverpool 20.9, London 17.3, Manchester 22.1,
Newcastle-ou-Tyne 18.8, Nottingham ::i.O, Sheffield 17.4,
Swansea 14.8, Wolverhampton 21.6.

OFFICIAL LIST OF CHANGES IN THE STATIONS AND
UUTUiS OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM JUNE 2, 1894, TO
JUNG 8. 1894.

Upon being relieved from dntyat Camp Merritt, Montana, by
FiKST-LiBUT. William H. Wilson, assistant surgeon, Fikst^
LiBUT. Edwa&d L. Munson, assistant surgeon, will proceed
without delay to Fort Yellowstone, Wyoming, and report to the
commanding officer for temporary duty with troops in the
National Park during the season.

OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS
OF THE U. 8. NAVY FOB THE WEEK ENDING JUNE
9, 1894.

6bo. a. Briqht, medical inspector, detached from U. 8. 8.
" Newark," ordered home and granted three months' leave.

R. A. Mabmion, surgeon, detached from Smithsonian Institu-
tion and ordered to the U. 8. 8. " Newark."

D. McMuBTBiE, medical inspector, ordered to the Smithsonian
Institution.

OFFICIAL LIST OF CHANGES OF STATIONS AND DUTIES
OF MEDICAL OFFICERS OF THE UNITED STATES
MARINE-HOSPITAL SERVICE FOB THE FIVE WEEKS
ENDING HAY 26. 1894.

MuK&AT, R. D., suKeoD. To proceed to Brunswick, Ga., for
special duty. April 30, 1894. To proceed to WaynesviUe, Ga. ,
as inspector. May 17, 1894.

HuTTON, W. U. H., surgeon. Detailed for duty as inspector
of Quarantine Stations. April 27, 1894.

HAMiLTOir, J. B., snrgeOD. Granted leave of absence for
three days. Hay 14, 1894.

Gassawat, J. U. gnrgeon. Granted leave of absence for fif-
teen days. Hay 1'.!, 1894. Leave of absence extended five days.
May 26, 1894.

Stonkb, G. W., surgeon. To inspect Cape Charles Qnaran-
tine Station, monthly. April 27, 1894. Granted leave of ab-
sence for thirty days. Hay 18, 1894.

GODFBKT, John, surgeon. To represent the service at meet-
ing of the American Mmlical Association at San Francisco, Cal.
Hay 11, 1894.

iBWOf, Faibfax, surgeon. To proceed to Berlin, Germany,
for special dnty. Hay 6, 18M.

Cabtkb, H. B., surgeon. Granted leave of absence for three
days. Hay 3, 1894. To proceed to Key West Quarantine for
temporary duty. Hay 4, 1894.

Banks, C. E., passed assistant surgeon. Granted leave of
absence for five days. Hay 1, 1891.

Cakmichabl, D. a., passed assistant surgeon. To proceed
to St. Louis, Ho , for temporary duty. Hay 15, 1894.

Pbcxhak, C. T., passed assistant surgeon. To proceed to
San Francisco Quarantine Station for duty. Hay 17, 1894.

Glknnan, a. H., passed assistant surgeon. To proceed to
Wilmington, Del., for special temporary daty. April 26, 1894.

Wbitb, J. H., passed assistant surgeon. To inspect quaran-
tine Stations. April 27, 1894. Granted leave of absence for
seven days. April 29, 1894. Granted leave of absence for
twenty-three days. Hay 4, 1894.

Bkatton, W. D., passed assistant gnrgeon. To report at
Bureau and then to proceed to Delaware Breakwater Quaiantine
for duty. May 19, 1894

Maqkudeb, G. M., passed assistant surgeon. To proceed to
Key West Quarantine Station for duty. May 16, 1891.

KiNYOUN, J. J., passed assistant surgeon. To proceed to
Wilmington, Del., for special temporary duty. April 26, 1894.
Detailed as chairman, Board for physical examination officers,
Revenue Marine Service. April 30, 1894. Detailed to attend

annual meeting State Board of Health of North Carolina. Hay
11, 1894. To inspect property at Wilmington, N. C. May 14,
1894.

WooDWABO, R. U.. passed assistant surgeon. To proceed to
Chicago, 111., for special duty. Hay 7, 1894.

VAtiGBAN, G. T., passed assistant surgeon. Detailed as re-
corder. Board for physical examination officers, Revenue Harine
Service. April 30, 1894.

Stonbb, J. B., passed assistant surgeon. To inspect quaran-
tine porU. April 26, 1894.

Pbbbt, J. C, passed assistant snrgeon. To assume command
of service at Norfolk, Va. Hay 4, 1894.

YouNO, G. B., assistant surgeon. To proceed to Key West,
Fla., for duty. Hay 16, 1894.

Bbown, B. W., assistant surgeon. To proceed to Pittsboig.
Pa., for duty. April 27, 1894.

RoBBirAU, U. J., assistant surgeon. To proceed to Boston,
Mass., for duty. April 23, 1894.

Cofkb, L. E., assistant surgeon. To proceed to San Diego,
Cal., as Inspector, and to assume command of the service after
June 30th. April 26, 1894.

Eaobk, J. H., assistant surgeon. To proceed to New Orleans,
La., for duty. Hay 16, 1894.

Ntoeoobb, J. A., assistant surgeon. To proceed to Savannah,
Ga., for duty. April 28, 1894.

Stbatbb, Edoak, assistant snrgeon. To report for duty on
Revenue Bark " Chase." April 28, 1894.

Oaklxt, J. H., assistant soixeon. To rejoin station San
Francisco, Cal. Hay 16, 1894.

FBOXOTIOHS.

G. B. Yotmo, assistant gnrgeon. Commissioned as passed
assistant snrgeon. Hay 26, 1894.

W. G. Stimpsom, assistant surgeon. Commissioned as passed
assistant snrgeon. Hay 26, 1894.

APFOINTKXIITS.

Aktbub R. Thomas, of Illinois, commissioned as assistant
surgeon. Hay 26, 1894.

Hbmbt W. Wickbs, of Uaryland, commissioned as assistant
gnrgeon. Hay 25, 1894.

HcoH 8. CuMMiNQ, of Virginia, commissioned as assistant
snrgeon. May 26, 1894.

APPOINTMENT.

Governor Oreenhalge has appointed Mb. Hknbt S. Howb, of
Brookline, Trustee of the Massachusetts General Hospital in
place of Hk. T. E. Pboctob, resigned.

BOOKS AND PAMPHLETS RECEIVED.

Non Nocere. By A. Jacobi, H.D., New York. Reprint. 1894.

Transactions of the Indiana State Hedical Society, 1893, Forty-
Fourth Annnal Session held in Indianapolis, Ind., Hay 11 and
12, 1893.

Two Cases of Brain Tumor ; A Contribution to Cerebral Sur-
gery. By Clarence Bartlett, U D., and W. B. Van Lannep,
A.M., H.D Reprint. 1894.

Physiotherapy First; Nature's Medicaments before Drug
Remedies: Particularly Relating to Hydropathy. By Edward
Playter, H.D., OtUwa. Reprint. 1894.

Removal of the Gasserian Ganglion as the Last of Fourteen
Operations in Thirteen Years for Tic Douloureux. By W. W.
Keen, U.D., and John K. Hitchell, H.D. Reprint. 1894.

An Illustrated Dictionary of Medicine, Biology and Allied
Sciences, Based upon Recent Scientific Literature. By George
M. Gould, A.M.. H.D. Philadelphia: P. Blakiston, Son & Co.
1894.

Transactions of the Obstetrical Society of London, Vol.
XXXV, for the Year 1893. Part IV for October, November
and December. Edited by P. Horrocks, M.O., Senior Secretary
and F. H. Cliampneys, H.D. London : Published by the Society.
1894.

Essentials of Refraction and the Diseases of the Eye. By
Edward Jackson, A.M., M.D., and Essentials of Diseases of the
Nose and Throat. By E. B. Oleason, S.B., H.D. Second edi-
tion, revised, 124 illustrations. Philadelphia: W.B.Saunders.
1894.

The Nurses Dictionary of Medical Terms and Nnrsing Treat-
ment, Compiled for the Use of Nurses and Containing Descrip-
tions of the Principal Medical and Nursing Terms and Abbrevia-
tions, Instruments, Drugs, Diseases, Accidents, etc.. Encountered
in the Ward or Sick-Room. By Honnor Horten. Philadelphia:
W.B.Saunders. 1894.

Digitized by

Google

Vol. CXXX, No. 25.] BOSTON MEDICAL AND SUSGIOAL JOURNAL.

609

%vtvt^^.

THE LEGISLATIVE CONTROL OF MEDICAL
PRACTICE.'

BY KKUINALD U. KITZ, U.D., BOSTOK.

(Coutluued from No. 24, p. 685.)

Thk success of medical legislation in this country
is now a matter of history ; and it will be attempted
to give a short sketch of what has been accomplished.

According to the researches of Dr. Joseph M.
Toner," the earliest legislation in the colonies rela-
tive to the practice of medicine was in Virginia in 1639.
It appears that the charges of physicians and surgeons
were so excessive

*' that the hearts of divers masters were hardened rather to
suffer their servantb tu perish for want of fit means and
applications than by seelcinc; relief to fall into the bands of
griping and avaricious men ; it be apprehended by such
master.«, who were more swayed by politick respects than
Xian duty or charity, that it was the more painfull and
saving way to stand to the hazard of their servants than
to entertain the certain charge of a physitian or chirurgern,
whose demands for the most part exceed the purchase of
the patient." "

A few years later this act was revised for the pur-
pose of making a distinction between the charges of
" surgeons, apothecaries, or such as have only served
apprenticeship to those trades, who often prove very
unskilful in the art of a physician " ; and of those who
have studied physic in any university and taken any
degree therein."

Ill 1649 Massachusetts passed a law forbidding
" pbisitians, chirurgiaus, midwives, or others," pre-
Bumiug " to exercise or putt forth any act contrary to
the knowne rules of arte," or exercising " any force,
violence or cruelty ... no, not in the most difficult
and desperate cases, — without the advice and consent
of such as are skilful in the same arte, etc., etc" ^* This
law was also inserted in the Duke of York's laws en-
acted about 1665 for the government of the province
of New York.

Dr. Toner's valuable article contains no evidence of
further attempts at regulating the practice of medicine
during the subsequent century. The number of care-
fully educated physicians was inconsiderable, quacks
abounded, and of New York in 1753 it was stated : "

" That place boasts the honor of above forty gentlemen
of the faculty, and far the greatest part of them are mere
pretenders to a profession of which they are entirely igno-
rant." . . .

" The war resulting in tlie con(|uest of Canada and sub-
jugation of the French in 1 763 created a demand for skilled
medicid uflieers and aided in the training of American
students. Many of the English medical staff remained for
several years in the vicinity of New York, establishing mili-
tary hospitals and aroused the ambition of the colonial
practitioners.'*. . . .

" Although partial recogtiition of the profession and pro-
tection of the jteople had buen secured in several of the
colonies, and particularly in some of the larger cities, by
legislation, the first well considered act regulating the prac-

1 Tlie Annual Ditcoimu before ttie Massacliiuettt Medical Society,
delivered .) une l:i. IK!I4.

■■ ContribDiioiis to the Annals of Medloal Progress and Medical
Education iu the Uuiiud States before and during ibe War of lude-
liendeuce, tHT4.

" Henliig'i) Statutes at l.arge, i, 316. 317; Toner, loc. dt.

'» Heniiig, op. oil., iv. .'509, 510; Touer, loc. ell.

1* liecortlH of MiveHciiuiietlH, 1S,')4, ill, 153,

>° New York iDdepenUeni Ketlector, Touer, loc. oit., 49.

" Uavis, Ulftory of Medical Kducsliou ; Touer, loc. oit,, 37,

tice of physics was that passed in New York, June 10, 1760,
beginning as follows : ' Whereas many ignorant and on-
skilful persons in physick and surgery, in order to gain a
subsistence, do take upon themselves to administer jihysick
and practise surgery in the city of New York, to the en-
dangering of the lives and limbs of their patients, and
many poor and ignorant persons inhabiting the said city,
who have been persuaded to become their patients, have
been great sufferers thereby ; for preventing such abuses
for the future —
'"1. Be it enacted,' " etc."

According to this act no person was allowed to prac-
tise, under a penalty of five pounds and costs, who had
not previously passed an approved examination in
physic and surgery before one of his Majesty's council,
the Judges of the Supreme Court, the Attorney-Gen-
eral and the Mayor for the time being, or any three
of them, taking to their assistance for such examination
such person or persons as they in their discretion shall
think fit."

Twelve years later a similar act was passed in New
Jersey at the instigation of the New Jersey Medical
Society, and wsts the first comprehensive, protective
law applied to a colony, the legislation above mentioned
applying only to the city of New York. The exami-
nation wag approved of and admitted by " any two of
the judges of the supreme court, taking to their assist-
ance for such examination such person or persons as
they in their discretion shall think fit." "

In the following year, 1773, the code of Virginia
required every surgeon, physician and dentist to take
out a license, which authorized the holder to practise
anywhere in the colony. Neglect to procure a license
was punishable by a fine of not less than thirty nor
more than one hundred dollars, nor could such negli-
gent practitioners collect compensation for services.^
In the same year, in Connecticut, a law for the sup-
pression of mountel)anks was enacted,^ although a
year later the Lower House of Assembly in this colony
negatived the memorial of Norwich physicians asking
for the appointment of a committee legally authorized
to examine and approve candidates if found qualified.**

The War of the Revolution now occurred. Dr.
Toner ** thinks it probable that at this time

" there were not living in all the colonies 400 physicians
who had received medical degrees ; and yet, as is stated
elsewhere, there were presumed to be over 3,500 practi-
tioners."

According to the same authority,** the war gave

" great impetus and energy to the whole population of the
colonies. The experience gained by the medical men who
served in the army elevated their views, gave them con-
fidence in the exercise of their professional duties, en-
deared them to the public, and made them almost oracles
in the communities in which they resided. The spirit of
gratitude also created friends for the profession in the vari-
ous legislatures, led to the enactment of laws which were
more just and protecting in tlieir character, and popularized
the more recent and thorough modes for the scientific study
of medicine."

In 1783 New Jersey was the first of the States to
pass a law regulating the practice of medicine, it was
followed in 1792 by New York, which demanded of

>' Toner, loc, clt., 61.

<• Trana. Med. Soo. Slate of New York, 1840-43, 12.

» Touer, loc. clt., 62.

xi Trans. III. Slate Med, Soo,, 18SI,uxl,2S«.

" Toner, loo. olt„ 70,

u TlmeB and Register, 18S3, XZTi, 102T,

» Toner, loo, oit., loe.

» Toner, loo. oit., lOi,

Digitized by

Google

610

BOSTOS MBBICAL AND SVBGICAL JOURNAL.

[JcNE 21, 1894.

practitioners in the city aud county of New York two
years of study with a reputable physician, if the candi-
date was a graduate of a college in the United States,
otherwise three years of study. Also au examination
before the Governor, Chancellor, Judges of the Su-
preme Court. Attorney-General, Mayor and Becorder
of the city of New York, or any two of them who were
to take to their assistance any three respectable practi-
tioners with whom the examined person had not lived.
The certificate of this board was a license to practise,
and without it no legal demand could be made for
services. Physicians who had regularly received the
degree of Doctor of Medicine, those already in practice,
and consulting physicians from neighboring States or
counties were exempt from the provisions of this law.
The above, somewhat modified, was made, in 1797,
the general law of the State.'*

In 1798 power was given to the Medical and Chir-
urgical Faculty of Maryland to grant licenses " upon
full examination or upon the production of diplomas
from some respectable college." The penalty for prac-
tising without a license was $50.00 for each offence.**

During the first forty years of the present century,
legislation, with a view to regulate the practice of
medicine, was frequent and various. The initiative
was taken by those desirous of protecting the people
from ignorance, lack of skill and extortion ; and the
opposition came from quacks and pretenders of every
kind.

New York, in 1806, incorporated medical societies
for the purpose of regulating the practice of physic
aud surgery, following the example set by Massachu-
setts, and which proved so successful in that State
after the amendments adopted by the Massachusetts
Medical Society in 1804. In 1808, a few years after
the territory of Orleans was set off from the Louisiana
purchase, a bill was enacted by the territorial govern-
ment, stating "that no person shall presume to practise
medicine " without an examination, for which a diploma
from some university or school was a qualification.
This law was amended in 1816, and was enacted aa
the law for the State of Louisiana."

From this time on. State after State passed some
form or other of a law for the prevention of quackery.
And it is stated by Senn ^ that during the first half of
our national existence every State had enacted such
laws, with the exception of Pennsylvania, North Car-
olina and Virginia.

These laws, however, did not long remain operative ;
they were premature in many instances, there not
being enough educated physicians to provide for the
needs of the people. Quacks thus found their way
into the remoter sections of the State, and their pres-
ence and assertions were welcomed by the sick and in-
firm. They practised in defiance of the law, where-
as, now, unlicensed practitioners are declared exempt
from the penalties of the law in States like Arizona
and Idaho, when there is no licensed physician living
within a convenient distance of the patient. Quackery
spread from the remoter districts towards the centres
of population, became more and more popular, and
excited the more sympathy the more it was opposed.
The difficulties in the way of enforcing the laws be-
came greater. Juries refused to convict, officers of the

» TrttDB. Med. Soc. SUte of New Tork, 184(M3, 12.
*• Quinan, New York Med. Record, 1386, xxix, SOS.
n Chains, New Orleans Med. and Surg. Jonraal, 1877-78 ; N. S., 5
909.
» Traua. Wis. State Med. Soo., 1879, xlU.

medical societies neglected to bring charges, and finally
the laws were so amended as to exempt all quacks,
mountebanks and charlatans from the penalties. This
result attained, the laws became useless, and in certain
States were effaced from the Statute Book.

The first serious blow to the regulation by the State
of the practice of medicine was the result of the spread
throughout the country of the doctrines of Samuel
Thomson, who died in 1843. He was an illiterate
farmer of New Hampshire, an empiric of the first
water, but distinctly a remarkable man. He denounced
the heroic treatment then in vogue by means of bleed-
ing, mercurials and mineral medicines in general, and
advocated the use of certain vegetable agents whose
value he claimed to have discovered. He stated that
he was in the habit of tasting herbs and roots, and was
thus enabled to ascertain what were useful for any
particular disease. In his " Narrative," ** first pub-
lished in 1822, he announces as his general plan of
treatment :

"to cleanse the stomach by giving No. 1, and produce s.<i
great an internal beat as I could by giving Mo. 2, and wben
necessary made use of steaming, in which I have always
found great benefit, especially in fevers ; after this I gave
No. 3, to clear off the canker ; and in all cases when tbv
patient had not previously become so far reduced as to have
nothing to build upon, I have been successful in restoring
them to health."

No. 1 consisted of lobelia ; No. 2 of red pepper ;
aud No. 3 of a variety of herbs, including rosemary,
bayberry, myrtle, sumac or raspberry, although he
states that a great many other articles were " useful
in removing canker."

In 1809, he was tried for the murder of oue of his
patients.*"

" As the learned Judge could find no law, common or
statute, to punish the accused, he directed or advised
those present to stop this quackery, as he called it, and
for this purpose to petition the Legislature to make a Isw
that should make it penal for all who should practice
without license from some medical college to debar them of
law to collect their debts ; and if this should not answer,
to make it penal by fine and imprisonment.

" This hint, thus given by the judge, was seized upon first
in Massachusetts ; from thence it has spread to nearly all
the States of the Union. From this source may be traced
all those unconstitutional laws which have been enacted in
relation to this subject, and all those vexatious suits which
I have had to attend in many of the States, from Massa-
chusetts to South Carolina, more or less almost every year
since. But I have been able to break them down by my
patent being from higher authority, which Judge Parsons
could not prevent, or perhaps he never thought of. He,
however, made his own report, and handed it to the re-
porter, which is published in the sixth volume of Massa-
chusetts Reports, and is resorted to by all the enemies of
the practice for a defence against the system."

He afterwards brought suit against his principal
accuser, Dr. French, which came to trial, again before
Chief Justice Parsons, in 1811.*'

" The judge then gave his charge to the jury, which was
considered by those who heard it, to be the most prejudiced
and partial one that they had ever heard. He made use of
every means to raise the passions of the jury and turn them
against me ; stating that the defendant was completely ju^
tmed in calling me a murderer, for if I was not guilty 0|
wilful murder, it was barbarous, ignorant murder; and

»■ A Narrative of the Life and Medioal Dlsooraries of Samuel
Thoauon, eto., 8th ed., 1832.
*> Op. clt., p. 167.
»' Op. olt., p. 176.

Digitized by

Google

Vol. CXXX, No. 25.] BOSTON MBDIOAL AND SURGICAL JOURNAL.

611

even abused my lawyers for taking up of me, saying that
they ought to be paid in screw augers and bull dogs.

The jury brought in a verdict for the defendant.

In 1813 be obtained a patent to secure to him the
exclusive right of his system, and to put him above
the reach of the law in any State. But in 1821 Judge
Story decided that its specifications were improperly
made out, and in 1823 a new patent was obtained."

" The preparing and compounding the foregoing vegetable
medicines, in manner herein described, and the admmister-
ing them to cure disease, as herein mentioned, together
with the use of steam to produce perspiration, I claim as
my own invention."

The simplicity of his theories of disease and of its
treatment, the use of simples, always commeuding it-
self to the popular mind, and the notoriety attained by
numerous lawsuits, all served to attract attention to
Thomson's doctrines. Many editions of his writings
were published, and agents were employed to travel
throughout the States, selling with the book and medi-
cines a family right to practise for $20.00. " Friendly
Botanic Societies" were established, the membership
being composed of those who had purchased family
rights, and the privileges in which are stated by him
as follows : **

" Every one who purchases a right for himself and family,
becomes a member of the Friendly Botanic Society, and is
entitled to all tlie privileges of a free intercourse with each
other, and to converse with any one who has lx>ught a
right, for instruction and assistance."

Thomson's doctrines were especially favored in the
eastern section of Massachusetts, and along the adja-
cent borders of Maine, New Hampshire and Vermont.

After the publication of his "Narrative" and the
employment of agents, he and they travelled exten-
sively in the South and West. Although they were
unlicensed practitioners in most States, the laws had
no penalties sufficient to prevent them from practising.
His followers succeeded in securing the enactment of
lawB by. which no person was to be debarred from
nsing or applying for the benefit of the sick person
any roots, barks or herbs, the growth or produce of
the United States. At first the proviso was added,
that they should be unable to recover by process of
law any debt incurred from such practice. This ob-
jection was easily met by obtaining fees in advance.
The restriction was of greater value to them for ad-
vertising purposes in creating sympathy, and we learn **
that " thousands have had their sympathies enlisted in
their behalf; have come to believe their senseless
clamor, and had their prejudices aroused against the
medical profession." Finally medical schools, called
" eclectic," were established by those who were will-
ing to take advantage of Thomson's success, adopting
his practice, but avoiding his interference.

Thomsonianism prepared the way for the success of
homoeopathy, which proved to be the more effectual
agent in annulling the licensing of physicians. In the
words of Dr. J. W. Hamilton,*^ " It swaggered on the
stage long enough to give a wholesome check to the
excesses that brought it into being, and proved itself
the bloodiest murderer that ever visited our too credu-
lous community in the form of quackery."

In certain respects homoeopathy bore a close resem-

» Op. Oit., p. 243.

» Op. oit., p. 220.

" Trans. Med. Soo., State of New York, I844-49, Tl, 46.

» Trans. Ohio State Med. Soe., 1867, 36.

blance to Thomsonianism. It represented a reaction
from the heroic treatment of the regular physicians ; it
offered a few remedies, although in palatable form,
with such specific and authoritative directions that the
family provided with pellet and pamphlet had but lit-
tle need of the educated physician. Its leaders, how-
ever, came from the ranks of the latter, and its follow-
ers were to be found among the more intelligent,
prosperous and influential members of society. Its
adherents increased in numbers in the cities and larger
towns, and it throve upon the opposition it encountered
from members of the regular profession. Like Thom-
sonianism, it called for sympathy on the ground of
intolerance, and persecution on the part of licensed
physicians, and Thomsonianism and homoeopathy com-
bined succeeded in so emasculating existing laws regu-
lating the practice of medicine that they became use-
less, and their removal from the statutes was often
sought by all alike.

In 1838, Maryland made it lawful for every citizen
of the State to charge and receive compensation for
his services and medicines. In the following year,
Georgia passed a revised medical act, in which it was
" provided nothing be so construed as to operate against
the Thomsonian or botanic practice or any other
practitioners of medicine in this State." ** A few
years later, in 1847, it established a Botanicomedical
board, with the same powers and duties as the regular
board." In New York, in 1844, a bill was enacted,
of which Judge Beardsley said : "Since the passage of
the act of 1844, quackery may certainly boast its tri-
umphant establishment by law." **

At the close of the first half of the present century
there were practically no efficient laws controlling the
practice of medicine by the licensing of physicians in
this country. The history of such legislation in Mas-
sachusetts from the War of the Revolution to that of
the Rebellion has been given elsewhere.** Existing
laws had either been repealed or were not enforced,
and the regularly educated physicians had ceased in
their efforts to suppress quackery by attempting any
legislative prohibitory enactments. 'JThey were largely
responsible for this result With the best of intentions
throughout these fifty years, they failed to read aright
the signs of the times, and by errors of omission and
of commission they rather aided the progress of quack-
ery than checked its growth.

With the incorporating of medical societies by the
State, the licensing of physicians was placed in their
hands. Examining boards were established and candi-
dates were to appear before them. But in some States
these boards were so few, and the members lived so
far apart, that the examinations were not held. Such
evasions of the law made it easy for a rejected candi-
date to obtain a special act of the legislature allowing
him to practise. In case of rejection by one board he
might appear before another less exacting. If all the
boards in any one State were too stringent, it was
possible for the candidate to obtain a license in another
State, where the terms were less rigid, even by mere
payment of the registration-fee. A license thus ob-
tained was usually valid in other States. If he prac-
tised in violation of the law, it was the duty of no one
to bring suit. Although the licensing power was trans-
ferred by the State to the medical societies, members

» Trans. Med. Soo., State of Mew York, 1844-48, rl, 4S.

>' Sonthem Med. and Surg. Journal, 1866, 7, 3d s., i, 4S6.

u Purrlngton, Xew York Med. Record, 1886, zxx, 452.

" The Preaident's Address, Trans. Asaoe. Am. Phjrs., 1894, ix.

Digitized by

Google

612

BOSTON MEDICAL AUD SURGICAL JOVRBAL.

[JcNK 21, 1894.

of the latter were anwilling to act as accasers and
proaecators from the demand it made upon them for
time and money, and the necessity it placed them under
of assaming a disagreeable and opprobrious task.
Even if cases were brought to trial conviction was
difficult, since the penalty was so severe that the jury
was unwilling to condemn what it was told was essenti-
ally a difference of opinion.

What must be regarded as their chief mistake was
the treatment of their homoeopathic brethren. Irre-
spective of all questions of ethics it was a decided and
decisive error of policy. The latter were educated
physicians, certainly as honest as many of their asso-
ciates, whatever may be said of their intelligence.
Their expulsion and ostracism created two powerful
opponents, largely representing two distinct classes of
society, but united in their efforts to resist repression.
The botanic, eclectic and physio-medical practitioners
(the off-shoots and successors of Thomsoniauism) and
the homoeopathists, as they increased in numbers and
strength, were, combined, enabled to secnre the repeal
of all restrictive legislation. They became exempted
by law from the need of a license, and the regular
physician saw no necessity of paying the fee for a
license which placed him in no different light before
the public than the quack. As the irregulars formed
chartered medical societies with the same privileges as
those possessed by the regular societies, members of
the latter in many States became active m securing the
repeal of laws which proved of no value to the coxa-.
mnnity. Eclectic and homoeopathic medical schools
were established, and the name of physician and the
title of doctor of medicine no longer became of the
least value in acquainting the public with any distinc-
tion between the educated practitioner and the ignorant
pretender, and no check whatever was placed on the
increase of the latter.

An interval of some twenty years now elapsed, dur-
ing the first half of which the State medical societies
were perfecting their organization with the view of
maintaining a high standard of membership. A cer-
tain degree of uniformity in this action was the result
of the formation of the American Medical Association
in 1847. The annual meetings of this organization
brought together representative men from the various
State societies, most of whom had been actively in-
terested in the legislative control of medical practice.
They endeavored to improve the standard of medical
education and the ethics of the regular profession
throughout the country. The War of the Rebellion
created a sudden and extensive demand for educated
physicians and surgeons, their numbers speedily in-
creased, and the subsequent rapid growth of the country
has continued this increase. The brilliant progress in
the various specialties of medicine made more apparent
the distinction between the educated and skilful physi-
cian and the ignorant but pretentious quack. Homoeo-
pathic and eclectic medical schools were paying more
attention to the instruction of their students, and the
line wag thus being more sharply drawn between prac-
titioners of no training and those who had received
some teaching. All educated physicians, whatever
their degree of instruction, were interested in defend-
ing the community from mere pretenders, and their
combination has led to the successful medical legisla-
tion of the past twenty-five years.

Since the law recognizes no distinction between regu-
lars, homoeopathists and eclectics, on the contrary, the

legislators have given like privileges to each, by in-
corporating them into medical societies and medical
schools, it became obvious that if any legislation was
to be secured against the worst forms of quackery, it
must be obtained by the practical agreement of these
incorporated medical bodies. The numerous experi-
ments which have been made in the various States dur-
ing the past twenty-five years, and which have led to
the enactment of licensing laws in nearly all the States
and Territories, have been the result of this harmony
of action.** It hits been justified not only by the needs
of the community for protection, but also by the fact
that both homoeopathists and eclectics represent a kind
of practitioner whose education is constantly improv-
ing. Homoeopathists, in particular, have been, from
the beginning, physicians of a certain, and at times of
a considerable degree of education. They are honestly
and earnestly endeavoring to improve their educational
facilities, and some of the eclectic schools are follow-
ing in their footsteps.

In 1872, a bill was prepared under the auspices of
the New York Medico-Legal Society, and was favor-
ably acted upon by the legislature, but was subsequently
vetoed by the governor.*^ This unsuccessful attempt
was followed in 1873 by the passage of a law in Texss,
requiring the registration of diplomas by all practi-
tioners entering the State. It was repealed and replaced
in 1876 by an act establishing boards of examiners,
who were to examine all applicants for certificates of
qualification without preference to any school of medi-
cine. This law, to-day, in the words of Dr. West of
Galveston, " is practically inoperative, as but few
boards are organized, and about most that any of them
do is to license non-graduates."

In the District of Columbia in ] 874 it was the daty
of every physician to register at the office of the board
of health, under penalty of from $25.00 to $200.00.
This regulation was legalized by Congress in 1880.
All physicians required to register must do so upon a
license from some chartered medical society, or upon
a diploma from some medical school or institution.

The law of Nevada, enacted in 1875, makes a law-
ful practitioner one who has received a medical educa-
tion and a diploma from some regularly chartered
school having a honafide existence when the diploma
was granted. The county recorder accepts the diploma.

In 1877 a law was passed in Alabama according to
which a license or diploma, or certificate of qualifica-
tion, was essential to the lawful practitioner. If he
wished to practise any irregular system, he was obliged
to pass an examination in anatomy, physiology, chem-
istry and the mechanism of labor before the Censors
of the Medical Association of the State of Alabama,
or of some affiliated County Medical Society. This
act was replaced by that of 1887, which was amended
in 1891, and according to Dr. Cochran of the Board
of Censors is

" almost ideally perfect. If the State would invite us to
change it according to our wishes, we would not know what
change to suggest. All we have to ask of the State is

«> For much o( the Information relatlre to the proTisionsof the
laws in thevartotis States and Territorte9, I amtnileWtedtotbeadmif^
able SynopsiB of tlieeziating Statutes, prepared by William A. Poete,
late deputy attoruey-geuerul of the State of New York, and Charles
A. Boiion, Esq., of the New York City Bar, for the text-book of
Medical Jurisprudence, Forensic Medicine and Toxicology, of Wttt-
baus and Becker, just publUhed. By the aid of our librarian, Pr.
K. H. Brigbam, I hare been enabled to obtain from the respectire
officials of many of the States copies nf the medical licensing lavs of
these States, and take this opportunity of expressing my thanks to all
concerned.

" New York Med. Journal, 1874, zx, 6t.

Digitized by

Google

Vol. CXXX, No. 25.] BOSTOS MEDICAL AND SURGICAL JOURNAL.

613

simply to let our law stand as it is and enforce it in the
courts. . . . We have a very few homoeopathic practi-
tioners in Alahama, but a considerable number of doctors
who, graduated in eclectic schools, have availed themselves
of the advantages we have to offer them, and have become
good working members of our organization." *"

In the same year Illiuois passed its first law, which
was amended in 1887. It is annecessary to enter
into the details of medical legislation daring the next
fourteen years. It is merely to be stated that laws
were passed as follows :

Tear.
1880
1882
1888
1884
1885
1886
1887

1888
1889
1890

1891
1892
1893

State or Territory.

Vermont

Georgia, Rhode Island.

Maine, Michigan, North Carolina.

New Mexico.

Indiana.

Iowa.

California, Idaho, Minnesota, Virginia, Wis-
consin, Wyoming.

Tennessee.

Delaware, Kansas, Missouri, Montana, Oregon.

New Jersey, North Dakota, Uhio, South Caro-
lina, Washington.

Colorado, Nebraska, West Virginia.

Florida, Maryland, Mississippi, Utah.

Arkansas, Arizona, Connecticut, Kentucky,
New York, Oklahoma, Pennsylvania, South
Dakota.

iTobeeanUinited.)

Original %xt\t\t^,

THE FREQUENCY OF RENAL ALBUMINURIA,
AS SHOWN BY ALBUMIN AND CASTS,
APART FROM BRIGHT'S DISEASE, FEVER,
OR OBVIOUS CAUSE OF RENAL IRRITA-
TION.'

BT rSRDSBICK C. IHATTOCK, H.D., OF BOSTON.

In no branch of human activity, perhaps, can more
striking illustrations be found of the dangers of hasty
cooclasions from insufficient data than in medicine.
This is no reflection on oar calling. It naturally
flows from the fact that our knowledge of many things
is still very imperfect, while the demands for the prac-
tical application of our knowledge are constant and
imperative. The sick man wants instant help, and
cannot wait while doubtful points are being settled.
Medicine is more than an art, less, in a sense, than an
exact science. The clinical significance of albumin
and casts affords one of these illustrations. The chem-
ical preceded the microscopical examination of the
arine, and the latter first made it possible to determine
with any accuracy the portion of the urinary tract
from which the albumin is derived. The presence of
casts shows that the true renal tissue is involved, and
was for some time held to be diagnostic of Bright's
disease. I well remember the grave prognosis which
the discovery of albumin and casts was thought to
necessitate when I was a hospital interne, not much
more than twenty years ago. Perhaps I incorrectly
interpreted my teaching — students sometimes do —
but I think this was at that time generally regarded
by the profession as damning evidence. Albumin and
casts meant Bright's disease, and that meant an in-

' Paper read at tbe Ninth Annual Meeting of the Association of
American PbTSlciaas, Washington, D. V., Thursday, Majr 31, 1S94.

evitably and more or less rapidly fatal disease. Further
experience and the irresistible logic of facts has led to
such changes in these views that considerable discus-
sion has been held as to whether albuminuria might
not be physiological, so common is it found to be, so
little bearing may it have on the vigor or longevity of
its possessor. Into this discussion 1 do not propose
really to enter. Absolute physical perfection is occa*
sionally found in the human being ; but the ideal and
the real are nearly as sharply contrasted in the more
purely bodily as in the moral qualities. Whether
there be a physiological albuminuria is largely a
matter of definition of the word physiological.

Much ingenuity has been devoted to the discovery
and application of tests of extreme delicacy for albu-
min. My friend and colleague, E. S. Wood, assures
me that for clinical and qualitative purposes none of
these tests can compare with the old heat and nitric
acid tests ; and I am glad to see similar views expressed
very recently by D. D. Stewart,* of Philadelphia.
These are the tests used in the cases which I have
analyzed. A cloudiness of the boiled upper layer of
urine in the test-tnbe after the addition of acetic acid,
and tbe opaque zone with nitric acid are therefore
considered proof positive of the presence of albumin,
as a negative result is proof of its absence. To my
eye the heat test is tbe more delicate of the two, but
I know that all do not find it so. Vanderpoel,* in a
recent paper on albuminuria without manifest organic
renal lesion, has collected the literature of the suoject
and justly calls attention to the discrepancy which
exists between the percentages of different observers
examining considerable numbers of presumably healthy
persons. Cbateaubourg finds albuminuria in 84 per
cent, of 701 examined ; Grainger Stewart in 31 per cent,
of 407 examined. Others put the percentage still
lower, but even this discrepancy is sufficient to show
that something is the matter. Doubtless Millard is
right in believing that Cbateaubourg, who used Tan-
ret's test in many of his examinations, mistook mucin
or some other non-albuminous organic substance for
albumin. As far as I know casts have not been
looked for as carefully as albumin. The search for
them demands a good deal of time if the sediment is
scanty ; and they may easily be overlooked when
present if ample time is not allowed the urine to settle,
and if skill in the selection of portions of the sediment
is not exercised. Experience has led me to be skepti-
cal when the statement is made to me that a distinct
trace of albumin is present, but that casts as well as
other formed elements, such as blood and pus, are ab-
sent. In such cases I have repeatedly found that
more careful examination revealed the casts.

These bodies still enjoy a worse reputation in the
minds of the laity than albumin, as well as in the minds
of the profession in general. Patients are alarmed by
the knowledge that there are casts in their urine, much
as they used to be by hearing that they had a murmur
in their hearts.

For five or six years now I have been more and
more particular to have a thorough examination of
the urines of patients seeking my advice made by com-
petent men, quite irrespective of the nature of tbe
complaint which brought the patient. The frequency
with which albumin and casts, chiefly hyaline and
finely granular of small diameter, was reported in

' Dongllw>D, Coll. A Clin. Itec., 1^90, zl, II.

> Philadelphia Medical News, Mav 6, li'94.

> Medical Kecord, November 11, li)S3.

Digitized by

Google

614

BOSTON MEDIO AL AND SVBGIOAL JOURNAL.

[JuHE 21, 1894.

those at or bejood middle life entirely apart from auy
other evideoce of renal mischief, attracted my atten-
tion. This led to the preservation of the reports of
those of fifty years of age or more, and more recently
also of the yoonger patients. Consequently I deal
with larger figures relatively or absolutely at the later
ages. I now regret that I did not begin my collection
on a more compreheusive basis. All the same, it does
not seem probable that the result would be very ma-
terially modified. In the decade of twenty to thirty I
believe that a larger number of cases would reduce
the percentage of those with renal albuminuria, and I
think also that larger figures would show the condition
to be quite as frequent between eighty and ninety as
between seventy and eighty ; but I cannot regard
these sources of error as serious.

In the collection of these cases I have excluded all
those with fever; all in which such well-known renal
irritants as bile and sugar were present, no matter
how small in amount ; and also those in which exami-
nation rendered it probable that the mechanical effect
of crystalline formation in the kidneys was directly
responsible for the albumin and casts.

In the division of cases reported as showing albu-
min and no casts, no cases are included in which there
was sufficient blood or pus, either from the vagina or
lower urinary passages, to account for the reaction.
In many of these I am convinced that more careful
search would have revealed casts. Gases of cardiac
and other organic disease are included, but I have
tried to omit all those in which passive congestion
could account for the findings. Of course, all cases of
unquestioned Bright's disease are excluded. In short,
the attempt has been made to determine approximately
how frequently renal albuminuria and casts are en-
countered in the urine in the ordinary run of adults
who consult a doctor, but present no evidence outside
of the urine of primary or secondary renal disease.
Some sixty of the patients were hospital cases, partly
medical, partly surgical, suffering from widely varying
maladies or injuries. No record has been kept as to
the time at which the urines of my cases were voided.
The larger number probably were passed on rising in
the morning ; many were passed at mid-day in my
office; some both morning and evening; not a few
were mixed specimens of the twenty-four hours.

TABLE.

Age.

■No. of
Caaea.

Albumin and
Cuts.

Albumin and
no UaiM.

No Albumin
or Cuts.

20-00

25

8, or 32%

3, or 12%

14, or se%

30-40

38

9, or 23%

4, or 10%

26, or 66%

4(M!0

47

26,orS6%

'3, or e%

18, or 38%

so-eo

99

ei,or6»%

U,orlI%

24, or 24%

60-70

SI

42, or 74%

B, or9%

10. or 17%

70-«)

10

16, or 100%

00

00

80-90

14

11, or 79%

00

S, or 21%

The personal equation can be eliminated from my
results for the reason that the examination was made
in, roughly speaking, nearly equal proportion by four
different observers, and a few by two others, all com-
petent to distinguish mucous from renal casts. The
small percentage of cases in which albumin was found
without casts shows, I think, that no serious snspidon

can attach to my results on the ground that other sub-
stances were often mistaken for albumiu. In die
great majority of cases but a single examination was
made, but in a fair number there were two or more.

The table needs little explanation. It shows that
the percentage of urines containing albumin and casts
rises steadily with each decade from the fourth to the
eighth, while those free from albumin and casts are
in steadily decreasing percentage, and the proportion
of those containing albumin but no casts remains
nearly the same throughout. The number of cases in
which casts were found without albumin was so small
that these have not been classified.

The question remains as to the significance of these
results. The pathological meaning is not easy of ab-
solute proof. The class of patients who form the
basis of my statistics are slow to die, and ofiice and
hospital patients are easily lost sight of. A conside^
able number of the patients I know to be alive, and
apparently as well as when albumin and casts were
discovered a number of years ago. In only two have
I notes of autopsies. In one patient of eighty-five
death was the result mainly of old age, and the kid-
neys were exceptionally healthy to the naked eye.
In another of eighty-six years death was due to sudden
urnmia supervening on prostatic enlargement necessi-
tating repeated catheterization, cystitis, and impacted
calculus at the vesical end of the left ureter; the kid-
neys were cystic and atrophic, especially in the
cortices. Albumin and casts were found four years
before death, and yet the general health was remark-
ably good for a person of upwards of eighty. In some
of the cases albumin and casts were undoubtedly due
to active hyperssmia or to irritation of the kidneys,
and was perhaps transitory ; but it is my belief that
the facts in my table are best explained on the theory
that the albumin and casts are the expression of senile
renal atrophy, especially as far as the higher decades

go-
There is no internal organ in which it lies in oar
power to detect so unerringly minute and slight changes
as in the kidney. The heart, lungs, and blood-vessels
as a whole are far less accessible to our examination.
Age is not a matter of years, nor do we grow old
symmetrically. I see no other reasonable explanation
for the progressive increase in the frequency of alba-
min and casts as age advances. Whether this patho-
logical doctrine be true or not the clinical significance
admits, to my mind at least, of no doubtful interpreta-
tion. My anxiety is not awakened either for the
present or the future by the report that a faint trace
of albumin and hyaline and finely granular casts of
small diameter are found in the urine of a patient
after the age of fifty, provided that the kidneys are
doing sufficient work as is shown by the twenty-four-
hour excretion of solids, and provided that there are
no symptoms.

Three years ago I was consulted by two brothers,
fifty-two and fifty-five years of age, who had been
urgently solicited to take out life insurance policies
for one hundred thousand dollars each. But the ardor
of the company was cooled when it was found that
their urines contained a slight trace of albumin and
casts, and their anxieties were awakened. Albumin
and casts were constantly found in several examina-
tions during the succeeding year; but the men were
and remain perfectly well. The urines were rather
concentrated. In patients under fifty albumin and

Digitized by

Google

Vol. CXXX, No. 25.J BOSTON MEDICAL ASD SURGICAL JOURNAL.

615

casts do not disturb me anything like as much as they
did formerly. The important practical point is that
they are not necessarily the precursors of serious kid-
ney disease, and that their presence does not inevitably
demand very careful regulation of the life and constant
medical supervision.

In a certain proportion of cases, bow large this pro-
portion may be it will take years to determine, inter-
stitial changes will reach a d^ee to shorten life,
advancing more or less rapidly. It is not in our power
at present to distinguish accurately which these cases
are- Some help is affocded by the close estimation of
solids in the twenty-four-hour urine; but in the aver-
age individual the reserve balance of kidney power is
sufficient to permit of estensive renal impairment with-
out curtailment of the ordinary daily work. The
reserve may be diminished or gone ; but if the re-
serve is not drawn upon too much or at all no appar-
ent stringency is felt. We can grant that reual
albuminuria is always pathological. Chronic pharyn-
gitis is also pathological. It may be heresy, but I
cannot resist the feeling that we are coming to believe
that the clinical signiBcance of the one is not necessa-
rily greater than that of the other. I shall follow op
my cases as far as I can and hope to be able in the
course of years to throw further light on this impor-
tant practical question. Life insurance companies are
right in refusing risks reported as presenting albumin
and casts. Life insurance is more like the French
than the English criminal law ; — it holds that inno-
cence must be proved beyond reasonable doubt. But
I have no doubt that risks are daily accepted by the
best companies where an expert examination would
detect albumin and casts. Few examiners apply the
heat and nitric acid tests in a manner to try their full
delicacy, and a microscopical examination is practically
not demanded. Even if it were it would not ordina-
rily be sufficiently careful to be of much value.

Finally, my results may be summed up in the fol-
lowing conclusions :

(1) Renal albuminuria, as proved by the presence
of both albumin and casts, is much more common in
adults quite apart from Bright's disease or any obvious
source of renal irritation than is generally supposed.

(2} The frequency increases steadily and progres-
sively with advancing age.

(3) This increase with age suggests the explanation
that the albuminuria is often an indication of senile
degeneration.

(4) Though it cannot be regarded as yet as abso-
lutely proved, it is highly probable that faint traces of
albumin and hyaline and finely granular casts of small
diameter are often, especially in those past fifty years
of age, of little or no practical importance.

PELVIC INFLAMMATIONS.'

BV LKUMABD WHICISLBK, M.D., WOUOBSTEB, MASS.

The subject of Pelvic Inflammation is one of great
importance to every practitioner ; for the condition is
very common, and, for two reasons beyond inherent
difficulties, it is not easy to diagnosticate. These two
reasons for the difficulty in diagnosis are, first, that in
its present aspect the subject is so novel that only the
younger men among us learned anything of it in the

> Read before the Woroeiter Society tor Medlo»l Improrement,
April 4, IS94.

medical school ; second, that any degree of expertness
in diagnosis requires the handling of a good many cases.

The pathological history of pelvic inflammations has
been long and varied, but the salient points are interest-
ing, and may be made very brief. Up to 1850 there
was nothing extraordinary. Correct post-mortem ob-
servations had been made and recorded. Forty years
ago, however, Nouat in France, followed by West and
Simpson in Great Britaiu, and they again by Emmet
in this country (of course, there are other names in
plenty, but these were leaders), placed the seat of all
these pelvic indurations and suppurations in the cellular
tissue of the pelvis. It is wrong to say that these
men based their ideas unduly on what they were able
to feel during life, on clinical appearances and signs
rather than the revelations of the post-mortem table.
Autopsies do give strong credence to this view. It is
ouly abdominal surgery, after all, that baa proved it
false. Where the pelvic inflammation has gone on to
a fatal result, this cellular tissue has become exten-
sively involved, and it is quite impossible to determine
the point of origin of the disease. The suppurative
process gets into this cellular area and follows it along,
just as Schlesinger's air and liquid glue followed it be-
tween the folds of the broad ligament, along the psoas
muscles, inward around the cervix, outward to the
inguinal ringanddownward between vagina and rectum.
Having felt the disease during life and in its earlier
stages apparently in the broad ligament, and after
death finding a vast suppuration involving this very
cellular area, it was natural enough to conclude that
the disease had been all the time an affection of the
cellular tissue, and that the diseased tubes always found
with it were secondary. All this time, however, the
opposite and correct view was stoutly maintained by
Aran and his followers. He insisted that the masses
felt during life were the same as those found so often
after death from other causes as well as this pelvic in-
flammation, namely, diseased Fallopian tubes.

In 1857 appeared the first account of Bernutz's re-
markable researches on the nature and pathology of
pelvic inflammations. He clearly described the disease
clinically ; and he showed pathologically that it was a
disease of the tubes and ovaries accompanied by perito-
nitis, and that cellulitis had no influence in causing
the symptoms, that, in fact, it rarely existed at all as
a primary disease except as a phlegmon in puerperal
cases. This is the accepted doctrine of to day, in the
past few years made plain by hundreds of operations
for the radical cure of that large class of cases until
recently regarded and treated as chronic cellulitis.

Notwithstanding this thorough work and its thorough
discussion for years, the opposite theory still had its
supporters, and would have had to the present day but
for the revelation of Tail's operation, so-called..

In 1872 Battey did his first oophorectomy, and the
discussion and operations following prepared men's
minds for the favorable reception of Tait's operation.
Tait may have done some operations before, but the
table in his book " Diseases of Women " begins with
1880. The operation for removal of diseased append-
ages was not done in this country until 1882. In 1883
it began to be much talked about, and has been ever
since. The more it was discussed, the more attention
was diverted from cellular tissue and fastened upon
Fallopian tubes, though men were slow of conversion.
Emmet held his ground firmly until 1888 or 1889.

It seems strange that so common and so grave a dis-

Digitized by

Google

B16

BOSTON MEDICAL AND SURGICAL JOURNAL.

[June 21, 1894.

ease as salpingitis should have been neglected for so
long a time, especially after it had been so well de-
scribed as it was bj Bernutz. Still there would prob-
ably have been no further advance in these times
except that Lister's grand discovery and proof of the
value of cleaDliness in surgery had made modern ab-
dominal work* possible. Except for this the pioneer
work of Battey, Hegar, and Tait would have been
quite likely to be dropped aud forgotten.

With the advauce in pathological knowledge and
surgical treatment has come an eager study of the
causes producing these inflammations, and all this at-
tention has resulted in finding the disease of far more
frequent occurrence than had been supposed. Grouor-
rhoea in the female has received a new meaning, and
the necessity of surgical cleanliness in all gynecological
aud obstetrical work has received a capital emphasis.

In 1875 Noeggerath first published in this country
his ideas in regard to latent gonorrhoea, which have
given rise to a vast amount of discussion. It was a
saying of Ricord that in the great conflagration of the
final judgment the last thing to be consumed would be
a drop of gleet. Noeggerath's ideas were in the same
line. He maintained that any stricture after a gonor-
rhoea supplied a secretion capable of infecting the
female, aud that the favorite chronic abiding place of
this inflammation in the female was in the tubes. His
views have not been proved, but they went far in
bringing about the modern idea of gonorrhoeal disease
in women. It used until quite recently to be considered
a trivial disease. But with the present better knowl-
edge of tubal pathology it becomes plain that it may
be a very serious and dangerous disease.

It seems to be proved that some, perhaps many,
deaths ascribed to puerperal fever are really cases of
ruptured gonorrhceal pyosalpinx.

Another aud probably more important cause than
even gonorrhoea is the septic inflammation that ex-
tends over the genital mucous membranes after an un-
clean confinement, or especially abortion, or after the
use of unclean instruments obstetrically or gvnecologic-
ally.

There are other causes like syphilis, tuberculosis,
exanthematic fevers, tubal pregnancy ; but the impor-
tant truth is that pelvic cellulitis, as it used to be
understood, practically does not exist. The hard
vaginal vault, the pre-uterine masses, the lumps by
the side of or behind the uterus, the thickenings, the
indurations, the areas of fulness with which we are so
familiar, all these come from diseased tubes and con-
sist either of swollen and adherent tubes and ovaries,
or of peritoneal adhesions, or cicatricial bands. Other
masses, of course, are often enough felt in the pelvis,
but practically all the cases which used to be con-
sidered cellulitis are of this sort, and they are caused
by an extension of inflammation from the uterine
mucous membranes into the tubes.

Having in mind the bacterial nature of the disease
its etiology may be expressed as follows : pus iu the
pelvis may owe its origin, first, to an inflammation of
one sort or another (that is, may be owing to some
form or another of germ growth) extending over the
uterine mucous membrane into or through Fallopian
tubes (gonococcus, etc.) ; second, to an inflammation
extending through the parenchyma of the uterus via
lymphatics or veins (streptococcus, etc.); third, to an
inflammation derived from the intestine — the appen-
dix, in one of my cases (bacillus coli communis).

In the great majority of cases it comes in the first
way, via ntero-tubal mucosa. It is a pyo-salpinx or
the sequelae of a pyo-salpinx. Those occurring iu the
second way, by an infection through the lymphatic
or venous channel of the uterus, are of septic origin,
starting from an abortion, confinement, or some surgi-
cal operation on the genital organs. The third sort is
rare.

The prognosis and treatment of these cases of pelvic
inflammation is a matter of much perplexity, and each
case has to be decided on its own merits. One woold
thiuk that a consultation of the authors writing just
before the surgical treatment of the disease began,
would give a definite idea of the prognosis of the dis-
ease. As a matter of fact, however, one finds merely
vague Btatemeuts of personal impressions, the general
idea being that pelvic inflammation, except in puerperal
cases, is not often fatal but is apt to entail a vast
amount of distressing sequelae. Wherevef figures are
used, however, the mortality becomes more conspicu-
ous, as in McClintock's twenty four cases with seven
deaths.

The comparison is often made between salpingitis
and appendicitis, but the two cases are only distantly
similar. The appendix is a useless organ, and it is an
advantage to be rid of even a healthy one, whereas
there is no more important organ, except those neces-
sary to life, than the Fallopian tube. Again, the dis-
eased tube more frequently drains successfully into the
uterus than the appendix into the caicum. The uni-
versal surgical treatment of appendicitis may be main-
tained with some show of reason. Not so with sal-
pingitis. Men make very definite statements as to
certain conditions of the tubes entailing sterility, but
it is a matter of much difficulty to determine what
tubes are hopelessly diseased. I have seen a chronic
pelvic inflammation, many months in duration, where
the pelvis from side to side was of wooden hardness,
in a woman who afterwards bore several children.
Diseased appendages are not to be indiscriminately
removed.

The cases to be operated upon are those where
there is a recurrence of disease arising from a per-
manent focus of disease; second, those where there is
a permanently palpable enlargement of the tube caus-
ing symptoms which wear upon the health ; third, a
few acute cases which have to be treated simply as
abscesses.

As an illustration of my subject I have briefly re-
ported the following ten cases, all but one of which
occurred in my last year's service at Memorial Hospi-
tal. Four recovered without operation, two after the
removal of the appendages, one after vaginal drainage,
one died of peritonitis after operation, aud one (a
puerperal case) of peritonitis without operation.

Case I. D. W., admitted October 28, 1892.
Thirty-eight years old ; widow ; three children,
youngest thirteen years. History of salpingitis one
year before entrance. Recurrent attack two weeks
before entrance. Whole pelvis found filled with hard
irregular, sensitive mass, in which no organs could be
made oat. In three months this had gradually disap-
peared until there was nothing abnormal beyond slight
lateral thickenings with backward displacement of the
uterus. Patient was feeling well and having no pain
even at time of menstruation.

Case II. £. D., thirty-six years old, married.
Admitted to Memorial Hospital November 24, 1892.

Digitized by

Google

Vol. CXXX, No. 25.] BOSTON MEDIOAL AND SURGICAL JOURNAL.

617

No children. Abortion four months before admission,
foUovred by pelvic inflammation. Probable abortion
five weeks before admission, followed again by pelvic
inflammation. Oo admission there was a hard, tender
mass extending from the retroflexed uterus to left pel-
vic wall. Under treatment this mass slowly disap-
peared, leaving an adherent retroflexed uterus ; and
patient had pretty well recovered ber health in ten
weeks.

Cask III. J. S., twenty-two years old, single.
Admitted to Memorial Hospital February 16, 1898,
with appendicitis. Abscess opened and drained (pus
two ounces) February 17th. Limits of abscess cavity
could be touched by finger in all directions except
toward pelvis. This wound was completely closed by
March 23d. Two weeks before this a purulent
vaginal discharge led to the discovery of a double
salpingitis, which gradually disappeared under trea^
ment in the course of two months, leaving nothing
palpably wrong in the pelvis except a retroflexion
«^ith adhesions.

Cabb IV. J. McS., twenty-two years, single. Ad-
mitted to Memorial Hospital January 10, 18i>3. Con-
fined with first child in Canada two weeks before
entrance. Placenta adherent and removed. Chill on
seventh day with abdominal pain and tenderness, vom-
iting and diarrhoea. Acute symptoms abated; but
patient lost flesh, color and appetite, and complained
of nearly constant pain up to time of entrance. Ex-
amined at this time, pulse was 95, temperature 101°
Abdomen somewhat distended and tender. P. V.
ateruB crowded backward and to the right by a hard,
tender, immovable mass, filling left side of pelvis and
extending above pelvis brim. After six weeks in the
hospital, the mass had entirely disappeared, and the
uterus was normally movable.

Case V. L. R., twenty-one years, single. Admit-
ted to Memorial Hospital January 20, 1893. A thin,
pale, nervous girl. Gives history of invalidism, amen-
orrhcea, polyuria, etc., for four years. Has had local
treatment. On left of uterus is a pear-shaped mass,
twice as large as uterus, closely juxtaposed but not
adherent to that organ. The diagnosis was solid tu-
mor of ovary. The abdomen was opened February
15th. The tnmor proved to be a huge pyosalpiox
larger than the fist, with a few light adhesions to floor
of i>elvis and one very firm attachment at ntero-vagi-
nal junction, where the pus was apparently creeping
toward the vagina. The breaking of this adhesion
allowed a single drop of pus to escape. The tumor
was easily tied off and removed. The right tube was
found enlarged into half the size of this, and filled with
pus. This was also removed. The recovery was un-
eventful. Discharged well March 14th.

Cask VI. B. W., twenty-five years, single. En-
tered Memorial Hospital November 22, 1893. Suffer-
ing from acute gonorrhceal salpingitis (gonococci found
in vaginal discharge). Pain was very severe, and
patient altogether very sick. The acute symptoms
passed away in the course of a few weeks, and she
began to improve decidedly. The pelvic organs be-
came less matted, and it was possible to distinguish the
uterus with the swollen tubes on either side. At this
point improvement ceased, pain became worse, and we
decided to remove the tubes. This was done January
26th. The tubes were perhaps double the size of the
thumb, and tensely filled with thin pus. As always
in these cases, they were folded downward and back-

ward under the broad ligament. Adhesions were strong
and universal. At first, it seemed impossible to find
any place of cleavage. By patient scratching they
were dug out, tied off without the losx of any pus.
Was allowed to sit up in two weeks. Discharged well
March 2d.

Casb V'II J. E., twenty-five years, married. En-
tered Memorial Hospital March 2, 1893. Artificial
abortion a year ago followed by severe haemorrhage.
Confined at term six weeks ago. Had chill and fever
on second day, otherwise recovery was not interrupted.
Yesterday, March 1st, was seized with severe pain in
pelvis accompanied by nausea and vomiting. Entered
hospital March 2d at 5 p. h., temperature 104.4°,
pulse 120. No dejection for two days ; no urine for
thirty hours, 22 ouuces drawn by catheter. Abdomen
moderately distended and tender. • Masses on both
sides of uterus felt by vagina. Uterus much enlarged.
Free catharsis caused improvement in symptoms. Pa-
tient was so severely sick that hesitatTon was felt about
opening the abdomen, so an opening was made per
vaginam, drawing off four ounces of pus, and a drain-
age-tube inserted. The cavity was washed out daily,
discharging pus for two weeks. Patient slowly im-
proved, and was discharged after six weeks in hospital
feeling nearly well. Uterus was still too large ; aidhe-
reut to it on the left was a mass the size of an English
walnut. The right adnexa were naturally soft.

Case VIII. N. M., thirty-one years, married.
Entered Memorial Hospital March 12, 1893. Patient
had a history which led to a probable diagnosis of
tubercular peritonitis. Laparotomy was done. No tu-
bercles found, but the whole pelvis was found occupied
by what appeared to be a soft, solid mass, easily bleed-
ing, in which pelvic organs, omentum aud intestines
were hopelessly involved. The next day began a dis-
charge of pus from the rectum, which continued sev-
eral days and was estimated at about a pint in amount.
She improved rapidly ; the pelvic mass melted down
to an insignificant thickening ; and she was discharged
well on April 16th.

Case IX. M. C, twenty-eight years, married.
Entered Memorial Hospital February 14, 1893. Mar-
ried at eighteen ; child one year later. Three years
ago had inflammation of the bowels. lu bed four
weeks. Unable to do full work for a year, and has
been subject to pelvic pain since. December period
copious, followed by recurreuce of inflammation. In
bed since. January, flow scanty, and followed by
purulent vaginal discharge, which has continued since.
Patient is thin, pale, with little appetite, small pulse,
temperature nearly normal. Hard mass felt by palpa-
tion above pubes. Uterus in nearly normal position,
partially embedded in hard mass on right, which ex-
tends from pelvic wall to beyond mediau line. Mass
is hard, immovable, not sensitive. Oriflce of sinus
from which the pus comes, felt behind cervix to right.
It was found impossible to follow this sinus for the
purpose of dilatation. It was thought better to attack
the trouble through the abdominal wall.

At the operation on March 28th, the right tube was
found divided into two distinct four-ounce cavities filled
with pus, extending from the side of the uterus to the
caecum and universally adheren t. Omentum could not be
separated, and was tied off. When the tube was nearly
enucleated, it burst and covered the fleld of operation
with pus. This was washed out with hot water, the
euucleation completed, and the tumor tied off. There

Digitized by

Google

618

BOSTON MEDICAL AND SURGICAL JOURNAL.

[J DUE 21, 1894.

was DO difficulty of separation at the point of the fistu-
lous opening into the vagina. Left tube healthy.
Large gauze drain was left in. Patient died of peri-
tonitis at the end of the third day.

Case X. R. £., forty years, married. Admitted
to Memorial Hospital March 15, 1893. First child
born three weeks before entrance. Confinement nor-
mal. Was up feeling qaite well on the eighth day,
March 10th. Five days before entrance, eighteen days
after confinement, after exposure, wetting feet, etc.,
had a chill followed by fever, vomiting, abdominal
pain and tenderness. On 13tb, temperature 103°,
pulse 130. On 1.5th, when she entered hospital, tem-
perature 103°, pulse 100. Abdomen moderately dis-
tended and tender; countenance dull. Said she felt
better than the day before. Nothing abnormal was
felt by the vagina. A few hoars later she grew rap-
idly worse. At evening, temperature was 105°, palse
170; and she died at 4 a. m., March 16th. Autopsy
five or six hours^fter death. Body warm. Rigor mor-
tis not present. When abdominal cavity was opened,
a sero-purulent fluid escaped. The amount of this
fluid in abdominal cavity estimated at from six to eight
ounces. Peritoneum everywhere covered with lymph
flakes. Intestinal coils just beginning to adhere one
to another. Signs of peritonitis as much marked in
upper part of abdomen as lower. Vermiform appen-
dix and gall-bladder normal. Uterus possibly a trifle
■ubinvoluted. Site of placenta evident upon poste-
rior part of fundus. Fallopian tubes and broad liga-
ment free from adhesions. Broad ligament not thick-
ened. Cause of the general peritonitis not determined
by the post-mortem appearances.

Vix^wt^ or IbxytitAt^,

ASSOCIATION OF AMERICAN PHYSICIANS.

Ninth Anhdal Mbbtino, Washington, D. C, Mat
29, 80, 31 AND Junk 1, 1894.

FIRST DAT. — TUB8DAT.

President Reginald H. Fitz, of Boston, called
the Association to order, and delivered an address
on the

BISE AND FALL OF THE LICENSED FHTSICIAN IN
MASSACHnSETTS, 1781-1860.'

Db. Beverlt Robinson, of New York, read a
paper on

TBE TREATMENT OF CERTAIN STMPTOMS OF CROCP-
ODS PNEDHONIA, PABTICULARLT IN ADULTS.

The treatment of pyrexia and pulmonary congestion,
he said, are of special interest in the first stage.
The modern antipyretic drugs are not ordinarily use-
ful, although good, occasionally. Phenacetine is the
most satisfactory. More reliance is placed upon the
use of spirits of Mindererus, citrate of potash and sul-
phate of magnesia to reduce temperature by action on
the skin, kidneys and bowels. Three to five grains of
quinine every four to six hours tends to diminish fever
while strengthening somewhat the heart. Cold spong-
ing, the ice coil, cold pack or cool bath for the purpose
of reducing temperature do not act with any special
efficacy as usually employed. Occasionally, when the

• Se« page S29 of tbe Joamal.

temperature is beyond 104° and there are evidences of
adynamia, the tub-bath at 80° to 90° F. may be usefully
employed, combined with continuous friction.

Aconite or aconitin may often be injurious by di-
minishing the energy of cardiac contraction. Even
when combined in its use with digitalin, or digitalin
and strychnine, it is not free at times from grave ob-
jections. There are other drugs eminently more use-
ful, both theoretically and practically. In this stage of
pneumonia no drug acts as well as antimony in small
repeated doses. Kermes mineral, or the oxysulphuret
of antimony, is the best form. It is given usually in
doses of ^ of a grain every two hours, or every hour
for a while, in a mixture with syrup of gum and
orange-flower water. Employed in this manner, fever
and pulmonary congestion diminish at times in a very
obvious manner. Expectoration becomes easier and
more abundant, and the sputa from being very tena-
cious and viscid are more fluid and brought up with
relative ease and increased frequency. Kermes min-
eral given in this way is not irritating to the digestive
tract as tartar emetic often is, and does not produce a
collapsed condition. It suits children, also, remarka-
bly well. To aid its advantageous effect, we should
employ at times alcohol internally, and revulsives to
the chest wall. The great mistake formerly made in
the use of antimony was the employment of the wrong
salt and its use in excessive doses.

When the heart is particularly taxed by reason of
pulmonary congestion and a tendency to oedema, no
drug produces the rapid and remarkable results of
nitroglycerin given by the mouth, or better still, hypo-
dermically. We must not rigidly adhere to the ordi-
nary dose of i^jy grain, but should use j>q or 3*^ if the
condition of the patient is iminenily threatening.

The use of inhalations of oxygen in relieving pul-
monary congestion affords marked temporary relief to .
breathing in the greater number of cases of pneumo-
nia; but, in a few instances, not even relief is afforded,
bat the dyspnoea, and subjective distress is obviously
increased. These differences of action cannot always
be accounted for.

It is essential to have pneumonia patients drink
abundantly of water, and not force them simply to
take milk, beef-tea, or broths of different kinds, with
the idea that all that is required is to give nutritious
fluids, losing sight of the great importance of water
given by the stomach to promote the elimination of
poisonous excreta through the skin and kidneys. The
abundant use of cold spriug-water or soda-water gives
relief to thirst and helps reduce the fever, and may
diminish slightly the viscidity of the expectoration.

The proper use of alcohol in the treatment of pneu-
monia is a diflScult problem. Unquestionably, in many
instances it is very beneficial. It is generally judi-
cious practice when any reasonable doubt prevails as
to the condition of the patient with respect to any one
of the numerous conditions which seem threatening to
life, to give moderate and repeated doses of alcohol.
There are two absolute contra-iudications : first, cases
in which the patient is highly plethoric; second, cases
in which the hepatic engorgement and gastric catarrh
render it pernicious because nausea and stomachal in-
tolerance are increased by its exhibition even in mod-
erate amount, and assimilation of food and water is
prevented.

The use of calomel in small repeated doses often
has marked beneficial effect in cases where the tongue

Digitized by

Google

Vol. CXXX, No. 26.] BOSTON MBDJCAL AND SURGICAL JOURNAL.

619

remains yellow and thickly coated vrith far, while the
breath is offensiye. Ad engorged and eometimes ten-
der liver, a hard and distended abdomen, are frequently
dissipated by this medication.

The two dangers most to be feared in the state of
hepatization as well as that of crisis, come from heart-
failure or pulmonary hyperemia. How are these con-
ditions to be met ? The author's convictions are op-
posed to the use of digitalis or digitalin, except in very
small doses, and then only to control cardiac irregular-
ity when it occurs. The pulse is sometimes lowered
in a sudden and alarming manner from this drug. The
author employs in these conditions, large doses of
strychnia, at first by the mouth, and later, whenever
there is evidence of beart-failnre coming on, by the
hypodermic method. Results of considerable value
have been obtained by the use of hypodermic injec-
tions of extract of coco, made up aseptically. Reli-
ance must also be placed in these cases upon the use
of nitroglycerin hypodermically. Bleeding, alone,
saves certain cases. After venesection, the use of the
drugs mentioned is more valuable. In reflecting upon
some cases in which general pneumonic congestion at
first seemed to be the immediate cause of death, the
author has concluded that a slowly forming ante-mor-
tem heart-clot had much to do with the fatal termina-
tion. Frequently repeated doses of strong black coffee
is often beneficial. Black coffee and alcohol, particu-
larly old brandy or ram, will be assimilated and hold
the vitality of the patient when other food or stimulant
will be of little or no apparent benefit. Caffein does
not replace the use of coffee.

In the treatment followed at St. Luke's Hospital,
New York, half-milligramme doses of arseniate of
strychnine are usually given together with digitalin
and aconitin. The author has for some time watched
this method of treatment, and prefers the treatment
outlined in bis paper to the one with the so-called
" trinity pill."

Dr. 6. L. Peabodt, of New York, said that he
was in accord with Dr. Robinson, that at the present
time there was no possibility of any other treatment of
pneumonia than the symptomatic. One combination
of symptoms which is very distressing and which needs
treatment, had not been given by Dr. Robinson, namely,
pain together with insomnia. Frequently doctors ob-
ject to the administration of morphine in pneumonia,
even in the minute doses in the cough mixtures, on
the ground that opium and its alkaloids impair the
activity of the respiratory centres; and as here the
respiratory system is at fault or impaired, it is un-
desirable to do anything that would still further impair
it. This reasoning is very fallacious, for it is not the
respiratory centre that is impaired, but the respiratory
periphery ; and small doses of morphia do not further
impair the respiratory- system of the thorax but will
often act as a cardiac stimulant and aid matters in the
chest. Small doses of morphia, one-sixth of a grain,
repeated once or twice if necessary, during the conrse
of the night, will relieve the symptom of pain, or
insomnia dependent upon pain or excessive cough, in
a way that nothing else will.

It is not necessary to treat every case of pneumonia
whose temperature reaches 103° by any form of bath ;
but if the temperature is particularly high or prostrat-
ing, then the bath is exceedingly valuable, in conjunc-
tion with friction to the surface.
Dr. Robinson's experience as to the occurrence of

heart-clot as a cause of death in pneumonia was at a
variance with that of Dr. Peabody. In many autopsies
in deaths from pneumonia, he had very rarely found
heart-clot present. He thought that the French
authors particularly have been inclined to mistake a
post-mortem for an ante-mortem heart-clot. They
have relied for a differential diagnosis upon the im-
print of the aortic valve upon the clot, which is
fallacious. The heart-dot is so infrequent that it is
not possible to predict it or to avert it by treatment.

Dr. J. C. Wilson, of Philadelphia, said, in croupous
pneumonia we have to deal with a pathological condi-
tion associated with certain clinical phenomena which
vary within the widest limits, so that the croupous
pneumonias of infancy, of early life, of adult life and
of old age ; the croupous pneumonias of alcoholic
subjects ; the croupous pneumonias which are second-
ary to antecedent infectious processes; the croupous
pneumonias in which there are corresponding or equally
varying local lesions ; central pneumonias, apex pneu-
monias, crossed and double pneumonias, and so on,
give us a series of clinical pictures which present not
only wide variations in symptoms, but indicate an
equally varying treatment. So that the treatment of
pneumonia to-day, while we have no specific treatment
to fall back upon, must be, in the first place, a treat-
ment of expectancy, and, in the second place, a treat-
ment in which the symptomatic factor mast enter
largely in the process.

The experience with cold baths in the Grerman Hos-
pital in Philadelphia has not been satisfactory in the
treatment of any form of pneumonia. The cases have
not done well that have been immersed in the cold
bath. The application of cold locally to the chest has
at times seemed to be of decided benefit.

Regarding venesection, it would appear from the
literature of the subject that too much attention is
paid to the mechanical indications for venesection.
Venesection in croupous pneumonia has often proved
advantageous, doubtless by relieving the toxaemia by
withdrawing from the blood-supply in large volume
the toxic principles to which the nervous symptoms
and other serious symptoms must be due. Venesection
is therefore useful in cases where the old mechanical
indications are not very well marked.

Regarding the use of opium, it is not only safe but
often advantageous, in a large proportion of cases of
pneumonia, to give small amounts of morphia. Small
doses of Dover's powder, two, two and one-half or
three grains, at intervals of two, three or four hours,
according to the degree of pain or restlessness of the
patient, may be given throughout the case.

Dr. V. C. Vaughan, of Ann Arbor, believed that
Dr. Robinson had not used the true digitalin, but a so-
called digitalin the greater part of which is digitoxin.
The true digitalin, which has been studied by Pfaff,
has a wholly different action from that described by
Dr. Robinson.

Dr. B. Robinson said that he had purposed in his
paper to oppose what seemingly is the conviction of
some eminent practitioners in New York of the efficacy
of the so-called *' trinity pill," or a modification of it,
in the treatment of certain threatening symptoms of
pneumonia.

He also wished to direct attention to the fact that
we are using drugs very often in a way that is not
altogether rational, simply because we do not know
what we are using. Different doctors, using what

Digitized by

Google

620

BOSTOm MBDICAL AND 8VBG10AL JOVBNAL.

[Junk 21, 1894.

tbey soppose to be the game drug, secure different
results, which are due to the fact that the agents they
use are not the same.

Dr. J. W. Roosevelt, of New York, stated that
the " trinity pill " was not used in all the cases at the
Roosevelt Hospital. It had been used in about one-
third of the cases daring the past year.

Dr. S. a. Fisk, of Denver, read a paper on

A TRKATUEMT OF TTPHOID FKVER.

Dr. Fisk exhibited a chart on which his article was
based. It was compiled from thirty average cases of
typhoid under bis treatment, running through three
years. The chart is a composite of these cases. The
morning temperature for any one day of all the cases
are added together and divided by thirty, and a mean
temperature is thus obtained. The same way with the
evening temperature ; so that the chart as presented
is a composite of the thirty cases, both with reference
to the temperature and the pulse-rate.

The cases were mostly hospital cases, and were ob-
tained, as most hospital cases are, about the fourth or
fifth day. They were cases of undoubted typhoid, not
selected, having the usual symptoms, including rose
spots, and treated almost by routine according to the
method outlined.

The chart shows a steady decline in both tempera-
ture and pulse-rate from the very beginning and a
short duration. Together with this chart was exhibited
a typical chart of typhoid fever taken from Pepper.

The treatment is : Calomel, five grains, at the very
start, followed by a saline; a tumbler of milk, pep-
tonized if necessary, every three hours, followed in
twenty minutes by four minims of the oil of turpentine,
four minims of castor oil, ten grains of the subnitrate
of bismuth and a drachm of mucilage of acacia. This
has the effect of constipating the bowels, so that every
second morning anywhere from two teaspoonfnls to a
tablespoonful of castor oil is given, the patient usually
feeling better on the days on which he takes the oil.
Plenty of water, which can be iced if they prefer;
lemonade, not to conflict with the milk, if they choose.
Delirium of the early stage is quieted with Dover's
powder, five grains, repeated once or twice p. r. o. at
night. But little attention is paid to high temperature ;
occasionally the patient is sponged a few times, if the
temperature runs very high. Dr. Fisk believes with
Dr. Steadman, in the city hospital reports of Boston,
that the pulse is a better indicator of prognosis than
the temperature. After the temperature has remained
normal, or in many cases subnormal, a week or ten
days, be begins to feed gradually, preferring animal
diet, in the way of broths, eggs and the juice of beef,
to starchy foods. If the pulse becomes feeble, he
stimulates with whiskey, one-half ounce every two or
three hours p. r. n., and uses digitalis or strophanthus,
rather preferring the latter.

Dr. I. E. Atkinson, of Baltimore, agreed with Dr.
Fisk that milk was the proper diet of typhoid fever
patients, but with some qualifications. He had a num-
ber of times seen patients whose death was doubtless
due to the efforts made in attempting to expel the
undigested portion of the casein of the milk which
had accumulated in the rectum. He thought that the
judicious mingling of liquid animal food with the milk
toward the end of treatment of typhoid fever was use-
ful and desirable in nearly all cases.

Insomnia in typhoid, especially that insomnia which

may be called the coma vigil, is extremely ominous.
In a number of cases Dr. Atkinson had averted fatal
consequences by abandoning the use of ordinary
hypnotics and using a slight inhalation of chloroform.
In cases where the patient has taken the ordinary
hypnotics to the danger point, a few whiffs of chloro-
form has allowed the patient to go into a slumber and
permitted the other hypnotics to assert themselves.

It has been well established that all the symptoms
of typhoid are favorably modified by the use of the
cold bath. The dry, brown tongue is not present;
there is absence of tympanites, subsultns, of delirium
and of profound depression, all due to the use of the
cold bath, even where the temperature is only tempo-
rarily modified.

The eflScacy of the line of treatment which Dr.
Fisk points out is not shown quite clearly by the chart.
One or two cases widely different from the rule would
have given quite a different picture. It is not shown
that his method is as good as the cold-bath treatment
now in vogue.

Dr. C. F. Folsoh, of Boston, thought that Dr.
Fisk had had the luck to have treated 80 unusually
mild cases. Since Dr. Folsom has been a visiting
physician at the Boston City Hospital, probably 1,500
to 2,000 cases of typhoid have been treated ; and of
these, 800 to 400 were under his care. After he had
treated 150 cases, he had been rash enough to write a
paper and to generalize from these cases on the treat-
ment of typhoid fever. Now, when he needs a little
humiliation he refers to that paper. The number of
Dr. Fisk's cases is altogether too small to generalize
upon. Medicine, strictly speaking, has very little ef-
fect in typhoid, excepting in controlling symptoms
which cannot be better controlled in other ways, and
those are very few. Almost all the symptoms are
best treated with cold water.

Dr. J. F. A. Adams, of Pittsfield, Mass., expressed
his appreciation of the composite charts presented by
Dr. Fisk, and thought it would be well for others to
follow the same plan. He referred to the fact that
typhoid fever in different parts of the country, and at
different times in the same locality, is almost an en-
tirely different disease. In Western Massachusetts,
about ten years ago, there had been an invasion of
intermittent fever, and following this invasion typhoid
fever became greatly changed, and instead of follow-
ing the typical chart of Dr. Pepper, followed more
nearly the chart of Dr. Fisk. The mortality was very
much diminished ; and every form of treatment that
was used during the two or three years following the
invasion of malaria, was highly successful, because of
the mild and short form of typhoid fever.

Dr. Wm. Osler, of Baltimore, said that the paper
of Dr. Fisk illustrated a common therapeutic faJIacy,
as it was doubtful whether Dr. Fisk's treatment had
any influence on the disease. The chart indicates that
he had a peculiarly mild series of cases which would
have doubtless recovered with diet and a nurse. For
the year ending May 15th, Dr. Osier had treated in
his wards at the Johns Hopkins Hospital, 80 cases by
the Brand method with a mortality of only just over
six per cent., which is a very satisfactory showing for
a general hospital to which the cases are brought at all
stages.

Dr. S. a. Fisk said that the criticisms upon his
paper were as he expected. While the treatment he
outlined was not a specific, yet it bad been employed

Digitized by

Google

Vol. CXXX, No. 26.J BOSTON MBDIOAL AND SURGICAL JOURNAL.

621

Batisfactorily in Denver for many years, where there
has been much typhoid fever. In the fall of 1890,
there were 700 cases of typhoid in Denver daring the
month of October. He believed that there were other
methods of treating typhoid fever than by cold baths.
Dh. C. F. Folsom, of Boston, read a paper on

CASES OP TRAUUATIC HEADACHE.*

Six cases were reported of injury to the bead from
severe blows, in five of which there were irregular,
ragged cicatrices from healing by granulation. In two
trephining was done. In the others the cicatricial
tissue was excised. The pathological conditions found
by Dr. W. F. Whitney were interstitial neuritis,
thickened pericranium, increased cell proliferation
causing pressure, and, io one case, diffuse hyperostosis
of the skull. The symptoms — pain, various morbid
nervous and mental indications and petit mal — were
relieved. In two cases, there was also an ocular de-
fect as a partial and contributing cause of the trouble.

Dr. M. Allen Starr, of New York, said that al-
though such a severe operation as trephining was a
ratber serious matter to recommend for headache, yet
there are some cases, such as those related by Dr.
Folsom, in which it should be used as a last resort.
He related a case similar in many features to the cases
of Dr. Folsom. A young man struck upon the head
four years ago bad suffered very intensely since that
time from constant pain at the seat of injury, and his
disposition had changed very much. From being a
good-natured, fairly intelligent boy, he had become a
perfect little devil. He had, at times, attacks of rage
in which he would act in a maniacal manner. After
all other measures had been tried in vain, Dr. McCosh
trephined at the position of the pain, which coincided
with the position of the cicatrix. A slight depression
was found in the external table, but there was no fract-
ure of the internal table and no adhesion of the dura
to the bone. Under the dnra was a small angioma,
which was taken away. Punctures were made with a
hypodermic needle in three directions under the wound,
in search of a possible cyst beneath the cortex, but
nothing was found. The patient made a good recov-
ery. He has been entirely free from headaches ; his
disposition has become tractable ; and he is in every
way a new and better boy.

Id a large experience with traumatic epilepsy and
other cases of traumatism of the scalp. Dr. Starr has
found pain at the seat of the injury the exception and
Dot the rule.

An interesting observation in connection with this
case was, that for six weeks subsequent to the opera-
tion the boy had an absolute loss of muscular sense in
the right hand and arm below the elbow. There was
no disturbance whatever, of motor power, no disturb-
ance of touch, temperature or pain senses. It is per-
haps the only case on record in which a cortical lesion
baa produced a loss of muscular sense alone, and settles
a disputed question as to the existence of muscular
sense as separated from motion and sensation.

Dr. Frederic P. Henrt, of Philadelphia, read

▲ CLINICAL report OP TWO CASES OP RATMADD'S
DISEASE.

The author gave in detail the history of two interest-
ing cases of Raynaud's disease, and exhibited colored
sketches of the patients. He then discussed the distino-
> To be published in fall in tbe Jonmal.

tion between genuine and spurious cases of Baynaod's
disease, the genuine affection being distinguished by
the stages of local " syncope " and " asphyxia," the
absence of traumatism, and symmetrical distribution of
lesions. The disease has nothing in common with
senile gangrene.

The chief theories of the cause of Raynaud's disease
are : (1) that it is due to an endarteritis obliterans ;
(2) that it is due to peripheral neuritis ; (3) that it is
the result of vascular spasm. The last is the theory
of Raynaud himself, and, in the opinion of the author,
is the one that is in accordance with the clinical phe-
nomena. The disease is most prevalent in females
and in the youns;, that is, in those whose vaso-motor
system is most impressible. It occurs in paroxysms,
which are caused by the surest exciter of vascular
spasm — cold. Finally, in several cases, during the
paroxysm, there has been dimness of vision, which was
shown by the ophthalmoscope to depend upon a con-
traction of the central artery of the retina and its
branches ; and in one recently reported by Dr. H. M.
Thomas, the attacks of local syncope were followed by
a chill, loss of consciousness and convulsions. Such
facts are in the highest degree corroborative of Ray-
naud's view that the disease is due to an " enormous ex-
aggeration of the excito-motor energy of the gray parts
of the spinal-cord which control the vaso-motor in-
nervation."

The symptom hsemoglobinoria, occasionally observed,
is best explained by the theory of vascular spasm, and
is dependent upon an excretion of haemoglobin which
has been separated from the red corpuscles in the pe-
ripheral asphyxiated parts.

Dr. Henrt M. Lthan, of Chicago, thought that
from the physiognomy of the pictures presented both
of the patients were arthritic subjects. The relation-
ship between arthritism and Raynaud's disease should
be borne in mind. He had seen quite a number of
cases in which that relationship was very evident.

Dr. Wh. Osler said : Dr. Henry has referred to a
case reported by Dr. H. M. Thomas from my clinic.
It was very interesting in this respect, that the attacks
occurred only during winter, were always associated
with epilepsy, and usually associated with hsemoglobin-
uria. In connection with the cerebral manifestations
of the disease, we have also had under observation a
remarkable case in which with the local asphyxia,
sometimes without, the patient has aphasia sometimes
with and somtimes without hemiplegia.

Dr. M. Allen Starr said that the disease could
be entirely outgrown, and spoke of a case under bis
observation which had resulted in recovery.

Dr. W. H. Welch, of Baltimore, said that it was
not at all clear to him how there could be a connection
between heemoglobinuria and arterial spasm. It is
possible that the heemoglobinuria in these cases belongs
to the general type of paroxysmal hemoglobinuria
that follows exposure to cold. The experiments of
Ehrlich and of Rosenach indicate that the red blood-
corpuscles in this condition are unstable and readily,
under the influence of cold, give up their haemoglobin.
It is probable that the corpuscles give up their haem-
oglobin in those cases described by Dr. Henry from
this cause, and that vascular spasm has nothing to do
with it

Dr. F. p. Henrt believed that there was a greater
vulnerability on the part of such patients to such
causes as dissolve the red blood-corpuscles than on the

Digitized by

Google —

622

BOSTON MMDICAL AUD SVSGICAL JODHIfJl.

[JtNB 21, 1894.

part of other people ; but it seemed to him also, that
the arterial spasm, the effect of which is to produce
local aaphjxia, is also concerned in the production of
the hemoglobiuiemia. The haemoglobinuria is a result
of the hsemoglobiusmia.

Dr. H. C. Ernst, of Boston, then reported

DR. 8. C. martin's RK8KARCHE8 ON THR BACTKHIA
OF VACCINIA.*

The paper presented was made up of the work of
Dr. Stephen C. Martin upon Vaccine Virus, obtained
from a complete set of notes left to Dr. Ernst by Dr.
Martin before his death, which occurred last fall, and
which he wrote oat when he found that he would not
be able to continue his work by reason of the illness,
that finally proved fatal. Briefly stated, the results
of Dr. Martin's investigations are as follows :

(1) The germ of cow-pox is a bacterium.

(2) This bacterium, in different stages of develop-
ment, is in the form of a coccus or of a bacillus.

(3) It can be isolated and grown in pure culture on
blood serum at the temperature of the blood.

(4) Inoculation on the calf from such cultures
readily produces the typical cow-pox, while inocala-
tions in man, have produced typical cow-pox but once
in eleven times.

All that remains to be done now is to find under
what conditions to grow the pore culture, that it may
be uniformly relied upon for vaccination in man.

Dr. W. H. Wblch thought that the results reported
in this paper were very important, if true. Others
have made observations in much the same way, with
negative results. The work is left by Dr. Martin in
that condition where it needs confirmation.

Dr. a. C. Abbot, of Philadelphia, thought the re-
sults obtained by Dr. Martin exceedingly interesting,
but felt that subsequent observations might modify the
results.

Db. 6. M. Stbrnbbbo said he would like to have
these experiments repeated by an accomplished bacte-
riologift. There ought to be no difficulty in confirm-
ing the experiments if they were reliable.

Dr. H. C. Ernst said that the work had been done
in his laboratory, that he had carefully questioned Dr.
Martin at different times, but could never detect any
fallacy. His object in presenting the work to the
Association was to secure confirmation or refutation.

(To be continued.)

ASSOCIATION OF AMERICAN ANATOMISTS.

Thb Sixth Annual Meeting of the Association of
American Anatomists was held in conjunction with
the Congress of American Physicians and Surgeons in
Washington, D. C, May 29 to June 1, 1894.

The Secretary reported that Dr. Chas. B. Ewing,
Assistant Surgeon, U. S. A., and Dr. F. C. Schaefer,
Professor of Anatomy in the Chicago Medical College,
had resigned ; and that three members had died,
namely. Dr. Wm. Lee, Professor of Physiology,
Columbian University, Washington ; Dr. Wm. B.
Towles, Professor of Anatomy and Materia Medica,
University of Virginia, and of Anatomy, University
of Vermont, and Dr. Corydon C. Ford, Professor of
Anatomy and Physiology, University of Michigan.

The officers elected for the ensuing term were: Dr.

> Tobe pnbllshed In (nil In tbe Jonmal,

Thos. Dwight, of Harvard University, President; Dr.
B. 6. Wilder, of Cornell University, 1st Vice-Presi-
dent ; Dr. F. J. Shepherd, of McGtll University, Mon-
treal, 2d Vice-President; Dr. D. S. Lamb, Army
Medical Museum, Washington, Secretary and Treas-
urer. Prof. C. L. Herrick, Denison College, Granville,
O., delegate to the Congress of American Physicians
and Surgeons ; Dr. D. K. Shute, Columbian Univers-
ity of Washington, D. C, alternate. Dr. Theo. M.
Gill, Smithsonian Institution, Washington, D. C, was
elected to the vacancy in the Executive Committee.

The following new members were elected: Dr.
John A. Boger, Assistant Demonstrator of Anatomy,
University of Pennsylvania ; Dr. H. B. Ferris, Assis-
tant Professor of Anatomy, Tale University; Dr.
Robert L. Greene, Professor of Anatomy, University
Medical College and Western Dental College, Eansu
City, Mo. ; Dr. Wm. Keiller, Professor of Anatomy,
University of Texas; Dr. Joseph Leidy, Assistant
Demonstrator of Anatomy, University of Pennsylvania;
Dr. Mary B. Moody, New Haven, Conn. ; Mr. Robert
O. Moody, Yale Medical School ; Dr. Chas. D. Smith,
Professor of Physiologv, Bowdotn College ; Dr. Wm.
O. Stillman, Albany, N. Y. ; Dr. W. C. Woodward,
University of Georgetown, Washington, D. C. Sir
Wm. Turner, of London, was elected an honorary
member.

The following papers were read: '* On tbe Identity
of Structure of Protoplasm with that of Striped
Muscle," by Dr. Carl Heitzmann, of New York Git; ;
" Some Problems Relating to Cerebral Fissures," Dr.
Wilder, of Cornell University ; " A Plea for a
Methodically Written Text-Book on Anatomy," Dr.
E>lmond Souchon, Tulane University, New Orleans ;
" Study of the Human Cranium," also, " Shortening
of the Face-Axis in the Evolution of the Mammalia,"
Dr. Harrison Allen, University of Pennsylvania;
" Methods of Estimating the Height from Parts of the
Skeleton," Dr. Dwight, Harvard University; "The
Perineum and Perineal Body," Dr. Shute, of Colum-
bian University, Washington, D. C. ; " The Study of
the Muscular Tunic of the Large and Small Intestine
of Man in the Region of the Csecum," also ** A Note
on the Occurrence of the Scapulo-Clavicular Muscle,"
Mr. Moody; "Theoretical Anatomy of the Sympa-
thetic System," Dr. Wm. Carr, Columbian University,
Washington ; " The Female External Genital Organs,
a Criticism on Current Anatomical Description," Dr.
Lamb, Army Medical Museum, Washington, D. C.

The following papers were read by title in tbe ab-
sence of the authors : " In Our Two Years' Study of
Anatomy, What Part of the Subject should be Covered
in the First Year's Work, What Part in the Second ?"
by Dr. A. D. Bevan, Rush Medical College; two
papers " The Form and Relations of the Nerve-Cells
and Fibres in Desmognathus Fusca," and " The Ter-
minology of the Nerve-Cell." by Prof. P. A. Fish,
Cornell University.

A Strikb Caused bt Tootbacbr. — A dentist is
attached to all the French lucifer match factories. At
one of these all the hands went on strike recently, so
it is said, because the dentist made them suffer so
much. As their visits are compulsory at certain stated
intervals, there was no escape except by the means
adopted. The dentist resigned, and was replaced, and
the hands returned to their work.

Digitized by

GoQgle

Vol. CXXX, No. 25.] BOSTON MBDIOAL AND SUBGIOAL JOUBNAL.

623

AMERICAN MEDICAL ASSOCIATION.

FoKTY-FiFTH AirauAL Mkbtino, San Francisco,
Cal., Junk 5, 6, 7 and 8, 1894.

first dat. — tce8dat.

Tbk Fortj-fifth Annual Meeting of the American
Medical Agsociation wa8 held at San Francisco, June
5th. The general session of the opening day was at-
tended by over two hundred members, and was held
at Odd Fellows Hall, which was abundantly decorated
with orange, scarlet and white festooning. The Presi-
dent, James F. Hibberd, of Richmond, Ind., called
the meeting to order at 10.45 A. M. In the unavoid-
able abeence of both the Governor and the Mayor,
Supervisor J. C. James extended to the guesU " the
freedom of the city and a hearty and cordifd welcome."

The formal Address of Welcome by the California
State Medical Society was given by Dr. J. L. Dm-
MONS, of Sacramento.

Dr. H. R. Plcumer, Chairman of the Committee
of Arrangements, reported that the entire expenses of
the meeting had been provided for without calling
upon the funds of the Association. After announcing
the official programme, he presented President Hib-
berd with a gavel made of orange-wood (representing
the State color) and manzanita-wood. The sides were
of gold, one inscribed "A.M.A., S.F., 1894," and the
other " James F. Hibberd, President."

The chairman of the various sections were each pre-
sented with a gavel of yew and myrtle wood by the
physicians of Oregon.

THE president's ADDRESS.

After thanking the convention for its gift, Presi-
dent Hibberd delivered the address.

Ha discussed the various points at which the Asso-
ciation comes into touch with the general medical
needs and work of the country. He considered it of
the greatest importance that a more satisfactory ar-
rangement sbonld be made of sobordinate medical
societies in their relation to the American Medical
Association. At present many delegates are annually
not received because their credentials are not issued
by a society tecl^nically entitled to representation.

" Every medical man who belongs to any medical
society should belong to a county or an equivalent
mediciU society, and every member of a county society
should be ipto facto a member of his State society,
and this is an " open sesame " to the American Medi-
cal Association.

By this arrangement, all reputable physicians in
the United States would be brought together in the
common fold, whose power for good within its legiti-
mate sphere would be limited only by its aggregate
wit aud energy. Such a consummation would elevate
the American profession to a plane for useful work
the highest conceivable for the disciples of scientific
medicine.

This would in no wise interfere with the organiza-
tion of medical men devoted to special lines of practice
or investigation ; indeed, the more of these, and the
more special their fields of labor and inquiry, the more
rapid will be the development of medical knowledge,
the nearer will expert art approach to perfection, and
the greater will be the blessing to humankind. In
these special aud limited societies there will be a con-
centraiioii of thought and labor that will yield results

advanced and true to a degree beyond hope from a
more promiscuous assembly.

All the adherents of the special organizations will
be members of county societies, and thereby of their
respective State societies, whence, for the asking, they
can step through the portals of this Association, and
find in our sections a department already organized
and at work, into which they can enter, each accord-
ing to his tastes or qualifications, and feel at home
among fellow-laborers.

After discussing in detail the organization aud func-
tions of the various sections and committees of the
Society, he devoted the remainder of his address to
the more public duties and opportunities of the So-
ciety. A determined effort should be made by the
whole Association to prevent the threatened mistake
of reducing the number of assistant surgeons in the
army, and to have Congress restore the appropria-
tion for the National Medical Library to its original
$10,000. Reviewing the efforts to secure a National
Bureau of Public Health, he said :

" Without rehearsing details, I feel free to declare
my conviction that enough has been ascertained of the
sentiment of the executive and legislative departments of
the government to rob us of all hope of the establish-
ment of a Department of Public Health within the
remainder of the nineteenth century."

A bureau of public health, with a commissioner as
its chief, within one of the existing departments of
the government, was apparently within reach of a
united, harmonious, aggressive effort of the profession
for a year or two previous to the enlargement of the
power of the Marine- Hospital Service by the last pre-
ceding Congress, but the excellent work of that service
at home aud abroad since its increase of authority and
means has lessened the anxiety of the government aud
the apprehension of the public in such degree as to
make those in power less attentive to appeals to do
what should yet be accomplished.

As to the relation of the medical profession to
public opinion on small-pox and vaccination, he said :

"It seems to me the reasonable duty of this Asso-
ciation at this time is to declare and proclaim its un-
abated faith in the virtue of vaccine to protect from
small-pox, to render persons as immune against variola
as an attack of variola itself, and that it is innocent of
all mischief when the vaccination is done by a vacci-
nator who is a competent judge of both the purity of
the vaccine and the fitness of the vaccinee.

" The progress of medicine in the immediate future
must be along biological lines. The microscope has
revolutionized our knowledge of the world of living
things, and to us has been discovered the generators
of the most extensive and persistent and malignant
epidemics that periodically decimate the earth, as well
as intrattable and fatal disorders that we have always
with us. Another line of biological workers have
carried us back through the morphology organs, tissues
aud cells to the origin of vital activity in protoplasm,
and still more important, in doing so have given us
glimpses of the origin and development of the somatic
mind that will, when the scheme of nervous organiza-
tion aud function shall be clearly portrayed, dissolve
the mystery that has in the past obscured our realiza-
tion of the true nature of hypnotism, Christian science
and other anomalous neuroses which the sciolists and, in
an especial manner, those claiming to be doctors, are
promulgating- and practising to the discredit of true

Digitized by

Google

624

BOSION MBDICAL ASD SVJtGJCJL JOVEHAL.

IJUNE 21, \hU.

scientists and the injury of the weali-minded and igno-
rant classes. We should apotheosize protoplasm, the
dividing line between organic and inorganic matter, it-
self at once the result of the law of perpetual motion
with which the Creator endowed the atoms of ele-
mental matter, and the beginning of that phase of
energy known as vital activity, which constitutes the
entire vegetable and animal kingdom. No one people
or class of people can claim exclusively to have opened
the way into this more primitive arcauom of nature.
The physicists of all nations, botanists, zoologists,
anatomists, physiologists and their congeners, have
all participated in this progress. The distinction of
Schawn, Vircbow, Ferrier, Jackson, Pasteur, Koch
and Steinberg is due to their advanced study of
biology."

As to the proposed changes in the Code, he said :

" For years there has been a feeling among many
most excellent and intelligent working members of the
guild that the Code of Ethics did not fairly accord
with the demands of the advanced profession in their
intercourse with each other, nor with the proper recip-
rocal relations between the profession and the public,
while, on the other band, many members equally in-
telligent and devoted to the Association have felt that
the Code of Ethics that has guided the Association
through nearly half a century prosperously and honor-
ably, and is still a reliable guide in every advanced
thought and action, cannot be bettered for our present
status, and should not be disturbed."

The Address of the President was referred to a com-
mittee of five — Drs. W. T. Bishop, Z. B. Todd, R.
B. Cole, F. W. Maun, and J. P. Woodbridge.

On motion of Db. Qcimbt, of New Jersey, a com-
mittee was appointed to draft a resolution of protest
to Congress against the threatened reduction of the
medical and surgical force of the army. Dr. Quimby
was appointed chairman of this committee.

The Report of the Treasurer, which was read by
the Secretary owing to Dr. Dunglisou's illness, showed
a balance of $6,156, in the treasury.

The Secretary's Report was largely devoted to
presenting the action of the various State societies as
to the revision of the Code. Twenty-one societies were
opposed to the change. Nebraska, Vermont and Indi-
ana were in favor of the change. Wisconsin and Florida
laid the matter on the table. Three had not yet con-
sidered the question, and from eleven no reply bad
been received.

The following resolution was adopted :

Whereas, Dr. R. J. Dunglison has been for seventeen
years a faithful, energetic Treasurer of this Association,
without any compensation ; therefore, be it

Resolved, That the hearty and unreserved thanks of this
Association be cordially extended to him fur his efScient
and laborious duties on behalf of this Association, and a
copy of this resolution be forwarded by the Secretary to
Dr. Dunglison.

In the afternoon the sections held their meetings.

In the evening the San Francisco County Medical
Society gave a reception to the members of the Asso-
ciation and ladies, which was attended by over five
hundred guests.

SECOND DAT. — WEDNK8UAT.

The general session of the second day was called to
order at noon by the President to listen to the Address
on Medicine by Da. C. U. Hdoues, of St. Louis, on

THE KERVUUS SYSTEM IK DISEASE AND THE PRAC-
TICE OF MEDICINE FBOM A NEDROLOOICAI, STAND-
POINT.

He spoke first of the great advance of modern medi-
cine, saying that as Hippocrates drove the devotees of
superstition from the Temple of Hygeia, and taught
the people that offended gods could neither bring, nor
propitiated gods dispel, disease, and as Andreas Ves-
alius defied the popular prejudice and ecclesiastic
power of bis day, at the risk of his life, to make his
first human dissection, so hi^ professional descendants
of to-day continue breaking down barriers of ignorance,
of prejudice and superstition in the way of man's hap-
piness and prosperity, unlocking the secrets of Nature's
arcanum and setting the captive mind and organism
free from the enthralment of disease.

The recent epidemics of influenza had done much to
emphasize to physicians the great therapeutic impor-
tance of understanding the intricate influence of the
nervous system. Ail forms and manifestations of dis-
ease were dominated by the nervous system, and it was
in the slightly disordered functionation of this marvel-
lous organization that the early approach of disease
was to be recognized. Even bacteriology was second
in importance to an understanding of neurology for
the explanation of the origin and onset of disease.

" And now in the sunlight of advancing science, and
of the approaching twentieth century, I proclaim that
neoriatry and the practice of general medicine are
practically one. The practice of medicine is rapidly
becoming one of neurological methods, of neuriatry
and psychiatry ; and the best neurologist, all other
attainments being equal, must of necessity make the
best general practitioner. The boon of hypnosis and
narcosis under the many methods for its induction
known to our art, saving the insomniac from the pre-
cipice of mental overthrow or neural failure in the
lower centres of the cerebro-spinal axis or peripheral
nervous system ; the power of antisepsis, and through
it the wonderful procedures and possibilities of modern
surgery, and thisjin d» riieU hygiene; the many and
marvellous therapeutic and hygienic advances in
promoting the phagocytosis of the toxic bacteria, the
destruction of the ptomaines, and in other directions
of relief and cure: the discoveries of pathology, histol-
ogy, medical chemistry, biology, neurology, psychol-
ogy, psychiatry, and the contributions of surgery,
gynecology, ophthalmology, otology, laryngology, proc-
tology, and the other specialties of study and work,
have made the later decades of the present century the
most memorable in resourceful discovery in the history
of medicine or in the history of mankind."

The Librarian's Report recommended the transfer
of the library of the Association to the Newberry
Library in Chicago.

The Report of the Trustees of the Journal was ac-
cepted, after some opposition, by a vote of 86 to 33.

THIRD DAY. — TBDRSDAT.

The Society was called to order at 10.30 a. m. After
some general business, and the election of Dr. H. H.
Brown of Chicago to fill the vacancy in the judicial
council caused by the death of Dr. Murphy, the Com-
mittee on the Revision of the Constitution made its
reports. The majority report was presented by Dr.
W. M. HoLTON and the minority report by Dr. H. D.
DiDAMA. After a sharp discussion, the minority re-

Digitized by

Google

Vol. CXXX, No. 25.] BOSTON MEDICAL AND SURGICAL JOURNAL.

625

port (opposed to a change) was adopted as the report
of the Committee by a vote of 161 to 70.

FOURTH DAT. — FRIDAY.

The closing gesaiou of the AsBOciation was called to
order at 10.30 A. u., the President in the chair.

The first business to come before the meetiog was
the debate on the

REVISION or THE CODE OF ETHICS,

which followed closely the lines of the discussion on
the Constitution of the day before. The minority re-
port, presented by Dr. Didama, was adopted. The
next business was

THE ELECTION OF OFFICERS.

The ticket presented by the Nominating Committee
was elected by acclamation.

President, Donald McLean of Michigan. Vice-
Presidents — Starling Loving of Ohio, William
Watson of Iowa, W. B. Rodgers of Tennessee, F.
S. Bascom*of Utah. Treasurer, II. P. Newman of
Illinois. Permanent Secretary, William B. Atkinson
of Pennsylvania. Assistant Secretary, G. H. Rohe of
Maryland. Librarian, passed. Chairman of Committee
of Arrangements, Julian J. Chisholm of Maryland.
Board of Trustees — Joseph Eastman of Indiana, J. T.
Priestley of Iowa, John E. Woodbridge of Ohio (un-
expired term), J. W. Graham of Colorado, (ric« D. C.
Patterson, deceased). Judicial Council — D. W.
Grouse of Iowa, R. C. Moore uf Nebraska, T. D.
Crothers of Connecticut, G. B. Gillespie of Tennessee,
W. T. Bishop of Pennsylvania, C. H. Hughes of
Maryland, 1. J. Heiberger of the District of Columbia,
H. Brown of Kentucky.

The meeting of 1895 will be held in Baltimore.

The Address in Medicine will be given by Dr. W. E.
Quine of Illinois ; in Surgery, by Dr. C. A. Wheatou
of Minnesota ; and that in State Medicine, by Dr. H.
D. Holton of Vermont.

The question of excluding advertisements of prepar-
atory remedies from the Journal of the Association
was referred, after some discussion, to the Judicial
Council, which decided, after debating the whole after-
noon, that one of the advertisements complained of
had been inserted throngh inadvertence. The atten-
tion of the Trustees was called to the other one.

The Annual Addresses in Surgery and in State Medi-
cine were then read by title only, as neither Dr. Rohe
or Dr. Laplace attended the meeting or sent any
manuscript.

MASSACHUSETTS MEDICAL SOCIETY.
The One Hundred and Thirteenth Meeting.

The sessions of the Sections in Medicine and in
Surgery were held at the Harvard Medical School on
Tuesday, June 12ih.

The Shattuck Lecture was given on Tuesday even-
ing, by Dr. Thomas Dwioht, upon

THE RANGE AND THE SIQNIFICANCB OF VARIATIONS
IN THE HCHAN SKELETON.

The exhibit this year was chiefly edacational in
character. Boards of health were represented by
those of Cambridge and Lowell. The latter had an
excellent set of diagrams, tables, photographs, etc., il-
lustrative of its special duties. The plant for crema-

tion of garbage, in which Lowell has led the way, was
illustrated in detail. Especially instructive tables
were thjse giving the statistics relative to the riscent
small-pox cases, also to the falling off in the death-rate
since the establishment of the board. Mr. James H.
Emerton had a unique exhibit of his papier mache
models of human bones, etc., so valuable for class pur-
poses. Among them were a gigantic skull, two and a
half by three and a half feet in diameter, long bones,
vertebrae, brain, liver, ao encysted trichina, all corre-
spondingly enlarged.

There were the usual exhibits of representative in-
strument-makers and publishers.

The exhibit of especial interest was that of the
Massachusetts College of Pharmacy. It consisted of
a carefully prepared and authentic collection of all the
cruile drugs, preparations, organic products, chemicals,
test and volumtric solutions and reagents ofiicial in the
revised United States Pharmacopoeia of 18'JO, col-
lected, prepared and tested by students of the college.
It was a surprise to all to see that the Pharmacopoeia
was so great a work as to permit so extensive an ex-
hibit of over eleven hundred articles. Few of us real-
ize that provision is made for seventy-two tinctures
and nearly twice as many extracts and fluid extracts ;
and it was new to a good many who saw it that by
following Pharmacopceial directions any pharmacist,
just as the students had done, can prepare pills,
troches, etc., of exact dosage, ready solubility in the
body's fluids, and also of elegant appearance. As this
pharmacopceial collection is unique, is of uuusual in-
terest, and as complete as it could be made, regarJless
of expense, the College of Pharmacy intends preserv-
ing it in its museum for permanent exhibition.

The One Hundred and Thirteenth Annual Meeting
was held on Wednesday, June 13, 1894, the President,
Dk. James C. White, in the chair.

The Secretary reported that during the year 153
members had been admitted, and that 26 had died.

Papers were read upon the following subjects :

ICHTHTOL IN OTNGCOLOOT,

by Dr. Malcolm Storer, of Boston.

CHRONIC inflammation OF THE SEMINAL VESICLES,

by Dr. G. W. Allen, of Boston.

THE FREQCENCr OF PUERPERAL SEPSIS IN MASSA-
CHUSETTS, ITS DIAGNOSIS AND EFFICIENT TREAT-
MENT,

by Dr. Edward Rbtnolds, of Boston.

Discussion by Drs. C. M. Green, of Boston ; E.
H. Stevens, of North Cambridge.

THE ANNUAL ORATION*

was delivered at noon, by Dr. B. H. Fitz, of Boston.

the annual dinner

was served at one o'clock, there being about nine hun-
dred and fifty members present.

At the close of the dinner the Anniversary Chair-
man, Dr. Silas D. Pbesbret, of Taunton, spoke as
follows :

Another year has passed, and once more our Society
welcomes you to her annual festivities. At our last
meeting we were reminded that we were then at the
beginning of a great national celebration ; at this time

< See page 681 of the JoamaL

Digitized by

Google

626

BOSTON MEDICAL AUD SVBGICAL JOl'SXAL.

[Jlkk 21, 1894.

the Columbian Ezpositioo is fiuisbed, and we may well
consider some of the contributious that were made bv
the medical profession of the State, and we may justly
take pride in the work that was done by members of
this Society.

The Masaachusetts State Board of Health has re-
ceived high praise, both in this country and abroad, for
the comprehensive exhibit of its work and its methods.
The Journal of tht American Medical Auociation says :
"This exhibit is an object-lesson well worthy of study
by other States, as owing to the increased density of
population and increase of manufacturing wastes, our
water-supplies are annually becoming more polluted,
and the necessity for such work more and more imper-
ative." Thus the oldest board of health of the coun-
try justified the opinion that it is a leader a'nd an au-
thority iu the work in which it is engaged.

The Medical Department of Harvard University
made a striking exhibit of the most advanced methods
of instruction, and in some respects methods entirely
unique. A Harvard man could not fail to feel a thrill
of satisfaction when he found himself surrounded by
the familiar frozen sections and the mammoth models.
Studies in physical culture, as expressed by charts, pho-
tographs and models, showed the zealous care with
which the health and growth of the Harvard student
are watched and promoted.

I would not miss the opportunity to call to your at-
tention an innovation of the last year which seems to
me especially worthy of your notice and of yonr pat-
ronage. Through the school year the Faculty of the
Harvard Medical School has given a course of evening
lectures on special subjects, which physicians were in-
vited to attend without charge. The lectures were
given OD each Wednesday evening from October to
May, vacations excepted. This work was done by
gentlemen of great experience in teaching, and each
lecturer is an acknowledged authority on the subject
which he handled. 1 hope this, the first and experi-
mental year, may prove the beginning of a permanent
custom.

The third feature of the medical year is the adoption
by the Legislature of an Act to provide for the Regis-
tration of Physicians and Surgeons in the State of
Massachusetts. I am happy to say that after hard
work and careful management the Act has passed both
branches of the Legislature and has received the Gov-
ernor's signature.

Fellows, the weightier matters of the physician's
work and duty have had ample discussion for two days
in the neighboring halls; here we have met for re-
freshment and entertainment. How well your admira-
ble Committee of Arrangements have attended to the
refreshment you are all able now to judge ; it only re-
mains for me to introduce to you the entertainment.

Dr. Presbrey then offered the first regular senti-
ment: "The Massachusetts Medical Society," which
was responded to by the incoming President, Dr. F.
K. Paddock, of Pittsfield, who spoke as follows :

It wonld seem to me more proper that the response
to this toast should be made by my predecessor. Dr.
J. C. White, who has so faithfully and successfully
conducted the affairs of the Society for the last two
years. It will be my greatest ambition to perform the
duties of this oflSce as satisfactorily as he has accom-
plished them.

There is no question about the importance and emi-

nence of the Massachusetts Medical Society. Its mem-
bers embrace the best medical talent in the State, and
for seventy years it exerted a controlling iufiuence
over the practice of medicine throughout the Common-
wealth. In 1859, for various reasons, the Legislature
deprived the Society of this control, so that for thirty-
five years the people of the State have been preyed
upon and. defrauded without opposition by hordes of
quacks and charlatans.

The dignity of this Society and the welfare of the
community demand that this condition shall be changed.
Other States have laws to regulate the practice of
medicine -, this State should do likewise. During the
last session of the Legislature a successful effort has
been made to establish a law to regulate the practice
of medicine. For this legislation we are indebted
to a member of this Society, Dr. Harvey, of Westboro'.

The good influence of this Society is increased by
every regularly educated, respectable physician who
joins it ; and I think that it is the duty of the mem-
bers to personally solicit candidates for adsiission.

" Lessons from the Experience of Two Years in the
Presidency of the Massachusetts Medical Society."

Dr. J. C. White, in response, said : I told you at
a former dinner, iu the few words I then addressed to
yon, that 1 hoped to have more of interest to say when
I should have become better acquainted with the con-
dition of the Society and the functions of the high
office with which you have honored me. There is do
other opportunity offered to the President to meet so
large a gathering of members of our Association, and
to present any opinions he may have formed concern-
ing its welfare, as this occasion, so that he tnust avail
himself of it for this purpose.

During my term of office I have visited, for pur-
poses of observation and inquiry, all the eighteen dis-
tricts into which our Society is divided, and which
present so striking a diversity in their physical aspect
and in the character of their inhabitants, as in the long
stretch of sandy Barnstable, with its remote settle-
ments, the lonely and sparse hill-towns of Berk:>hire,
and the many busy centres of factory life, with their
dense throngs of foreign peoples. We hardly appre-
ciate here in the metropolis and its immediate sur-
roundings how unlike our own are the life and profes-
sional relations of these other districts, which are so
essential a part of our State Society. Think of a
Massachusetts township with only 219 inhabitants,
and of these all but 19, Indians; and of 80 or more
towns in the State without a resident Fellow of this
Society. It has been my object to study its workings
in all these regions, and to gather the views of its
members living under such diverse conditions as to
how satisfactorily it may be fulfilling its mission.

Let me first briefly define what, in my opinion,
should be the chief objects of this Association :

(1) The cultivation of friendly relations and mutual
support among its members.

(2) The establishment and maintenance of rules to
regulate the practice of medicine in its relations to the
community.

(3) The stimulation of progress in our art by meet-
ings for medical improvement, by encouragement of
scientific research, by the foundation of scholarships
and lectureships.

(4) The elevation of medical education.

(5) The securing and enforcement of laws for the

Digitized by

Google

Vol. CXXX, No. 25.] BOSTON MEDICAL AND SURGICAL JOURNAL.

627

presorration of the public health and the enlighten-
meut of the people concerning it.

Now I have foand that, on the whole, a satisfactory
loyalty to these objects prevails throughoat the So-
ciety ; that mach interest is everywhere manifested in
the district meetings, and that the papers there pre-
sented are most praiseworthy. In some parts of the
State, where the towns are thinly peopled and widely
separiited, the attendance was not large. '

It was a great surprise to me to note how small a
proportion of the physicians in many places were grad-
uates of oar Massachasetts schools of medicine. Thus,
in one district containing S6 Fellows, only three, and
in another of 38 members, but two, had received such
a degree of M.D. In the seveuteeu districts of the
State (omitting Suffolk), representing 1,200 members,
only 463 are graduates of our medical schools.

Again, I was astonished to learn how many physi-
cians were practising medicine in this State, graduates
of medical colleges whose diplomas are recognized by
as, of excellent reputation, regarded as their peers by
our Fellows, their associates in private medical bodies
in many instances, and with whom they consult freely,
and yet who are not members of the Massachusetts
Medical Society. Many of these are gentlemen who
have come from other States, where they were in good
standing in their State societies. 1 cannot give you
their exact number, but it is very large. The presi-
dent of one district informed me that there were
twenty such men in his city. Another president of a
small district named twelve to me. The Treasurer of
the Harvard Medical School Alumni Association in-
forms me that 775 of its members reside in this State,
and that of this number 118 are not members of our
Society, or 15 per cent. Now it is very important
that every good physician should be enrolled upon our
list of Fellows. It is better for them, mnch better so
for us, and why are they not members ? Because in
the majority of cases they are unwilling to run the
possible risk of being stamped by our examining boards
as incompetent. There can be no doubt that the ex-
aminations of our censors have often been too severe,
and of a character to test the school rather than the
practical knowledge of the candidate. Within two
years two distinguished professors, recently become
residents amongst us, and desiring membership, have
refused to offer themselves to the test of such methods
of examination. How many of my colleagues on this
platform would venture to act otherwise? At the
time when our present laws defining the duties of cen-
sors were formed, the requirements for a medical
degree in most or all schools were lax and insuSicieut,
and the Society had to protect itself by an independ-
ent and rigid examination. It is very different now,
and in all good schools the requirements for the degree
of M.D. give practical assurance of sufficient medical
knowledge for our purpose. Yet within the last two
years graduates of the Harvard Medical School have
been turned aside by our censors. At a meeting of
one district society I heard read aloud the names of
several young men who had failed to pass the exami-
nation of a neighboring board. Can one wonder that
our present system repels candidates, and serves to
keep good men out of the Society, whereas its object
is to get them in ? You are aware that at a recent
meeting of the Council a system has been adopted by
which the entrance to this Society may be made more
lax, but still sufficiently protected. This plan is to

come before a special meeting of the Society next Oc-
tober, and deserves your careful consideration.

"The Commonwealth of Massachusetts."

LiEUTENANT-GovERKOR WoLCOTT Said that, hav-
ing addressed the Society before, it required the deli-
cate touch of a Hawthorne to give any charm to
twice told tales. The two characteristic actions
of the medical profession which were unparalled in
any other are, first, the gratuitous treatment of the.
poor in hospitals and asylums, whereby the most un-
fortunate person can call upon and receive the aid of
the most skilful physician; and, secondly, the close
observance of that unwritten law, which has more
force than statutory law, that whatever device or
remedy for the alleviation of suffering a physician may
by skill or study discover, shall be freely given to the
public. The benefit to a community of the scientific
knowledge and enthusiasm which the osedical profes-
sion brings so freely to the service of the public good
is not easy to estimate. For this, too, Massachusetts
offers her congratulations and acknowledgment.

The Medical Rpgistration Bill is certain to prove
of permanent utility to the Commonwealth, although
Massachusetts comes a little haltingly into line. If it
but keeps the word. " doctor " back to its old meaning
of teacher — a teacher of sound sanitary law, of a
high standard of honor, a teacher of the laws of public
health — so that no charlatan can use it, the Gov-
ernor and members of the Legislature are entitled to
your thanks and those of the community.

"The City of Boston: New England's Thought-
Centre."

Mator Matthews being unable to attend the din-
ner, no response was made to this toast.

" Harvard University."

President Eliot said that in looking back over
the last twenty-five years nothing was more clearly
marked than the progress of professional education,
and in this mediciue has taken the lead. There has
been more gain in the education of physicians and
surgeons than in any other department of the univer-
sity. He had often felt the wish that medical schools
in general, and those of Massachusetts in particular,
were producing more country doctors. The country
doctor should be given chief place. He needs a better
education than the city doctor. He has no specialist
at his elbow. He must know himself, and act him-
self. The training of the country doctor is most im-
portant, and needs to be developed, for he is more
than a physician. He is a missionary. He is a social
reformer — a sanitary reformer. He brings to his
community the scientific spirit, a most valuable and
important thing. The country doctor has one immense
privilege and great happiness for his comparative iso-
lation, that of living in the country, an inestimable
prize for himself and for his family — as one who
from long observation of where the most promising
students come from can testify.

Commenting on the examinations of the Society, he
said it had been proven useless to examine at one time
;a man on studies which had taken six or seven years
to acquire. This practice had been given up in the
university, and it was not reasonable to do so in this
Society. What is wanted is an examination which
will test power. The question which the Council

Digitized by

Google

628

BOSTON MEDICAL AND SVBGICAL JOURNAL.

[Jlke 21, 1894.

should pnt to each candidate is not, " What do yoo
know of this book or that book?" bat "What can
you do in judgment and tact and good temper for your
patients ? "

" The Physician as seen by the Lawyer."

Attornet-Genrhal Knowlton spoke of the
general relations of the lawyer and the physician.
As the physician had been his first friend in this
world, so be would be with him at the close of life
to make it easy. It seemed to him that the same
quality of character was essential to success in both
the lawyer abd the physician — that peculiar quality
which for lack of a better term is calleid " nerve," the
ability to face great danger and risk in an impasiionate
manner uninflneDced by personal feeling. The doctor
who attempts to care for his own case was likened to
the man who makes his own will ; both are more dar-
ing than wise.

" The Physician as seen by the Journalist."

Hon. William Reed, Jr., spoke of the earlier at-
tempts to secure a Medical Registration Bill, in some
of which he was actively engaged himself while in the
Legislature. He congratulated the Society, not that
the members had protected themselves, for they needed
no protection beyond the honor of the Society, but
that the people of the State had been protected.

" The Medical Man of Japan."

Rev. Arthur M. Knapp spoke of the remarkable
progress of medical science in Japan since 1854, and
the magnificent work done by the medical school of
Tokyo, which was the first step in the formation of
the great university there. He related many interest-
ing facts about the medical history of Japan.

MASSACHUSETTS MEDICAL SOCIETY.
CovKCiLLORs' Meeting.

Tub annual meeting was held at the Medical Lib-
rary, Boston, on Weduesday, June 13, 1894.

The meeting was called to order at eleven A. H. by
the President, Dr. James C. White. One hundred
and fifty-five Councillors indicated their presence by
signing the roll.

The Secretary read the names of 153 Fellows ad-
mitted since the last annual meeting, and of 36 whose
deaths had been recorded.

The Treasurer, Dr. Forster, presented his report,
which wai accepted, showing the receipts of the So-
ciety for the year ending April 15, 1894, with the
balance on hand at the beginning of the year, to have
been $11,887.92, and the expenditures $8,895.09,
leaving a balance of $2,992.83.

Dr. Draper, for the Committee on Membership and
Finances, reported the names of four Fellows whom
the Committee recommended to become retired mem-
bers ; of eight to be allowed to resign ; and of four to
be dropped for non-payment of assessments.

The report of the Committee was adopted.

It was also voted, on recommendation of this Com-
mittee, that $1,900 of the surplus in the treasury be
distributed among the district societies.

The Committee on Publications reported that Dr.
Robert T. Edes, of Jamaica Plain, has been ap-

pointed to deliver the Sbattuck Lecture at the annual
meeting of the Society in 1895.

The Librarian, Dr. Bkioham, presented his report.

The Committee on Nominations reported, and tha
following were chosen officers of the Society for the
ensuing year: President, Dr. Franklin K. Paddock,
of Pittsfield ; Vice-President, Dr. Frederic A. Saw-
yer, of Wareham ; Trea«urer, Dr. Edward J. Forster,
of Boston ; Corresponding Secretary, Dr. Charles W.
Swan, of Boston ; Recording Secretary, Dr. Francis
W. Goss, of Roxbury; Libra'ian, Dr. Edwin H.
Brigham, of Boston. Dr. Alfred Worcester, of Wal-
tham, wa^ chosen Orator, and Dr. Herbert L. Burrell,
of Boston, Anniversary Chairman, for the annual
meeting of the Society in 1895.

Voted, That the next annual meeting of the Society
be held in BoAon on the second Weduesday in June,
1895.

The following Standing Committees were appointed :

Of Arrangements : Drs. H. Jackson, J. C. Munro,
A. Thorndike, A. K. Stone, J. G. Mumford, N. V.
Pierce.

On Publications : Drs. B. E. Cotting, 0. F. Wads-
worth, G. B. Shattuck.

On Membership and Finances : Drs. F. W. Draper,
J. Stedman, E. G. Cutler, L. R. Stone, A. H. John-
sou.

To Procure Scientific Papers : Drs. H. P. Bowditch,
F. H. Zabriskie, H. L. Burrell, S. B. Woodward, L.
Wheeler, C. W. Townsend.

On Ethics and Discipline : Drs. G. E. Francis, F.
C. Shattuck, C. G. Carlton, E. Cowles, J. F. A.
Adams.

On Medical Diplomas : Drs. E. J. Forster, H. £.
Marion, £. N. Wbittier.

Dr. C. M. Green called attention to the fact that
for two years there has been no session of the Section
in Obstetrics and Gynecology at the annual meeting of
the Society; that owing to the interest of members in
the other sections it is di£Bcult to obtain a satisfactory
audience, and an injustice to ask for the preparation
of papers. He moved, and it was voted, that the rule
by which the Obstetrical Section was established be
rescinded, and that the Section be abolished.

Dr. 6. B. Shattuck offered resolutions which
were adopted :

That a Standing Committee on State and National Legis-
lation be appointed at the annual meeting of the Council-
lors.

That this committee shall consist of five memliers, in-
cluding the President, ex officio.

It shall be the duty of this committee to take such action
in reference to proposed legislation as shall, in their opin-
ion, be most conducive to the interests of the medical pro-
fession, and to make an annual report thereon.

Dr. Gaoe offered the following, which, after some
discussion, was adopted :

Whereas, the expenses attending the annual meeting of
the Society have been increasing in recent jears, and now
exceed what seems to be a reasonable amount for tbid ob-
ject; and whereas, it is desirable that such expenditures
should be more under the immediate control of the Council
than hitherto,

Voted, that the Committee of Arrangements for the an-
niversary shall hereafter consist, in part, of members of the
Council.

Dr. J. F. A. Adams presented the following, which
was passed :

Digitized by

Google

Vol. CXXX, No. 26.1 BOSTOlf MEDICAL AND SURGIOAL JOURNAL.

62d

WkereoB, it is evident that the affairs of the Society can
be best administered by the cooperation of those who have
the widest experience with its condition in all sections of
the State,

Resolved, that in the opinion of the Council it is advis-
able that District Societies shall include in their election
to this body such ex-Presidents of the State Society as
may reside Uierein.

The following preamble, together with amendments
to the By-Laws abolishing the otBce of Anniversary
Chairman were, on motion of Dr. Cheever, adopted :

Whereas, it is more consistent with the dignity of the
oifice, and in conformity with the custom of all societies of
such high character, that the President should preside over
all meetings, and especially at the most important public
occasion, tiie annual dinner : Resolved, etc.

Adjourned at 1.15 p. h.

AMERICAN CLIMATOLOGICAL ASSOCIATION.

Eleventh Annual Meeting, Washington, D. C,
Mat 29, SO, SI and June 1, 1894.

FIBST DAT.

- TCE3DAT.

Aptss a brief Introdnctory Address, the President,
Dr. Andrew H. Smith, New York, read a paper on

alimentation in FCLMONABT DISEASE.

In pulmonary affections the problem of alimentation
is complicated by special conditions growing out of
the functions of the affected organs. We are too apt
to regard nutrition as if it were only another term for
digestion, , and practically to assume that, if the food
t4tken into the stomach goes through the proper changes
in the alimentary canal, and the nutritive portion is
properly taken into the blood, that is all with which
we need have concern. The products of digestion
when received into the circulation are not blood.
They represent neither serum nor corpuscles: they
are, iu fact, dead matter, requiring to be vitalized by
the process of assimilation before they become a part
of the living blood.

Of the manner in which this change takes place we
know almost nothing. But we do know that an essen-
tial factor is the process of oxygenation that takes
place in the lungs. Material which has not under-
gone this change is, for the time being, not only use-
less to the economy, but a hindrance to proper meta-
bolism.

If, then, a considerable obstruction exists to the en-
trance of air into the lungs, it follows that an addition
of more nutritive material to the blood than can be
acted upon under the circumstances of crippled respira-
tion, will only add to the circulatory embarrassment
and aggravate the condition of the patient.

Under these conditions, therefore, we should study
in acute cases to give as little nourishment as will sus-
tain the vital powers, rather than as much as the
stomach can be made to digest.

If we pass to chronic affections of the lungs, the
same principle will hold good, with certain important
modifications in practice. We have a chronic condi-
tion in which we are confronted with a restricted
hxmatosis on the one hand and urgent necessity for a
high degree of nutrition on the other. The difficulty
of reconciling these two conditions will be in propor-
tion to the degree of lung-insufficiency.

In the minor degrees of chronic lung-insnfficiency.

the respiratory movements make up in frequency what
they lack in amplitude. So long as this compensation
can be fully maintained, there may be no considerable
defect in hsematosis, and, in the absence of fever, no
marked failure of nutrition. But, sooner or later, a
time comes when the respiration is so far impaired that
enough oxygen cannot be taken into the blood to act
upon such an amount of nutritive material as is neces-
sary for the full maintenance of the economy. The
moment this stage is reached, the appetite fails in pro-
portion to the defect in hsematosis. Unless we can
improve the hsematosis, and with it the whole process
of metabolism, we shall only do harm by high feeding.
Digestion in these cases ftuls as well as a,88imilation.
Moreover, in these chronic cases 4vith pronounced
anaemia and emaciation, we cannot rely chiefly upon
nitrogenous food, as we must do in acute affections of
the lungs. The heat-producing hydrates and fats are
required in addition, and these are more difficult of
assimilation. A vicious circle is established, the de-
fective hsematosis aggravating the dyspepsia, and this
in turn resulting in greater poverty of the blood. Under
these conditions, life in the open air is of the utmost
importance.

The speaker has obtained much benefit in cases of
this kind from rectal injections of defibrinated blood.
This material seems to be absorbed almost unchanged,
the corpuscles as well as the serum ; it being a frequent
experience that no trace of blood is found in the next
dejection. There being no digestive action upon the
blood, its absorption into the venous circulation is al-
most equivalent to transfusion very slowly performed ;
and but little change in the way of hsematosis is re-
quired to fit the added material for the immediate use
of the tissues.

Dr. Smith described a case of phthisis treated in
this way. There was an enormous cavity at the sum-
mit of the right lung ; the patient was emaciated to
the last degree, weighing only 101 pounds. After
two weeks of the treatment with blood enemata, he
gained seven pounds. At the end of three months he
left the hospital ; the cavity in the lung had contracted
greatly ; expectoration had nearly ceased ; he httd
gained 33 pounds.

Dr. Smith said : Though defibrinated blood is pre-
ferable for this purpose, good results may be obtained
with the materials usually employed for rectal feeding,
provided the patient can live much in the open air.

In the discussion which ensued, Dr. Karl von
Ruck referred to twenty or thirty cases in which he
followed the method suggested by Dr. Smith, aud
carefully observed the number of corpuscles and the
haemoglobin present. All the cases showed marked
improvement in the blood condition.

The paper of Dr. Boardman Reed, of Atlantic
City, on

THE relation WHICH ALIMENTATION SHOULD BEAR
TO OXTOEMATIOM IN LUNO DISEASES,

was read by Db. Jambs B. Walker.

Dr. Reed concurred in the opinion of Dr. Smith,
that any excess of food beyond the amount which can
be perfectly digested and assimilated, is injurious.
When the intake of oxygen is large, as in the case of
a robust person exercising actively iu the open air, a
maximum amount of food can be safely given. When,
on the other hand, a patient has one or even both
lungs crippled, the amount of food which he can digest

Digitized by

Google

630

SOSTOH MEDICAL ASD SVRGJCAL JOUBHAL.

[JpNS 21, 1894.

and thoroDghly oxidize into a nutritive pabulnm for
the uses of the economy, is much less. Between
these two extremes are found patients with all possible
degrees of capacity and opportunity for absorbing
oxygen, and iu consequence equally varying degrees
for digesting and assimilating food. Evidently, then,
there is such a ratio as baa been assumed. It is ex-
ceedingly important that this fact be borne in mind in
deciding the proper feeding of a case of lung disease.

Dr. Reed gave a detailed report of six cases (four of
the number being now either well or convalescent),
concerning which he says : The results are, on the
average, considerably better than when it was my
practice to .encourage the fullest feeding of consump-
tive patients. They have been obtained with the aid
of so little internal medicine, and that addressed al-
most exclusively to the digestive tract, that the man-
agement of the diet and hygienic regimen generally
should receive the credit.

An abundance of pure healthy blood circulating
normally in the lungs is the most essential prerequisite
to a cure of phthisis pulmonalis. Hence the paramount
importance of looking closely to the blood-making pro-
cesses by securing as perfect digestion as possible, to-
gether with a complete oxidation of its products, so as
to spare the lungs from the injurious task of assisting
in the excretion of the poisonous compound resulting
from suboxidation and decomposition. To obtain
these ends satisfactorily, the total amount of aliment
ingested must not be in excess relatively to the amount
of oxygen absorbed. Dr. Beed considered the impor-
tance of selecting a special climate for such cases greatly
over-estimated, though changes of climate exert a
powerful stimulant action upon nutrition, for a few
months especially.

TUK METHODS AND VALUK OP 8UPBRTI8ED EXERCISE
IN THE PROFHTLAXIS OF POLMONARY PHTHISIS,

was the title of a paper by Dr. Glentworth R.
Butler, Brooklyn. The substance of Dr. Butler's
paper was as follows :

Pulmonary tuberculosis is essentially a disease of
defective nutrition. Although of microbian origin, a
certain vulnerability of the tissues precedes and under-
lies the bacillary growth. The same individual may
be at one time vulnerable, at another time invulner-
able, as shown by the onset and arrest of the disease.
The therapeutics of this disease demands that every
possible means should be employed to strengthen the
resisting power of the tissues. Aside from measures
designed to prevent tuberculous infection, these means
may be thus enumerated : climate ; abode and out-door
life ; medication, general and local ; personal hygiene
and habits of life ; diet ; exercise, general and local,
with its corollary, rest.

For the pretubercnlous status and incipient cases,
one of the valuable resources for permanently increas-
ing vital capacity is " pulmonary gymnastics." The
appreciably best methoid of taking such exercise is
under the instruction and supervision of a trained
operator, acting under general directions from the
physician. This method admits of beginning with the
gentlest exercise and progressing to the severest, in
accordance to the patient's varying condition. It en-
sures the patient's attendance and economizes the
physician's time. Graduates of physical-culture schools
can be found in all of the larger and most of the
smaller towns and cities.

The paper embraced a detailed discussion of the
physiologic effects and relative advantages of the use
of compressed air, breathing-tubes, and voluntary ex-
ercise, with a report of cases, and a series of photo-
graphs from the living model.

Dr. £. O. Otis, in the discussion, laid great stress
on the careful supervision of exercises by the physi-
cian, in contrast with the ordinary hap-hazard direc-
tion, " to take physical exercise." He said : " If this
careful arrangement of exercises, in the first place,
and careful supervision, in the secopd place, can be
followed out with pretuberculous cases and incipient
ones, as Dr. Butler has suggested, much might be
achieved. The practitioner who treats cases of
phthisis is bound to study the application of chest
gymnastics as he would the effect of any drug he
uses.

SECOND DAT. — WEDNESDAY.

The second day's proceedings began with a paper
entitled :

three tears' experience in the sanitarium

treatment OF PULMONARY DISEASE, NEAR BOSTON,

by Ds. Vincent Y. Bowditch, which will be pub-
lished in full in the Journal.
Dr. R. G. Ccrtin, in a paper on

CBBASOTK, OUAIACOL AND BENZOYL OF OUAIACOL
IN PHTHISIS,

gave a brief retumt of observations in the use of these
drugs, covering a period of fifteen years. Concerning
guaiacol, he says : " In acute catarrhal phthisis with
high temperature, little or no good is to be expected
from its use. In acute tuberculosis no material bene-
fit results from its employment. The class of cases
that seem to be most benefited is the one in which we
have slight elevation of temperature with poor nutri-
tion, slow digestion with fermentation. Guaiacol has
no specific effect upon the bacillus. In cases where
the process was slow, beneficial results followed the
use of guaiacol."

Dr. Curtin's conclusions were as follows :

Guaiacol is not so irritating to the stomach as crea-
sote. Guaiacol is not so liable to produce irritation
of the kidneys, nor to be followed by hgematnria.

Among the advantages of guaiacol are : First, it is
more easily taken ; second, the process of manufacture
insures purity ; third, the exact quantity of medicinal
substance administered is known.

Dr. a. L. Loomis : We find no evidence that these
drugs have any other effect than to aid assimilation
and digestion in a certain class of individuals. We
cannot use them bypodermically. Whether we shall
gain something by the use of the vapor seems to nae
still unsettled. They have no specific action upon the
bacillus.

Dr. Jcdson Daland reported five cases at the
Philadelphia Hospital, in which the object was to see
if guaiacol, administered by the skiu, had any effect
upon the temperature. No results were obtained.

Dr. yon Buck reported one case where a danger-
ous fall of temperature followed the administration of
guaiacol by the skin ; the other cases showed little
change.

SHALL ANYTHING BE DONE BY LEGAL AUTHORITY TO
PREVENT THE SPREAD OF TUBERCULOSIS ?

Dr. Frederick I. Knight, of Boston, called at-

Digitized by

Google

Vol. CXXX, No. 25.1 BOSTON MEDICAL AND SURGICAL JOURNAL.

631

teutioD, in this paper, to the fact that, though tvrelve
years had elapsed since the infectious natare of tuber-
culosis was established beyond question, very little had
been done to prevent its spread. This was attributed
by Dr. Knight not to a want of belief in the infections-
ness of the disease, but to the magnitude of the prob-
lem and manifest difficulties in dealing with it. Dr.
Knight claimed, however, that boards of health are
organized to keep people informed, and not in igno-
rance, of the dangers by which they are surrounded ;
and gave notice that in the business meeting he would
introduce a resolution upon this subject.'

An interesting discussion followed the presentation
of this resolution. All the members agreed that some-
thing ought to be done to prevent the spread of tuber-
culosis ; the only difference of opinion being as to the
means. Much regret was expressed as to the present
constitution of boards of health in this country and
their connection with politics ; Massachusetts was con-
gratulated upon tlie high character of the Chairman
of its State Board of Health.

{To be continued.)

THE BOSTON

Thursday, June 21. 1894.

IGlecent literature*

A Practical TrtaUu on ZHteates of the Skin. Third
edition, thoroughly revised and enlarged. By
James Nevins Hyde, A.M., M.D. Philadelphia':
Lea Bros. & Co. 1893.

Ten years have passed since the appearance of the
first edition of this excellent text-book of skin diseases.
The third edition, just issued, fulBls all the expectations
warranted by the great accumulation of dermatological
material since the earlier editions were brought out,
and puts this work at the head of the modern American
treatises on skin diseases. The author has introduced
thirty-five new diseases in this edition, and has corrected
and improved almost every page. He is especially to
be congratulated on his chapter on tuberculosis, which
be has amended so that lupus vulgaris, and scrofulo-
derma assume their proper place as varieties of this
disease, and are intelligently considered in the light
of modern pathology. Five plates and twenty-two
wood-cuts, all of great excellence, have been added to
the illustrations. The excellence of the chapters on
treatment, together with the care that has been be-
stowed on subjects that have acquired new interest,
make the book one to be warmly recommended to any
one seeking for a reference book in this branch of
medicine.

A Treatise on Headache and Neuralgia, including
Spinal Irritation, and a Disquisition on Normal and
Morbid Sleep. By J. Leonard Coknino, M.A.,
M. D. With an Appendix, £lye Strain, a Cause of
Headache, by David Websteb, M.D. Third edi-
tion, bvo, pp. 275, 17 illustrations. New York: £.
B. Treat. 1894.

To the third edition of this book a chapter has been
added on the localization of the action of remedies
upon the brain. This method of treatment consists of
applying the remedies to the nasal mucous membrane,
and increasing their effect by compression of both
jugulars.

> Ths artiols of Dr. Kulght, Ineludlng the resolution, will be pub-
liihed lu full in the Journal.

A Jommal of Medicine, Surgery, and Allied Soienees, published at
Sotton, weekly, by the undereigned.

S0B8OBIPTIOV Tkrhs : VB.OO per year, in advance, pottage paid,
for the United States, Canada and Mexico; f 6.M per year for all for-
eign comtriei belonging to the Postal Union.

All oommynications for <Ac Editor, and all books for reviete, should
be addressed to the Editor of the Boston Medical and SurgicalJoumal,
283 Washington Street, Boston.

All letters containing btuiness eommuniecUions, or referring to the
publication, subscription, or advertising department of this Journal,
should be addressed to the undersigned.

Bemittances should be made by money-order, draft or registered
letter,payable to

DAMRELL & UPHAH,
383 Washisotoh Stxskt, Bostok, Mau.

THE PLAGUE IN CHINA.

The word plague has had but little of its terrible
real meaning for Europeans for many years. Eastern
Russia and Persia had a short and mild experience
some fifteen years ago ; but practically Europe has
been free from the disease since 1 665, when London
was scourged. Its native home is China ; and in some
cities there it appears every year during the dry season,
but with a mild degree of poison, attacking only the
poorer class of natives. The present epidemic is so
widespread as to be of serious menace, as it has al-
ready attacked European settlers in the healthy por-
tion of the cities.

Toward the end of April the extent of the outbreak
at Canton became so alarming that the Board of Health
at Hong Kong wrote to the Consular Surgeon at Can-
ton, for a report of the true state of affairs. Dr. Ren-
nie replied as follows : •

" The first outbreak occurred in the last week of March, and
was coDflned to a poor quarter of the city, near the South Gate.
This neighborhood we visited on the 8th of April, and had an
opportunity of examining one or two cases and also inquiring
into the sanitary condition of the houses.

" The symptoms are as follows : With or withont premonitory
warning in the shape of malaise or chill, there is a sudden onset
of fever rising to 10S°, or over. There is much headache and
cerebral disturbance, accompanied by stupor. In from twelve
to twenty-four hours a glandular swelling occurs in the neck,
arm-pit, or groin, rapidly enlarging to the size of a fowl's egg ;
it is hard and exceedingly tender. With or without a decline
of the fever, the patient sinks deeper into a condition of coma
and dies usually at the end of forty-eight hours or sooner. If
six days are renched recovery is hopeful. The glandular swell-
ing shows no signs of suppuration. In some cases epistaxis or
vomiting of blood occurs ; petechias appear in a few cases, but
oo regular eruption. Such are, briefly, the symptoms at the
beginning of the disease. It was then extremely fatal, over 30
deaths having occurred in the small street we visited. The
mortality was high, being over US per cent, of the patients at-
tacked, whose houses are occupied by laborers and artisans;
they are small and badly ventilated houseSi with damp earthern
floors. Underneath the flag-stones in front of the houses in
question is the usual drainage arrangement, which, at the period
of our visit, was in a very insanitary condition on account of
the lack of water and in consequence of the prolonged drought.

> Report of Sanitary Board : Houg Kong Daily Proas, May 11, 1894.

Digitized by

Google

632

BOSTON MEDICAL AND SVBGICAL JOVRBAL.

[JcKK 21, 1894.

The people stated that at fint many dead rata were found about
tbe bouses, but that after a few days these animals entirely dis-
appeared.

" On the 17th of April we bad again an opportunity of exam-
ining some cases in a Chinese hospital situated inside the North
Gate of tbe city. The cases were all of a milder character than
those we had seen the previous week. The native doctor in
charge informed us that whereas tbe patients he treated at tbe
outset of the epidemic died at the rate of about 80 per cent., tbe
mortality bad declined to about 26 per cent., and he seemed to
be of tbe opinion that the disease was declining. Since then the
disease has extended to other parts of tbe city, and also to
Honam. We have had no opportunity of examining cases re-
cently, but from what we can gather it appears to have in no
way diminished either in frequency or severity. It is impossi-
ble to obtain reliable statistics as to the mortality, and we
therefore refrain from expressing our (pinion on this point."

The uuspeakable filth of the poorer quarters of the
Chinese cities had been much increased by the long
drouth. For nearly seven months there had been no
rain to speak of, but only a few light showers. The
long time without serious epidemic had made tlie su.
pervision of sanitary conditions lax, and the uncleanli-
uess of the poorer quarters polluted the air for consid-
erable distances. A general cleaning out was at once
ordered at Hong Kong, but the water-supply was too
scanty to allow of thorough cleansing.

Some idea of what a cleaning up in a Chinese city
means may be bad from the Beport of the Sanitary
Board concerning the first general cleaning out some
years ago. This report says, that during the eight
days on which special facilities were offered for the
work, no less than 2,400 tons of rubbish were removed
in excess of the normal quantity, which was stated to
be 100 tons a day. Of late years there has been no
such accumulation ; but the drainage is still notori-
ously defective, and the amount of surface and con-
cealed filth is sufficiently large.

The cleaning and disinfecting at Hong Kong was
begun too late, however, for the plague had already
appeared, and some twenty cases were at that time in
the Tung Wah Hospital. The early deaths were re-
ported as due to fever ; and it was only when several
had occurred in quick succession that the true nature
of the dise-ase at Hong Kong was realized. At first,
it was hoped to keep the disease down ; but the up-
turning of dirt appeared to favor its spread, until even
the better portions of the city and the foreign inhabi-
tants were attacked. The mortality in Canton at first
was 80 per cent, falling for a while to 30 per cent.,
but soon rising to 55 or 60 per cent., where it re-
mained until the end of May.

Under ordinary conditions the disease is reported by
Dr. Lowsan, of Hong Kong, not to be contagious,
" but if healthy persons remain too long in the same
atmosphere there is great probability of their catching
the disease. The attendants at tbe Canton Hospital
take care to smell of a bag of sandal- wood and aromat-
ics during their work, and say that none of them have
taken the disease. The disease appears to me more
of a chemical origin than a bacteriological."

The disease had gathered such headway that it is
hardly possibly to expect the recent much longed-for
rains to do much in the way of checking the scourge.

Its course and developments unavoidably suggest a sim-
ilarity to anthrax.

The terrible mortality rate, over 80 jier cent., and
the frightful rapidity of the disease, death ensuing
often in twelve hours, should teach the lesson that
cleanliness and sanitation should be the constant and
precautionary care of a people, and not the last resort
of a i)lague-stricken city.

MEDICAL NOTES.

The Plague in China. — A terrible epidemic of
the plague is now raging in China for the first time in
eleven years. The disease is reported by medical ob-
servers to be very similar, if not identical with, the
Great Plague of London in 1665. Tbe disease ap^
peared first in Canton the 1st of April, and spread
with frightful rapidity among the poorer classes until
the deaths had numbered many thousands. Some
statements put tbe mortality at 60,006. About the
8th of June tbe disease appeared in Hong Kong,
where it is now epidemic. At first only the natives
were attacked, the mortality being about ninety per
cent., bat finally tbe European inhabitants have be-
come victims to the disease, and several deaths have
been reported. The daily death-rate in Hong Kong
is nearly one hundred. In Canton the spread of the
disease continues, but the mortality is lessening.

The Cholera. — With the return of warm weather
the cholera has made its reappearance at various cen-
tres in £nrope. The epidemic which began in April
at Lisbon has somewhat abated, and is now officially
reported once more not to be cholera. Cases have oc-
curred at various places in Spain, but none are offici-
ally admitted, so that early quarantine is much neg-
lected. In France cases have occurred in Finistere
since the middle of April and number about four cases
a day. In Bussia the disease is very widely scattered,
and has broken out in many of the provinces. Ap-
pearing first in the Polish districts and along the East
Prussian border, the disease has attained its greatest
severity in the districts of Plozk, Radom and Petro-
koff, where the number of cases has already reached
several hundred. During the last week tbere have
been reported nearly a hundred cases with twenty-five
deaths from Ciecnanowiece, a town thirty miles from
the German frontier. In Warsaw there have been
about ten new cases with six deaths each day since
tbe first of May. The disease has appeared at Mis-
lowitz and Stettin and throughout the Vistula district.
Many towns in Galicia have been affected, especially
Sicierzynce and Skala. Turkey, as might be expected,
has many centres of infection, none officially recognized.
Although the epidemic at Constantinople has been
severe, it is now stated to have ceased in that city,
and the quarantine has been abolbhed. Several of
the Black Sea ports are now infected.

Small-Pox Qcabamtine against Staplbton,
S. I. — Dr. Doty, of the New York Board of Health,

Digitized by

Google

Vol. CXXX, No. 25.] BOSTON MEDICAL AND SURGICAL JOURNAL.

633

has recommended that a quarantine be established
against Stapleton, S. I., for the reason that small-pox
is epidemic there, that it is not properly dealt with by
the local authorities, and that the conditions in the
village constitute a menace to New York City. He
urges the Board to act promptly by asking the inter-
vention of the State Board to the end that Stapleton
may be cut off from communication with New York.

Unseeult Jesting. — The Medical Record makes
the following comment on the recent cartoon in Life
called the " Vivisectionist " : " The esteemed contem-
porary, Punch, does not always seem funny at this
distance from its proper atmosphere, but it is always
good-natured and generally just. Its New York imi-
tator. Life, is sometimes neither one nor the other, but
simply scurrilous. Its recent cartoon on the ' Vivi-
sectionist ' was a loathsome and cowardly performance,
utterly false in its representation, mean in its insinua-
tions and low in its intent." As descriptive of the
picture, the Record's remarks are gentle and its lan-
guage mild.

The RE6DLA.TION ON THE UsE OF OpEN STREET-

Cars. — The New York City Board of Health has
passed au amendment to the sanitary code, prohibiting
the use of open street-cars except from June 1st to
October Ist, and directing that during the daytime
every fourth car on each line shall be a closed car, and
during the night every third car.

Honorary Degrees. — At the annual commence-
ment of Princeton College the degree of LL.D. was
conferred upon Dr. Alfred A. Woodbull of the Army
Medical Corps, and that of A.M. honoris causa on Dr.
Austin Flint, Jr., of New York. Dr. Landon C.
Gray, of New York, was given au honorary A.M. by
Columbia College at commencement, June I3th.

Dk. Billings's Appointment Confirmed. — The
Senate of the United States, on June 1 6th, confirmed
the appointment of Dr. John S. Billings to be Lieu-
tenant-Colonel and Deputy Surgeon-General of the
United States Army.

A New Professorship for Northwestern Uni-
versity.— Dr. William Deering, of Chicago, has given
to Northwestern Medical School the sum of $50,000,
to found a professorship to bear the name of Dr. N.
S. Davis, who has been a life-long friend of the donor.

'Becent Appointments at Jefferson Medical
College. — At a recent meeting of the Board of
Trustees of Jefferson Medical College, Dr. W. Joseph
Hearu was elected Clinical Professor of Surgery ; Dr.
Edward P. Davis, Clinical Professor of Obstetrics;
and Dr. S. MacCuen Smith, Clinical Professor of
Otology.

The American Association for the Advance-
ment OF Science. — The Forty-third Meeting of
the American Association for the Advancement of
Science will be held in Brooklyn, N. Y., from Au-
gust Id to 24, 1894, under the presidency of Dr. Daniel
G. Brinton.

Dr. Lanphear's Removal to St. Lodis. — Dr.
Emory Lanphear has resigned the chair of Operative
and Clinical Surgery in the Kansas City Medical Col-
lege to become Professor of Surgery in the St. Louis
College of Physicians and Surgeons.

A New Departure in Medical Literature. —
The first number of Teratologia, a new medical quar-
terly, has just been issued in Edinburgh, under the
editorship of Dr. J. W. Ballantyne. Its pages will
be devoted exclusively to the subject of antenatal
pathology.

Professor Czernt and the Professorship of
Sdrgert at Vienna. — Professor Czerny is reported
to have refused to be made Professor of Surgery at
Vienna because of the inadequacy of the laboratory
equipment of the hospital.

"Birthday" Knighthood for Physicians

In the distribution of honors on her seventy-fifth
birthday. Queen Victoria conferred knighthood upon
Dr. J. C. Bucknill, F.B.C.P., F.R.S., Mr. F. S.
Haden, F.R.C.S., and Dr. T. Grainger Stewart, F.R.
C.P., Edin., Professor of Physics in the University of
Edinburgh. Of these and several others, Dr. Stew-
art's is said to be the only one purely medical in
origin.

Magistracy, Medicine and Malingering. —
The special usefulness of a medical magistrate is re-
ported from England. A workhouse inmate was ar-
raigned before a medical J .P., charged with refusing
to work, to which he pleaded that he was a victim of
heart disease, whereupon the magistrate promptly de-
scended from the bench, produced a stethoscope, aus-
cultated the culprit, and re-ascending the throne of
justice, sent him " up " for seven days for malinger-
ing.

boston and mew ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon, June 20, 1894, there
were reported to the Board of Health of Boston, the
following numbers of cases of acute infectious disease :
diphtheria 43, scarlet fever 59, measles 12, typhoid
fever 9.

Harvard Medical Alumni Association Din-
ner. — The fourth annual dinner of the Harvard
Medical Alumni Association will be held at the Hotel
Vendome on Tuesday, June 26th, at one P. M. The
guests will be Dr. W. M. Polk, of New York, Dr.
W. W. Keen, of Philadelphia, Dr. William Osier, of
Baltimore, and Deputy Surgeon-General John S. Bil-
lings, of Washington.

College OF Physicians and Surgeons. — The
commencement exercises of the College of Physicians
and Surgeons of Boston were held in the Y. M. C. A.
Hall on Wednesday afternoon, June 20th.

A Laboratory Course in Bacteriology at
THE Yale Medical School. — A six-weeks' coarse
in bacteriology is to be given at the Yale Medical
School commencing June 20th.

Digitized by

Google

634

BOSTON MEDICAL AND SURGICAL JOURNAL.

[June 21, 1894.

Thk Maine Medical Association. — The Maine
Medical Association held its annual meeting at Port-
land, last week.

MEW TORK.

MosTALiTT. — The recent hot weather has had the
effect of augmenting to some extent the weekly mortal-
ity of the city. During the week ending June 16th
there were reported 841 deaths, which represents an
annual death-rate of 22.45 per thousand of the esti-
mated population; an increase of nearly three per
cent, over the previous week. The principal increase
was in diarrhceal diseases, and there were also three
deaths by sunstroke.

Columbia College Commencement. — On June
13th the annual commencement of Columbia College
was held at Carnegie Music Hall, and the degree of
M.D. was conferred upon 120 graduates of the Medi-
cal Department, the College of Physicians and Sur-
geons. The Hippocratic oath was administered to the
class by Dr. James W. McLane, the President of the
latter. The alumni fellowship in anatomy was awarded
to Dr. F. J. Brockway, in physiology to Dr. R. J.
Cunningham, and in pathology to Dr. W. S. Stone ;
and Dr. Ira T. Van Giesen received the Alonzo
Clark scholarship. The degree of A.M. was conferred
upon Dr. Landou Carter Gray.

Sterilized Milk for the Poor. — Mr. Nathan
Strauss has been enlarging the field of his depots for
tlie supply of sterilized milk and other food for infants
aud young children at the lowest possible prices by
issuing blanks, (which have been distributed to the
police stations and dispensaries) which, when signed by
any reputable physician, will enable parents, too poor
to pay at all, to secure these supplies free of charge.
In addition, he has secured permission from the Park
Commissioners to have pure milk sold at the low rate
of one cent a glass in the varioOs parks of the city.

Death of a Physician from Drugs and
Septicemia. — A physician. Dr. Frank W. Carmon,
thipty-iive years of age, recently fell a victim to his
inordinate craze for drug*. It is stated that he had
long been a great sufferer from rheumatism, and in
order to relieve the pain used morphia freely, and
became addicted to the opium habit. After a time he
also took larger quantities of chloral, paralydehyde
aud other hypnotics, and a few days before he died,
he is said to have swallowed about an ounce aud a
quarter of paralydehyde at a single dose. Yet the
next day he had sufficiently recovered from its effect
to go out. It was at first supposed that he had died of
morphia poisoning, but the coroner's investigation
showed that death was in reality due to septictemia
resulting from the excessive use of the hypodermic
syringe. Both the arms, from the shoulders to the
wrists, were in a state of violent inflammation. Dr.
E. B. Squibb, of Brooklyn, mentions a case reported by
Dr. T. Mackenzie, of Douglas, Isle of Man, in which
a patient recovered, after thirty-four hours of sleep,
from a dose of three and a half ounces of paralydehyde.

THE INFLUENCE OF ODORS ON THE VOICE.

The subject of smells seems at present to be most
passionately studied by French writers. We have
recently been shown the psychological influence of
smells on character and morals, as evidenced by M.
Zola ; and now another writer, M. Joal, has published
a volume upon " Odors and their Influence on the
Voice." That various odors may affect the voice is
well known among singers, who consider the violet to
be especially detrimental to a clear voice. A story is
told of an envious soprano who sent her unsuspecting
rival a large corsage bouquet of violets, and thereby
caused her failure in a brilliant part. Now M. Joal
rejects the idea that the odor of violets prevents a free
vibration of vocal cords, which are unaffected by roses.
" It is not a property of any particular perfume, but is
wholly a question of individual susceptibility. One
person may be unaffected by flowers, musk, civet or
various toilet perfumes, but becomes at once hoarse
and oppressed on perceiving the odors of oils or fats.

"It is difficult to offer any explanation of these
vagaries which we mast be content to call olfactory
idiosyncrasies. There is no doubt, however, that
odors may cause vocal disturbances, especially in per-
sons of nervous temperament."

ST. LOUIS AND ITS MEDICAL SCHOOL.*

Professor W. S. Chaplin, Chancellor of Wash-
ington University, St. Louis, in a recent address, gave
the following explanation of the present condition of
medical education in St. Louis:

" Don't think for a minute that these many medical
schools in the West have been established for purely
pecuniary reasons. The doctors do not make enough
out of them certainly to pay for the work which they
put into them. They might make more money, prob-
ably, by sawing wood'* the same amount of time.
They do it in order to establish themselves as special-
ists. They have no other reason. Is this not a case
where you have put on too much restriction in one di-
rection ? Aud that has produced an abnormal growth
in another direction. If you look into the history of
these medical schools, you find that there was a time
when there was but one medical school. Some fifty
years back, in St. Louis, I believe, there was just one.
Then, by a process which the naturalists understand
perfectly, by the growth of a kind of septum across
the medical school, suddenly there were two medical
schools, equipped fully, and those two medical schools
were running in the most violent opposition. Here,
in the East, I understand the medical profession have
uune of these differences and troubles, but in the West
every medical school means a new set of mutual ad-
mirers. The professor of ophthalmology sends all his
cases of surgery to the surgeon who is connected with
his medical school. Go into St. Louis to-day, and yoa
find just eleven sets of men who generally recommend
and send all their patients to the men connected with
their own schools. I do not despair of medical educa-
tion in the West. I hope there will be constant and
rapid deaths among the medical schools. The condi-
tion is certainly a disgusting one when viewed frona
the point of education."

> Medical Keoord, Juna 9tb.

Digitized by

Google

Vol. CXXX, No. 25.] BOSTOH MEDICAL AND SURGICAL JOURNAL.

635

CorrejE^pottHeme.

[Special CorrespODdeoce.]

LETTER FKOM SAN FRANCISCO.

Annual Meeting of thr American Medical
Association.

San Francisco, June 11, 1894.

Mr. Editor : — The American Medical Association has
had its meeting and adjourned, or as the daily papers here
express it, V The Medicos have gone and Odd Fellows'
Hall no longer shivers with the echoes of comminuted fract-
ures and the creaking of tubercular joints."

The regular reports of the meeting you have already
had. While living quietly on milk and seltzer and think-
ing of the gastronomic glories of the recent past, it occurred
to me that your readers might enjoy a bit of gossip about
the social side of the convention, it was extremely social I
The hospitality was generous and constant, and even when
making allowance for Californian fondness for florid ex-
pre!^sion, the newspaper accounts were but just.

The first " feast and frolic " was a banquet tendered the
American Medical Editors Association by Mr. R. E. Queen,
on Monday evening, before the Congress met. Nearly two
hundred guests were present. Dr. I. N. Love acted as
toast-master, while Dr. Hughes made his usual speech to
his " fellow cranks." The papers reported that " it was
long after midnight when the last ' cat died,' and although
the electric lights were out for a few minutes, neither tLe
brilliancy of the wit nor the sparkle of conversation was
dimmed for one moment."

The same evening a reception was held by the Committee
of Arrangements in the Rotunda of the Palace Hotel.

On Tuesday evening occurred the great reception of the
San Francisco County Medical Society. I quote : " Over
five hundred ladies and gentlemen, nearly all of whom ap-
peared in full evening dress, were present. The ladies,
without exception, appeared in elegant toilets, lending to
the scene charming grace and vivacity. The greater num-
ber were visitors n-om the East, and all expressed them-
selves in the highest terms of praise at the magnificent
reception tendered them. Refreshments were served at
ten o'clock. Liquid refreshments were served at the buffet
in the vestibule throughout the entire evening."

On Wednesday evening Dr. W. F. McNutt entertained
the Association with great hospitality. About six hundred
persons were present. " Many, after paying their respects
to the host and hostess and strolling around engaging in
social converse, departed, but the majority remained and
partook of the generous hospitality extended to the fullest
extent. The toilets of the ladies present were elegant in
every respect, and were only rivalled by the beauty and
vivacity of the wearers of them."

The same evening a large reception was given by Dr. L.
C. Lane at the new hospital of the Cooper Medical College ;
and it is probable that those who left Dr. McNutt's before
supper were more eager to taste the bounties offered them
at the College.

The ladies were given afternoon lunches and entertain-
ments by Mrs. McLean and Mrs. Lane, and by Mr. Sutro at
Sutro Heights, where they had an opportunity to see the
" most sublime view in the world."

Many of the sections had dinners of their own ; and the
Obstetrical Section was banqueted by the Gynsecological
Society of San Francisco. Besides those already mentioned
there were several private dinners. The meeting of the
Medical Temperance Association, which was held on
Thursday, was not largely attended.

The numerous boat-rides and excursions, the visits to the
Mid-Winter Fair, and other attractions of the neighbor-
hood— though tempting to the casual visitor — I did not
attend. What little time was left from the sessions and the
dinners was required for rest and gastric repose. Certainly
the thousand guests of this Golden Citv of the West have
reason to remember a most generous hospitality and wel-
come. Yours truly, S. F.

A QUALIFIED SIGNATURE TO THE REGIS-
TRATION LAW.

Boston, June 18, 1894.
Mr. Editor : — For any members of the State Society
who do not wish to ignore their "license to practise,"
given to members bv the act of incorporation, perhaps, as
the present law reads, the best phrase, over their signature
of registration, would be this, reserving (he claim of a right
to practise, irrespective of registration. Thus, it would
seem, no one need have any objection to registering.

Yours very truly, J. L. W.

THE MEDICAL REGISTRATION LAW.

Boston, June 14, 1894.

Mr. Editor ; — A law, as now enacted by the General
Court, which calls upon medical graduates of Harvard
University, and others already legally licensed, and upon
members of a medical society authorized to license, whose
charter has not yet been repealed (if indeed it can be with-
out its own consent), while it expressly excepts certain
noted quacks and persons who practise > " cosmopathic or
any other method of healing " — such a law, some of us,
young and old, are inclined to think a little loo utter for an
intelligent community. A clause above is italicized be-
cause it would seem to let in the whole crowd, — regulars,
irregulars, one and all.

I suppose any one classed as a healer of any other method,
may be entitled to subscribe himself.

Yours to register as, H. O. A. o. M. o. ii.

1 Thanks to Dr. Oaytoi- his authoritative adoption o( " praotlser,"
the simple and oorreet form — " practitioner " being " an unlovely
intruder." See " Words and Their Uses," by RIebard Qranl White,
page 216.

RECORD OF MORTALITY
Fob thx Wbek bmoimg Satvkdat, Junk 9, 1894.

a

■
h

r

Percentage of deaths from

Oitles.

si &

3.26

.66

1.12

23.49
1.08
1.82

2.70
17.92

6.90

6.00

6.66
18.18

ate,

P

9.38

9.24

7.84

.87
2.1C
1.82

3.85
3.48
4.76
5.00

20.00
12.60

|l

New York

Chicago .

Philadelphia

Brooklyn

St. Louis .

Boston .

Baltimore

Washington

Cincinnati

Cleveland

Pittsburg

Milwaukee

Nashville

Charleston

Portland .

Worcester

Fall River

Lowell .

Cambridge

Lynn . .

Springfield

Lawrence

New Bedfon

Uolyoke .

Brookton

Salem . .

Haverhill

Maiden .

Chelsea .

Fltohburg

Newton .

Gloucester

Taunton .

Quincy .

Pittsfleld
Everett .
Nortbampto
Newbury por
Amesbnry

1 '.

a .
t .

1,891,306

1,438,000

1,116,662

978,3W

660,000

601,107

600,000

308,431

306,000

290.000

263,709

260,000

87,764

66,165

40,000

100,412

92,236

90,60)1

79,611

66,124

60,286

4!«,902

47,744

43,348

33,939

33,166

32,926

30,209

29,806

29,3C3

28,837

27,293

26,961

23,068

19,642

18,802

16,686

16,331

14,073

10,920

696

362

179

116
93
110

37
39

26
29
21
20
14
15
11
22

6
11
10

8

10
6

iio

8

4
3
7
0

279

146
44

63

24
63

10
13

8
14
7
9

4
0
8

2
2
1
2

4
2

8
3

1

1
0
0

19.01

19.04

13.44

29.68
9.72
li.29

10.80
17.92

7.70
13.60
14.28
30.00

6.66
36.36
4.66

20.00
12.50

12.60

14.00

11.70

6.96
9.72
9.30

16.20
2.66

24.80
10.33
9.62
15.00

20.00

9.10

-.0.00
9.09

12.60

10.00
20.00

33.33
14.28

2.38

.56
2.24

1.08
•2.73

2.70
20.00

Deaths reported 1,899: under five years of age 716; principal
Infectious diseases (gmall-pox, measles, diphtheria and croup,

Digitized by

Google

636

BOSTOS MBDIOAL AND SURGICAL JOVSNAL.

[JcNE 21, 1894.

diarrboeal diseases, whooping-couf;b, erysipelas and fever) 327,
acute long diseases 24S, consamption 2iiU, diphtheria and croup
126, diarrboeal diseases 73, scarlet (ever 33, measles 23, whoopiug-
congh 23, erysipelas 13, typhoid fever 13, small-pox 10, cerebro-
spinal meningitis 8.

From measles Brooklyn 10, Cleveland 7, New York 6. From
wbooping-cough Broolilyn 7, New York 6, Washington, Cincin-
nati and Cleveland 3 each, Boston 2. From typhoid fever
Brooklyn, Washington, Cincinnati and Naahville 2 each. New
York, Cleveland, Lowell, Sonierville and New Bedford 1 each.
From small-poz New York 7, Brooklyn 2. From cerebro-spinal
meningitis New York and Lawrence 2 each, Washington,
Worcester, Lowell and Lynn 1 each. From malarial fever
Brooklyn 7, New York 3, North Adams 1.

In the thirty-three greater towns of England and Wales with
an estimated population of 10,408,412, for the week ending
June 2d, the death-rate was 17.0. Deaths reported 3,403:
acnte diseases of the - respiratory organs (London) 222, measles
210, whooping-cough 112, diphtheria 63, scarlet fever 40, diar-
rhoea 36, fever 26, small-poz (London 4, West Ham and Birming-
ham 3 each, Liverpool and Bradford 1 each) 12.

The death-rates ranged from 13.6 In Bristol to 30.0 in Wolver-
hampton ; Birmingham 17.2, Bradford 16.8, Cardiff 18.9, Gates-
bead 17.3, Hull 14.0, Leeds 17.4, Leicester 13.8, Liverpool 20.0,
London 16.4, Manchester 1U.6, Newcastle-on-Tyne 16.8, Norwich
18.8, Nottingham 19.4, Portsmouth 14.6, Preston 13.6, Sheffield
16.3, Sunderland 20.3.

HETEOBOLOOICAL RECOBD,

For the week ending June 9th, in Boston, according to ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corps:—

Baro-

Tbermom-, Belatlve

Direction

Velocity
of wind.

We'U'r.

i

•8

meter

•ter.

humldltT-

of wind.

•

Oate.

i

i

a

i

a

a

-a
i

ai

a

f

a

H

a

a

a

a'

a

I

1

00

0.

1

i

s

S

S

CO

!•

S

S.. S

29.68

62 . 70 ! G6

72

63

62

s.w.

w.

9

10

c. c.

0.14

M.. 4

29.66

70

82

r>7

63 36

60

8.W.

w.

14

12

F. C.

T.. 6

29.82

.17

60

M

52 67

60

K.

S.K.

6

6

0. C.

W. 6

29.91

M

«6

47

59 66

62

N.W.

S.W.

14

11

0. 0.

T.. 1

29.78

M

60

61

74 65

64

N.

W.

10

12

O. C.

.11

P.. 8

30.0-J

60 73

48

44 44

44

W.

w.

9

8

c. o.

8.. 9

30.07

68 8215(1

60 39

44

W.

N.W.

18

4

C. 1 0.

tr

1

1

•O.,ol*lldri Celwri F.,ftlTi Q.,logi H.,luuTi S.,uilok7i It.,nlni T.,thrMl-
ilDst N..fliDV. tliMllefttMtnevoXnuntell. i^ Mean for wMk.

CBlDS]

OFFICIAL LIST OF CHANGES IN THE STATIONS AND
DUTIES OF OFFICERS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM JUNE 9, 1894, TO
JUNE 16, 1894.

FiasT-LisuT. Dkank C. Howakd, assistant surgeon, is re-
lieved from duty at Fort Buford, North Dakota, and will report
in person to the commanding officer, Fort Sneiling, Minnesota,
for duty at that station.

The following named officers, having been found by Army
retiring boards incapacitated for active service on account of
disability incident to the service, are, by direction of the Presi-
dent, retired from active service: Libut.-Col. Samuel M.
HoKTON, depnty sargeon-general ; Captain Makcus E. Tay-
ix>K, assistant surgeon ; Captain Williah G. Spbncsb, assis-
tant surgeon.

PBOMOTIONS.

FiBST-LiBUTS. Philip G. Wales and Bkkjauin L. Tbn
Eyck, assistant surgeons, to be assistant surgeons with the rank
of Captain, June 7, 1894, after five years' service, in conformity
With the act of Jane 23, 1874.

APPOINTMENTS.

Db8. J. G. Mumfokd, W. a. Brooks and C. A. Pobtbb have
been appointed surgeons to out-patients at the Massachusetts
General Hospital.

RECENT DEATHS.

Jambs Edwin Walkeb, M.D., M.M.S.S., died in Brookline,
Mass., June 16, 1894, aged sizty-two years.

Db. Middlbton Michel, of Charleston, S. C, died in that
city, June 4th, aged seventy-two years. He was a graduate of
the Medical College of South Carolina and at one time Associate
Editor of the Charletton Medical Journal.

Elua S. Eldbb, H.D., President-elect of the Indiana State

Medical Society, died in Indianapolis, May 19th, aged fifty-three
years. He was a graduate of tne Medical College of Ohio and
of Bellevue Hospital Medical College. In 1890 be was chosen
Dean of the Medical College o( Indiana.

AooosT KOMDT, Director of the Physical Institute of the
University of Berlin and the successor of Von Helmholtz, died
recently, aged fifty-five years.

Db. William Frost Cunningham, formerly of Cbarlestown,
died in Leamington, England, June 6th, aged thirty-five years.
He was a graduate of the Harvard Medical School, class of
1881.

Db. Spebk, the Director of the Imperial Institute of Ezperi-
mental Medicine in St. Petersburg and a syphilologist and der-
matologist of high repute, died recently. For twenty-one yean
he was chief physician to the Kalinkin Hospital in St. Peters-
burg. His best known works are those on " Prostitntion and
Prostitutes."

BOOKS AND PAMPHLETS RECEIVED.

A Contribution to the Study of the Physiological Actions of
Sparteine. By David Cerna, M.D., Ph.D. Reprint. 18<)4.

Myzosdema, Acquired and Congenital, and the Use of the
Thyroid Extract. By George W. Crary, M.D., of New York.
Reprint. 1894.

Brain Surgery, with Report of Nine Cases. Surgical Clinic,
given at Wesley Hospital, March 31, 1894. By F. C. Schaefer,
M.D. ReprinU. 18!»^.

De I'Hydrone'phrose Intermittente. Par le Docteur Locas-
Championniire, Chirurgien de I'hopital Saint-Louis. Paris:
Coccoz, Libraire-Editeur. 1892.

A Case of Primary Tuberculosis of the LAmins and Spinoo*
Processes of the Vertebral Column. By John B. Roberts, M.D.,
of Philadelphia. Reprint. 1894.

Tumor of the Brain Simulating a Vascnlar Lesion ; to which
is added an Account of the Autopsy, with Remarks. ByJ. T.
Eskridge, H.D., of Denver, Col. Reprint. 1894.

Recent Studies in Nanpathia, or Seasickness, Symptomatology,
Diagnosis, Pathogenesis and Treatment by a New and Efficacious
Method. By Winslow Warner Skinner, M.D. (Par.) Reprint.
1894.

Sur la Cure Radigale des Hemies. S^rie Nouvelle de 116 Css,
Compl^tant un Total de 391 Cas, M^moire prdsente' i. 1' Associa-
tion pour I'avancement des Sciences h, Besancon. Far le Dr.
Just Lucaa<;hampionni&re. Paris: Cocooz, Libraire-Editeur.
Reprint. 1894.

Zur Lehre von der Entwickelnng des Beckons nod Seiner
Geschlechtlichen Differenzirung. Inaugural-Dissertatioa zur
Erlangung der Doctorwiirde einer Hohen Hediciniscben Facultat
der Universitat Bern. Vorgelegt von Moses Konikow, Aus
Zarizin (Russland). Reprint. 1893.

Surgical Shock. Procidentia Uteri. Profuse Menstruation.
The Perfect Needle-Holder. A New Uterine Curetting Forceps.
Acute Puerperal Cellulitis and True Pelvic Abscess. A New
Method of Ezamining the Kidney, Especially for Stone. By
Charles P. Noble, M.D., Philadelphia. Bepriute. 1894.

Practical Lectures on Dermatology, Comprising a Course of
Fifteen Lectures delivered at the University of Vermont Medi-
cal Department, during the session of 1892-93. By Condict W.
Cutler, M.S., M.D., Professor of Dermatology, University of
Vermont Medical Department, ete. New York : G. P. Putnanu'
Sons. 1894.

Rotura de la Uretra por Estrechez; Absceso Urioario y Oan-
grena del Escroto; Pcrdida de Cinco Centimetres de Uretra;
Uretrotomia Interna, por la Electroiisis — Curacion. Por el Dr.
Ramun Martin Fil, Medico-director del Hospital Noble de
Malaga. Barcelona: Establecimiento Tipografico de Amat y
Martinez. Reprint. 1894.

Further Remarks on the Occurrence of a Form of Non-
Albuminous Nephritis other than Typical Fibroid Kidney. A
Serious Fallacy Attending the Employment of Certain Delicate
Tests for the Detection of Serum-Albumin in the Urine, Espe-
cially the Trichloracetic Acid Test. By D. D. Stewart, M.D.,
Philadelphia. Reprints. 1891.

Pathological Notes on Two Pedunculated Tumors. Three
Specimens of Tumors of the Heart: Metastatic Carcinomatous
Nodule in the Myocardium ; Implantation Sarcoma of the Right
Ventricle; Primary Ronnd-Celled Sarcoma of the Epicardiam.
A Specimen of Four Healed, Ascending, Ileal Invaginations,
Symmetrical and Equidistant. By Ludvig Hektoeo, M.D., of
Chicago. Reprints. 1893.

The Relation of the Patellar Tendon-Reflez to some of the
Ocular Reflexes fonnd in General Paralysis of the Insane. A
Series of Wools for the Beady Detection of " Color Blindness.'
Clinical History of a Case of Spindle-Celled Sarcoma of the
Choroid, with a Study of the Microaoopic Condition of the
Growth. By Charles A. Oliver, H.D., of PblUdelphia, Pa.
Reprints. 1893.

Digitized by

Google

Vol. CXXX, No. 26] BOSTOS MBDIOAL AND SURGICAL JOURNAL.

637

ntttt^a.

THE LEGISLATIVE CONTROL OF MEDICAL
PRACTICE.I

BY RKaiSALD H. FITK, 1I.I>., BOSTOIT.

(Continued from No. 26, p. 613.)

Thus, at the preseot time, there are laws iuteuded
to regulate the practice of medicine to a greater or
less extent in all the States of the Union, except in
Massachusetts and New Hampshire.

The requirements of these laws vary within very
wide limits. Rhode Island merely demands that the
name and residence shall be recorded in the town
clerk's office. In Maine and Wisconsin the physician
cannot recover compensation unless he has a medical
degree from a public medical institution in the United
States, or a license from the State Medical Associa-
tion, or, in Maine, a certificate of good moral character
from the town authorities. The simple registration
of the diploma or license suffices in Arizona, the Dis-
trict of Columbia, Georgia, Idaho, Indiana, Kentucky,
Louisiana, Michigan, Nebraska, Nevada, South Caro-
lina, South Dakota, and Wyoming. The possession
of a diploma or a certificate of qualification from a
State or County Medical Society is sufficient in Kan-
sas and Ohio.

The diploma must be verified by boards of exami-
ners in California, Colorado, Connecticut, Delaware,
Iowa, Montana, New Mexico, Oregon, South Caro-
lina, Tennessee, Vermont ; by boards of health in
Illinois, Kentucky, Louisiana, Missouri, Nebraska,
Oklahoma, South Dakota, West Virginia. They are
only approved when representing certain periods of
study in Maryland, Minnesota, Montana, Nebraska,
New York, New Jersey and North Dakota.

Candidates who have no diploma are required to
pass an examination in Alabama, Arkansas, Colorado,
Connecticut, Delaware, Missouri, Montana, New
Mexico, North Carolina, Oklahoma, Illinois, Iowa,
Oregon, Tennessee, Texas, Utah, Vermont, Virginia,
West Virginia.

Examinations are the sole qualification for license
in Florida, Maryland, Minnesota, Mississippi, New
Jersey, New York, North Carolina (except for gradu-
ates prior to 1880), North Dakota, Pennsylvania,
Utah, Virginia and Washington.

The effect of these laws also is extremely various.
In Arkansas, California, Florida, Georgia, Ohio, South
Carolina and Texas the laws are said to be either un-
worthy of the name, contain glaring defects, are of
low standard, unsatisfactory or practically inoperative.
Even in North Carolina the law is defied with impu-
nity. On the contrary in Alabama, Minnesota and
Virginia, the laws are almost ideally perfect. In New
York the promise has been more than fulfilled. More
and more support is being given to the law in West
Virginia, while in Illinois, Indiana, Iowa; Kentucky
and Missouri the laws are efficient, salutary, working
well, or meeting with general favor. In New York
the number of physicians entering practice has been
diminished, and the quality has been improved. Of
327 candidates in 1892, 267 fulfilled the requirements,
of whom 244 were regulars, 17 homceopathists and six
eclectics. In Indiana 559 practitioners left the State ;

1 Th6 Annaal Diiooune before the ManaobnaettlMedloal Society
delirered June 13, 1894.

in Kentucky 400 or 500, and 250 iu Minnesota, dur-
ing the year 1885.

A conspicuous effect of these laws has been seen
in the improvement of the standard of medical educa-
tion. To them, more than to any one cause, is due
the difference which exists between the condition now
and in 1870. In Alabama, Colorado, Connecticut,
Illinois, Nebraska, Oregon, South Dakota and Wash-
ington, at least three full courses of five to six months
each, no two in the same year, are demanded. The
State of Oregon, after 1898, will require four courses
of six months each from physicians who wish to prac-
tise in that State. There is not only a prolongation
of the period of study as the effect of these laws, but
there is also an increased demand for a preliminary
education, the establishment of new professorships,
and more exacting examinations for the degree. Of
all agents distinctly bringing about this change, the
Illinois State Board of Health, and especially its sec-
retary, the late Dr. John H. Bauch, deserve the
highest consideration.

Let us now consider the recent efforts in Massachu-
setts. In the address, previously referred to (p. 611),
it is stated (hat all laws relating to the licensing of
physicians by the State of Massachusetts were stricken
from the statutes in 1859. The influence of the
homoBopathists in bringing about this result was obvi-
ous, but a number of them still retained their member-
ship in our Society. They were inoffensive, but the
feeling against homoeopathy was so strong in the
minds of certain members that, in 1870, a protest was
made by some of the latter against the admission to
the American Medical Association, then meeting in
Washington, of delegates from the Massachusetts
Medical Society. The Association voted, in effect,
" that the Massachusetts Medical Society voluntarily
and improperly furnishes shelter and gives counte-
nance to irregular practitioners to such an extent as
to render it unworthy of representation in the General
Assembly of American Physicians." **

At the annual meeting of our Society, May 24,
1870, the following vote, "amid much confusion,"
was passed :

" Resolved, That the Massachusetts Medical Society
hereby expels from fellowship all those who publicly pro-
fess to practise in accordance with any exclusive dogma,
whether calling themselves homceopaths, hydropatbs, eclec-
tics, or what not, in violation of the code of ethics of the
American Medical Association."^^

This vote, however, had no legal force, since no
member could be expelled except after a trial in con-
formity with the by-laws. But Dr. Cotting, at the
Councillor's meeting, June 6th, 1871, offered the fol-
lowing preamble and resolutious, which were adopted
by the Council, and on the following day by the So-
ciety :

'■ Whereas, The Massachusetts Medical Society has
always endeavored to make, as its charter emphatically
enjoins, ' a just discrimination between such as are duly
educated and properly qualified for the duties of their pro-
fession and those who may ignorantly and wickedly admin-
ister medicine,' while at the same time it has ever acted in
accordance with the ' liberal principles ' of its foundation,
and shows itself ready to examine and to adopt every sug-
gestion, from whatever source, promising improvement in
the knowledge and treatment of disease ;

u Proo. Mmb. Med. Soo., 1871, 204.
« Loo. cU., mo, 159.

Digitized by

Google

638

BOSTOS MSmOAL AtfJD 8VMG1CAL JOURNAL.

[JuME 28, 1894.

" And, whereas, It ia alleged that some of ita Fellowi,
in opposition to the spirit and intent of its organization,
consort, in other societies or elsewhere, with those whose
acts tend * to disorganize or to destroy ' the Society ;

" Therefore, resolved, That if any Fellow of the Massa-
chusetts Medical Society shall be or shall become a mem-
ber of any society which adopts as its principle in the treat-
ment of disease any exclusive theory or dogma (as, for
example, those specified in Art. I. of the By-laws of this
Society), or himself shall practise, or profess to practise,
or shall aid or abet any person or persons practising, or
professing to practise according to any such theory or
dogma, he shall be declared to have violated the By-laws
of the Massachusetts Medical Society by ' conduct unbe-
coming and unworthy an honorable physician and member
of this Society.' By-laws, VII., § 5.

" Resolved, In case the Society concur with the Coan-
cillors in the foregoing resolution, that the President of the
Society shall appoint a committee of five Fellows (to hold
office one year and until others are appointed) to bring
before a Board of Trial any Fellow who, three months
from this date or after, shall be found chargeable with the
offence set forth in the foregoing resolution.

" Resolved, That, after concurrence by the Society, the
foregoing preamble and resolutions shall be printed, and a
copy sent to every Fellow of the Massachusetts Medical
Society.

" Resolved, That a committee of three be appointed by
the chair to report the action of the Councillors on the
foregoing preamble and resolutions to the Society, to-mor-
row, for concurrence." *•

A board of trial was appointed ; it reported in 1878,
1875 and in 1877, in each of which years a certain
number of the homoeopathic membera were expelled
antil all were thus disposed of.

In the meaDtime, as already stated, successfal eSortB
were being made to secure the legislative control of
medical practice in various States. Their aucceaa dfr
pended upon the recognitioa of the principle that no
attempt ahould be made to interfere with the chartered
rights of existing medical societies. The action of
onr Society towards its homoeopathic members waa
based on the view that their " conduct waa unbecom-
ing and unworthy an honorable phyaician." It, there-
fore, could not, then, consistently unite with the
homoeopathic society in favoring a law which should
place both on the aame level.

But the need of discriminating between educated
and honorable physicians and the Teverse was strongly
felt by individual membera of the Society, and the
earlier attempts at aecnring legislation were initiated
by them.

In 1877 a bill ** waa introduced by Mr. Ewing of
Hampden, and was entitled " An Act to regulate the
Practice of Medicine and Surgery in the State of
Massachusetts." It provided that each and every ex-
isting chartered medical society shall elect censors,
with authority to examine and license practitioners of
medicine, surgery and midwifery. The license waa to
be valid for a year only, and was to be furnished on
presentation of a medical diploma or satisfactory certifi-
cate of examination from an authorized board. The
certificate of license waa to be recorded by the county
clerk, and might be revoked for cauae. The penalty
of practiaing without a certificate waa from $50.00 to
$100.00 for the firat offence, from $100.00 to $400.00
for any subsequent offence, and fees for aervices ren-
dered could not be collected by law.

Thia bill was intended to prevent the practice of

w Proo. Man. Mad. Soo., 1891, 201-216.
«• Senate, No. 48.

medicine by uneducated peraons, without, however,
establiahing any common or definite atandard, and re-
quired merely the verification of certificates. It waa
referred to the Committee on the Judiciary, who re-
ported against the bill,*^ and it was rejected. A month
later another bill, relating to medicine and pharmacy,
waa presented, and was referred to the next General
CourU«

In the following year the same bill waa again
brought before the Senate,'' and waa referred to the
Committee on Water-Supply and Drainage. They
reported, February 20, 1878, that it ought not topaas,
and it waa rejected. A similar bill ** " to regulate the
Practice of Medicine and Surgery in the City of Bos-
ton " was also referred to the Committee on Water-
Supply and Drainage. The clause relating to the in-
ability to collect fees by law was omitted. It was
expreaaly stated that veterinary surgeons, exclusive
practitioners of the Thomsonian or botanic system of
medicine, clairvoyants or healing mediums, not assum-
ing the title of doctor, physician, surgeon or midwife,
persona practising gratuitously, and those not occupy-
ing an office or place of business for the practice or
advertisement of medicine, surgery or midwifery in
the city of Boston, were exempt from its provisiona.

The practical effect of this bill waa to limit the use
of the tide of doctor, physician, surgeon or midwife to
persons of some degree of education, but the difference
in standard might be extreme. It was less restricting
than its predecessor. The committee reported leave
to withdraw, but a minority recommended its passage.
This bill also appears as House, No. 122, submitted in
reply to a petition from the mayor of Boston, for an
order relative to regulating the practice of medicine
and pharmacy in the city of Boston. The same minor-
ity, as before, of the Committee on Water-Supply and
Drainage, recommended its passage, but leave to with-
draw was voted, March 15, 1878.

In 1880, Governor Long, in his inaugural address,
stated that the necessity of protecting the community
against medical impostors had been urged upon his
attention, and he referred it to that of the legislature.
At this time the health department of the American
Social Science Aasociation had its headquarters in
Boaton, and a number of the younger Fellows of the
Massachusetts Medical Society were among its mem-
bers. Through their initiative, a powerful effort waa
made in the name of the above association to secure a
law to regulate medical practice. Dr. E. W. Gushing,
of Boaton, at a meeting of the Suffolk District Medi-
cal Society early in the year, explained ** the steps
which had been taken and the provisions of the bill.
He stated that it had been prepared after conaultation
with eminent lawyera and repreaentative physicians.
The experience of other States had been utilized in its
preparation, and the final draft met with the approval
of the leaders of the homoeopathic and eclectic medical
societies. It was supported by eminent citizens of
Massachusetts in Boston and elsewhere. It provided
for the appointment, by the Governor and Council, of
a board of medical registration composed of eight
physicians and one dentist. The former were to be
selected from the incorporated medical societies of the
State in proportion to the whole number of members

« am»*», No. 119.

" Seiukte Joornal. 1877, 2SS.

<• Senate, No. 87.

» House, No. 86.

'• Boston Medical and SarK<oal Journal, 1880, ell, 180.

Digitized by

Google

Vol. CXXX, No. 26.] BOSTON MEDIO AL AND SURGICAL JOURNAL.

639

in each. This board was to examine, in medical 8ab-
jecU exclaaire of tlierapeutics, applicants fur a license
to practise medicine, dentistry or midwifery. All
members of the State medical societies incorporated
at the time of the passage of the act were to be exempt
from examination. Also all practitioners in the State,
of one year's standing, having an approved diploma or
license ; all practitioners of good moral character and
reputation having practised in the State for ten con-
secutive years ; non-resident practitioners with an ap-
proved degree or license, and stadents of incorporated
schools rendering gratuitous services. Licenses could
be refused or revoked for cause. The penalty for
practising without a license was a fine not exceeding
five hundred dollars.

This bill was referred to the Committee on Public
Health, which held six hearings, and reported " An
Act relating to Practitioners of Medicine," ** providing
that persons ofTriring or advertising to practise medi-
cine, surgery or midwifery, without a reasonable degree
of learning, skill and diligence therein, shall be fined
not exceeding five hundred dollars. Another provi-
sion was that persons professing to heal or cure disease
in whatever manner, shall not assume the title of
doctor, or of doctor of medicine, without having re-
ceived the degree of doctor of medicine from a reputa-
ble chartered medical institution, under penalty of a
fine not exceeding five hundred dollars. There were
exempt from this provision persons who had used the
title for ten years in the State, and members of any
medical society of the State lawfully exercising the
power to examine and approve its members before ad-
mission.

The bill was rejected by a very large majority in
the House. This attempt of the Social Science Asso-
ciation to protect the community against medical im-
postors was defeated, according to Dr. Granger,"
largely because of counter-petitions and complunts
that the law was intolerant and exclusive, for the
benefit of the few, and an interference with the rights
of the many. The opposition was determined and
powerful. It comprised some of the oldest and most
honored physicians, many educated and intelligent
citizens, all the quacks and their friends, and was sup-
ported by many newspapers, and advocated by eminent
counsel.

In 1882, Governor Long, in his veto of the bill to
" regulate the practice of dentistry," stated : " It would
perhaps be better worth while to consider the expedi-
ency of a general statute to the effect that any person
pursuing a business or profession without sufiScient skill
therein shall be punished. Such a statute, in the hands
of judge and jury, would never work injustice, and yet
would be ample for those exceptional cases of imposi-
tion, on the strength of which vicious special statutes
are urged from year to year."

This suggestion from Governor Long was in har-
mony with the provision of the bill of 1880. It was
eminently necessary in the practice of medicine, since
at that time, the ruling of Chief Justice Parsons in
the case of the Commonwealth v. Samuel Thomson
was generally held to be sound law. As has already
been stated,** this ruling was replaced in 1884 by that
of Judge Holmes. It was urged by Mr. Benton, in
his argument before the Committee on Public Health

"* Sonato No 196

<" Buffalo Mad. and Snrg. Journal, 1880-81, xz, 97.

in 1885, against the petition of the Massachusetts
Medical Society for a law to regulate the practice of
medicine, that the latter decision made further legisla-
tion unnecessary. He says :

" The present law is clear and ample. A man or woman
who assumes to practise the healing art impliedly contracts
that he or she has suflficient skill and knowledge to do the
thing which they assume to do, to cure the disease which
they assume to treat, and no other. And if he or she does
not have it, they are liable in damages for all the conse-

?uences that result from the lack ot knowledge and skill.
i he or she is grossly or presumptuously ignorant and
negligent, and a person is thereby killed or injured, he or
she is liable for manslaughter or for assault."

Even with this interpretation of the law, the
security to the public is insufficient. As has already
been shown, the cases of imposition are not so ex-
ceptional as assumed by Governor Long, neither is
the victim nor his or her friends always conscious of
it or competent to judge of the skill or knowledge of
the medical adviser. None are more aware of the de-
fenceless state of the public in these respects than
physicians.

The next attempt was made in the name of our
Society. In June, 1884, on motion of Dr. H. O.
Marcy, it was voted ** that a committee be appointed
by the President of the Massachusetts Medical So-
ciety to secure, if possible, an act to protect the people
from ignorant and incompetent practitioners of medi-
cine. A committee of sixteen was appointed, Dr.
Townsend, of Natick, being the chairman. This
committee was subsequently strengthened by the addi-
tion of Drs. G. C. Sbattuck, Cotting, Lyman, H. W.
Williams and Hosmer, as a special committee to aid
that of the Society in its petition.

A hearing was given, lasting four days, was largely
attended, and excited much public interest. It was
shown as probable that there was in Boston, at the
time, "greater ignorance and criminality, disguised
under the name of the profession, than in any other
city of the Union. Even houses of ill-fame are
covered under the name of a physician." ^

The committee reported " June 3, 1885, " An Act
to regulate the Practice of Medicine," bat one mem-
ber dissenting. It provided for a board of nine ex-
aminers, not more than four to belong to the same
medical society or school of medicine, who were to
register as qualified physicians all graduates of legally
chartered medical colleges or universities having the
power to coufer degrees ; also all practitioners of med-
icine of ten years' continuous practice in the State.
All other applicants for registration were to be ex-
amined, and at the close of a year all applicants what-
soever were to be examined. The examination was
to be elementary and practical, and to embrace the
subjects of anatomy, surgery, physiology, chemistry,
pathology, obstetrics and the practice of medicine,
exclusive of therapeutics. Persons practising medi-
cine or surgery without being registered were liable
to a fine of not less than fifty nor more than five hun-
dred dollars.

The bill was refused a third reading in the House
by an overwhelming majority. According to the
Boston Medical and Surgical Journal,^' despite the
origin of the movement at the annual meeting of the

» ProoMdlngs of the MMsnchiuetti Medical Sooietj, 1884, 68.
>• DungUson and Maray, Collage and CUnleal fieoord, 18SS, Ti, ii23.
" Home, No. *W.
» 1880, ozll, 203.

Digitized by

Google

640

BOSTOS MEDICAL ABD SURGICAL JOVBHAL

[JcKB 28, 1894.

Society, and its advocacy, both by a general and
special committee, " the sentimeDt of the great majority
of the Society was one of entire indifference. But a
small portion thought it worth while to put themselves
on record at all."

DunglJBon and Marcy state:** "It was presented
daring the last hours of a heated, long drawn out
political contest, when time could not be given for its
proper consideration, and, loaded down with amend-
mente offered for its destruction, it failed of passage."

Fonr years later the attention of the legislature
was again called to this subject through the labors of
Dr. J. Frank Perry, at the time editor of the Journal
of Heakh. The draft of the bill then presented **>
required that licenses to practise should be given by
the Board of Health to medical graduates of legally
chartered colleges, to members of at least one year's
standing of incorporated medical societies, and to
practitioners who had been in practice for ten years.
All other applicants were to be examined by the cen-
sors either of the Massachusetts Medical Society, the
Homoeopathic Medical Society or the Eclectic Medi-
cal Society, and the Board of Health was to license
the successful candidates. Violation of the law was
punishable with a fine not exceeding $500.00, or im-
prisonment not exceeding six months. Three peti-
tions were presented in favor of the object of this bill,
and twenty-six against it.

The subject was referred to the Committee on the
Judiciary, who reported, May 23, 1889, a bill*' en-
titled *' An Act to Regulate th« Practice of Medicine
and Surgery." It provided that practitioners should
file an affidavit of their qualifications with the city or
town clerk, who should give a certificate stating the
Bubetance of the facts set forth in the affidavit, which
certificate was to be conspicuously displayed in the
practitioner's office. Violation of the provisions of
this act was to be punished by a fine not exceeding
one thousand dollars, or imprisonment not exceeding
one year, or by both fine and imprisonment.

This bill was sent up for concurrence by a vote of
eighty -two to fifty-nine, and was defeated in the Senate.
Dr. Ferry informs me that he used every effort to de-
feat this bill in the Senate, since he was determined to
obtain a good bill or none at all.

In 1890 the attention of the legislature was again
called to the subject by Dr. George S. Wilson, of
Boston, representing the Working People's Aid So-
ciety, and other workingmen's organizations. The
matter was referred to the Committee on the Judiciary,
who reported it inexpedient to legislate.

In the following year Dr. Wilson succeeded in ob-
taining a hearing before the Committee on Public
Health, and presented the draft of a bill " to establish
the registration of Medical Degrees." No one was to
use the title of " Doctor," or of " Doctor of Medicine,"
or any abbreviation thereof, unless possessing a diploma
from some reputable college or institution legally em-
powered to confer the degree. At the end of the
year, after the passage of the act, no medical college
was to be considered reputable which required less
than three years of medical study and three annual
courses of lectures of not less than twenty weeks each.
The penalty was a fine of $50.00 to $200.00 for the
first offence, and from $100.00 to $500.00 for each

M Boston Med. and Surg. JournBl, 1886. cxil, -JOit.
M New York Medical Jouriial, lt>»9, zllz, 196.
•1 Uouae, No. 481.

subsequent offence, or imprisonment from thirty to
ninety days, or both fine and imprisonment.

The committee reported March 24, 1891, a bill**
entitled : " An Act to regulate the Practice of Medi-
cine by the Registration of Practitioners," the pro-
visions of which were similar to those of the bill
reported in 1889. This bill was returned to the com-
mittee, slightly amended, and again reported April 7,
1891.** Dr. Wilson states tha^ in bis opinion, the
bill was so unsatisfactory to the working people, that
he " went to the State House and saw several in-
fluential members, who succeeded in killing the bill."
It was refused a third reading in the House by a vote
of eighty-six to forty-two.

In the present year. Governor Greenhalge, in hia
address to the legislature, makes the following re-
quest : •*

" I ask you also to consider the expediency of requiring
that practitioners of medicine be registered in somewhat
the same manner as pharmacists are now registered. In
every State of the Union, except five, such a system of
registration has been established, and it cannot fail to pro-
tect the public, and at the same lime help to maintain a
high standard among medical practitioners."

Pharmacists are registered by a board of registra-
tion appointed by the Governor and Council. The
candidate is examined, receives a certificate, if quali-
fied, and the certificate must be conspicuously dis-
played in his place of business. Unregistered phar-
macists transacting the business of pharmacy are
punished by a fine not exceeding fifty dollars.

The above section of the Governor's address, also a
bill to regulate the practice of medicine and surgery
by the registration of practitioners,** were referred to
the Committee on Public Health. They reported,
three members dissenting, the bill ** " to provide for
the Registration of Physicians and Surgeons." This
bill was essentially the same as the House bill (No.
445) of 1885, and corresponded very closely with the
act of the same year to establish a Board of Regis-
tration of Pharmacy. As a substitute for this bill,
Senator Kittredge offered another," which is practi-
cally the bill recommended in 1889," with a smaller
penalty and a clause making it a misdemeanor to
append, without authority, the letters M.D. to the
name of the person. The committee's bill was advo-
cated in the Senate by Dr. Harvey, and was passed to
be engrossed ; Mr. Kittredge's substitute being de-
feated by a vote of tweuty-two to six. The bill **
as passed by the Senate differs from the committee's
bill, in containing, as amendments, a clause prevent-
ing more than three members of the board being at
one time members of auy one chartered State medi-
cal society ; also that practitioners of three year*'
continuous practice before the passage of the bill
should be entitled to registration ; also, that all ap-
plicants with the degree of M.D. from a legally
chartered medical college or university having the
power to confer degrees in medicine in this commou-
wealth shall be registered in the future without ex-
amination.

Finally, the bill was so amended as not to apply
" to clairvoyants, or to persons practising hypuoiisoa,
magnetic healing, mind care, massage methods, Chria-
tian science, cosmopatbic or any otber method of

" Hooae, No. 292.
•» House, No. 396.
» AddreaB. p. 39.
u UouM, No. 137.

•• Senate, No. 159.
'•' Senate, No. 178.
« Home, No. 4»7.
« Senate, No. 263.

Digitized by

Google

Vol. CXXX, No. 26.] BOSTON MBDIOAL AND 8VROIOAL JOURNAL.

641

healing," provided aacb persoDB do not advertise or
hold themselves oat by the letters M.D., or the title
of doctor, meaiitog doctor of medicine.

Seniitor Kittredge claimed that there were four
tboDsaud remonstrants against the bill, and none but
doctors iu its favor."*

Some of the opponents of the attempt to secure the
legislative control of the practice of medicine in
Massachusetts have placed themselves on record in
the public press. The personal characteristics of
many of those present at the hearings have been thus
described : ^'

" What a collection of them there was in the Green-room
at first, and afterwards in the large hall of the House of
Representatives, to which an adjournment was necessary
on account of the crowds I Medical blacklegs of all kinds,
deceitful clairvoyants, long-haired spiritualists, necroman-
cers, wizards, witches, seers, magnetic healers, pain charm-
ers, big Indian and negro doctors, abortionists, harpies
who excite the fears and prey on the ' indiscretions ' of the
young of both sexes, who treat venereal diseases with the
utmost secrecy and despatch, who have good facilities for
providing cemfortable board for females suffering from any
irregularity or obstruction, who sell pills wliich they are
very particular to caution women when pregnant against
using ; el id genxu omne. Some of them looked sleek, well
fed and prosperous ; others seemed to have come from the
very slums of destruction. Most of them bad a coarse,
animal, degraded look."

ITo becontintted.)

Original Stcticlejet.

CASES OF TRAUMATIC HEADACHE.^

BY CHARLKS V. rOLSOM, M.D.

In studying the varions causes of headache, I have
grouped together six similar cases due to traumatism,
which I report to-day. Others, where the injury was
to the nose, are not included, inasmuch as the cause
of the symptoms iu them was complex.

Case I. C. H., aged seventeen years, with healthy
antecedents, strong, well developed and nourished, and
sensibly brought up, was referred to me in October,
1890, by Dr. Hasket Derby, who had carefully exam-
ined his eyes and found them without defect. Four
years previous to my seeing him, he was thrown from
a horse and strock by the freshly-shod hoof of another
horse, over the upper and middle region of the left
parietal bone. There was a large irregular cut in the
scalp which bled freely and finally healed by granula-
tion. There was no unconsciousness after the accident
and there were no cerebral symptoms at that time.

A year later, he began to have headache now and
then, which was not severe, but which, still a year
later, had become very bad and more frequent. These
headaches began just back of the left eye, a couple of
inches anterior to the cicatrix, extended over the tem-
poral region, and finally involved the whole head.
They lasted several days and were quite disabling.
They were not affected in a causative way by the use
of the eyes. The headaches became more and more
troublesome until the summer of 1890, when they
were almost constant, although the boy was at the

* Read at the meeting of the ABSoaUtionof Amerioan Physloiani,
Wuhlngton, D. C, May 29, 1894.

" Boston Dally Advertiser, April 18. 1»91.
'■ New Koglaod M««lloal Uuzette, 18o0, zv, 65.

time leading an outdoor life on a farm where he was
passing his vacation. He made as little as possible of
his symptoms, as he was very desirous of returning to
school, which he did in October. He was not able to
study and was sent back to me by his teacher as being
in constant suffering. From his mother, whom I then
saw for the first time, I learned that he had been
obliged to give up the active occupations and amuse-
ments of boyhood, and walked about, and especially
up and down stairs, with the greatest care in order to
avoid the least jar, which made his head much worse.
He could not study or read and there was no let-up to
the pain which varied from time to time in degrees of
severity. There had never been any convulsions nor
vomiting.

Physical examination of the patient was negative,
except that over the uppei middle part of the left
parietal bone there was an irregular cicatrix, quite
tender on pressure, about an inch and a quarter long,
and three-sixteenths of an inch wide at the widest part.
The boy had the general appearance of health, except
that his face usually had the expression of pain. He
was unnaturally irritable, and disagreeable to himself
and to others.

After four years of medical treatment, it did not
seem wise to try that any further. I advised that the
cicatricial tissue should be cut out and that trephining
or further exploration should depend upon the indica-
tions— an opinion in which Dr. Weir Mitchell con-
curred after seeing the patient in consultation.

The operation was performed by Dr. Warren, Octo-
ber 29th, in the presence of Dr. Weir Mitchell, Dr.
C. B. Porter and myself, but nothing was found to
justify any apprehension of possible serious injury to
the brain. There were three small indentations in the
external table of the skull and trephining showed some
reddening of the dura with adhesions to the adjacent
bone. Dr. W. F. Whitney found, ou microscopical
examination, diffuse hyperostosis of the skull, and in-
terstitial neuritis in the cicatrized tissue.

The patient made a complete recovery, has been
able to resume his studies, and has remained entirely
well.

Case II. Miss , aged twenty years, was seen

by me in January, 1891, complaining of persistent
dull headache, obstinate constipation which did not
yield to ordinary remedies, and of paroxysms of severe
pain throughout the head, with mental confusion be-
ginning a few days before menstruation and lasting a
week or more.

The patient's health had otherwise been excellent
except for debility and some neurasthenic symptonts
of three years' duration, which began a few months
before the appearance of her heudaches, and which
bad been attributed in part to worry and in part to a
life involving some exposure ou a cattle ranch iu the
West, with food not altogether suited to her somewhat
exacting needs. She had lost twenty pounds iu
weight.

The family history was negative.

In July, 1884, the patient was kicked iu the head
over the upper and posterior portion of the right tem-
poral bone by a well-shod horse. There was a large
irregular scalp wound which got filled with sand and
gravel. The wound was tied up and healed by granu-
lation. There had been no unconsciousness or cere-
bral symptoms of any kind. There was no headache
of consequence until iHarly four years later, iu 1888,

Digitized by

Google

642

BOSTON MBDIOAL AND SUBGIOAL JOURNAL.

[June 28, 1894.

when she was again thrown from a horse and dragged
about fifty feet, being debilitated at the time. She
was also generally bruised about the same time in a
third accident with a horse. Then severe and per-
sistent headaches began, gradually becoming worse,
and being at last completely disabling a few days be-
fore menstruation.

The more or less constant headache was quite moder-
ate in degree and attended with slight mental confu-
sion, which became quite marked at the time of the
severe headaches of the menstrual period. There was
also a degree of a peculiar motor aphasia at such times
with hysterical symptoms, and there were often acts of
cerebral automatiem and attacks resembling petit mal.

After fourteen months of treatment the general
health was restored, the constipation was relieved,
and the persistent headache was somewhat better, but
the paroxysmal attacks which have been described
were not very much improved. There was nothing
peculiar in the character of the headaches, which were
general all over the head ; and there was no tender-
ness in or near the cicatrix, which was irregular and
ragged in shape, an inch and three-quarters long, and
at the widest part nearly a quarter of an inch broad.
It may be said in passing, that in this case and in the
preceding case, the diagnosis had been made of eontrt-
eowp injury to the brain.

The cicatrix was removed by Dr. Warren in March,
1892, with complete relief to all the symptoms which
I have enumerated.

Dr. W. F. Whitney found in the cicatricial tissue
marked interstitial neuritis.

Case III. F. R., aged eleven years, seen Novem-
ber, 1892, in consultation with Dr. V. Y. Bowditch ;
of neurotic temperament and family history.

In 1886 he was stunned by a fall, striking on a
curbstone, with the result of a small scalp wound over
the right frontal region about an inch above the supra-
orbital ridge. In 1888 he was thrown from a small
cart over a stone fence and was unconscious for a con-
siderable time. There was a small scalp wound over
the superior and posterior portion of the right tem-
poral bone from this accident. In the same year he
was partially stunned by being thrown from the rear
platform of a street-car. His only serious illness had
been intermittent fever in Italy.

Between two and three years after the second in-
jury to the head he began to have persistent headache
of slight degree, with frequent paroxysms of intense
pain throughout the head. He lost flesh, became very
thin and irritable, and bad to give up study and read-
ing. He also had frequent attacks of partial loss of
consciousness, the precise nature of which I never
ascertained. The only one which 1 saw resembled
petit mal and probably was that. The eyes had been
examined by an expert and found without defect.
Medical treatment had been exhausted.

The two small, faint cicatrices were excised by Dr.
Warren, November 23, 1892. The relief from the
operation was not immediate, but gradual, and in a
mouth's time the patient was virtually well in every
respect. Two months later he was run over by a
sled, the runner striking the upper cicatrix, and he
was at about the same time accidentally struck a heavy
blow over the other scar. There were pain and ten-
derness over both for three days, and the headaches
returned, to be soon relieved \a massage, and the pa-
tient returned to his school. A short time afterward

a new type of headaches appeared which were dis-
tinctly periodic and in part yielded to quinine, but
which did not absolutely disappear until a re-examina-
tion of the eyes and the use of glasses for a trifling
astigmatism.

Interstitial neuritis was found in the tissue of one
scar by Dr. W. F. Whitney. There was considerable
cell infiltration around the perineurium, as in the other
cases.

These three cases were reported chiefly from the
pathological point of view, and with illustrations of
sections under the microscope, by Dr. Warren, at last
year's meeting of the American Surgical Association.

Case IV. Miss , aged nineteen years, seen by

me in February, 1891.

Family history good, except for recent alcoholism
in one of the parents.

At the age of eleven years she struck her head vio-
lently against a spike, making a wound through the
scalp which left an irregular, ragged cicatrix an inch
long just to the right of the median line, and over the
posterior portion of the parietal bone. Six years later
the patient fell backward from a piazza eight feet high,
striking the back of her head on a rock. She was
unconscious for some time, and for several months
there were pain and tenderness at the seat of the in-
jury. There was no flesh wound.

Very troublesome headaches appeared a few years
after the first injury, and were not increased after the
second accident. They did not yield to treatment,
and were so constant and severe that the patient had
to give up school, and finally all mental work. The
disability increased, and there had been for a year be-
fore I saw her a dull mental state, occasional mild
melancholia, cataleptiform attacks and imperative con-
ceptions, with a generally debilitated physical condi-
tion.

The patient was well developed ; not well nourished ;
the internal organs and the eyes were free from dis-
ease or defect.

After trying medical treatment for four months
without much benefit, except to make the physical
state one of apparent health, I advised excision of the
cicatricial tissue, which was done by Dr. Post, June,
1891. The result was entirely satisfactory in dispel-
ling the headaches and all the morbid nervous and
mental symptoms.

Case V. W., aged thirteen years, was first seen
by me in 1884. There was a neurotic tendency in
the family, which his parents had tried to counteract
by country life and sensible habits of living. The boy
was physically strong, well formed, and with the ex-
ternal appearance of physical health.

Somewhere about 1880 to 1882 he had received
three severe blows on the head, the precise dates of
which could not be learned, in play with other boys.
From two there was no indication as to the site of the
injury. The third, from the corner edge of a hoe, left
a ragged scar a little over an inch long over the upper
and superior portion of the right parietal bone. I
could not ascertain just when his headaches appeared,
as the precise time had been forgotten, but it was
some months after the injuries ; and when I saw the
patient they had become entirely disabling, so that the
boy was obliged to give up the common occupations
and amusements of his age. He was irritable to the
last degree, with very little initiative or interest or
power of self-control, timid and apprehensive. He

Digitized by

Google

Vol. CXXX, No. 26.J BOSTON MBDIOAL AND SURGICAL JOURNAL.

643

had freqnent attacks of Iobb of conBciousneaa, no one
of which I ever saw, but which I supposed to be petit
mal. A description of his various nervous and mental
morbid symptoms, including a very curious type of
topophobia, for the next six years, occupy many pages
of my note-books.

Treatment for seven years under the most favorable
conditions, the greater part of which was in the country
under judicious direction, and away from home, was
only disappointing in its results. Although there was
some gain, the patient was a young man of twenty
years, quite unable to take his part in the world in any-
thing but the simplest vegetative life.

The cicatrized tissue was excised by Dr. Post, June,
1891. The headaches ceased at once, and all the other
neurasthenic and mental symptoms almost as soon.
The young man entered a large business house, in
which he worked hard and has done well.

Cask VI. Miss , seen in 1882, on account of

frequent and severe epileptic convulsions. She was
nineteen years of age, well developed, talented, accom-
plished, with a well-trained mind.

The family history was excellent.

Ten years before, when she was nine years old, she
fell backward from a high swing and struck the back
of her head violently on the ground. A few weeks
later she began to have attacks of petit mal, which, as
time went on, became more frequent, and in a few
years there were also typical epileptic seizures, which
occurred mostly at night or before breakfast in the
morning. She had been under the care of the leading
specialists in Boston and New York, and had been
treated by Dr. Brown-Sequard. None of the treat-
ment did any good, and some made her worse. After
exhausting, as she supposed, the regular pharma-
copoeia, she was taking a proprietary medicine, which,
on chemical examinatioa, proved to be chiefly bro-
mides ; and while fully bromidized, she had more severe
and more freqnent attacks of epilepsy than ever before.

She had had for many years — none of the family
could say how many — a persistent nagging headache,
which had at last made her excessively irritable and
difficult to get on with, although she was naturally
most amiable.

Nothing abnormal was detected on physical exami-
nation. To bodily symmetry there was added a
highly-trained, well-developed mind. No cicatrix was
found, only a slight local tenderness on hard pressure.

The attacks of petit mal were often from twenty to
thirty in twenty-four hours, and the grand mal once in
a few weeks. After nine years of treatment the pa-
tient was, to all appearances, in a condition of bloom-
ing physical health. Very few people knew of her
freqnent attacks of petit mal, which were mostly in
the morning, and of true epilepsy once in two to four
months. The headache, chiefly in the back part of
the head, persisted, and the patient had become more
irritable and self-willed, more difficult to live with, in
spite of greatly improved general health.

This patient, by the way, is the only one in my ex-
perience who has taken borax for a long period of
years with greater benefit than from any other medi-
cine.

The sensitive area, about as large as a silver half-
dollar, remained just to the right of the median line
and above the occipital protuberance where she struck
when she fell, and where a marked unevenness could
be felt on the outside of the skull.

It was thought that the conditions might be similar
to what was found in the first case reported, and such
proved to be the fact. The operation of trephining
was done by Dr. Bradford, assisted by Dr. Monks and
Dr. Brackett, in September, 1891. There was no dis-
tinct indication for opening the dura, and that was not
done. The bone removed was quite irregular in thick-
ness, but was, unfortunately, lost on the way to the
pathologist.

As a result of the operation, the headaches quite
disappeared, the attacks of both kinds have greatly di-
minished in frequency, and the irritability and impaired
self-control are things of the past. The young lady's
parents say that life with her is now a constant
pleasure, and she herself takes her full part in social
life, believing that, as she rather overstates the re-
sults, she has had a new life given her.

Observations might be made, and inferences could
be drawn, and pathological theories and physiological
speculations are possible on these cases, that would be
interesting and perhaps instructive. But I have not
had time to make them short, and you have not the
time for me to make them long.

The symptoms described were evidently refiex and
secondary for the most part. So far as they were
direct, they were doe to more or less extensive altera-
tions in the nerve and to the existence of pressure.

TUMORS OF THE BREAST.

J. COLLIMS WA.BBRK, M.D.,
Pnfeuorqfavrgery in Barvard l/nivertUr.

The following cases are selected for the purpose of
illustrating certain points in the diagnosis and treat-
ment of tumors of the breast, and are presented as a
contribution to the clinical study of disease of this
organ which may prove of interest to the general prac-
titioner.

They emphasize the importance of an early diagnosis
and the necessity for the most radical type of surgical
operation in cases of malignant disease. In spite of
the greatly increased severity of the operation the per-
centage of mortality is constantly diminishing, owing
to the improved technique, not exceeding at present
2^, and convalescence is rapid. There is little doubt
also that the percentage of cases of permanent cure of
cancer is steadily increasing under the present system
of treatment.

MEDULLABT OANCER OF THS BREAST. BSHOVAL

OF THE PECTORAL MUSCLES.

S. E., forty-five years old, having good general
health, first noticed a lump in the right breast while
bathing, on August 1, 1892. There was no pain or
tenderness at that time. The breast was examined by-
Dr. Helen Morton on December 6, 1892, when a tu-
mor of glandular outline was noticed in the right breast
and below the nipple. There was no pain. The pa-
tient had, however, had some pain like that of writer's
cramp in the right arm for two or three years. Men-
struation had been more copious for the last two years,
the intervals being shorter ; the last one being only
two weeks long.

The family history of the patient was good, there
being but one suspicious case of malignant disease in the
family, an aunt having died at about seventy years of

Digitized by

Google

($44

BOSTON MEDICAL AND SURGICAL JOURNAL.

[JtmK 28, 1894.

age with some abdominal disease thought to be cancer,
though no autopsy was made.

I first saw the patient on December 27th, and on
examination foand a tumor in the ooter hemisphere
and considerable enlargement of the axillary glands.

The operation was performed on January 1, 1893.
It oousisted in amputation of the breast and a free dis-
section of the axilla, together with the removal of the
greater portion of the pectoralis major muscle, and the
whole of the pectoralis minor muscle. The wound
was closed throughout by interrupted sutures, and
healed by first intention except at one point, where a
small abscess formed around a catgut ligature. The
patient left St. Margaret's Hospital for her home two
weeks after the operation, and the abscess healed soon
after.

The following is the microscopical report of the
specimen made by Dr. W. F. Whitney :

" The tumor of the breast of S. E. (St. Margaret's, Janaary
1, 18y2), was a soft medullary Dodale, close to the nipple and
lying deep in the breast tissue, its lower surface against the
fascia, through which, however, it conid not be seen to have
brolten.

" Microscopic examination showed it to be made up of large
masses of very large epithelial cells, separated by a little fibrous
tissue stroma. The axillary glands were large, but without
any distinct nodules of new growth. The microscope showed,
even in the smallest, a few scattered large epithelial cells mixed
in with those of the glands proper.

" The diagnosis is medullary cancer, with secondary infection
of the lymph-glands of the axilla."

The malignant character of the growth in this case,
and the involvement of the glands of the axilla neces-
sitating a careful dissection as high as the clavicle,
rendered the prognosis extremely unfavorable, and a
statement to that effect was made at the time. The
patient, however, recovered her health and strength
entirely after the operation, was able to visit the
World's Fair and enjoy herself the following summer ;
and the report in answer to frequent inquiries from
myself is that there has been no return of the disease
up to the present time (May, 1894). The favorable
result of the operation in this case would seem to be
due in some measure to its radical nature. The neces-
sity of such an operation was forced upon me at the
time by the extensive infection of the breast, and the
result has been a most encouraging one for cases of
this class.

CANCEB OF THE BREAST ORIGINATINO FROM A
CHRONIC MAMMART TDHOR.

Mrs. F., fifty-one years old, was examined by me in
June, 1893. Her father lived to be eighty-nine years
of age, and died of cancer in the neighborhood of the
eye. Her brother also suffered from a suspicious
growth in the eyebrow, which was removed by me
several years ago, and has never returned.

Before the patient's marriage, at the age of thirty,
she had noticed a small lump in the lower, outer quad-
rant of the left breast, which had been regarded as a
chronic mammary tumor. This had given her no trou-
ble, although she had since passed through several
confinements. No change was noticed in the tumor
until about February, 1893, when it began to enlarge,
and for two weeks before my examination it had in-
volved the skin above it. At the time when I saw it
there was a red lump involving the gland, slightly
tender and communicating with a nodule in the right
lower quadrant of the left breast. Glandular enlarge-
ment was felt in the axilla. The patient's general
health had been good.

The operation was performed on June 12th, and a
careful dissection of the axilla was made, with the re-
moval of the breast, together with the fascia of the
pectoralis major muscle. The muscles were, however,
undisturbed. The wound was closed throughout by
interrupted sutures, no drainage-tube being used, and
it healed by first intention, the patient leaving St.
Margaret's Hospital on June 30th.

" The specimen from the case of Mrs. F. showed a prominent
nodule involving the skin, of a dark-reddish color, al>ont the
size of a small peach. Section through this gave a grayish
opaque surface, gradually merging into a more whitish trans-
lucent one, in which were nnmeroas irragalarly shaped fiaMue-
like openings. This latter portion was quite sharply defined
from the rest of the breast tissue.

" Microscopic examination showed the soft growth beneath
the skin to be composed of solid masses of epithelial cells sepa-
rated by relatively narrow bands of fibrous tissue. The rest of
the tamor Into which this gradually passed was made up of a
fibroua-tissne basis in which were portions of gland tisane, some
markedly dilated in an irregular manner by in-growtlis of the
connective tissue.

" The axillary glands were enlarged, and presented the same
character as the soft growth first described.

"The case is one of a chronic intra-canalicular papillary
fibroma, in one part of which a medullary cancer has devel-
oped." (W. F. Whitney.)

The patient made a good recovery from the effects
of the operation, and was able to visit Chicago during
the summer ; but in the course of the autumn a coagh
developed, and the patient's strength slowly and grad-
ually failed. Emaciation set in, and finally an exami-
nation about January, 1894, showed the presence of a
small nodule in the outer portion of the cicatrix, and
a marked dulness over the upper portion of the left
lung. From this time on, the patient failed more rap-
idly, and died in March, 1894.

The origin of cancer from a benign tumor of this
nature is undoubtedly rare. The fact, however, that
malignant disease may develop from such a growth is a
reason for operative interference, even in the mildest
forms of this affection. In many cases of chronic
mammary tumor appearing in young girls shortljr after
the period of puberty, I have advised non-interfer-
ence, and have been able to follow the history of
one or two such cases for a number of years, and have
found that they have given no trouble whatever. After
the experience in the above case, I should feel less
disposed to give such advice in the future. Benign
tumors of this nature may, however, take on a rapid
growth early and assume a comparatively formidable
size. Inasmuch as under these circamstances they
may develop into a sarcoma attaining sometimes great
size, and assuming a very malignant type, it is im-
portant that they should be removed without delay,
as was done in the two following cases :

ADENO-FIBROMA OF THE BREAST.

Miss H., nineteen years of age, noticed a growth in
the right breast in the upper and outer quadrant, in
August, 1893. The tumor grew slowly at first, but,
during the three months previous to my seeing it, had
increased in size more rapidly. There is no history
of any such tumors ever having been observed in any
member of her family. The case was seen by me first
in April, 1893. On examination, a nodular, well-
defined growth, about the size of a small orange, was
observed in the locality above mentioned. It was
freely movable under the skin, but seemed firmly at-
tached to the gland tissue. There was, however, a
well-defined outline to the growth. There was no en-
largement of the axillary gland. .

Digitized by

Google

Vol. CXXX, No. 26.]

BOSTON MEDIOAL AUD SURGICAL JOURNAL.

645

The operation was performed daring the same
month, the tumor being dissected from its attacbmeut
to the mammary gland without difficulty; and the
woand healed by first intention. An examination of
the growth, by Dr. W. F. Whitney, showed the tomor
to be an intra-canalicular papillary fibroma. Two or
three small glands removed from the axilla were found
to be simply hyperplastic. In response to a recent
inquiry, the patient states that there has been no re-
turn of the growth.
The second case of this afEection is the following :
Miss J., twenty-two years of age, consulted me in
Jane, 1898, for a tumor of three years' duration
in the right breast, in the upper and outer quadrant.
The patient was a tall and slender person, but iu good
general health. There was no family history of any
such growth. The case was in all respects similar to
the one jost reported, and micro8copi<»l examination
showed the growth to be of the same nature. The
wound healed by first intention, and the patient made
a rapid recovery from the operation. In the early fall
she was married. During the course of the winter she
Bofiered from an attack of the " grip," which was fol-
lowed by symptoms of pulmonary consumption, from
which she died about the first of April, 1894. There
had been no return of the tumor, and her breast had
given her no trouble or inconvenience of any kind
since the operation.

MEOnLLART CANCER OF THE BREAST. — OPERATION,
INCLUDING RBHOTAL OF THE PECTORAL MUSCLES.

M. F. M., fifty-two years of age, consulted me in
March, 1894, for a growth in the upper hemisphere of
the breast, which she thought had been growing for
about three months. On close questioning, however,
the patient remembered that she had occasionally felt
a lump during the past year or so, which had subse-
quently disappeared. There was no history of any
cancer in the family. Her general health was good,
but she had not been strong, and had suffered from neu-
ralgia in the arms, for which she had been under the
treatment of Dr. J. J. Putnam for some time. The
breast had given her some discomfort on arranging her
dress, early in the autumn, and the presence of a lump
was first definitely noticed early in December.

The operation was performed on February 3, 1894.
The infiltration of the breast and axillary gland was
found to be so extensive that it was thought desirable
to remove the greater portion of the pectorales, major
and minor. After the removal of these muscles, a
nest of these glands forming a nodule the size of a pea
was found just beneath the edge of the clavicle and
beyond the apex of the axilla. The following is the
report of Dr. W. F. Whitney :

" The specimen from the cnse o{ Mrs. M., received on March
3d, ooDsUted of the breast and contents of the axilla.

"On the breast «raa a nodule the size of an English walnut
situated just outside of the nipple, which was noi retracted.
The section surface of the growth was in general of a uniform
grayish, slightly opaque aspect, with numerous yellow opaque
dots and lines; the periphery passed into the adjacent fatty
and fibroas tissue by an irregnlarly, slightly-retracting outline.

" Microscopic examination showed the growth to be made of
solid masses of relatively large, irregularly-shaped cells, many
of them extremely fatty degenerated. Between the masses was
a fine Tascolarized stroma of connective tissue rich in round
cells.

"The lymphatic glands from the axilla were enlarged from
the size oi a pea to that of a cherry, and were infiltrated with a
new growth similar in gross appearance and microscopical
structure to that of the breast.

" There was a wide margin of sound tissue about the tnmor,
and no evidence of disease was found in the mtiscle removed.

" The diagnosis is medullary cancer, with secondary growth
in the lymph glands."

The nature of the growth and its extension close to
the boundary line of the axillary space make the prog-
nosis of this case (in spite of the radical nature of the
operation) an unfavorable one. If there be a long
period of immunity or a cure in this case, the fact that
glands of considerable size were traced to the edge of
the clavicle, would become a point of interest to the
surgeon, as indicating that although the disease had
made considerable progress up to this point, it need
not necessarily have involved the lymphatic region be-
yond.

In making a diagnosis in the case of a growth in the
breast, it is important to remember the earliest symp-
toms which enabled us to determine the presence of can-
cer. One of the most important of these — and perhaps
the most frequent period in this part of the world — is
the age which has been mentioned in the cases above
quoted. The most frequent period commonly ascribed
to cancer, is between forty and fifty years, but in my
experience the most prolific years are from fifty to
fifty-five. One point of value is the seat of the dis-
ease, which in cancer is more frequent in the upper
hemisphere and iu the outer hemisphere, the upper
and outer quadrant being, therefore, the most frequent
of all localities. The retraction of the nipple does not
appear to be of much value as a symptom in the early
stages of the disease, a time when an accurate diagno-
sis is of the greatest importance.
{To be conHfiMed.)

CIttttcal aDqiartmettt.

SURGICAL CASES.

BBPOKTKD BT C. L. SOUDDBR, M.D.

The following operations were done by the Sur-
geons of the Staff on duty at the Massachusetts Gen-
eral Hospital on Tuesday, June 12, 1894, before the
members of the Massachusetts Medical Society at the
Annual Meeting. The operations were performed in
Ward E, the abdominal and cerebral ward of the
hospital, and in the public operating theatre.

Case I. A man with fsecal fistula. Operation by
Dr. M. H. Richardson for closure of the fistula; end-
to-end suture of the bowel ; gauze drainage. Recovery.

The patient was a man thirty-one years old. Two
years ago history of obscure abdominal trouble, which
in October, 189.S, was relieved by operation, with the
immediate establishment of a faecal fistula. The fistula
has been open to both fteces and gas, although the
rectum has been functionally active. The sinus lead-
ing to the bowel was dissected out ; all cicatricial tissue
removed from about the bowel ; the intestine divided,
and the ends united by an interrupted Lembert suture.
Throughout the operation there was very great hgem-
orrhage from the vessels iu the cicatricial tissue about
the fistula aud the very large mesenteric veins. After
suturing, a bit of gauze drainage was left projecting
from the abdominal wound reaching to the wound in
the intestine.

Case II. Male. Recurrent sarcoma of the thigh.
Amputation in the upper third of the thigh. Re-
covery.

The patient, aged thirty-two, entered the hospital in
April, with a history of an injury ten weeks previously

Digitized by

Google

646

BOSTON MBDICAL AND 8VS61CAL JOVBNAL.

[JcNK 28, 1894.

to the left knee-joiut. The region of the knee was
greatly swollen and extremely Bensitive.

An amputation was done by Dr. M. H. RichardBon
in the lower third of the thigh April 21, 1894.

Examination of the specimen demonstrated that it
was a spindle-celled sarcoma. To-day the patient hav-
ing recovered from the previous operation, and there
being some recurrence in the stump, a reamputation
waa done in the upper third of the thigh. The bone
was found healthy, but there was a general oozing from
the stump, so that the permanent dressing was not
applied until later in the day, primary dressing being a
packing with gauze.

Cask III. Woman. Perinephritic abscess. Drain-
age. Recovery.

The patient, a woman thirty-one years old in July,
1893, had the following symptoms : frequent micturi-
tion and foul urine. Five months ago a swelling ap-
peared in the right iliac fosea, accompanied with great
loss of flesh and strength.

Examination finds in the lower half of the abdomen,
on the right side, extending well into the right loin, a
tumor. Fluctuation is obtainable from the right iliac
region backward into the loin through the tumor.

Operation by Dr. M. H. Richardson. Incision from
the tip of the last rib to the crest of the ilium obliquely
towards the iliac crest. An abscess cavity was opened,
from which a large amount of foul, thick, greenish pus
was removed. A counter-opening was made in the
right groin, and the cavity was well douched and
drained by tube and gauze.

Case IV. Woman. Epithelial growth of the leg.
Amputation at junction of the middle and lower third
of the thigh. Recovery.

The patient, a woman fifty years old, had had all her
life ulcers of the leg, which had at times entirely healed.
At present there is an ulcer in the middle third of
the leg, with raised edges, and a base extending deeply
to the bone. Microscopical examination by Dr. Whit-
ney proved the ulcers to be malignant.

Operation by Dr. M. H. Richardson. Amputation
of the thigh by antero-posterior flaps, about three and
a half inches above the joint

Case V. Double ovariotomy.

The patient, thirty-five years old, and married, has
one child five years old. Has been married twelve
years, and during the past ten years has had some pain
in the left side, together with a constant dragging
feeling in the pelvis ; leucorrhoea for years ; has had
recently chills and fever.

Examination finds a woman well-nourished. Vaginal
examination finds the cervix and uterus in the middle
line. The uterus is slightly retroverted ; the left ovary
is enlarged ; both ovaries are prolapsed and held fixed
by adhesions. The uterus is normal in size.

Operation in Trendelenberg position by Dr. F. B.
Harrington. Incision in the liuea alba. Uterus found
retroverted; both ovaries prolapsed. Both ovaries
removed ; broad ligaments tied oS. with silk. Uterus
was freed from adhesions, and brought up into the
abdominal wound, and two silk sutures passed from
the fundus of the uterus through the peritoneum and
fascia of the interior abdominal wall. Abdominal
wound closed.

Case VI. Boy. Stone in the bladder. Litho-
lapaxy. Recovery.

The patient, aged three years, was well until eight
months ago, when he began to complain of pain in

both groins. Fain is intermittent — worse with mic-
turition and upon running about — sharp in character.
The child was treated by Christian scientists for four
months without improvement 1 Pain is increasing in
severity and frequency ; micturition is frequent ; and
urine is now passed involuntarily. The child has a
long prepuce.

Operation by Dr. F. B. Harrington. A stone was
detected by sounding the bladder, and it was crushed
by a small-sized lithotrite.

Case VII. Old pelvic abscess. Abdominal sec-
tion, with removal of the abscess wall by dissectiou
through an abdominal incision.

Patient, a woman thirty-eight years old, came to the
hospital with a pelvic abscess May 17, 1894. This ab-
scess was opened anteriorly through the abdominal wall
and through the vagina. Drainage by tube through
the vaginal opening ; this drainage appeared to be iu-
sufficient. It waB thought wise to reopen the abdomi-
nal wound, and to dissect out, if possible, the sac of
the abscess. The incision opened the abscess cavity,
which was washed out clean, and the edges sutured to-
gether, thus preventing the abdominal cavity's infec-
tion by the foul abscess ; and the section was carried
around on either side of the abscess wall until a greater
part of the wall was removed. Both Fallopian tubes
were found enlarged and. full of pus. Both tubes were
freed from adhesions and removed. The cavity re-
maining was drained by iodoform gauze and a glass
tube. Patient was in poor condition at end of oper-
ation, but has recovered well with no rise of tempera-
ture.

Dr. C. B. Porter showed a case of extreme interest
and importance :

A fracture of the surgical neck of the humeras,
complicated by dislocation of the head beneath the
coracoid process of the scapula. The operation for
reduction of the dislocated head of the humerus was
done fifteen days after the accident.

The shoulder-joint was approached through a U-
shaped incision through the deltoid muscle. The head
of the bone was found out of the glenoid cavity. A
drill-hole in the anterior surface of the head of the
humerus was made allowing a blunt steel hook to be
inserted into the bone. Traction was made by the book
outward, aided by pressure of the thumb, this reduced
the head of the humerus into the glenoid cavity. The
wound was closed in the soft parts, a sterile dressing
applied, and the arm held fixed by a plaster-of-Paris
dressing around the chest and shoulder. In five weeks
the apparatus was removed in the day-time, and worn
a short time longer at night only. Union was firm in
five weeks.

Eight months after the operation : The motion in
the dislocated shoulder is about perfect ; the arm, tho
patient reports, is as useful as it was before the opera-
tion. ^

Dr. J. W. Eliot operated upon au acute appendicitis
of four days' duration.

The patient had worked the day before the operation,
but had much abdominal pain. The temperature was
99°, the pulse was 170. The abdominal wall waa
rigid, aud there was paiu iu the right iliac fossa upon
pressure. By an oblique inguinal incision the gangren-
ous appendix was found and removed. Pus was found
free in the abdominal cavity. A counter-opening waa
made iu the median line. Drainage with tube aud
gaiue was made through both incisions.

Digitized by

Google

"ot. CXXX, No. 26] BOSTON MEDICAL AND SUBOIOAL JOURNAL.

647

lElepocti^ of ^octetteif*

ASSOCIATION OF AMERICAN PHYSICIANS.

NiMTH Annual Mektino, Washington, D. C, Mat
29, SO, 31 and Junb 1, 1894.

(CoDtlnoed from No. 2S, p. 622.)

SECOND DAY. — WKDNE8DAT.

JI>R. Theobald Smith, of WashiDgton, read a
p&per entitled

MODIFICATION, TEMPORARY AND PERMANENT, OF THE
PBTSIOLOOIOAL CHARACTER OF BACTERIA IN
MIXED CULTURES.

A.n accidental contamination of a culture of the bog
cholera bacillus with Proteus vulgarit, both probably
inoculated together from the original material, gave
rise to a remarkably rapid attenuation of the patho-
genic bacteria. The symbiotic growth bad lasted
about three months before it was discovered. The
attenuation showed itself when rabbits were inoculated
into the abdomen. A prolonged disease associated
with the eruption of pseudo-tubercles took the place
of the usual inoculation disease. Subsequent trials
with mixed cultures of P. vulgaris and hog cholera
bacilli yielded the same result. The cultures of the
former after repuriflcatiou failed to destroy rabbits af-
ter subcutaneous inoculation.

An unexpected outcome of these observations was
the return to a higher level of virulence of the hog
cholera bacilli in pure agar cultures in every case.
This return did not cooie at once after Proteus had
been removed, but appeared in two cases nine months
after the culture bad been purified and grown on agar
continuously.

Another result of these mixed culture experiments
was the appearance of a series of varieties of the I^o-
Uus culture, all descended from one colony originally.
Two of these corresponded closely with Hauser's P.
mirabilis and P. zeukeri.

These marked changes in mixed cultures are sug-
geaiive when taken into consideration with the life
processes of bacteria in the depths of the soil, espe-
cially in polluted soil in which the bacterial flora may
be presumed to be most abundant and active. The
possibility of an ectogenic development of the non-
toxic species which act as true disease germs is made
plausible and deserves further attention.

The method of mixed cultures may prove useful in
obtaining different degrees of virulence of the same
organism, so essential in the study of the relation be-
tween the host and the parasite, or, in other words,
immunity.

Dr. G. M. Sternberq said that a few years ago
bacteriologists were disposed to look upon cultures
which showed small differences as being of different
species. We now know that the colon bacillus, the
typhoid bacillus and other organisms undergo various
modifications. Liquefying organisms may fail to liq-
aefy ; phosphorescent bacteria may after a time fail to
produce phosphorescence, and the pigment bacteria
msy fail to produce their pigment. Starting with
pure cultures from the same source, we can get a large
numbsr of varieties. It is still to be decided whether
any of these varieties do have permanent characters
and fail to return to the original type.
Referring to the researches of Dr. Martin, reported

by Dr. Ernst, Dr. Sternberg spoke of the pathogenic
power of a pseudo-tetanus bacillus which had been cul-
tivated in the soil where the tetanus bacillus had pre-
viously been cultivated, and after being propagated
through successive tubes, still killed animals with all
the symptoms of tetanus. This fact corresponds with
the results obtained by Dr. Martin in his inoculations
with a particular bacillus obtained from the vaccine
lymph. After several generations be still produced a
typical vaccine vesicle. Whether his bacillus would
continue to do so indefinitely is a matter to be deter-
mined by further experiment.

Dr. Wu. H. Welch said it was well to bear in
mind that nearly all of the artificial modifications pro-
duced by the action of different agencies on bacterial
cultures are changes in function, and not morphologi-
cal changes, and that the present tendency among
biologists is to eliminate, so far as possible, in the
classification of species, physiological properties. In
these observations there is nothing that necessitates
our supposing that these changes justify the recogni-
tion of anything more than races and varieties, and
not of separate species.

Dr. Welch agreed with Dr. Smith as to the remark-
able tenacity of the hog-cholera bacillus in its patho-
genic properties. This is contrary to the statements
of Selauder, and of Metchnikoff and others who
have worked with the hog-cholera bacillus. Selander
claimed to increase the virulence of the hog-cholera
bacillus so that it became a germ almost identical with
that of ordinary rabbit septicaemia that would kill in
twelve to eighteen hours. His work has been gone
over repeatedly here, but without the same results.
It is quite evident that these foreign observers are
working with some different organism.

As to the lesions in the intestines of rabbits which
Dr. Smith attributed to the attenuated bacillus, these
same lesions have been found occasionally after inocu-
lations with the ordinary bog-cholera bacillus.

The results obtained by Dr. Smith are very sugges-
tive that the conclusions which we draw from experi-
menting with pure cultures are not exactly applicable
to the real conditions as they exist in nature, where
the different micro-organisms are associated in various
ways.

Dr. Theobald Smith said that he had studied the
typhoid-like lesions produced by bog-cholera, and had
come to the conclusion that they can only be produced
in two ways : either by an attenuation of the germ, or
by au increase of the resistance of the animal.

Db. Meade Bolton, of Baltimore, then read a
paper entitled

THE EFFECT OF VARIOUS METALS ON THE GROWTH
OF PATHOOBNIO BACTERIA.

Some metals seem to leave no influence upon the
growth of the bacteria, while others have a more or
less marked inhibitory action, as shown by a broader
or narrower clear zone around the pieces of metal on
plates otherwise crowded with colonies of bacteria.

Just outside the clear zone, whether this is broad or
narrow, there is nearly, in every case, a zone of inten-
sified growth where the colonies are thicker than on
other parts of the plate.

In the few tests as yet made for this purpose, there
was entire absence of living bacteria in the clear zones.
Inocalations from the clear zones remained sterile.

Id some cases there are three zones around the

Digitized by

Google

648

BOSTON MBDICAL AUD SUSOIOAL JOVSSAL.

[Jdnb 28, 1894.

metala, namely : a clear zone immediately aarroonding
the metal, a zone of intensified growth, and a second
narrower zone where growth was inhibited.

It has been possible to detect in the mediom, by
chemical reagents, the presence of traces of those
metals that exert inhibitory power.

The solution of the meUtls in the nutrient medium
takes place independently of the growth of bacteria,
as it is possible to detect the presence of the metals in
sterile media in which they have been placed, after
they have lain for a few days, at any rate. A discol-
oration of the medium surrounding the metal often
makes a special test unnecessary.

Some metals have a much more powerful inhibitory
action than others, as is shown by the broader clear
zone. There is also some difference in the different
bacteria with one and the same metal.

Some of tbe metals that have been tested were abso-
lutely pure; others were commercial metals, marked
chemically pure, and a few were either impure or
alloys.

Dr. W. H. Welch said he was very familiar with
the investigations of Dr. Bolton. The most mysteri-
ous thing about them is the clear zone outside of the
intensified zone. The first clear zone immediately
around the metal is unmistakably due to a solution of
the metal in the form of oxide or salt. The most
probable explanation of the intensified zone is that
there is a minimum amount of metal there which is
favorable to the growth of the bacteria, whereas the
larger amount in the clear zone is a poison to the bac-
teria, and prevents their growth.

Dr. W. Gilhan Thompson, of New York, read a
paper entitled

MOTES ON THE OBSERVATION OF MALARIAL OROAN-
I8M8 IN CONNECTION WITH KNTKRIC FEVKB.

The possibility of typhoid and malarial fever mani-
festing their symptoms at one time in the same indi-
vidual has afforded a fertile subject for debate for
many years, with the result that the belief in the sim-
ultaneous action of the two infections has been gener-
ally losing advocates. The theory originally advanced
by Woodward, that a " typho- malarial " fever exists as
a specific and independent disease, has been abandoned
by competent clinicians and by Woodward himself,
although it is occasionally revived in the South and
Southwest, in discussions upon the continued fevers of
the South. Tbe belief is almost universal that typhoid
fever, as observed in New York, is uncomplicated by
malarial infection, and that quinine, except as a tonic
in convalescence, is worse than useless in its treat-
ment. For this reason, the cases of the author seen
in New York last summer and autumn are of unusual
interest.

Case I. The patient, J. McN., male, forty-three
years of age, was admitted to the Presbyterian Hospi
tal, August 18, 1893.. He had continued fever which
lasted for seven weeks, during which time he devel-
oped the following symptoms : A genuine typhoid
eruption, there being some forty distinct rose spots on
the abdomen and chest, which appeared in successive
crops; haemorrhages from the bowels, tympanites,
bronchial catarrh, slight albuminuria with granular
casts, semi-stupor and delirium, subsultus, great pros-
tration and emaciation, and the facies of the typhoid
condition. On the thirteenth day of the illness there
was a severe chill, lasting about three-quarters of an

hour, and so violent that the patient shook the bed.
It was accompanied by a rise of temperature to 106.6°
F., but there was no sweating. During the third week
two other chills occurred of equal violence. The ma-
larial Plasmodium was found in exceptionally large
numbers invading the red blood-corpuscles and also
independent of them. The hypodermatic administra-
tion of quinine reduced the temperature very mark-
edly. No more chills occurred after the beginning of
the fourth week, but the use of quinine was continued
by the mouth, and the bathing, previously interrupted
by the htemorrhages, was resumed. The patient made
a good recovery, and after fifty-five days in the hospi-
tal was discharged cured.

Cask II. The patient, J. J., an Irish laborer,
thirty years old, had a typical case of typhoid fever,
and was treated by the cold tub-bathing without medi-
cine, receiving in all thirty baths. The temperature
became normal on the thirty-first day, and remained
below 99.4° F. for several days, and on the thirty-
seventh day suddenly rose to 106° F., and was accom-
panied by profuse perspiration. There were chills and
high fever on the two successive days at the same hour,
and malarial organisms in abundance were found in
the blood. From the continued giving of quinine the
patient had no more chills or fever and in a few days
was discharged cured.

Case III. This case was very similar to the pre-
ceding one. The patient, after making a good recov-
ery from typhoid fever, was about to be discharged as
cured on the forty-first day, when he had a severe
chill followed by fever and sweating. The chill was
repeated the next afternoon at about the same time,
also with increased temperature. Quinine was promptly
given and the blood was not examined until the patient
had received twenty grains. No malarial organisms
were found, but abundant malarial pigment granules
were contained in the blood-cells. Under the contin-
ued use of quinine, the patient recovered three days
later.

While it is unwise to accept the term " typho-mala-
rial " fever as indicating a third form of disease, which
is neither typhoid fever nor malarial fever, it cannot
be denied that the two latter diseases ntay co-exist.

Dr. Wm. M. Osler, of Baltimore, thought the first
case of Dr Thompson's one of unusual interest, and he
knew of no instances in the literature in which the two
diseases had been so accurately and carefully described
running concurrently. It would, however, be a great
mistake to suppose that chills in typhoid fever always
indicate malaria, since it is well recognized that they
are by no means uncommon, and due to various causes.
In the past year at the Johns Hopkins Hospital there
have been several instances of typhoid fever with
heavy chills in which the malarial parasites were not
present. Dr. Osier exhibited a chart of the only case
in which a patient was admitted to the hospital with a
double infection of malaria and typhoid fever. He
entered the hospital October 16th with tertian inter-
mittent fever, the organisms being found in his blood.
He was given quinine, and tbe temperature from the
18th to the 22d remained normal or subnormal. Ou
the night of the 22d the temperature began to rise and
did not fall to normal till the sixth week, during which
time the patient had a very severe attack of typhoid
with not a single feature pointing to any malarial in-
fluence. Dr. Osier also related an interesting case iu
which malaria and pneumonia were concurrent. Qui-

Digitized by

Google

Vol. CXXX, No. 26.J BOSTON MEDICAL AND 8VBGI0AL JOURNAL.

649

nine caused the parasites to disappear from the blood,
but had no influence upon the temperature. These
are the only two instances in a series of nearly 800
cases of malaria and 309 cases of typhoid, and with
blood examined in all, in which malaria has occurred
with another infection.

Dr. F. p. Einnicdt, of New York, said that Dr.
Thompson's first case was certainly a distinct double
infection. We should, however, be guarded in our
conclusions in regard to the frequency of these double
infections until we have further observations. It is
very possible to mistake a remittent fever for a ty-
phoid, and as an illustration of this Dr. Kinnicut de-
tailed the case of a patient in St. Luke's Hospital
where this error had occurred. The practical lesson
to be deduced from these cases is that the blood should
be examined in wwy case of fever coming into the
hospital wards.

Dr. G. L. Peabody, of New York, called attention
to the fact that there are other chills occurring in
typhoid fever which are of more importance than ma-
larial chills. He bad twice seen severe chills late in
typhoid fever which were pyssmic in character, as
proved by autopsy. He had seen severe chills fol-
lowed by rise of temperature in typhoid, which did not
affect the subsequent course of the disease, the patients
getting well without quinine. It is important that the
idea should not be given that typhoid and malaria is a
frequent combination. That is a fallacy that prevails
largely in the country districts of New fork, and in
some places every case of typhoid fever is treated as
" typho-malarial " fever.

Dr. £. G. Janewat, of New York, said that when
a chill comes on in the course of typhoid fever, it is
often not necessary to suppose that it is due to the
intercurrence of other diseases, for it is due in many
cases to treatment by the modern antipyretics. Drop
the antipyretics, and the chills disappear.

That the two diseases are at times combined, is
proven by the occurrence of both typhoid lesions and
pigmentation at autopsy. Dr. Janeway reported a
case showing these characteristics. Although malaria
and typhoid sometimes coexist, it is not advisable to
give the name " typho-malarial " fever to this combi-
nation ; it should be called typhoid fever with malarial
coexistence. Physicians who give the name " typho-
malarial " to it, assure the family that it is not typhoid
fever, and thus take away the preventive measures for
typhoid fever, and the disease has spread in conse-
quence.

Dr. G. M. Stkrnbbro said that Dr. Thompson's
first case was a clear case of mixed infection, which,
in so pronounced a form, is rather a rare thing. The
other cases showed the development of malarial fever
during convalescence from typhoid, which is not a very
rare occurrence in malarial countries. The cases pre-
sented by Dr. Thompson differ from those commonly
diagnosed as " typho-malarial " in the Southern States
and in other sections of the country. These cases are
usually of the comparatively mild character, and do
not present distinct malarial paroxysms. The temper-
ature is often quite irregular during the first week, and
remittent in character. This leads the doctor to make
a diagnosis of malarial fever and to prescribe quinine.
In the course of the second week the difference be-
tween the morning and evening temperature is not so
marked, and he says that the fever has assumed a
typhoid type. It has really been typhoid from the

outset. The war statistics show that the mortality
from the fever diagnosed as typhoid, was very much in
excess of that from the form denominated "typho-
malarial " fever. If the typho-malarial was a mixed
infection, it presents the anomaly of being less fatal
than typhoid fever, in other words, the complica-
tion modified the severity of the specific fever. It is
possible that there is a widely prevalent endemic fever
which is specifically distinct from typhoid. If so, it is
equally distinct from the malarial fevers, as quinine
has no effect in terminating its course. lu any case,
the uame " typho-malarial " is a mistaken one, and can
only lead to confusion of ideas.

Dr. J. C. Wilson, of Philadelphia, objected to the
use of the term "typho-malarial." This term, so
catching, and apparently so proper at the time it was
coined, has done much harm and has stood in the way
of advancement in the knowledge of fevers. Dr.
Thompson's opportune presentation of these cases re-
opens the whole subject in a most fortunate way. His
paper shows how much clearer and how much more
definite the work of the medical profession is becoming
with our newer and more exact methods of investiga-
tion.

Dr. J. H. Mdssbr, of Philadelphia, reported a
case of mixed infection or rather of repeated infection.
The child, nine years of age, had in the spring of 1893
an attack of intermittent malarial fever, and in the
same year had a second attack which yielded to anti-
periodic treatment. In December, the child had scar-
latina. Four days after the temperature became nor-
mal, measles developed in the child. This was
followed by otitis. During the course of the otitis,
intermitteut fever developed which promptly responded
to the administration of quinine.

Dr. H. M. Lthan said that he had seen cases in
which typhoid fever ran its normal course, terminating
apparently, in convalescence; and then there Were
successive chills, with rise of temperature following.
These chills were usually quotidian, but not at any
certain hour of the day and not yielding to quinine,
being also accompanied by slight jaundice. These
cases have been explained by the French observers as
due to the migration of the typhoid bacilli and other
pathogenic germs from the intestines into the biliary
passages, producing angio-cholitis, which is accompa-
nied by chills and a certain amount of jaundice, not
yielding to quinine but being far more benefited by
local measures addressed to the liver. These cases
must be carefully differentiated from the pyssmic cases,
some of which are notable and easily recognized be-
fore their conclusion.

Dr. W. T. Councilman said that there did not
seem to be any special opposition to the growth of
other organisms in the body due to the presence of the
bacillus of typhoid. He reported in this connection a
case interesting from the number of mixed infections.
It was a case of typhoid fever which, while in the hos-
pital, was accidentally exposed to diphtheria. The
patient died in the third week of typhoid fever.
Throat lesions were seen during life. There were
marked typhoid lesions in the intestines ; there was a
typical diphtheritic process in the throat with false
membrane. There was an acute endocarditis and a
septic embolus in the spleen. There were typhoid
bacilli in the spleen and mesentery glands ; diphtheria
bacilli in pure cultures, in the pharynx and lungs;
streptococci in the bronchial and tracheal glands and

Digitized by

Google

650

BOSTOm HBDICAL JUD SVSGICAL JOVJSXJl.

[JoNB 28, 1894.

on the heart valvea and in the teptic embolus in the
spleen. There was also a colon infection in the
mesenteric glands, in the liver, and in the lungs along
with the diphtheria bacillus.

Db. F. C. Sbattuck, of Boston, said that some of
the inexplicable chills which occurred during convales-
cence from typhoid fever might be due to phlebitis in
the internal and inaccessible veins. The chills and
gubeequent pyrexia mav be very similar to those ac-
companying phlebitis in superficial veins. The impor-
tance of a routine blood-examination is apparent.
Phlebitis would be accompanied by leucocytosis.

Dr. J. E. Reeves, of Chattanooga, Tenn., said that
this fever, which has been described as a mixed fever,
is a source of constant confusion to the physicians of
the South. The clinical history of the fever called
" typho-malarial," is not that of pure typhoid fever,
and he thought it possible that there may be a species
of fever intermediate between malarial and typhoid
fever. In the so-called typho-malarial fever there is
no diarrhoea, no epistaxis ; there is a fitful rise and
fall of temperature, and the course of the disease
thronghout is difierent from that of typhoid. The
first attack makes the subject more permissible to a
second and repeated attacks of the same disease. In
typhoid, after recovery, the patient fattens up; in
typho-malarial fever, the patient is debilitated, has a
sallow appearance and probably does not recover his
health for six months.

Dr. George Dock, of Ann Arbor, thought that
the cases reported went but a short way in showing
the existence of double infection in any proper sense.
In Dr. Thompson's first case, the temperature chart
did not show that there was any malarial element in
the symptomatology before the chills occurred. In
Dr. Osier's case the malarial infection seemed to have
no influence at all on the coarse of typhoid. Dr.
KiDyonn, of the Marine-Hospital Service, in 1890,
reported patients who had typhoid fever and in whom
he also found the malarial organisms. The so-called
typho-malarial disease is often asserted to be milder
than typhoid alone. From the cases reported to-day
this is not shown to be the case. While in Texas,
Dr. Dock had made autopsies in six cases, diagnosed
as typho-malarial by experienced men, and in all cases
the lesions were those of typhoid. He therefore con-
cluded that fatal cases having a supposed malarial as-
pect, were not ancommon.

Such observations as those of Dr. Thompson ought
to be repeated on every case of typhoid, especially in
those parts of the country where the term " typho-
malarial " is nsed.

Dr. W. G. TaoMPSON, said that the object of his
paper was to make a contribution to the natural his-
tory of the malarial organism, rather than to discuss
the wide subject of chills in enteric fever. The cases
reported by Dr. Osier, taken in connection with his
own, proved that the malarial organism may be pres-
ent throughout the period of infection of typhoid fever.
Just how far the malarial germ influences the action
of the typhoid germ is a question which still re-
mains undecided.

Two practical points may be deduced from this dis-
cussion. The first is the value of routine examination
of the blood for malarial organisms in cases of enteric
fever that are at all irregular ; the second is, that we
should determine the value of quinine in those cases
where malarial organisms are present.

Dr. Thomas M. Rotch, of Boston, read a paper
entitled

SOME OF TBE CHEMICAL AND BACTERIOLOOICAL
CHARACTEBISTIC8 OP MILK.*

This paper gives the results of some investigations
in cow's milk, as to its behavior with different breeds,
and something about its bacteria ; also some remarks
on the ash of human milk.

Dr. F. Forchueimer, of Cincinnati, said that the
work of Dr. Rotch is laudable, if only in the direction
of telling us what is normal milk. The normal reac-
tion of milk is undoubtedly alkaline. He had long
ago given up the idea of correcting the reaction by
adding alkalies, because that is only adding another
element to already bad milk. A great number of
troubles in infants arises from impure milk, and just
as the surgeon protects bis patients from sepsis, so it
is the duty of the physician to protect infants from
milk sepsis. Any one who has taken the trouble to
ceotrifugate milk and examine imparities, will com^ to
the conclusion that the best samples of milk in cities
are extremely impure and very dangerous. Any one
who has ever seen a cenirifugate of ten to fifteen gal-
lons of milk, knows that it almost acts as an inhibition
upon the desire to drink milk in the future.

Dr. Theobald Smith said that the milk might be
directly infected from the udder with disease germs
other than tuberculosis. In a sample of milk, milked
into a sterile bottle with ordinarily clean hands, he had
gotten pure cultures of the staphylococcus pyogenes
aureus. Referring to the oentrifugalizing of milk, he
said that the deposits, so far as the morphological ele-
ments were concerned, were made up largely of poly-
nuclear leucocytes, in one case where the leucocytes
were exceptionally abundant, the milk was found to
contain tubercle bacilli ; possibly there may be a rela-
tion between leucocytosis in milk and tuberculosis.

Dr. T. M. Rotch said that a practical result of the
bacteriological examinations was, that where you can-
not provide otherwise for properly sterilized milk, you
can get practically sterile milk if you take the last half
of the milking.

(TObtoOKUimed.)

AMERICAN CLIMAT0L06ICAL ASSOCIATION.

Eleventh Annual Meeting, Washington, D. C,
May 29, SO, 31 and June 1, 1894.

(Cooelnded from Ko. 2S, p. 629.)

THIRD DAT. — THDR80AT.

On Thursday, in the absence of the President, Dr.
Isaac Hull Platt presided.

Dr. Leonard Weber, of New York, read a paper

SOME pathological CONDITIONS OF THE HEART
AND THRIR RELATION TO DIABETIC COMA.

He said that among the sixty cases of diabetes
mellitus which he bad treated in the course of hia
practice, he had seen a number die in coma. It is
true that the majority of these were the well-known
forms of diabetic coma brought about by acid intoxi-
cation of the blood, as it is supposed, by acetone and,
especially, diacetic acid, but in addition also through
the poisonous effects of ptomaines produced by the

To ba publtehad In full In Uw Jonnukl.

Digitized by

Google

7oL. CXXX, No. 26.] BOSTON MBDIOAL AND SUBGICAL JOUBNAL.

661

pvtrefactive processes so frequently occurring in. the
alimentary canal of diabetic patients ; but quite a num-
ber go into collapse through deficient cardiac action,
by disease of the heart developing in the coarse of
diabetes, as already pointed out by Frerichs. In these
cases there are generally no turbulent symptoms, but
syncope followed by cardiac death. They might
properly be named collapse-coma, as distinguished
from the more frequent forms by blood-poisoning.
The causes of neuro-muscular disease of the heart in
diabetes are manifold. We have, in the first place,
the wear and tear of the heart by a chronic disease
producing functional weakness and predisposing it to
dilatation and atrophy ; fatty overgrowth, and later
fatly degeneration in the diabetes of fat persons ; the
poisonous effects of acetone and diacetic acid upon
cardiac nerve and muscle, and in addition those of
ptomaines resulting from intestinal putrefactive pro-
cesses. And arterial sclerosis and chronic nephritis,
which are quite often associated with diabetes, also
have a baneful influence upon the heart.

In the management of diabetes be believes it to be
good practice to allow the patient a certain daily
amount of carbohydrates as soon as the disease has
been gotten under control, and has found this amount
to be about three ounces. An absolute meat-diet can-
not be maintained very long on account of disturbing
digestion and placing the patient in danger of coma.

Every case of diabetes is to be investigated and
studied by itself, and the treatment and management
adapted to individual requirements. In addition to
carefully regulated diet and mode of life, Dr. Weber
has prescribed salicylate and bicarbonate of soda (gr.
XT each) before meals, or Carlsbad water instead.
Where the alkaline treatment did no good, or did not
agree with the patient, he has ordered opium in small
doses with benefit. In every case be saw good ser-
vice from the use of massage judiciously applied, and
the frequent use of baths. It is by the latter two
remedies that the heart is kept fairly strong and active
in this disease, which is as yet not curable but manage-
able.

Db. Bobkbt H. Babcock, of Chicago, gave

▲ BEPOBT OF CA8B8 OF CBBONIC HEABT DISEASE
TBKATED BT THE SOHOTT METHOD OF BATHS
AND GYMNASTICS.

The aim of the report was to direct attention to the
Talue of baths and light exercises in cardiac thera-
peutics, by which it is believed patients suffering with
organic heart disease of chronic nature may be more
promptly and lastingly improved than by drugs. A
statement of the rationale and application of this sys-
tem was given. As to the baths : " The improvement
in the rate and quality of the pulse is an index of the
degree of benefit derived by the patient. If not coun-
teracted by exercise, this effect on the pulse will per-
sist for an hour or two subsequently. Changes for the
better in the size of the area of cardiac dulness and in
the sounds may be noted likewise. This was demon-
strated repeatedly last year both on myself by a com-
petent Russian physician, and by myself ou others.
Careful percussion immediately before and after a bath
of eighteen to twenty minutes' duration, showed a
demonstrable retraction of the deep limits of cardiac
duluess and the heart sounds were improved in
strength, the second pulmonary being less accentuated,
the second aortic stronger — in short, the abnormal

difference between the two sounds before, being ap-
preciably less marked after, the bath. Murmurs that
are almost inaudible before become intensified ; and,
conversely, some loud bruits are lessened in intensity.
In short, so far as can be determined by physical ex-
amination, these baths appear to lessen the rapidity
and increase the force of the heart's contractions,
thereby occasioning a better filling of the great arterial
system with corresponding depletion of the engorged
veins."

The exercises supplement and reinforce the balnea-
logic treatment.

In a detailed report of 19 cases, 13 showed more or
less improvement.

Contra-indications : " There can be no doubt of the
danger of this form of treatment in degenerative
changes of the blood-vessels and myocardium, such as
aneurism and advanced arteriosclerosis, acute soften-
ing and great fatty degeneration of the heart."

A NEW AND DISTINGDISHINa SIGN OF LATENT ANEC-
BISM OF THE AOBTA,

by Db. W. C- Glasgow, St. Louis.

The sign to which Dr. Glasgow referred, is the
presence of a systolic sound, or thud, in the brachial
artery, synchronous with the systole of the heart.
This sound is sometimes accompanied by an arterial
murmur. When this sound can be heard, and aortic
regurgitation can be excluded. Dr. Glasgow claimed
that a positive diagnosis of aneurism can be made,
even in the absence of all other signs or symptoms.
Dr. Glasgow reported five cases of aneurism in which
this arm-sign could be heard. He also exhibited a
patient from one of the Washington hospitals who
showed this sign.

OZONE IN PHTHISIS, WITH ESPECIAL KKPERBNCE TO
THE PNEUMATIC CABINET,

was the subject of a paper by Db.. Cuables E.
QuiMBY, of New York.

FOUBTH DAY.

■ FRIDAY.

THE COMFABATIVE BABITY OF PHTHISIS IN THE
HIGHLANDS OF PENNSYLVANIA AND THE ADJACENT
COUNTIES OF NEW YOBK,

by Db. Guy Hinsdale, of Philadelphia, was the first
paper read on Friday (Db. R. G. Cubtin in the chair).
Attention was called in this paper to the low mortal-
ity from consumption in a district falling partly within
New York and partly within Pennsylvania, embracing
an area of 12,000 square miles. Throughout this re-
gion, there is, according to the best available informa-
tion, a population of over 1,000 persons living to each
annual death from phthisis. The maritime district of
New York, including West Chester County and Long
Island, has a population of only 400 for every annual
death from phthisis, while the seven counties of the
southern tier, namely, Chautauqua, Cattaraugus, Alle-
ghany, Steuben, Chemung, Tioga and Broome, have
an average of 1,091 persons living to each annual
death from phthisis. The Highlands of Pennsylvania
particularly referred to, embrace the counties of Mc-
Keau, Potter, Forest, Clarion, Elk, Cameron, Union
and Sullivan. This entire region has an elevation of
from 1,200 to somewhat over 2,000 feet ; it is charac-
terized by extensive forests, a dryer air and lower
temperature than preyails at the seaboard or lake
shore ; and by reason of its distance from the atorm

Digitized by

Google

652

BOSlOm MBDICAL AS J) SVSGICJL JOVBHAL.

[JuKK 28, 1894.

tracks of the St. Lawrence Valley and the changing
temperature of the seaboard, it is eminently suited for
the consnmptire. In Fennsylvania, Kane, in McKean
County, is very favorably situated, and has acquired
considerable reputation as a resort in phthisis and hay-
fever. Pneumonia, pleurisy and diphtheria are rare
in this locality. The country surrounding Kane is an
elevated table-land of 2,000 feet elevation ; the water-
courses are quite small, and fogs which are common in
the deep valleys are not observed in this high plateau
or '* Big Level," as it is called.

BOMS METEOROLOGICAL DATA OP COLORADO.

Dr.Samdel a. Fisk, of Denver, reported as a mem-
ber of a committee of the Association appointed to
collect meteorological data of the resorts of this coun-
try. Dr. Fisk exhibited tables giving a comparative
study of the elevation, relative and absolute humidity,
precipitation, velocity of wind, etc., of eighteen differ-
ent stations scattered all over the United States. These
tables were used mainly to illustrate the C!olorado cli-
mate. He claimed for Denver (or the region for
which it stands) the advantages of elevation, atmos-
pheric dryness, a small annual precipitation, a cool
climate, a prevailing mild wind of only moderate ve-
locity, and an open sky.

Hon. Mark W. Harrington, chief of the Weather
Bureau, read an exceedingly interesting paper on

8EN8IBLE TBMPBRATDRE8,

and exhibited charts in illustration.

In introducing his paper, Professor Harrington said,
" The subject is so new that 1 am obliged to invent
some terms to describe it." By " sensible " tempera-
ture, he explained, is meant that which is felt at the
surface of the skin, especially where the skin is ex-
posed as on the face and hands. To change a definite
quantity of water from the liquid to the vapor state
requires the utilization of a definite quantity of that
form of energy which we call heat. On evaporation,
this heat changes to other forms of energy ; it is no
longer sensible, and a sense of coolness results from
its change. Thus is caused a reduction of temperature
at the spot where the evaporation takes place; and
while the evaporation continues, the surface from
which it takes place is cooler than the general air-
temperature.

The reduction of temperature caused by evaporation
depends on the rapidity with which evaporation takes
place, and this, in turu, on the amount of moutnre
already in the air. Jn general, when the air is satu-
rated with moisture (that is, when the shade-temperar
tnre and dew-point are the same), there is no evapora-
tion, and the reduction is zero. When the air is
supersaturated, condensation, the reverse of evapora-
tion, takes place, heat is released, and instead of a
reduction we have an addition to the temperature.
But when the air is not saturated, a reduction of tem-
perature takes place.

The amount of this reduction will be greatest where
the air is driest, least, where the air is moist. In
Washington, Philadelphia, or San Francisco, the moist-
ure is abundant, evaporation is relatively small, and
hot weather feels hot. On the other hand, at Denver,
Santa F^ or Prescott, the moisture is generally scanty,
especially in hot weather, and the reduction is great.
The most extreme case easily accessible is that of
Furnace Creek, Death Valley, Cal. During the ob-

servations taken there in the summer of 1891, on five
days the maximum temperature reached 122°; the
temperatures of evaporation from 74° to 77°. The
temperature felt by a person favorably situated was
from 45° to 48° lower than that shown by the ther-
mometer in the shade, and was almost cool for a sum-
mer afternoon.

It appears that in arid regions, the reduction may
make hot weather not only endurable but even agree-
able and refreshing.

So far it has been only a question of temperatures
in the shade. Temperatures in the sun are always
higher, and may be very much higher. On a hot
summer afternoon, a temperature of 130° in the direct
sun's rays is not rare in any latitude of the United
States. Sometimes this temperature reaches 140°,
and occasionally it is even higher. The conditions for
sensible temperatures already stated do not apply in
such cases — in part, it may be because of the failure
of suflBcient perspiration to give free evaporation ; in
part, because of the special effects which strong and
direct insolation has on organic structures.

To obtain the beneficial effects of the reduction of
temperature by evaporation, the shade must be sought,
and the direct sun's rays avoided. The effects may be
heightened by a natural or artificial breeze or wind ;
and for parts of the body covered by clothing they
may be obtained by adapting the clothing to the free
passage of air and moisture.

Dr. JnDSON Dalamo, Philadelphia, gave a detailed
report of three cases of

BERI-BEBI,

with examination of the blood. The greatest interest
in these cases surrounds the question of etiology.
Beri-beri has been observed in Japan, portions of
Africa, and in the East and West Indies, and, as has
been shown by Schenbe and Baelz, it is an endemic
peripheral multiple neuritis. Muira believed it to be
due to fish, especially decomposed fish, while others
attribute it to rice. These cases tend to bear out
Muira's theory. The food of these men was almost
exclusively fish and rice. Some of the fish was dried ;
much was spoiled ; the quantity was insufficient. The
main facts, as given by L>r. Daland, seem to point con-
clusively to poisoning by some substance in rice or
decomposiug fish, probably of the nature of miscarin.

These three cases recovered, as did eight others,
sailors in the Brazilian navy, reported by Dr. Gihon.

Unfortunately, the time of the meeting did not allow
for the reading in full of the paper of Ds. Dalt on

SOMIi PRACTICAL OBSEKVATIONS ON SO CALLED
MALARIA,

and that of Dr. W. C. Glasgow on

FBI8ICAL SIGNS OK CELLULAR (EDEMA OF THE LUNG
CONSIDERED IN THEIR RELATION TO THE PATHO-
LOGICAL CHANGES.

A Bit of Medical Corrkspondbnce. — A corre-
spondent of the Norihwetttm Lancet sends the follow-
ing letter received from a Dakota patient :

Ha7 6th, 1891.
Dear Sar. I will write and tell Tou how he is he is gust the

same and his stomick bloth np and is so hard that he thing that
it ia gunt butg be is sick over his hole body and it eita ap on
under his brist but he is gnt good opening in front and behind.

Digitized by

Google

Vol. CXXX, No. 26.] BOSTON MBDIGAL AND SURGICAL JOVRBAL.

653

%lecent Xiterature.

An American Texl-Book of Gynecology, Medical and
Surgical. For Practitiouerg aud Students. By
Henry T. Byfokd, M.D., J. M. Baldy, M.D.,
Edwin B. Cragin, M.D., J. U. Ethebidgb, M.D.,
William Goodell, M.D., Howard A. Eellt,
H.D., Flobian Krcg, M.D., £. E. Montgomert,
H.D., William R. Pryor, M.D., Geobob M.
TcTTLK, M.D. Edited by J. M. Baldy, M.D.,
with 360 illustratious iu text, and 87 colored and
half-tone plates. Philadelphia: W. B. Saunders.
1894.

This is the most notable contribution to gynecologi-
cal literature that has appeared since the publication of
the " American System of Gynecology " in 1887. The
high professional standing of the authors and the thor-
ough manner in which they have utilized what has
Bt<x»d the test of time in this branch of medicine, and
have given us the latest ideas on the various subjects
treated, make it the most complete exponent of gyne-
cology which we have. How long it will hold this
position, in view of the rapid strides which are being
made especially in this department is another question ;
until that time it will be looked to as au authoritative
statement. Like a system of surgery published by the
same firm, though of composite authorship, its various
chapters are unsigned and the authors are as a body
responsible for the views advanced. While this may
have its advantages, yet where there is an editor-in-
chief who can see that every part is adequately treated,
and conflicting methods are not advocated, we think
it is better for each author to accept the responsibility
of what he has written. The average reader, especially
of a subject where there can honestly be differences of
opinion, naturally wishes to know who has made this
or that statement, and such knowledge may add or de-
tract from its value.

As a whole, the work has been well done as was to
be expected, especial attention has been paid to the
rules for ai d methods of antisepsis, to full descriptions
of the technique of operations, including many new
ones, aud to the modern views of pelvic pathology.
But no subject seems to have been neglected though
the difFereut parts vary in merit. Sometimes it seems
as if the sense of proportionate value had been lost, but
this is not strange when the natural bias of many of
the writers is taken iuto consideration. Thus as be-
tween operative aud non-operative methods of treat-
ment, the former are sometimes, as it seems to us, given
undue prominence, and this leads us to say that it is in
no sense a text-book or primarily adapted for the
student. It is too advanced and technical. But the
gynecologist and surgeon aud the general practitioner
who has any desire to practise diseases of women will
find it of practical value.

As we have read it through, there have naturally
been statements with which we were not wholly in ac-
cord. Some few points have seemed worthy of men-
tion. In Fig. 2 of the frontispiece the vulva is drawn
much too high. The opening of the anus would more
nearly represent its true position. The chapter on the
" technique of gynecological operations " is excellent,
though just what is gained by au illustration of a
" patient being etherized," or of " washing away per-
manganate of potash with oxalic-acid solution " we fail
to see.

In the chapter on the " examination of the female
pelvic organs " too much space is devoted to the uterine
elevator. Byford's is the best, but they are both dan-
gerous and useless.

A separate chapter is devoted to " genital tubercu-
losis," a subject which has been neglected heretofore.
It is thoroughly treated, beginning with lupus and fol-
lowing up the whole genital tract. As was to be antic-
ipated, the author's treatment of the subject of inflam-
matory diseases of the uterus is thoroughly in accord
with modern pathological views. The uterus is looked
upon as the source of the trouble and as a result of
this, they recommend that curettage of the uterus is
indicated in every case of acute tubal or peritoneal in-
flammation where the source of infection has been in
the uterus.

The chapter on " distortions and malpositions " is in
general very good. We think the authors condemn
too strongly the use of stem pessaries in the treatment
of dysmenorrhoea associated with anteflexion, aud are
unwise in advocating the use of a repositor to replace
the retro-displaced uterus. If Scbiicking's operation
for a backward displaced uterus is " mentioned merely
to condemn it," it is surely unnecessary to illustrate it
with two cuts. The chapters on " malignant diseases
of the female genitalia," and on " uterine neoplasms,"
are among the best in the book, and are very valuable
to the operator.

In the matter of illustrations and plates the book
surpasses anything we have seen. If we made any
criticism we would say that some of them are unneces-
sary, and that except where it is essential to illustrate
the point desired, absolutely nude figures are not in
good taste. The book is well gotten up, and the letter-
press admirable.

Minor Surgery and Bandaging. Including the Treat-
ment of Fractures and Dislocations, Tracheotomy,
Intubation of the Larynx, Ligation of Arteries and
Amputations. By Henry R. Wharton, M.D.,
Demonstrator aud Lecturer on Surgical Diseases of
Children iu the University of Pennsylvania, Sur-
geon to the Presbyterian Hospital, the Methodist-
Episcopal Hospital and the Children's Hospital,
Consulting Surgeon to the Presbyterian Orphanage.
Second edition, thoroughly revised and enlarged,
with four hundred and sixteen illustrations. Phila-
delphia: Lea Brothers & Co. 1893.
This work has quickly reached its second edition,
and the author has revised the aseptic and antiseptic
method of wound treatment, briugiug them up to date ;
a number of new illustrations have been added. The
book is divided into six parts. The first is on bandag-
ing, the second on minor surgery, the third on fract-
ures, the fourth on dislocations, the fifth on ligation of
arteries, and the sixth on amputations.

The part on bandaging is illustrated by some beau-
tiful half-tones, which add greatly to the text. A
little more attention to detail in the description of
some of the operations described would enhance the
value of the book. Some of the illustrations are with-
out value, except iu so far as they stimulate the imagi-
nation. The book, as a whole, though, is one of the
best minor surgeries that we possess.

On the authority of the Hamburger Freitinnige
Zeitung, there were in Prussia last year, 1,200 indi-
viduals who died from delirium tremens, and 500 who
committed suicide through intemperance.

Digitized by

Google

654

BOSTOS MEDICAL ASJD SVJtGJCJl JVVBUJl.

[JvNC 28, 1894.

THE BOSTON

icieiiical anD Surgical 3!oumaL

Thursday. June 28. 1894.

A Joamal o/Medieit, Swrgerg, euul AUitd 3ei*»et;fiMi$kei at
/toaton, weekly, ty the umdenigntd,

SnaacRiPTioK TBmm: VtM per ftar, im odvaMoe.poilag* paid,
n>r the n»{ted State*. Camada €md Mexieo; M-Se per tear far all tor-
nfk evKKMt* bela»ti»t (o "^ PoiteU Vnioa,

Alt aemmmUeatieiu for the Kdttor, and all 6ool( for review, ehotUd
beaddreuedlothe Xdilerqfthe Boeton Medical amdamrglealJomnuU.
3U WathimgtoH Street, Boet)m.

All iettere eontotata^ tmtineet eomm*»teailtmt, or re^erHmg to the
ptMieaiion, eubeeriptiim, or advertUiag department qf tkii JomnuU,
ehotUd be addremd to the trnderelgned.

JtmUtanon ehmM be made ty moaet-order, draft or regUtertd
tetter.paDaUe to

DAMRELL A UPHAM,
U3 W^SHoroTOH Stuxt, Bostos, Mais.

ZOLA AND LODRDES.

Zola's new novel. " Lourdes " is said to have been
received with furor in Paris. It has been running as
a serial through two of the leading daily papers.
Though the book is ranked as fiction, the author has
evidently pictured the scene in a realistic and on the
whole, truthful aspect. The story of the miraculous
appearance of the Virgin to Bernadette, a shepherd
girl in 1858, and the erection of a great temple and
sanitarium at Lourdes over the grotto, the scene of the
apparitions ; the innumerable pilgrimages of the sick
to the spot ; and the wonderful tales of sudden cures
are familiar to all. The subject, moreover, has been
recently reviewed in striking colors in two numbers of
the Berue det deux Mondet, by Emile Pouvillon, who
insists on the reality of alleged miraculous cures.

Zola's tale opens with the description of a crowded
train carrying sick pilgrims from Paris to Lourdes.
There are patients there who for years have been bed-
ridden ; some are in the last stages of consumption ;
some have frightful lupus sores; tome chronic ecze-
matous eruptions ; one passenger is at the point of
death ; one woman is taking her dying baby to be
cured at the miraculous grotto ; some are paralyzed.
Just as the train leaves a certain station, a young girl
gets on the car. She tells the story of the miraculous
cure accorded to her diseased foot by simply dipping
it in the water at Lourdes.

A vivid picture is given of the confusion when the
invalids are landed at Lourdes. Hundreds of them
are hurriedly conveyed in carriages and litters through
the mud and dark to the big hospital until the proces-
sion shall be formed.

The hospital is greatly overcrowded. The sisters
do their work heroically. At 8 a. h. the procession
to the grotto .is formed. The long line of invalids
afflicted with every conceivable disease makes a horri-
ble contrast to the beauty of tlie landscape. A priest

mounts the stone pulpit and asks the vast congregation
to pray for a great miracle, as the body of the man
who died on the train is to be immersed in the pool in
hopes that life will be restored. The dead man is
brought in and immersed amid vociferous supplications.
No miracle occurs, and the corpse is taken away.
The pool is thronged with sick persons, who eagerly
await their turn. The supplications of the bystanders
are of an urgent, imploring, sometimes almost of a
scolding nature. Cures are demanded, that the honor
of the grotto may be maintained, the good name of
the importuned vindicated, that unbelievers may be
convinced and converted.

So many are bathed in the pool that the water soon
becomes filthy beyond description. The water in the
pool is only changed twice a day, as the supply is
somewhat scanty. No one better than Zola could
describe the nastiuess of the water, so seldom changed,
in which so many persons suffering from cancerous
and tubercular affections, purulent sores, ophthalmus,
and offensive cutaneous diseases were bathed. " What
a home for microbes," exclums one of Zola's charac-
ters ; " the present mania for antiseptic precautions '
receives a fearful blow from such a spectacle ! How
does it not happen that one nasty disease does not kill
all the invalids ? "

Zola, in a chapter lately published, describes a visit
to the Bureau of Certifications, from which it would
seem that there is a good deal lacking in the thorough-
ness of the methods of verification. The testimony of
often unknown and obscure physicians was taken as
to the condition of patients when they came for treat-
ment ; they were not subjected to a preliminary ex-
amination by a competent commission, and when any
announced themselves as cured, there was always room
for scepticism as to whether they had come to Lourdes
with any serious malady, not amenable to cure by
some strong psychical influence.

As to the percentage of " cores " effected at Lourdes,
Zola estimates it as not more than 1.0 per cent., that
is, nine out of every ten coming to Lourdes with faith
and great expectations go away unrelieved ; cases that
expert physicians call clearly incurable are not bene-
fited. As for the miracles occurring at the grotto, he
is puzzled, and feels that probably a great mistake has
been made somewhere. We conclude by giving a
brief citation from the fourth chapter :

" Pierre began now to comprehend what this all meant —all
that was taking place at Loardes — this extraordinary spectacle
at which the world liad assisted (or yean, amid the devoted
adoration of some and the mocUng laaghter of others. Cer-
tainly, the whole matter was very badly understood — almost
Ignored ; but a hidden force moved it on — first the suggestion,
then the perturbation of anticipation, the fascination of the
journey, the prayers and the hymns, a growing exaltation and
finally the healing breath, the unknown power that separated
Itself from the masses in a marked crisis ot faith. He even
fancied it rather stupid not to beliere in these fraads. The
facta themselves were very great, but at the same time far more
simple. It was not necessary for the fathers of the grottn to
condescend to lie — they most only needs add to the cod fusion
to utilize the nniversal ignomnco. They might ereu confess
that all was done in good falih — iiiu uokuown doctors who gave
the certificates, the comforted invalids who fancied themselves

Digitized by

Google

Vol.. CXXX, No. 26.1 BOSTON MBDWAL AND SURGICAL JOURNAL.

655

oared and the enthusiastic witnesses vho roved they had seen.
After all this it was evidently impossible to prove whether there
had or had not been a miracle. From that moment did not the
miracle become an actual fact to the larger number for all those
who suffered and lor those who had need for hope? "

REVISION IN THE AMERICAN MEDICAL AS-
SOCIATION.

We call the especial attention of our readers who
are interested in the evolution of the American Medi-
cal Association to the clear statements in the excellent
letter on page 657 of this issue (from oar special San
Francisco correspondent). One finds therein not only
a capital account of this individual meeting, but also a
suggestive explanation of the forces at work to effect
a modification in the government of the Association.
An unavoidable delay gives our readers this letter
later than we had hoped, but it is none the less read-
able on that account, and one sees more accurately after
the smoke of the action has cleared away.

MEDICAL NOTES.

The RoTAL Societt or Edinburgh Medal. —
The Royal Society of Edinburgh hag awarded one of
its medals to Prof. T. R. Eraser of Edinburgh Univer-
sity, for his work on strophanthus.

Thb Dbclink or the Male Intellect. — Again
the senior wrangleship at Cambridge, England, has
been obtained by a young woman, who is reported to
have had a long lead over her male competitors. Her
name is Johnson.

A Medical Gentenabian. — Dr. Salmon, of Cam-
bridge, South Wales, u the oldest physician in Eng-
land. He was one hundred and four years old in
May. He has a patient in the same town who is one
hundred and five years old.

Bold Adyebtising. — The following advertise-
ment appears in the Alunchener MedicinUehe Woehen.
tchrifl of June 5th :

" To TKX Public. — I hereby take it upon me to make the
welcome announcement to physicians that I have acquired the
sole right of manufacturing the Anticokckption Waddino
Takfons, according to the formula of Dr. . See his pam-
phlet, " The Means to Prevent Conception," p. 2y, published by
& , price 1 mark 60 pf. I have them chemically pre-
pared in different-sized packages. With respect and pleasure,
, Apothecary and Chemist.

" Takb Noticb. — Chemically prepared Anticooception Wad-
ding Tampons. See page 29, etc"

Comment is unnecessary !

BOSTON AND NEW ENGLAND.

Acute Infectious Diseases in Boston. — Dur-
ing the week ending at noon, June 'il, liidA, there
were reported to the Board of Health of Boston, the
following numbers of cases of acute infectious disease :
diphtheria 44, scarlet fever 35, measles 26, typhoid
fever 15.

Opebations at the Boston City Hospital. —
During the visit of the members of the Massachusetts

Medical Society to the Boston City Hospital at the
recent meeting of the Society, the following operations
were performed : an eiternal urethrotomy, an appen-
dicitis, two hysterectomies and a complete removal of
the breast and glands of the axilla.

Honorary Degree. — Dr. D. W. Cheever,
Emeritus Professor of Surgery in the Harvard
Medical School, received the degree of LL.D. from
Harvard College at Commencement, June 27th.

Harvard Medical Aluuni Association. — The
Harvard Medical Alumni Association held its annual
meeting and annual dinner, in Boston, on Tuesday,
June 26th, at 12 and 1 o'clock. The usual routine busi-
ness was transacted at the meeting. At the dinner, at
which presided most felicitously Dr. James R. Chad-
wick, Dr. W. W. Keen, of Philadelphia, Dr. Wm.
Osier, of the Johns Hopkins University, Dr. W. M.
Polk, of New York, and Dr. J. S. Billings, U. S. A.,
made speeches. A full report of the occasion, which
was one of much interest, will be given later.

Harvard Dental Aldmmi Association. — The
Harvard Dental Alumni Association held its twenty-
third annual meeting and its annual dinner at the Hotel
Tborndike, Boston, Monday evening, June 25th. Dr.
Virgil C. Pond, President of the Association, presided ;
and after the dinner speeches were made by Bishop
Lawrence, of Massachusetts, Mr. Thomas, Private
Secretary of the Governor of the State, Dr. George
B. Shattuck, of the Board of Overseers of Harvard
College, and Mr. W. R. Thayer, Editor of the Bitr-
vard Alumni Magaxitu. The Association is in a flour-
ishing condition.

The Annual Address in Medicine at Yale
Unitbbsity. — The Annual Address in Medicine be-
fore the Medical Faculty of Yale University, was
given by Dr. William T. Lusk, on Tuesday, June 26th.
Dr. Lusk chose as his subject, " The Illustrious Boer-
haave." Prof. William H. Carmalt gave a reception
to Dr. Lusk in the evening of the same day.

Tufts Medical School CouMENCEitENT. — At
the commencement exercises of Tufts College held on
June 20tb, the degree of Doctor of Medicine was con-
ferred upon the first class to graduate from the medi-
cal school of the college. Seventeen persons were
given degrees. An honorary degree of LL.D. was
conferred upon J. S. White, of Brooklyn, Dean of the
Long Island Hospital Medical School.

The Massachusetts Infant Asylum. — The
twenty-seventh annual report of the Massachusetts In*
fant Asylum, shows a most successful year's work. Of
88 children in the hospital but five died, two of bron-
chitis in the hospital, and three who were out board-
ing — one of bronchitis, one of enteritis, and one of
convulsions of unknown origin. During the twenty-
seven years of its existence the hospital has cared for
nearly 3,700 children, with a total mortality of only
468, or less than 13 per cent.

Pbotests against the Continuance of two
Hospitals. — The Committee on Health of the Board

Digitized by

Google

656

BOSTON MEDICAL ASD SVRQICAL JOVBSAL.

[JcNs 28, 1894.

of Aldermen of BostoD, gave a hearing last week to
the remonstrants against tbe licensing of the Baptist
Hospital on Bellevue Street, Longwood, and of the
Free Consamptives' Home on Quincy Street, Dorches-
ter. The hospital having withdrawn its petition for a
license for a lyiug-in department, no especial permit is
required for the carrying on of a general hospital.
The Board, however, has statutory power to prohibit
hospitals in any particular portion of the city ; and it
is this restrictive power which the remonstrants desire
the Board to exercise, on the ground that both hospi-
tals are situated on residential streets to tbe disadvan-
tage of property owners.

NEW TOKK.

Thb Tenbment-Hodsk Population. — Dr. Roger
S. Tracy, Deputy Registrar of Vital Statistics, has just
completed the semi-aunual census of the tenement-
house population of New York, and his report was
presented at a meeting of the Board of Health held
June 19th. It shows that the total tenement-house
population is 1,332,773, and that the total number of
tenement-faouses is 89,138. Of this number there are
2,346 rear iionses, and the population of the latter
amounts to 56,130. In the ward which contains the
largest tenement-house population (the twelfth) there
are 7,702 tenement-bouses, with a population of
252,881 ; and in the ward which contains the small-
est (the second), there are 8 tenement-houses, with a
popnlation of 175. The total number of children un-
der five years of age residing in tenemen^houses in
the city, is 180,859.

Shall-Pox and Chicken-Pox. — A short time
since some cases of eruptive disease occurring at Sta-
pletoD, Staten Island, were pronounced by the local
health officer to be chicken-pox. Some of the other
Staten Island physicians believed these cases to be
really small-pox, and with the consent of tbe health
officer, Dr. A. H. Doty, Chief of the Bureau of Con-
tagious Diseases, and other experts from New York,
were asked to examine the cases. They unhesitat-
ingly expressed the opinion that the disease was small-
pox, and the health officer, although not convinced,
promised to take all possible precautions in the way of
quarantine and disinfection. The matter having been
brought to the attention of the State Board of Health,
representatives of that body visited Stapletou on June
20th, and reported that the cases were undoubtedly
small-pox, and on the day following, at the request of
the State Board, Dr. Bryant, of tbe New York City
Health Department, was sent to Stapletou to take
charge of the disinfection of the premises where the
cases had occurred, and to direct tbe vaccination of all
persons who had been exposed to tbe disease.

Trephining for Headache. — At a meeting of
the New York County Medical Association held June
18th, Dr. J. Marshall Hawkes presented a patient, a
young man, whom he had trephined for persistent lo-
calized headache. In Starr's recent work on " Brain
Surgery," Dr. Hawkes said it was stated that this op-

eration had been performed bat twice for the purpose
in question, once in London, and once in New York,
by Dr. Robert F. Weir. From early boyhood this pa-
tient had sufiFered intolerably from frontal headache,
and though he had consulted a large number of physi-
cians, every remedy that had been tried had utterly
failed to give bim relief. Thinking that the trouble
might possibly be due to eye-strain. Dr. Hawkes first
sent bim to Dr. H. Knapp, but the latter found
that there was no difficulty of this kind. On mak-
ing an examination of the head, the only abnor-
mality that could be detected was a slight indenta-
tion of the hone in the right frontal region. As a last
resource, Dr. Hawkes determined to trephine at this
spot, and on June 80, 1892, a button of bone, about
two-thirds of an inch was removed under strict anti-
septic precautions. It was found that in the location
named there was a depression of the inner table of the
cranial bone, making pressure upon the brain sub-
stance, and the button removed was exhibited to the
Association. From the time of the operation there
had been complete relief from the headache, and as
two years had now elapsed, the cure could be pro-
oouooed permanent.

*

THE FIRST DISPENSARY.

In an account of the development of the Hospital Sun-
day Fund, the Zane«< relates tbe story of the establish-
ment of the first dispensary. "In 1696, an instru-
ment was signed by the President of the Royal College
of Physicians, most of the Elects, Senior Fellows and
Candidates, declaring that ' no method hath been
taken to furnish the poor with medicine for their cure
at low and reasonable rates," and subscribing sums of
money to be " expended in preparing and delivering
medicines to the poor at tbeir intriusic value." Not-
withstanding " the vigorous opposition of a few men
who thought it their interest to defeat so laudable a
design," a dispensary was erecteil in Warwick Lane
"being an apartment in tbe College set up for the
relief of the Sick Poor," and managed for many years
with integrity and disinterestedness. It was of thia
that Dr. Garth wrote :

" There stands a dome majestic to the sight

And Bumptaoos archea bear its oval height ;
A Golden Globe placed high with artful slcill
Seems to the distant sight a Gilded Pill."

JAPANESE GIRLS IN BOXES.

The beauty of Japanese girls is proverbial, and their
attractiveness led recently to an attempt to smuggle
some of them out of their country to become the slaves
of their purchasers.

According to the report of the officers of the North-
ern Pacific steamer Taeoma, just as that vessel left
Yokohama on a late trip, a Japanese man came ou
board with four large boxes, which he said he wished
put in the steerage as bis luggage. Just as the first
box was about to be lowered a rapping and faint cry
was heard from one of them, and on opening it a young
Japanese girl was found doubled up inside. Each of

Digitized by

Google

•1.. CJLXH, No. 26.] BOSTON MEDICAL ASD SUBGICAL JOVRJUAL.

667

i other boxes was foand to contain a similar DanSe,
t &U of these three were unconscious. Afterseyere
oor two of them were resuscitated, but the third was
Dribund when discovered and soon died.
On police iovestigation the responsible agent was
>t fouDd, bat the Japanese woman who had enticed
le girls to her house and drugged them was discnv-
'ed. It is said she has a husband in Portland, Ore-
an, to whom the girls were consigned.

It had been planned that the steerage passenger
lioulil open the boxes after the vessel left the Japa-
ese waters and release the girls, paying any fare
rhich might be required. Three air-holes had been
>ored in CHch of the boxes, but these had become al
iiO't closed by the bodies of the girls, which were
srowded into the coffin-like confines in a cruel manner.
Bach box was two feet three inches in length, and
iiboat eighteen inches in depth and breadth. In each
oi the boxes was a piece of bread.

€orreie(pon0eiice.

[From our Special Correspondent.]

LETTER FROM SAN FRANCISCO.

THE MEETING OF THE AMERICAN MEDICAL

ASSOCIATION.

Attbndanck. — Work in Gbvbbal Skssioms amd in 8ko-
TioNS. — Chanobs in Officbbs. — Cbntkalization. — Rb-

TI8ION OF THB CONBITTOTION. ThB CODB. — BNTBKTAIN-
HKNT8 AND HOSPITALITIBS.

San Francisco, June 11, 1894.
The forty-fifth annual meeting of the American Medical
Association has been voted a scientific and a social success.
In point of attendance it has exceeded many former meet-
ings held in populous eastern centres, nearly 600 members
having been registered in attendance. 'J'he greater num-
ber of the sections wure well organized, those failin>; to
make a good showing being usually in a similar posiHon.
Even the section on Oral and Dental Surgery, that had
been the despair of its energetic oflScers, was well sttended
and had ample material for its consideration. The section
on Surgery had been assigned quarters in Memorial Hall
which would accommodate 300 persons, but even this was
found too small at times, and this interesting section, which
had much more material than it could dispose of, was
shifted to the hall in which the general sessions were held.
The section on Medicine and that on Obstetrics and Dis-
eases of Women were always well attended. In fact,
throughout the meeting a genuine and lively interest was
taken in the scientific work, which was excellent in charac-
ter.

Of all the western cities none can surpass San Fran-
cisco in the facilities she presents for the entertainment or
for the reception of a large gathering, such as the .Ameri-
can Medical Association. Her hotel accommodation is of
the best, and of that which is strictly first-class there is al-
ways plenty to be had. The position which this city has
long lield as the metropolis of the Pacific Coast has created
a demand for all that goes to make up a large city in a
more populous region. Her halls are numerous and eoro-
modions, and of amusements and points of interest to the
viaitor there is no lack, 'i'he only thing therefore re-
quired to make the meeting a success were an ample at-
tendance and efiicient preliminary work on the part of the
committee of arrangements. The visitors came, and the
committee certainly did its work in a mo.st thorough man-
ner.

Twentj-three years is a long time in the life of a man or
of an organization. To paraphrase the statement of the
Governor of Carolina, " It is a long time between meet-
ings." During this interval the membership derived from

the former meeting had died off or dropped out, only a
few of the " old guard " remaining, supplemented by addi-
tions mainly by application. When, therefore, the Associ-
ation decided to go to California the chairman of the com-
mittee realized that he had a large contract on his hands ;
and after some consnltation with his committee he started
East on an educational tour. When fully informed as to
the machinery of the meeting, it was next necessary to
map out all the detail work and to instruct every one in his
particular task. When these facts have been taken into
consideration, the committee must certainly be congratu-
lated on the very successful results of its labors. The at-
tendance was good, and indeed more than the most san-
guine anticipated, amonnting in all to something like 1,200;
but it is now certain that more prosperous times would
have largely increased these figures.

The phenomenal weather was also an unfavorable factor.
At the last moment many who intended to go were afraid
to start. Some already under way failed to reach San
Francisco in time for the meeting. To crown these un-
certainties, it was announced at headquarters that the
Association train, with the President and many of the
officers, was " stalled " in Colorado, unable to proceed and
with some reason to fear that it could not return. This
train was ultimately rescued; and the belated travellers,
after two davs delay, reached California by the southern
instead of tne northern route. The railroads made the
best of the situation, the California company giving the
train the ri^ht of way in its territory and getting it in five
hours ahead of schedule time. " All's well that ends well,"
and most of the travellers were on hand for the opening of
the meeting.

I'he Palace Hotel, the largest in the city and centrally
located, had been selected as headquarters. The registra.
tion bureau was located in one of the large halls of the
hotel, and in an adjoining hall was the ladies' headquarters,
a feature that contributed in no little degree to the pleas-
ure of visitors. Previous to the meeting a ladies' commit-
tee had been appointed, whose duty it was to look after
visiting ladies and provide for their entertainment. Dur-
ing the entire session members of this committee were on
duty at headquarters, and all were made to feel at home.
The registration bureau, though hard pressed at times, did
effective work and did not break down. It was, during
the busy hours, often a little behind ; hut no flagrant mis-
takes were made, which is somewhat creditable where all
were new to the work. Here, as in eveir other depart-
ment, the local committers may he saiJ to have been
swamped. The most sanguine had not calculated on su
large an attendance, and the friends and relatives accom-
panying the members were an agreeable though unexpected
surprise. While supplies of all kinds had been, as was
supposed, liberally provided, fresh requisitions were de-
manded ; and it was even necessary to reprint the entire
programme, to provide for new arrivals.

A majority of the visitors found quarters at the Palace,
and here also rooms were provided for the committees.
The general sessions, all the section meetings and the ex-
hibition were housed in the Odd Fellows' Building. The
whole building had been engaged, and was ample for the
purposes of the Association. On the ground floor, which
was lighted by electricity, a very fair exhibition attracted
the attention of the members during their leisure moments
in the day. Immediately above was the main hall in which
the general sessions were held, and here also the section
on Surgery was compelled to seek better accommodations.
This had been very tastefully decorated by the local com-
mittee, greatly enhancing the effect of the fine hall and
materially improving its acoustic properties. Exclusive of
committee-rooms there were twelve halls, so that every
section was enabled to meet under the same roof. This
seemed to give general satisfaction, and while uncommon
in the past, should be adopted in every city offering equal
facilities. The main hall was well filled at every general
session, members and spectators alike anticipating interest-
ing debates.
Dr. Hibberd as a presiding officer earned a well-deserved

Digitized by

Google

668

BOSTON MBDIOAL AND 8UBGI0AL JOURNAL.

[June 28, 1894.

popularity. Hit decirions were prompt; his rulinga on
debatable points, if a trifle arbitrary and at times not
strictly parliamentary, were always well received. His
unfailing good humor and ready wit invariably carried the
large audience witb him, and enabled him to' quickly dis-
comfit any opposition that might be manifested. Even in
the midst of tne heated debates on Constitution and Code,
his unfailing good humor disarmed the contending factions,
and more than anything else contributed to lessen asperities
and to promote harmony throughout the entire meeting.
His address, a really presidential message, was broad and
comprehensive in character, and was well received. In it
he outlined the neutral position be proposed to occupy on
the question of revision, at the same time pointing out the
feasibility of speedily terminating controversy. His rec-
ommendations were heartily concurred in by the Associa-
tion.

Many will regret the resignation of Dr. R. J. Dunglison,
who has for seventeen years been Treasurer of the Associ-
ation. It is said he resigned to anticipate a movement to
oust him that was rather prominent at Milwaukee. It was
also hinted that he had not come to California, not desir-
ing to be present at his own funeral. It was further
rumored, and had even been published, that Dr. W. B.
Atkinson's official demise had been discussed ; but the
ceremony failed to materialize, and the venerable Secretary
has entered upon his thirty-first year of office. It appears
that all this is part of a policy of centralization that would
place the executive officers of the Association in Chicago.
This, no doubt, would facilitate the conduct of the Jourwd,
but might be regarded with suspicion by a large number of
the Association, which fact it would be well to bear in
mind.

As a feature of the meeting of 1894 the general addresses
were a failure. That in Medicine, by Dr. Hughes, as a
literary composition might be commended ; but it was ab-
struse and tjieoretical, and above all unpardonably long.
When will the readers of papers learn that the average
audience can only be held attentive by profoundly interest-
ing topics, briefly stated! The remaining addresses in
Surgery and in State Medicine were not rtad, the authors
being absent, and the papers also being out of reach. It
is true that more interest will attach to an address when
delivered by the author, but in his unavoidable absence
there is no reason why the meeting should be deprived of
so important a paper, which can be read by the Secretary
or by a reader of the author's selection. As it happened,
the business of the sessions so fully occupied the time that
the remaining addresses could only have been read by pro-
longing the sessions.

The sensational feature of the meeting, and one on which
interest concentrated to the exclusion of all else, was the
question of revision. The reports of the committees on
Constitution had virtually been before the country for
twelve months. A proposed Constitution and By-Laws
had been submitted at Milwaukee, and it was well known
that certain changes were to be made in the Code. At both
meetings when these reports were considerd, the hall was
filled to its utmost capacity, a number of ladies and a fair
representation from the medical students being present in
the galleries.

Whatever may be said to the contrary, it is quite plain
that the revisers of the Constitution have in mind a con-
centration of power in the hands of a few, with every indi-
cation that thin control would be self-perpetuating. With-
out for an instant impugning their motives, it must be plain
to any thinking man that such a result will inevitably be
reached. The president is an outspoken revisionist ; but
it is difficult to realize the soundness of his argument, that
from the mode of its election, the business committee must
be representative. It is quite true that it is representative
of the profession, in the sense that its components are rep-
resentative men or leaders in the profession. It is also true
that by virtue of that fact they are leaders in different
branches, or specialists, and equally true that there never
will be a general practitioner amongst their number and
that he would find no place there. The business committee

has charge of the scientific work of the meetingr, it fulfils
its function admirably, but it should not be embarrassed by
outside matters. These are the weak points of the proposed
Constitution, and they found no favor with the Western
men.

It was sought to remedy this defect by two propositions :
First, that there should be added to the business committee
for the purposes of nomination, a representative from each
State and Territory. This, while making a very unwieldy
committee, would leave things just where they Were, as the
voting power by numerical superiority would still rest with
the business committee. The second proposition would in
a few years decide the whole matter in favor of the revi-
sionists. This is to enable every man who has attended
twice as a delegate to have the right to vote in future. The
inevitable result of this would be to provide a greatly in-
creasing majority of the voters in the East«rn and Central
States, and to leave the West hopelessly out in the cold.
It is therefore hardly to be wondered that neither change
found much favor with the Western men who were averse
to committing suicide on the question of representation.
Whatever may be the defects of the Constitution proposed
by the minority, it was certainly more in consonance with
the feelings of the Pacific Coast States, and it is beyond
question that it could have been adopted at this meeting.
The management of the subject was, however, bad; the
supporters of the minority were unaware of their strength
or feared to trust themselves, and the tactics of the opposi-
tion were certainly superior. As a result, the matter has
been deferred for two years, to come up anew, when deci-
sive action would have given the Association the benefit of
a trial of the new Constitution.

On the question of a change in the Code, opinions were
even more radically divided. The supporters of a new
Code in the great West, and particularly on the Pacific
Coast, are few in number. The great mass of the profes-
sion desire no change, and are perfectly satisfied with the
Code as it is. It can hardly be regarded at a matter of
sentiment, but rather as being due to a clearer conception
of the honesty and fairness as well as of the ethics of the
Code. That no change could be effected at the San Fran-
cisco meeting was a foregone conclusion, when the Medical
Society of the State of California expressed itself as opposed
to any change and instructed its delegates to so record
their votes. Several of the local societies had also recorded
their vote as opposed to change, and those which had not
taken formal action were none the less opposed to iconoclas-
tic measures.

Whatever misconception may exist in the Eastern States
on the question of consultations, there is certainly none in
the Far West. An irregular practitioner or sectarian
physician is recognized as such, his honesty and conscien-
tious practice duly respected, or his dishonest methods
properly appreciated. Hence there is no association, ex-
cept by a very few black sheep, nor has the leaven of com-
mercial greed penetrated very deeply. Outside the ques-
tion of consultation, there is no point except that concern-
ing the holding of patents by physicians on which there
could be much controversy. While there are many who feel
that a physician should be allowed, if he so desire, to ob-
tain a patent, the majority certainly believe tiiat the present
course is the most respectable and professional.

'i'here was an expression of general satisfaction and
hearty good-will to do right when the vole on revision of
the Code was taken. It was ])urfectly within the power of
the supporters of the Code to have carried the adoption
of the minority report by a large majority; but here, as in
the case of the Constitution, affairs were mismanaged, and
at times many of the delegates did not know how they
were voting. There is, however, a temporary cessation in
hostilities, and every one parted in very good humor.

In the matter of entertainments California's hospitality
cannot be said to have been at fault. The medical societies,
the medical schools, private individuals, and, in fact, the
whole profession seemed most fully to appreciate the visit
of the Association. In several cities in which the Associa-
tion has been entertain.ed in recent years it has been cus-

Digitized by

Google

CXXX, No. 2«.] BOSTOS MBDIQAL ASL 8VRG1CAL JOOBSAL.

669

kry to solicit contribntions from citizens towards an
>vt;ak.innient fund. In this manner large sums have been
ed. It was early determined that such methods would
l>e pursued in California, and the decision was reached
iixiit subscriptions to medical societies and members of
profession. In spite of hard times a liberal response
s snade, and the committee found itself with ample funds
^^Sknd. During the short period of four days, with only
t e'venings for pleasure, it was necessary to apportion the
le so as to allow all tbat|were desirous of entertaining, an
port^unity to do so.

T*lie ladies were not forgotten, special features being
ranged for their amusement during the hours devoted to
tentific work. Of these the most enjoyable were: a
'ive tlirough Golden Gate Park, returning by the Presidio
td Ocean Beach, and a " tea " at the residence of Mrs. R.
. Sd cLean, that showed the visitors a charming home in
le most attractive residence section of the city. On Fri-
BLy, June 8th, Mr. Adolph Sutro, whose daughter Mrs. G.
V . Aderritt is a physician, entertained some 300 ladies at
inch. Refreshments were served in a Iftrge pavilion
vrbich will be part of the baths) below Sutro Heights and
lose to the famous Cli£F House, which Mr. Sutro is estab-
tshing on a stupendous scale.

Xhe general entertainments were as follows : commenc-
ng -with an informal instrumental concert at the Palace
Hotel on Monday evening, the San Francisco County
ftledical Society opened the festivites on Tuesday with a
reception at Pioneer Hall. The whole building, including
the State Mining Bureau, was open to the visitors and
many relics of early days were to be seen. On Wednesday
evening Cooper Medical College kept open house at the
college building, corner of Webster and Sacramento Streets.
The Lane Hospital adjoining, now almost completed, had
been temporarily lighted for this occasion, and the several
hundred people inspected everything, from auditorium be-
low to dissecting-room on the fourth floor. On the same
evening Dr. W. F. McNutt gave a reception at his residence,
1805 California Street. On Thursday afternoon and dur-
ing the early evening, Dr. L. C. Lane gave a reception at
his residence, corner of Clay and Buchanan Streets. Later
in the evening the Association, as a "committee of the
whole," visited the Mid-Winter Fair. The evening was
fortunately very pleasant, there being very little wind, and
the Court of Honor was thronged with the Association,
members being found at every turn. This was a special
occasion ; and after sufficient time had been allowed for a
thorough inspection, every one repaired to Festival Hall,
where refreshments were served and some short speeches
were made by the Director-General M. H. De Young, Dr.
6. Beverley Cole and others, not omitting Dr. U. O. Marcy.
On Friday evening the Medical Department of the Uni-
versity of California gave a very elegant reception at the
Hopkins Art Institute on Nob Hill. This palatial mansion,
originally built by Mark Hopkins, one of the famous four
who planned and constructed the Central Pacific Railroad,
is now, through the munificence of Mr. Edwin F. Searles,
of Great Harrington, Mass., the property of the University
of California.

Saturday had been reserved for the entertainment by
the medical profession of the State of California. This
took the form of an excursion on the bay ; and at 9 a. m.
the steamer Newark started with over 1,200 persons on
board. All points of interest in the lower bay were visited,
then passing the quarantine station, the steamer headed
for Mare Island, where about two hours were spent ashore
visiting the U. S. Navy Yard and inspecting the hospital
and the coast-defence vessel Monterey, which with other
war-ships was anchored o£f the yard. The homeward trip
w»B made without incident, though the water was not as
smooth as it should be at this time of year.

On all sides are heard words of commendation for Dr.
R. H. Plummer and the local committees, whose manage-
ment has been very successful. On the other hand, Cali-
fornians are unanimous in expressing the hope that the
Association will not wait twenty-three years before it re-
Tisits the western shores of its territory.

HETEOROLOOICAL RECORD.

For the week ending June 16th, in Boston, according to ob-
servations furnished by Sergeant J. W. Smith, of the United
States Signal Corps:-

B&ro-

lliermom-' Itelatlve

Direction ;Velo«ityjWe'th'r.
of wind, of wind. *

i
■§

meter

P.

eter, humidity.

Date.

1 1

i

8

M

f

a

■

■

»

ai

n

i

^

ti

^

».

>*

^

X

^

ft.

<

i.

la

* *

a

s

s

H

S

s

s

8

S

S

&

C

«,*^

S.

oo

00

c

QO

X

oc

00

at

OD

8. .10

30.07

72 86

69

48

48

48

w.

s.w.

7

11

c.

c.

M..n

'.(9.99

78 93

62

69

81

7(1

w.

S.K.

12

8

K.

K.

T,.12

30.0H

63 172

.54

78

93

M

N.W.

N.E.

3

20

O.

0.

W.13

30.22

54|68

50

81

71

7B

N.E.

SK.

12

4

0.

0.

T..U

30.20

6S 82

49

ff3

m

B

W.

S.

7

10

K.

0.

f. 1(1

30.05

74 fS

60

65

r*

62

w.

S.W. ' 10

to

U.

c.

8. .16

29.90

79^92

I 81

6«
71

66

66

66
69

w.

S.W.

8

9

C.

c.

w-

30.07

• U..elaDd7i C, elMri F., Isiri U., loc

1 B..buTi 8.,unokTi R.,raiiii T..U

rernl

nilniri N..I110W. t Jndieate* traM of ralnfftll. a^ Mean for wecli.

RECORD OF MORTALITT
Fob thb Wkkk bitdino Satdrdat, Jumb 16, 18D4.

6

1^

s

,%

Pereentage of deaths from

OltlM.

l|

P

h,

Ea

IS

P

New York . .

1,891,306

841 366

18.84 1 14.28

6.76

7.08

2.16

Chloaso . . .
tblladelpbla .

1,438,0UU

— —

1 "~

—

—

—

l.lt6.S62

— —

1

—

Brooklyn , .

978,394

4fi9 20S

18.92 1 11.00

4.94

7.26

.88

St. Louis . . .

IKO.OOO

—

—

— , —

—

—

—

Boaton . . .

6O1.10T

i(uy

63

10.68 ! 10.88

.61

4.88

866

Baltimore . .

eou.oou

—

— 1 —

—

—

Wwhington

308,431

167

1.4

31.36' 3.20

24.32

.61

Cincinnati . .

306,000

m

46

6.74 1 .82

l.«4

3.28

Clarelaud . .

S90.000

126

—

9.60 28.00

2.40

.bO

.80

Pittsburg . .

283,709

—

—

— —

—

—

—

Milwaukee . .

260,0110

.. ' -.

— —

—

—

—

Nashville . .

87.764

37 1 11

18.90 8.10

5.4U

2.70

._

Charleston . .

6S,1d6

33 1 12

17.64 —

11.76

—

.

Portland . . .

40,000

— ' ^ 1 — ! —

—

—

_

Worcester . .

100.410

28

9 14.28 10.71

10.71

—

_

rail Birer . .

92.233

37

18 10.80 13.!0

8.10

-_

_

Lowell . . .

90.613

23

10 1 13.06 1 13.06

8..0

4.30

_

Cambridge . .

79.607

27

10

44.40' 7.40

7.40

7.40

14.80

Lynn ....

66,123

17

1

11.76] 5.t8

—

—

...

SprlDgfleld . .

60,284

20

9

26.00 , 16.00

—

—

_

Lawrence . .

49,900

18

10

16.78 1 15.78

1S.78

—

_

New Bedford .

47,711

17 1 6 1 11.76

—

—

5.88

Holyoke . . .

43.348

^

—

-' .-

—

—

—

Brockton . .

33.939

6

2

- 16.66

—

—

^

Salem ....

33,168

10

4

^ —

—

—

__

Haverhill . .

32,928

10

4

- 10.00

—

—

...

Maiden . . .

30,209

8

2

12.60 25.00

—

—

I?.W

Chelsea . . .

29,806

10

3

20.00 —

—

—

20.00

ntohbnrg . .

29,»3

6

3

40.00 —

—

20.00

...

Newton . . .

28,837

6

2

16.66 ' —

16.66

—

—

Oloocester . .

».i»3

—

^

— 1 —

—

^

■^

Taunton . . .

26,954

3

0

—

—

—

—

..

23,068

4

«

^

—

—

—

_

Qnincy . . .
Pittsfleld . .

19.642

—

—

_

—

—

—

18,802

6

2

—

20.00

—

—

—

Ererett . . .

IF ,686

—

—

—

—

—

—

Northampton ,

16,331

0

1

—

16.66

—

—

—

Newbnryport .

14,073

6

2

—

— —

^

Aniesbnry . .

1U,»20

'

0

~"

^ ^

~

—

Deaths reported 2,239: under five years of age 886; principal
infections diseases (small-pox, measles, diphtheria and croup,
diarrhoeal diseases, whooping-cough, erysipelas and fever) 380,
acote lung diseases 263, consumption 211, diarrhcBal diseases 136,
diphtheria and cronp 111, scarlet fever 42, whooping-cough 33,
measles 24, typhoid fever 15, cerebro-spinal meningitis 11, ma-
larial fever 8, small-pox 6, erysipelas 5.

From wbooping-congb Brooklyn 9. New York and Washington
6 each, Cleveland 1, Springfield 3, Boston and Nashville 2 each,
Cincinnati, Fall River and Fitchburg 1 each. From measles
Brooklyn 11, New York 9, Cleveland and Springfield 2 each.
From typhoid fever New York 1, Washington, Nashville and
Charleston 2 each, Boston, Cleveland, New Bedford, North
Adams and Marlborough 1 each. From cerebro-spinal menin-
gitis New Yorlc 6, Washington 3, Lynn and Marlborough 1 each.

Digitized by

Google

660

SOSTOH MMDIOAL ASD 8VRG1CAL JOVBHAl.

[JcME 28, 1894.

From malarial fever New York S, Brooklyn 3. From (maU-pox
New York 3, Brooklyn 2.

In the thirty-three greater towni of EnEland and Wales with
an eitimated popalation of 10,408,412, for the week endloK
June 9tb, the death-rate was 1K.9. Deaths reported 3,388:
aente diseases of the respiratory organs (London) 236, measles
241, whooping-cough 108, diphtheria 61, scarlet fever 38, fever
33, diarrhoea m, amall-poz (Birmingham 8, Loudon and Manches-
ter 3 each. West Ham 2) Iti.

The death-rates ranged from 9.8 in Portsmouth to 2S.4 in Liver-
pool; Birmingham 20.6, Bradford 13.7, Croydon 13.6, Hull 15.9,
Leeds lri.6, Leicester 13.6, London 16.8, Manchester IT.l, New-
castle-ou-Tyne 18.8, Norwich 13.8, Nottingham 14.0, Plymouth
13.H, Salford 20.8, Sheffield 17.3.

OlfFlCIAL LIST OF ( HANGES IN THE STATIONS AND
DUTIES OF OFKICEKS SERVING IN THE MEDICAL
DEPARTMENT, U. S. ARMY, FROM JUNE 16, 1801, TO
JUNE 22, 1894.

Leave of absence for one month on surgeon's certificate of dis-
ability, with permission to apply to the proper authority for an
extension of three months, is granted MajokJosbpu R. Gibson,
surgeon. Fort Snelling.

The leave of absence on surgeon's certificate of disability
granted Major Joskph R. Gibson, surgeon, is extended three
months on surgeon's certificate of disability.

Leave of absence for one month, on surgeon's certificate of
disability, is granted Fikst-Likut. Fbanx T. Mkriwethbk,
assistant surgeon, with permission to leave the limits of the
Department.

Major Jambs 0. MBRBti.i., surgeon, is relieved from duty in
the oflice of the surgeon-general, to take effect July 1, 1894, and
ordered to report in person to the commanding officer Fort
Sherman, Idaho, for duty at that station.

Leave of absence for three months, to take effect July 1, 1894,
is granted Major Jakbs C. Mskbii.]:., surgeon.

OFFICIAL LIST OF CHANGES IN THE MEDICAL COUPS
OF THE U. 8. NAVY FOR THE WEEK ENDING JUNE
23, 1894.

KiTB, J. W., passed assistant surgeon. Detached from
U. 3. S. " Lancaster " and granted three months' leave.

Anzal, £. W., passed assistant surgeon. Detached from
U. 8. S. " Lancaster" and granted six months' leave.

Strbbts, T. H., surgeon. Detached from U. 8. 8. " Al-
liance " and granted three months' leave.

U&iB, J. F., passed assistant surgeon. Ordered to the U. 8. 8.
"New York."

Stbfbknson, F. B., surgeon. Detached from D. 8. 8.
" Marion " and granted three months' leave.

Kbnnkdy, R. M., passed assistant surgeon. Detached from
U. S. S. " Marion " and ordered to Mare Island Navy Yard.

Ai.FRBl>, A. R., passed assistant surgeon. Detached from
U. 8. 8. " Minnesota " and ordered to the U. 8. S. " Pinta."

GuTBRiB, J. A., assistant surgeon. Detached from the
C. S. Str. " Blake " and ordered to the U. S. S. " Minnesota."

Ward, B. R., assistant surgeon. Detached from the
U. 8. R. 8. " Vermont " and ordered to the U. 8. C. 8. Str.
" Blake."

Cook, F. C, assistant surgeon. Detached from instruction
at Naval Laboratory and ordered to the " Vermont."

RECENT DEATH.

Cbarlbs Edward Brioos, H.D., died in Boston, June 17th,
aged sixty-two years. He was a member of the class of 1893 of
Imrvard College. In August, li/iil, he was appointed assistant
surgeon of the 24th Massachusetts Volunteers then serving at
Newbern, N. C. In November, 1863, he was made surgeon of
the 94th Massachusetts Vo.unteers. He served in the expedition
td Charleston in July, 1864, and at Magnolia Cemetery, Savan-
nah, Georgetown and Sumterville. He was mustered out of
service in August, IMie. He was a member of the Massachusetts
Medical Society from 1896 to 1899, when he moved out of the
State.

BOOKS AND PAMUPLETS RECEIVED.

The Treatment of Typhoid Fever. By Elmer Lee, A.M., M.D.,
Chicago. Reprint. 1891.

Eightieth Annual Report of the Trustees of the Massachusetts
General Hospital and McLean Hospital, 1893.

Conservatism in Accidental Surgery. By Edmund J. A.
Refers, M.D., Denver, Colo. Reprint. 1894.

Report of the Commissioner of Education for the Year 1890-
91, Vol. I and II. Washington: Government Printing Office.
1894.

Analyses of Twelve Thousand Prescriptions. Compiled by
W. Martludale, F.C.:^., Joint Author of the Extra Pharmaoopgeia .
London : H. K. l^wis. 1894.

Extra-Uterine Pregnancy Simulated by a Small Tumor of the
Ovary; Operation; Recovery. By William U. Morrison, H.D.,
of Philadelphia. Reprint. 1891.

Ueber den Werth metbodisuher HoriibUDgen fiir Taubstumme
und fiir Falle von uervoser Taubheit im Allgemeimen. Von Dr.
Victor Urbantsohitsch. Reprint.

Les Hernies inguinales de I'Enfance. Par le Dr. G. F^lizet,
rhirugien de I'hupital Tenon (Eufants-Malades). Avec 73
figures dans le texte. Paris: G.Maason. 1894.

Treatment of Typhoid Fever. By D. D. Stewart, M.D.,
Lecturer on Clinical Medicine in the Jefferson Medical College
of Philadelphia, etc. Detroit: George S. Davis. 1893.

Retinitis Albuminuria. History of the Drop-Bottle. Ophthal-
mia Neonatorum ; Contraction of Eyelids; Glaucoma; Grattage
for Granular Lids. By L. Webster Fox, M.D., Philadel[diia, Pa.
Reprinu. 1891.

Ripening of Immature Cataracts by Direct Trituration. Sub-
volutiou : a New Pterygium Operation. The Spectacle Treat-
ment of Hypermetropia. By Boerne Bettman, M.D., Chicago.
Reprint. 1893-91.

The Care and Feeding of Children, a Catechism for the Use of
Mothers and Children's Nurses. Uy L. Emmett Holt, M.D.,
Professor of Diseat'CS of Children in the New York Polyclinic,
etc. New York : D. Appleton & Co. 1894.

An International System of Electro-Therapeutics for Students,
General Practitioners and Specialists. By Horatio R. Bigelow,
U.D., and thirty-eight Associate Editors. Thoroughly illus-
trated. Philadelphia: The F.A.Davis Co. 1894.

Fracture of the Skull; Trephining; Retro-Anterograde
Amnesia; Recovery; Death One Month Subsequently frona
other Causes ; Autopsy. By Edmund J. A. Rogers, M.D., and
J. T. Eskridge, M.D.,of Denver, Col. Reprint. 1894.

A System of Legal Medicine. By Allan McLane Hamilton,
M.D., Consulting Physician to the Insane Asylums of New York
City, etc., and Lawrence Godkin, Esq., of the Nsw York Bar.
Illustrated. Volume I. New York : E. B. Treat. 1894.

Diseases of the Skin : An Outline of the Principles and Prac-
tice of Dermatology. By Malcolm Morris, Surgeon to the Skin
Department, St. Mary's Hospital, London, etc. With eight
cbromo-lithographs and seventeen woodcuts. Philadelphia:
Lea Brothers & Co. 1894.

Materia Hedica, Pharmacology and Therapeutics, Inorganic
Substances. By Charles D. K. Phillios, M.U., 1J..D., f:r.8.
(Edin.), Late Lecturer on Materia Hedica and Therapeutics at
the Westminster Hospital Medical School, etc. Second edition.
London : J. & A. Churchill. 1894.

A Clinical Manual, a Guide to the Practical Examination of
the Excretions, Secretions and the Blood, for the Use of Physi-
cians and Students. By Andrew McFarlane, A B., M.D., In-
structor in Neurology and Diseases of the Chest in the Albany
Medical College, etc. New York: G. P. Putnam's Sons. 1894.

Essentials of Practice of Pharmacy Arranged in the Form of
Questions and Autiwers, Prepared Especially for Pharmaceutical
Students. Second edition, revised. By Lucius E. Sayre, Ph.G.,
Professor of Pharmacy and Materia Medica of the School of
Pharmncy of the University of Kansas. Philadelphia: W. B.
Saunders. 1894.

Die Bedeutung der hypnotischen Suggestion als Heilmittel.
Gutachten und Heilberichte der hervorragendsten wissenschaft-
iichen Vertreter des Hypnotismus der Gegenwart. Heraus-
gegeben von Dr. med. J. Grossmann, Redacteur der Zeitachrift
fiir Hypnotismus in Berlin. A. Ausgabe in original text. Ber-
lin: Ueutsches Verlagshaus Bouq & Co. 1891.

Essentials of Nervous Diseases and Insanity: their Symptoms
and Treatment; a Manual for Students and Practitioners By
John C. Shaw, H.D., Clinical Professor of Diseases of the Hind
and Nervous System, Long Island College Hospital Medical
School, etc. Second edition, revised, forty-eight original illus-
trations. Philadulphia: W B Saundera. 1891.

Le^ns de Therapeutique. Par Georges Hayem, Professenr
de Cliuique Medicate a la Faculte' de M^decine de Paris, etc.
Les Aleuts Physiques et Nnturels, Agents Tbermiques — Elec-
tricite. Modifications de la Pression Atmosph^rique Ciimats et
Eauz Minerales. Avec 130 figures et 1 carte des eaux mln^rales
et stations ciimate'riques. Paris: G. Masson. 1891.

Modification du Taux de I'Ur^e dans I'Urine: Abaissement
cbez les Canc^reux, Abaissement dans Certains Maladies non
Hallgnes des Ovaires, Ascension du Taux de I'Ur^ Aprfes lea
Operations Deductions Pratiques: Diite et Purgation Apr^s les
Operations Manvais Pronostic du aux Grandea Proportions
d'Urc'eavant les Operations. Par le docteur Just Chiunpion-
uiere, Chirurgien de I'hopital Saint-Lotds. Paris: A. CoMOS,
Libraire-Editeur. Kupriiil 1893.

Digitized by

Google

Digitized by

Google