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ANADA 


AL  RECORD 


JANUARY,     1902. 


Original  Communications. 

PROGRESS  OF  GYNAECOI.OGT. 

By  A.  Ija.PTH(jRN  SMITH,  MD.,  M.R.C  S.,  England. 

Professor  of  Gynecology  in  the  University  of  Vermont,  Burlington,  and  Professor  of 

Clinical  Gynjecology  in  Bishop's  University,  Montreal.    Surgeon  to  the 

Western  General  Hospital  and  Surgeon-in-Chief  of  the  Samaritan 

Free  Hospital  lor  Women,  Gvnascologist  lo  the  Montreal 

Dispensary  and  Consulting  Gynajcologist  to  the 

Woman-s  Hospital. 

In  the  December  number  of  the  "Annals  of  Gynaeco- 
logy" there  is  an  interesting  article  by  Dr.  Frank 
Higgins  on  the  treatment  of  infections  after  abortions 
and  confinements,  as  carried  out  at  the  Boston  City 
Hospital.  We  find  the  symptoms  are  practically  the 
same  in  both  classes  of  cases.  The  majority  of  abortions 
were  criminal  ones,  these  alone  necessitating  a  stay 
in  hospital  of  1,469  days  for  81  cases,  and  five  of  them 
died.  He  thinks  it  time  that  laws  should  be  made  strin- 
gent enough  to  put  a  stop!  to  the  work  of  the  abortionist. 
He  is  a  strong  advocate  of  the  curette  and  antiseptic 
douching.  "It  is  a  common  occurrence,"  he  says,  "to  see 
patients  enter  the  hospital  with  all  the  symptoms  of  an 
impending  acute  septicaemia  from  an  abortion  either 
complete  or  incomplete,  with  a  high  temperature  ranging 
from  103  to  105  degrees,  and  a  pulse  from  120  to  130  per 
minute,  with  foul  discharge  and  uterine  tenderness,  and 
after  complete  emptying  of  the  uterus  with  the  curette 
and  antiseptic  douching,  the  pulse  and  temperathrCY)''^^, 
rapidly  fall  to  normal,  often  within  twenty-four  hour^  '  c^  ' 
and  usually  within  two  or  three  days. 

"I  can  heartily   endorse   this  statement,  as  I    am  fre- 
quently called  by  friends  in  general  practice  to  perfotni 


'(\ 


Hi 


2\  PROGRESS  OF  GYNAECOLOGY. 

this  little  operation,  and    experience    has    so    convinced 
them  and  me  of  the  efficacy  of  it  in  removing  all  alarm- 
ing symptoms   that  some  of  them  call  me  in  to  every  case 
in  which  there  is  either  severe  hemorrhage  or  tempera- 
.  ture,  while  I  feel  so  sure  that  it  will  practically  cure  the 
patient  that  I  do  not  have  to  see  her  again  or  at  the  most 
just  once  to  remove  the  gauze  drainage.     In  using  the  dil- 
ator and  the  curette,  I  think  great  care  should  be  taken 
not  to  perforate  or  lacerate  the  body  of  the  uterus  which 
is  very  soft  and  pliable  in  these  cases.     When  possible,  I 
prefer  the  finger,  which  is  less  liable  to  do  harm."  He 
also  calls  attention  to  the  liability  to  retroversion,  pro- 
lapse and  pus  tubes  after  abortion,  and  especially  if  they 
are  allowed  to  remain  septic.     ''Each  year  many  patients 
enter  the  gynaecological    wards    with    various    forms    of 
pelvic  disease,  whose  origin  is  directly  traceable  to  a  previ- 
ous abortion  or  septic  puerperium."     With  regard  to  the 
anti-streptococcus  serum,  he  thinks  it  is  very  dangerous; 
it  was  employed  in  five  cases  and  four  of  them  died.     ''Its 
effects,"  he  says,  "on  the  patient  are  very  depressing;  its 
use  is  not  without  danger,  and  it  should  b6  employed  with 
great  care,  in  moderate  doses  and  then  only  in  the  most 
serious  cases.     Of  the    cases    of    puerperal    septicaemia," 
he  says,  "numerous  instances  of  fresh  lacerations    of   the 
cervix  are  found    among    the   infectious    cases,    and    the 
writer  believes  that  these  fresh  tears  are  the  avenue  by 
which  the  infectious  material  gains  an  entrance  in  many 
patients."     At  present  the  opinion  of  gynaecologists  is  not 
in  favour  of  the  immediate  repair  of  lacerated  cervix,  al- 
though it  has  been  done  in  a  few  cases.     It    is   possible, 
however,  that  opinion  may  change  and  that  it  will,  be  done 
as  a  matter  of  course  in  every  case. 

In  the  same  journal    Dr.    Kaan,  of    Tuft's    Medical 
College,  Boston^  makes  a  strong  plea  for  the  non-operative 


ledge,  judgment  and  mechanical  skill  of  the  practitioner, 

1^1  '    \^     will  be  useful,  useless  or  injurious.     The  most  usual  erroir 

'   ^    '   ^  is  to  choos^  too  large  a  size.     He  calls   attention    to    the 


PROGRESS  OF  GYNAEC Jl.OGY.  3 

necessity  for  hygienic  regulations  of  food,  dress  and 
evacuations.  ("  While  I  prefer  to  treat  retroversion 
and  prolapse  by  Alexander's  operation  of  shortening  the 
round  ligaments  or  ventrofixation  combined  with  restora- 
tion of  the  perineum,  yet  I  deem  it  my  duty  to  avoid  opera- 
tions when  possible,  and  I  quite  often  make  a  complete 
cure  without  them  in  cases  where  there  are  no  ad- 
hesions, simply  by  lightening  the  weight  of  the  uterus^ 
diminishing  intra-abdominal  pressure,  and  bj'  toning  up 
the  muscles  of  the  patient  generally  by  tonics,  proper 
food,  exercise,  fresh  air  and  sunlight.  As  to  the  choice 
of  pessaries,  I  prefer  the  soft,  spiral  ring  if  the  patient 
can  come  to  me  once  a  month  for  examination;  if  there 
is  no  tenderness  the  hard  rubber  Hodge  pessary  may  be 
left  in  for  two  or  three  months,  as  it  is  much  easier  to  keep 
clean.  In  either  case  a  cleansing  douche  of  plain  hot 
water  should  be  used  once  or  twice  a  week.") 

Curretting  the  Uterus  for  Endometritis. — Dr.  Augustin 
H.  Goelet  (in  the  "New  England  Medical  Monthly"  for 
April)  has  a  timely  article  on  "the  abuse  of  the  curette." 
He  says  curetting  is  too  often  done  in  obscure  pelvic  condi- 
tions where  no  diagnosis  is  made.  "The  general  sur- 
geon," he  says,  "who  should  stick  to  his  own  branch,  which 
it  is  to  be  hoped  he  understands  better  than  he  does  this, 
too  often  commits  the  error  of  attempting  this  operation, 
which  he  should  leave  to  the  gynaecologist.  This  same 
practitioner  would  not  attempt  an  operation  for  strabis- 
mus, though  it  is  far  more  simple,  requires  less  skill  and 
judgment  and  is  fraught  with  less  risk  to  his  patient."^ 
Dr.  A.  H.  Goelet  makes  a  great  distinction  between  the 
sharp  and  dull  curette;  every  practitioner  should  be  pro- 
vided with  a  dull  curette  with  large  fenestra  and  a  reliable 
placenta  forceps  for  removing  retained  placental  debris 
after  abortion.  He  should  not  attempt  it  with  a  smaJI 
curette  nor  a  sharp  one,  as  is  too  often  done.  Not  infre- 
quently curetting  for  endometritis  is  followed  by  metritis 
and  pelvic  peritonitis.  How  often  this  is  due  to  harsh  and 
needless  traumatism  and  how  often  to  imperfect,  crude 
technique,  unclean  methods  or  neglect  of  proper  after- 
treatment  cannot  be  estimated.     He  also    calls   attention 


4  PROGRESS  OF  GYNAECOLOGY. 

to  the  mistake  which  is  often  made  of  packing  thei  cavity 
of  the  uterus  and  cervical   canal   tightly  with   gauze  and 
leaving  the  channel  blocked  for  five  or  six  days.     Drain- 
age, he  says,  must  be  maintained  and  the  surfaces  kept 
clean  by  irrigation  of  the  cavity  until  a  normal  endometrium 
has  been  reproduced.     He  finishes  the  operation  by  irriga- 
tion with  hot  solution  of  compound  tincture  of  iodine,  one 
ounce  to  the  pint.     (I  apply  equal  parts   of  pure  carbolic 
acid  and  Churchill's  tincture  of   iodine  on   an   applicator 
through  a  cervical  speculum  which  is  removed  asi  soon  as 
the  applicator  has  reached  the  fundus);    Subsequent  treat- 
ment will  consist  of  another  thorough  irrigation  through 
the  double  current  catheter,  with  a  hot  solution,  at  the  end 
of  forty-eight  hours,  and  repeated  every  second  day  for  at 
least  a  week,  during  which  time  the  patient  is  kept  confined 
to  bed.     At  the  expiration  of  a  week  she  is  permitted   to 
get  up  if  there  is  no  rise  of  temperature  and  no  pain,  and 
the  irrigation  of  the  cavity  of  the  uterus  is  repeated  every 
second  or  third  day  at  the  office  as  long  as  any  discharge 
continues,  or  there  remains  in  the  cavity  anything    to    be 
washed  away.     The  same  author  has  written  an  interest- 
ing article  in  the  "St.  Louis  Medical  Review,"  June  30,  on 
senile   degeneration    of    the   endometrium,    diagnosis  and 
treatment.      The    symptoms    resemble    in    some    resjiccts 
those    of    cancer — there   is   an    offensive    discharge    in    a 
woman  well  advanced  in  years  past  the  menopause,  with, 
an  emaciated  cachetic  condition  of  the  system,  associated 
with  which  there  may  be  a  granular  erosion  of  the  cervix 
or  about  the  external  os  and  a  history  of  more  or  less  ir- 
regular bleeding.     There  will  be  impaired  digestion,  loss 
of  appetite,  insomnia,  nervousness,  cold  extremities  and  a 
poor  circulation,  an  itching  of  the  skin  not  necessarily  con- 
fined to  the  genitals,  headache,  particularly  at  the  top  of 
the   head     or    below   the  occipital    region    and   backache 
referred  to  the  lumbar  or  sacral  region.     There  is  a  pent- 
up  discharge  within  the  uterus  which  decomposes,   and, 
when  its  presence  in  sufficient  quantity    sets   up   contrac- 
tions and  is  expelled,  it  burns  and  excoriates  the  vagina 
and  vulva,  which  will  then  become  covered  with  red  spots, 
especially  if  it  is  very   acrid.     The   treatment    which  Dr. 


NOTES   FROM   A   GENERAL   PRACTITIONER.  5 

Goelet  advocates  is  summed  up  in  the  one  word,  drainage, 
which  he  thinks  is  best  obtained  by  the  negative  pole  of 
the  galvanic  batter^-,  five  or  ten  milliamperes  for  three  to 
five  minutes,  just  sufficient  to  cause  relaxation  and  to 
allow  the  electrode  to  move  freely  through  the  canal.  At 
first  these  applications  may  be  extremely  painful,  but 
usually  after  the  second  or  third,  no  pain  will  attend  them. 
They  should  be  continued  twice  a  week  until  there  is  no 
more  diseased  discharge  to  drain,  by  which  time  the  irrita,- 
tion  of  the  vulva  and  vagina  is  relieved.  (I  can  testify 
to  the  success  of  this  treatment  in  several  of  my  own  cases. 
At  the  same  time  I  give  my  patients  an  alkaline  mixture, 
and  I  apply  yellow  oxide  of  mercury  ointment  to  the 
vagina  to  protect  it  from  the  discharge  until  the  latter  has 
been  stopped). 


XOTES   FROM  THE   CASE  BOOK  OF  A  GENERAL 
PRACTITIONER. 

By  FRANCIS  W.  CAMPBELL,  M.D.,  L.B.CP.  L.,  D.CL. 

Dean  and  Professor  of  Medicine,  Faculty  of  Medicine,  UniverBity  of  Bishop's 

CoUege. 

The  following  cases  are  taken  from  my  note-book,  and 
are  not  intended  to  be  exhaustive.  Their  brevity  clearly 
shows  this,  for  they  are  but  outlines,  yet  I  hope  clearly 
showing  the  practical  results  in  each. 

Hydrocele. 

Case  1. — H.  G.,  aged  3G,  consulted  me  some  years  ago 
for  an  enlarged  scrotum.  On  examination  I  found  it  had 
been  growing  gradually  for  about  six  months — was  on  left 
side,  pyrifoim  in  shape,  fluctuating,  and,  on  being  tested  by 
a  candle  in  a  dark  room,  showed  it  to  be  clear  and  trans- 
lutant.  There  was  no  difficulty  in  making  the  diagnosis 
of  hydrocele.  The  question  of  treatment  had  to  be  decided 
upon.  Palliative  treatment,  viz.,  evacuating  the  contents 
of  the  sac  and  then  using  pressure  by  means  of  adhesive 
plaster  or  collodion,  I  had  never  known  to  be  successful. 
I  therefore  determined  to  operate  for  the  radical  cure  of 
the  disease.  Having  during  my  attendance  at  the  Royal 
Infirmary,    Edinburgh,    seen    the   great     Scotch     surgeon, 


O  NOTES   FROM   A   GENERAL   PRACTITIONER. 

Symme,  operate  often  for  this  disease,  I  determined  to 
follow  the  plan  he  advised.  I  accordingly  evacuated  the 
contents  of  the  tunica  vaginalis,  by  plunging  a  small  tro- 
car into  the  sac,  grasping  the  organ  below,  between  the 
thumb  and  fingers  of  the  left  hand,  so  asi  to  fix  and  distend 
the  tumour.  In  making  the  plunge  with  the  trocar,  you 
must  bear  in  mind  that  it  should  be  slightly  downward, 
so  as  to  avoid  the  testicle,  which  is  generally  situated 
posteriorly  and  near  the  median  raphe.  Having  the  con- 
tents evacuated,  I  injected,  by  means  of  a  glass  syringe, 
about  a  drachm  of  the  compound  tincture  of  iodine,  of  the 
strength  of  72  grains  of  iodine  and  24  grains  of  iodide  of 
potash  to  the  ounce  of  alcohol.  With  my  left  hand  I  then 
seized  the  bag,  and  kneaded  it  so  as  to  bring;  every  part  of 
the  sac  in  contact  with  the  iodine.  The  pain  for  a  few 
minutes  was  very  great,  but  soon  subsided.  The  patient 
was  put  to  bed,  and  the  bag  supported  on  a  small  pillow,. 
The  following  day  there  was  considerable  swelling,  which, 
however,  gradually  subsided,  and  in  ten  days  the  patient 
was  allowed  out,  and  a  few  days  later  wasi  able  to  get  to 
his  work.  I  have  notes  of  fifteen  cases  like  the  above, 
where  iodine  was  used  for  the  radical  cure.  All  were 
cured  by  the  first  injection  except  three  cases,  two  of 
which  required  a  second  injection  and  one  a  third  injec- 
tion before  the  case  was  complete.  In  only  two  cases  was 
there  severe  inflammation  following  the  injection.  It  was, 
however,  easily  subdued  by  a  solution  of  sugar  of  lead  and 
opium.  All  the  cases  were  obliged  to  rest  in  bed  after  the 
operation,  but  in  not  any  of  the  cases  did  this  rest  exceed 
two  weeks,  and  in  several  only  a  few  days.  Modern- 
surgery  seldom  uses  the  means  I  have  detailed.  It 
generally  pins  its  faith  to  alcohol,  a  five  per  cent,  solution 
of  carbolic  acid,  corrosive  sublimate,  sulphate  of  zinc, 
chloride  of  zinc,  none  of  which  are  in  my  opinion  equal  to 
the  plan  I  have  invariably  followed.  A  few  years  ago  a  sur- 
geon, with  an  unpronouncable  name,  recommended,  'after 
having  evacuated  the  fluid,  to  introduce  through  the  canula 
a  catgut  three  and  twenty  centimetres  (about  nine  inches) 
in  length.  This  thread  induces,  by  mechanical  irritation, 
an  adhesive  inflammation  of  the  serous  surfaces,  a  vagina- 


NOTES  FROM   A   GENERAL   PRACTITIONER.  7 

litis  obliteran,  and  in  a  few  days  the  thread  is  absorbed. 
Some  authors  claim  that  the  thread  is  absorbed  so  quickly 
that  not  suflficient  irritation  is  produced  to  cause  the  oppos- 
ing surfaces  to  unite.  It  has  therefore  been  recommended 
to  steep  the  thread  in  some  irritating  liquid,  such  as  the 
per  chloride  of  iron.  The  results  are  said  to  be  excellent, 
and  it  is  said  that  the  patient  can  return  to  his  work  in 
twenty-four  hours,  or  at  most,  two  days — a  matter  of  some 
importance  to  a  labouring  man. 

Erysipelas. 

Case  2. — F.  X.,  aged  32,  telephoned   me   about  half -past 
eight   in   the   evening,    stating   that  he  believed   he  was 
threatened  with  erysipelas,  as  a  red  spot  had  since  tea- 
time  showed  itself  on  the  left  side  of  his  nose.     He  desired 
to  come  to  my  office  and  see  me,  but  feared  he  could  not 
get  off   inside   of  an   hour.  About  ten    o'clock  he   was  in 
my  consulting  room,  and  stated  that,  since  he  had  tele- 
phoned me,  there  had  been  a  decided  increase  in  the  red- 
ness, which  now  extended  up  to  the  forehead,  and  across 
the  cheek  for  at  least  an   inch.  It   was  tight  feeling   and 
glazed.     His    diagnosis    was    correct.     It    was    a    case  of 
erysipelas.  The    tongue  was    slightly  coated;    there  was 
slight  headache,  and  the  pulse  was  about  90.     The  circum- 
stances   of  this    patiept  were    peculiar.    He    w^as    in  the 
midst  of  preparations  for  a  series  of  entertainments  to  be 
given  by  children.     To  be  laid  up  for  more  than   two   or 
three  days  meant  giving  up  entirely  these  entertainments, 
and  great  financial  loss.     This  he  fully  explained,  under 
considerable  excitement,  and  asked  me  to  do  my  best  for 
him.     After  a  few  moments'  consideration,  I  decided  to 
follow    a     suggestion     made    me    some    years     ago    by 
Surgeon    Lieut.-Col.    Codd,   of  the   Royal  Canadian   Dra- 
goons, Winnipeg,  while   I    occupied    similar   rank   in   the 
Royal     Regiment    of    Canadian    Infantiy.     This    was     to 
brush    the    inflamed     part     with     the     fluid     extract    of 
ergot  three  times  a  day.  I  had  tried  it  upon  two  soldiers 
in  my  military  hospital  at  St.  Johns,  and  once  in  private 
practice.     The  results  I  might   almost   say    were  remark- 
able.  I   accordingly  gave  my  patient  a  prescription   for 


»  NOTES  FROM   A   GENERAL  PRACTITIONER. 

fluid  extract  of  ergot,  with  the  necessary  instructions  for 
its  application  by  means  of  a  camel's  hair  pencil.  I  also 
gave  him  to  take  at  bedtime  ten  grains  of  calomel,  with 
five  grains  of  carbonate  of  soda.  He  was  directed  to 
remain  in  bed  till  I  called  next  day.  On  making  this  visit 
he  informed  me  that,  before  reaching  home  with  the  pre- 
scription, the  disease  had  spread  still  further.  He  had 
applied  the  ergot  three  times,  and  he  not  onl}'  said  there 
had  not  been  any  extension  since,  but  that  it  felt  much 
improved.  I  visited  him  next  day,  which  was  Sunday, 
and  the  patient  was,  comparatively  speaking,  well.  He 
was  directed  to  make  one  more  application  of  the  ergot. 
I  would  have  liked  to  have  kept  him  in  the  house  another 
day,  but  his  business  was  urgent,  so  I  permitted  him  to 
return  to  work  on  the  Monday  morning.  No  ill  effects 
ensued.  The  theory  of  the  action  of  the  ergot  is  that  it 
produces  marked  contractions  of  the  small  blood  vessels, 
and  thus  diminishes  the  blood  supply. 

Ascites. 

Case  3. — There  are  several  causes  which  produce 
ascites,  but  the  chief  is  obstruction  of  the  portal  vein, 
within  the  liver,  from  cirrhosis  of  that  organ.  Some  think 
that  the  disease  ought  not  to  be  considered  as  a  distinct 
disease,  but  simply  a  symptom  developing  in  the  course  of 
the  affection  which  produces  it.  The  case  I  propose  to 
give  a  brief  outline  of  was  undoubtedly  due  to  chronic 
alcoholism.  When  I  first  saw  (t.  McD.  in  1805  he  com- 
plained of  a  general  hepatic  uneasiness  with  dyspeptic 
symptoms  and  occasional  vomiting.  There  was  distinct 
although  not  very  great  hepatic  enlargement  downward. 
This  continued  for  about  a  month,  when  dullness  began 
to  diminish,  and  by  the  end  of  three  months  this  diminu- 
tion was  well  .  marked.  This  condition  continued  for 
rather  more  than  six  months,  the  only  additional  symp- 
toms being  some  emaciation  and  a  sallow  tint  to  the  skin. 
During  all  this  time,  with  an  occasional  day  on  two  off,  the 
patient  continued  to  follow  hisi  employment,  that  of  office 
work.  Two  months  later,  i.e.,  about  a  year  from  the  time 
he  first  consulted  me,  he  began  to  complain  of  abdominal 


NOTES   FROM  A   GENERAL  PRACTITIONER.  9 

enlargement,  which  was  recognized  as  commencing  ascites. 
He  was  ordered  to  bed,  and,  after  a  couple  of  weeks'  rest 
there,  was  allowed  up  and  about  the  house.  The  ac- 
cumulation of  fluid  was  slow,  so  slow  indeed  that  he  was 
able  to  move  around  the  house  for  at  least  six  months 
after,  just  taking  to  bed  when  he  was  compelled  to.  The 
fluid  now  began  to  accumulate  rapidly  in  the  peritoneal 
cavity,  and  oedema  of  the  extremities  showed  itself. 
The  patient  had  been  treated  by  purgatives,  diuretics  and 
diaphoretics  ever  since  ascites  began  to  show  itself,  and 
there  had  been  no  appreciable  benefit.  A  month 
later,  i.e.,  about  a  year  and  a  half  from  the  time 
he  first  consulted  me,  he  presented  the  following 
condition.  Emaciation  considerable,  anemia  marked, 
skin  of  a  decided  icteroid  hue.  Abdomen  largely  dis- 
tended with  fluid,  which,  pressing  on  the  diaphragm,  inter- 
fered with  breathing,  and  patient  was  unable  to  lie  down. 
Abdomen  shows  distented  superficial  veins  and  measures  at 
the  umbilicus  4.3  inches.  The  oedema  of  the  extrem- 
ities is  extreme  and  extends  to  Poupart's  ligament.  The 
limbs  are  so  heavy  that  it  is  almost  impossible  to  lift 
them  from  the  bed.  This  oedema  of  the  legs  is  largely 
due  to  pressure  on  the  return  circulation  by  the  ascites, 
and  partly  on  account  of  the  anemia  and  increasing  pres- 
sure of  the  blood  in  the  capillaries.  There  was  a  small 
quantity  of  albumin  in  the  urine  which  was  scanty  in 
amount.  Under  the  microscope  there  were  no  casts. 
Eegarding  the  case,  as  threatening  a  somewhat 
speedy,  fatal  termination,  a  consultation  was  held 
principally  to  settle  the  question  of  tapping.  After 
fully  discussing  this  operation,  it  was  decided  to  postpone 
it  for  a  short  time.  The  very  serious  condition  of  the 
patient  was  placed  before  his  wife.  The  evening  after  the 
consultation  I  determined  to  place  my  patient  on  what  is 
sometimes  called  Addison's  pill,  and  which  is  as  follows: 

R  Pulv.  digitalis gr.  xxiv. 

Pulv.  scillae gr.  xii. 

Pil  hydrarg 31. 

Div.  in  pil,  No.  xxiv.    One  to  be  taken  night  and  morning. 

Within  a  week  of  commencing  this  pill  the  improve- 
ment was  most  marked;  the  amount  of  urine  passed  was 


10  NOTES   FROM   A   GENERAL   PRACTITIONER. 

trebled  ia  quantity,  and  the  abdominal  distension  and 
oedema  of  legs  decidedly  diminished.  After  three  weeks 
the  pill  was  discontinued,  as  the  bowels  were  so  relaxed  as 
to  weaken  the  patient.  After  a  week  the  pill  was  re- 
sumed, now  giving  it  twice  a  day,  and  then  only  one  the 
next  day,  and  continuing  in  this  way.  By  this  method 
the  bowels  were  kept  open,  but  not  relaxed.  In  two 
months  the  abdominal  growth  had  been  reduced  from 
43  inches  t.o  39  inches,  and  the  oedema  of  the  legs  all  gone, 
except  about  the  ankles.  His  general  appearance  had 
greatly  improyed,  the  icteroid  hue  being  much  less; 
appetite  good  and  patient  enjoyed  his  food.  The  patient 
is  able  to  lie  down  with  comfort,  and  has  com- 
fortable sleep.  He  was  now  allowed  out  of  bedl  for  a  short 
time  daily,  the  time  being  increased  gradually.  In  ;twc» 
months  more,  that  is,  four  months  from  commencing  the 
pills,  now  given  three  times  a  week,  the  abdomen 
measured  33  inches,  and  there  was  no.  discoverable 
evidence  of  fluid  in  the  peritoneum.  All  oedema  has  dis^ 
appeared  from  the  legs.  Patient  was  now  allowed  out 
every  few  days  for  a  drive  and  to  move  freely  about  the 
flat  on  which  was  his  bedroom.  In  two  months  more,  i.  e., 
six  months  from  commencing  the  pills,  which  were  still 
continued  twice  a  week,  the  patient  was  able  to  walk  a 
mile.  From  this  time  the  convalescence  was  rapid  and 
marked,  and  the  pills  were  discontinued.  In  a  year  from 
the  time  they  were  first  given,  the  patient  declared  hini- 
self  to  be  perfectly  well,  and  his  general  appearance  was 
better  than  it  had  been  for  seven  or  eight  years.  I  made 
my  last  visit  to  him  in  January,  1898,  when  I  carefully 
examined  his  liver,  which  showed  a  marked  diminution  in 
size.  Since  that  date  he  has  had  really  excellent  health, 
and  so  continues  at  the  date  of  this  writing  (Sept.,  1901). 
There  is  no  doubt  in  my  mind  that  this  pill  saved  this 
patient's  life.  The  physician  who  saw  the  case  in  con- 
sultation as  well  as  myself  did  not  consider  it  possible 
that  the  patient  could  last  more  than  two  or  three  months, 
even  although  temporary  relief  to  his  distress  might  have 
been    subsequently    given  by  tapping.  I  have    since  this 


NOTES  FROM  A   GENERAL   PRACTITIONER.  II 

case  bad  two  other  cases  of  ascites  where  the  administra- 
tion of  this  inll  gave  excellent  results;  one  is  still  alive, 
the  other  died  a  few  months  ago  from  an  attack  of  acute 
pneumonia. 

Case  4. — Acute  crstitis  of  an  idiopathic  character  is 
not  very  often  met  with;  on  the  other  hand,  subacute 
cystitis,  due  to  cold,  very  often  the  result  of  sitting  on 
stone  or  grass,  is  not  by  any  means  uncommon.  In  my 
experience  of  nearly  forty  years  I  have  met  many  such 
cases.  Generally  they  are  fairly  promptly  relieved  by  a 
hot  bath,  and  the  administration  of  twenty  to  thirty 
grains  of  bicarbonate  of  potash  with  twenty  drops  of 
tincture  of  hyosciamus  e\ev\  four  hours,  in  half  an  ounce 
of  camphor  mixture.  Now  and  again  I  have  met  with  a 
case  which  did  not  improve  on  this  mixture.  Such  is  the 
case  I  now  briefly  record.  J.  B.,  clerk  in  a  wholesale 
house,  obliged  to  be  on  his  feet  most  of  the  day,  consulted 
me  for  frequent  and  painful  micturition,  which  from  the 
history  he  gave  me  was  due  to  sitting  for  some  hours  on 
grass  at  a  picnic.  He  was  fond  of  music  and  played  an 
instrument,  and  passed  at  least  two  or  three  evenings  a 
week  at  musical  soirees  at  which  ladies, were  present.  He 
was  obliged  to  discontinue  this  method  of  enjoyment,  for 
he  was  not  able  to  retain  his  mine  for  more  than  an  hour 
when  he  had  an  irresistible  desire  to  pass  it.  Before  com- 
ing to  me  he  had  consulted  a  medical  friend  of  mine, 
whose  prescription  he  showed  me.  The  treatment  was 
the  administration  of  alkalies,  and  had  not  given  him  any 
relief.  The  urine  was  clear  and  very  acid.  There  were 
no  abnormal  constituents.  He  was  low  spirited  and 
anxious,  fearing  some  chronic  bladder  trouble.  I  accord- 
ingly decided  to  give  him  one  drachm  of  Sanmetto  every  4 
hours.  Within  twenty-four  hours  he  had  received  some 
relief,  and  inside  of  a  week  was  so  well  that  he  was  able 
to  take  his  place  among  his  musical  friends.  After  this 
his  recovery  was  rapid,  and  in  two  weeks  he  declared 
himself  perfectly  well.  Since  the  case  came  to  me  1  have 
had  several  of  a  similar  character,  all  of  which  I  have 
treated  satisfactorily  with  Sanmetto, 


12  notes  from  a  general  practitioner. 

Strumous  Ophthalmia. 

Case  5. — In  my  early  years  of  practice,  and  before  eye 
specialists  were  niuch  in  evidence  in    Montreal,  cases    of 
this  disease  were  not  at  all    uncommon    in    my    practice. 
But    of    late   years    they    have    been    comparatively    few. 
About  five  years  ago,  at  one  of  my  clinics  in  the  General 
Hospital,  a  woman  forced  her  way  into  the   room   against 
the  will  of  the  porter.     She  had  a  child  in  her  arms,  whom 
he  claimed,  and  correctly,  was  a  patient  for  the  eye  depart- 
ment.      The  woman,  however,  begged  to  see  me,  and  I  at 
once  recognized  the  child,  a  boy,  aged  two  and  a  half  years, 
to  be  suffering  from   strumous    ophthalmia,  and,    a   large 
number  of  students  being  present,  I  took  advantage  of  the 
case  to  give  a  clinic  on    this   disease,  after   which    I    told 
her  she  must  go  to  the  eye  department  for  treatment.     A 
few  days  later  she  came  to  my  office  and  told' me  that  for 
nearly  three  months  she  had  taken  the  child  regularly  to 
an  hospital  eye  clinic  without  its  receiving  the  slightest 
benefit.     She  asked  me   to     treat    the     child,     admitting 
povert}',  but  promising  some  remuneration  (which  I  never 
received).     The    condition    of    the    little    patient    was    as 
follows: — The  fists  of  both  hands  were  pressed  up  against 
the  ejes,  while  the  head  was   bent   on  the  chest,  so  as  to 
cut  off  as  much  light    as   possible.     The   eyelids    were  in- 
flamed, and  thick,  whitish  yellow  matter  oozed  from  each 
It  was  impossible  to  examine  the    condition    of    the    eye, 
owing  to  the  struggles  of  the  little  patient.     The  mother 
was  instructed  as  to  the  necessity  of  keeping  the  eyes  clean 
with  pieces  of  absorbent  cotton,  and  a  few^  drops  of  a  five 
grain  to  the  ounce  solution  of  nitrate  of  silver  were  placed 
in  the  angle  of  the  eye,  and  by  manii^ulation  made  their 
way  under  the  eyelids.     The  child  was  ordered  a  teaspoon- 
ful  of  pure  cod  liver  oil  three  times  a  day.  For  a  week  the 
child  was  brought  daily  to  my  office  without  there  being 
any  visible  improvement.     I  then  increased  the  nitrate   of 
silver  solution  to  ten  grains.     In  a  few  days  there   was   a 
marked  decrease  in  the  amount  of  discharge  and  the  silver 
solution  was  now  only  used  three  times  a  week.     In  six 
weeks  the  discharge  was  entirely  gone,  and  examination 
showed  the  eyes  to  be  healthy,  but  weak.  The  lids  were 


NOTES   FROM  A   GENERAL  PRACTITIONER.  1 3 

only  opened  on  dull  days,  and  in  partially  darkened  rooms, 
A  solution  of  sulphate  of  zinc,  one  quarter  of  a  grain,  with 
ten  drops  of  vinum  opii  to  the  ounce  of  camphor  water 
was  ordered  to  be  used  as  a  collyrium  night  and  morning, 
and  the  cod  liver  oil  to  be  continued  in  the  same  quantity, 
I  saw  no  more  of  the  child  for  a  little  over  a  month,  when 
it  was  brought  to  me  absolutely  cured.  The  cod  liver  oil 
was  directed  to  be  continued  for  three  months  longer  and 
the  collyrium  discontinued.  The  child  was  not  seen  by  me 
again.  Two  years  later  a  similar  case  came  under  my 
care,  having  been  advised  by  the  mother  of  the  first  patient 
to  consult  me.  This  case,  a  boy  four  years  old,  had  also 
been  to  an  eye  clinic  of  an  hospital  for  several  months  and 
had  not  benefited  in  the  slightest.  The  symptoms  of  this 
second  patient  were  identical  with  the  first,  and  the  treat- 
ment was  practically  the  same,  with  the  exception  that  I 
used  Wampole's  cod  liver  oil,  as  the  child  could  not  take 
the  pure  oil.  When  I  was  able  to  examine  the  eyes,  on 
one  I  found  a  somewhat  large  ulcer  on  the  conjunctiva, 
which  healed  in  about  three  weeks  after  being  touched 
with  a  fine  point  of  solid  nitrate  of  silver,  and  the  use  of  a 
collyrium  similar  to  what  I  used  in  the  first  case.  In  about 
three  months  after  coming  under  my  xare,  this  patient 
was  able  to  go  about  the  house,  in  well  lighted  rooms  and 
out  on  dull  days.  In  six  months  he  was  absolutely  well. 
In  neither  case  has  there  been  subsequent  eye  trouble. 
Cod  liver  oil  had  not  been  prescribed  at  the  hospital  eye 
clinic  in  either  case. 


Progress  of  Medical  Science. 


MBDICINK    AND     NEUROI^OGY 

IN   CHARGE   OP 

J.  BRADFORD  McCONNELL,  M.D. 

Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bisliop's  College;  Physician  Western  Hospital. 


CONCLUSIONS  IN  REGARD  TO  THE  ClilNICAL  VALUE  OF 
THE    FOLLO^VING    NEAV   HYPNOTICS. 

Hedonal,  we  would  say,  is  applicable  to  slight  forms  of 
insomnia  unassociated  with  bodily  pain  or  severe  mental 
excitement.  It  is  valuable  as  a  "placebo,"  having  a  direct 
though  not  very  powerful  tendency  to  produce  sleep. 
Patients  take  it  quite  readily,  and  it  should  be  useful  in  a 
very  large  class  of  cases  in  general  practice. 

Chloretone  is  a  powerful  and  pretty  certain  hypnotic 
if  given  in  sufficient  doses.  Its  general  use  to  produce 
sleep,  however,  should  be  discouraged  on  account  of  its 
secondary  effects.  But  these  very  defects  may  make  it 
especially  valuable  in  certain  selected  cases.  Its  action 
should  always  be  carefully  watched.  The  disagreeable 
subjective  sensations  it  may  produce  are  ofttimes  insur- 
mountable objections  to  its  employment. 

Dormiol. —  While  certainly  not  the  most  powerful 
sedative  that  we  possess,  doraiiol  answers  well  the  reqaire- 
ments  for  a  generally  serviceable  hypnotic.  Its  rapidity 
of  action,  we  believe,  is  unsurpassed  by  any^  other  hypnotic 
taken  internally.  This  characteristic,  together  with  its 
ease  of  administration,  reliability  in  almost  all  forms  of 
insomnia  unattended  with  great  bodily  discomfort,  and 
almost  total  absence  of  any  after  effects,  subjective  or 
objective,  make  it  one  of  the  most  valuable  acquisitions-to 
the  physician's  armamentarium  of  recent  years.  It  prob- 
ably will  win  a.  place  in  the  Pharmacopeia. — The  Virginia 
Medical  Semi-Monthly. 

DISINFECTION   OF  THE  URINE. 

Dr.  N.  B-  Gwyn  has  recently  reported  the  results  of  an 
investigation  into  the  comparative  value  of  various  disin- 
fectants, in  rendering  sterile,  urine  containing  typhoid 
bacilli.  It  was  found  that  milk  of  lime  is  neither  rapid 
nor  certain  in  action.  Carbolic  acid  proved  of  value  only 
in  large  amount,  or  in  very  strong   solution.      Mercuric 


1        MEDICINE  AND  NEUROLOGY.  1 5 

chloride,  on  the  other  hand,  acted  as  a  powerful  and  rapid 
disinfectant,  only  a  small  amount  being  required,  and  hav- 
ing the  further  advantage  of  being  clean,  odourless  and 
easily  applied.  Formaldehyde  was  found  to  be  a  fairly 
eflBcient  disinfecting  agent,  but  its  cost  precluded  its  use  in 
any  but  dilute  solution-  Chlorinated  lime  prepared  in 
saturated  solution  and  using  the  supernatant  fluid  proved 
itself  a  most  reliable  disinfectant,  free  chlorine  being 
evolved  in  addition  to  the  urine. 

For  disinfection  of  the  urine  in  the  bladder  and  the 
urinary  system,  utropine  administered  by  the  mouth  has 
been  employed,  with  the  results  more  or  less  satisfactory. 
Solutions  of  mercuric  chloride,  1  to  100,000  or  1  to  50,000 
may  be  employed  for  irrigation  to  the  bladder,  and  with 
some  assurance  that  any  bacilli  in  this  viscus  will  be 
destroyed. 

In  obstinate  hiccough,  gargling  with  ice  water  has 
succeeded  in  stopping  the  spasms  after  all  other  measures 
had  failed. 

Ingalls  and  Yeager  report  36  cases  of  smallpox  treated 
with  baths  of  bichloride  without  any  deaths.  The  series 
included  13  confluent  cases  and  one  of  the  hemorrhagic 
form.  The  suppurative  fever  was  shortened,  pitting  was 
much  less  and  the  offensive  odour  absent. 


BRONCHITIS. 

Dr.  Leech  has  done  good  service  in  calling  attention  to 
the  fact  that  the  drugfs  useful  in  bronchitis  are  frenerally 
given  in  inadequate  doses.  Tn  the  treatment  of  acute 
bronchitis  there  is  no  better  combination  of  drugs  than  that 
of  acetate  of  ammonium,  spiritus  etheris  nitrosi  and  ipe- 
cacuanha or  antimony.  Liquor  ammonii  acetatis  is  generally 
prescribed  in  drachm  doses  to  be  given  every  four  hours  ;  it 
should  be  given  in  doses  of  three  drachms  and  increased  to 
six  drachm  doses  if  the  skin  does  not  act  freely.  Since 
marked  relief  to  the  breathing  often  accompanies  the  sweat- 
ing, sweet  spirits  of  nitre  should  be  given  in  two-drachm 
doses  and  repeated  at  short  intervals.  This  author  considers 
antimony  in  one-twentieth  of  a  grain  dose  is  of  most  service 
in  moist  bronchitis  with  oppressed  breathing,  and  that,  in  the 
dry  form  with  tight  cough,  ipecac  shonld  be  given.  If  the 
carbonate  of  ammonium  is  used  it  should  be  dissolved  in 
water,  and  the  dose,  at  least  five  grains,  should  be  given  in 
milk  and  repeated  every  hour  or  two. —  Jour.  Med.  and 
Science. 


1 6  PROGRESS   OF   MEDICAL    SCIENCE. 

HOW  TO  READ  THE  TONGUE.      * 

The  perfect  tongue  is  clean,  moist,  lies  loosely  in  the 
mouth,  is  round  at  the  edge,  and  has  no  prominent  papillae. 
The  tongue  may  be  furred  from  local  cause  or  from  sympathy 
with  the  stomach,  intestines  or  liver.  The  dry  tongue  occurs 
most  frequently  in  fever,  and  indicates  a  nervous  prostration 
or  depression.  White  tongue  is  diagnostic  simply  of  the 
feverish  condition,  with  perhaps  a  sour  stomach.  When  it  is 
moist  and  yellowish  brown  it  shows  disordered  digestion. 
Dry  and  brown  indicate  a  low  state  of  the  system,  possibly 
typhoid.  When  the  tongue  is  dry  and  red  and  smooth  look 
out  for  inflammation,  gastric  or  intestinal.  Sharp  pointed 
red  tongue  will  hint  of  brain  irritation  or  inflammation,  and 
a  yellow  coating  indicates  liver  derangement.  When  so 
much  can  be  gained  from  an  examination  of  the  tongue  how 
important  it  is  that  the  youngest  child  should  be  taught  to 
put  it  out  so  that  it  can  be  visible  to  the  uttermost  point  in 
the  throat. — Jour.  Med.  and  Surgery. 

DYSENTERY. 

Sulphur  successfully  is  used  in  the  treatment  of  dysen- 
tery. Twenty  grains  of  sublimed  sulphur  are  combined  with 
five  grains  of  Dover's  powder,  to  be  given  four-hourly.  In 
all  of  the  cases  that  have  been  treated  with  sulphur  the  re- 
covery has  been  rapid,  and  the  patient  has  seemed  to  derive 
relief  more  speedily  from  his  pain  and  strainin^j  than  with 
other  methods  of  treatment.  The  cure  with  sulphur  seems  to 
be  more  certain  and  stable,  as  chronic  conditions  and  relapses 
have  not  occurred.  Blood  and  mucus  are  easily  stopped  and 
the  motions  quickly  become  fecal.  In  some  cases  the  num- 
ber of  motions  per  diem  did  not  at  once  diminish,  but  the 
pain  and  straining  were  lessened  and  the  character  of  the 
mo. ions  became  more  fecal  and  cont  uned  little  or  no  blood. 
As  soon  as  the  diarrhoei  becomes  less  it  is  advisable  to  give 
the  powders  less  frequently. — G.  E.  Richmond,  in  Lancet. 

THE   CONDITION    OF    THE    KIDNEYS    W^ITH   REFERENCE 
TO  THE  EMPLOYMENT    OF   DIURETICS. 

D.  Arthur  R.  Elliott  {Med.  News,  August  10,  1901). 
— Except  in  the  case  of  the  irritant-epithelial  diuretics,  the 
entire  class  of  diuretics  may  be  said  to  exert  their  effect 
upon  the  urine  by  acting  indirectly  through  the  circula- 
tion.     Owing  to  the  necessity  for  sparing  the  kidneys  all 


SURGEUY.  17 

iiTitaticn,  drugs  given  for  diuretic  purposes  should  act 
indirectly  rather  than  directly,  consequently  the  secretory 
diuretics  are  contraindicated  in  irritative  and  inflamma- 
tory renal  conditions.  In  functional  urinary  disorders 
diuretics  are  contra-indicated  in  irritative  and  inflamma- 
hyperacidity  of  the  urine.  To  accomplish  this,  simple 
diluents  and  salines  are  best  adapted.  In  acute  nephritis 
saline  diuretics  are  permissible  throughout  the  entire 
course  of  the  disease  and  exert  a  beneficial  influence  by 
increasing  elimination  and  clearing  the  tubes  of  inflamma- 
tory debris.  Subcutaneous  saline  infusion  constitutes  our 
most  powerful  eliminant  in  desperate  cases.  In  chronic 
nephritis  the  cardiovascular  diuretics  are  the  most  useful, 
owing  to  the  fact  that  oliguria  and  dropsy  are  usually  the 
result  of  circulatory  failure. '  The  dropsy,  under  such  cir- 
cumstances, being  of  cardiac  origin,  may  be  benefited  by 
cardio-vascular  stimulants,  provided  the  kidneys  are  not  too 
badly  damaged.  Dropsy,  of  purely  renal  origin,  is  not 
amenable  to  favourable  influence  by  diuretics.  Although 
the  morbid  process  in  the  kidneys  may  furnish  us  with  our 
primary  inspiration  to  diuretic  medication,  it  is  the  condi- 
tion of  the  heart  and  circulatory  apparatus  in  most  cases 
that  determines  the  choice  of  an  agent. — l^eio  York  Medical 
Journal. 


SURGKRY. 

IN   CHARGE    OF 

ROLIiO  CAMPBELL,  M.D., 

Lecturer  on  Surgery,  University  of  Bishop's  College  ;  Assistant  Surgeon,  Western  Hospital  ; 

AND 

GEORGE  FISK,  M.D., 
Instructor  in  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeon,  Western  Hospital. 


EPISTAXIS. 

Treatment — All  that  is  necessary  in  epistaxis  is  to 
fashion,  with  a  pair  of  scissors,  a  dry  plug  of  prepared 
sponge,  in  size  and  length  comparable  with  the  little  finger 
of  a  twelve-year-old  boy.  This  should  be  carefully  soaked 
in  boiled  water,  to  free  it  from  grit,  squeezed  dry,  to  free  it 
from  unnecessary  fluid,  and  inserted- its  full  length  gently 
along  the  floor  of  the  bleeding  nostril.  No  styptic  is  neces- 
sary. The  expansive  pressure  of  the  soft  sponge  against 
the  bleeding  side,  increased  by  the  coagulation  of  a  few 
drops  of  blood  in  its  interstices,  will  check  the  bleeding  at 
once.  It  should  be  removed  in  twelve  hours  ;  under  no 
circumstances  should  it  remain  longer  than  twenty-four 
hours. — Sajoti's  Cijelo. 


8  SURGERY. 


ANAL  FISSURE. 


Fissure  of  the  anus  and  rectum  is  frequently  caused 
by  constipation,  and  hence  it  is  always  a  good  plan  to 
regulate  the  bowels,  and  relieve  the  congestion  of  the 
portal  veins.      For  this  purpose  we  may  give  : 

^  Sodii  Salicylcitis 2  drachms 

Tiiict.  Nucis  Vom ..4  drachms 

Ext.  Altaians  fl 2h  ounces 

M.  Sig.:      One  teaspoonful  before  meals  in  water. 

Apply  locally  a  solution  of  nitrate  of  silver,  ten 
grains  to  the  ounce,  every  second  day,  or  hydrate  of 
chloral  if  the  fissure  is  covered  with  pale,  flabby  granula- 
tions. The  latter  may  be  used  in  a  solution  of  twenty 
grains  to  the  ounce,  and  applied  twice  daily  on  absorbent 
cotton.  If  these  measures  fail  to  stimulate  the  growth  of 
healthy  granulations,  and  especially  if  the  edges  are  hard 
and  thickened,  pure  tincture  of  iodine  may  be  cautiously 
applied  once  in  three  days.  This  treatment  will  seldom 
fail  if  used  persistently  for  from  four  to  eight  weeks.  If 
there  is  much  pain  after  defecation  a  little  cocaine  will 
give  temporary  relief. — N.  Y.  Med.  Jour. 

APPENI>ICITIS  AND  LIFE  INSURANCE. 

J.  Weill-Manton,  Paris,  discussing  the  matter  of  granting 
insurance,  lays  down  these  rules  : 

1 .  Any  abnormal  sensitiveness  in  the  appendicular  region 
justifies  postponement. 

2.  Applicants  are  admissible  when  cured  by  operation,  a 
few  weeks  after  interval  operations ;  after  three  or  four 
months  when  the  resection  has  been  done  during  an  attack  ; 
in  eighteen  months  or  two  years  when  the  applicant  has  been 
cured  by  the  simple  opening  of  a  purulent  collection  about 
the  appendix.  It  will  always  be  best  to  require  a  statement 
from  the  operator  or  from  a  physician  present  at  the  operation, 
giving  the  precise  nature  and  the  results  of  the  intervention. 
The  same  conditions  will  hold  in  cases  of  circumscribed 
peritonitis  with  spontaneous  evacuation  of  the  purulent 
collection. 

3.  Any  typhlitis,  appendicitis,  appendicular  colic  or  crisis, 
however  slight,  acknowledged  by  the  applicant  or  suspected 
by  the  examiner,  will  subject  to  a  postponement  of  two  or 
three  years. 

4.  Two  or  more  attacks  will  require  a  more  lengthy 
postponement  which  will  be  proportionately  increased  accord- 
ing to  the  number  and  severity  of  the  attacks. 


SURGERY.  19 

5.  The  research  of  family  antecedents  will  he  considered 
as  an  important  element  of  greatest  moment  in  the  younger 
applicants. 

6.  In  cases  of  remo'e  anteceding  attacks  of  appendicitis, 
the  examiner  must  carefully  investigate  the  existence  of  signs 
which  might  reveal  the  slightest  awakening  of  the  old 
appendicitis. 

7.  Every  case  of  chronic  and  of  recurring  appendicitis 
must  be  rejected. — Med.  Examiner. 

TYPES    OF   ENTRANCE   AND  EXIT   VTOUNDS   AS   SEEN   IN 
THE   SOUTH  AFRICAN  CAMPAIGN. 

C.  S.  Wallace  :  Typical  Wounds  caused  by  Normal 
Small-Bore  Bullets. —  A  perfect,  underformed,  smaU-bore 
bullet  entering  at  right  angles  to  the  surface  makes,  as  a  rule, 
a  round  hole  slightly  smaller  than  the  bullet  itself.  Around 
this  aperture  is  a  narrow  ring  about  one-sixth  of  an  inch  in 
breadth,  from  which  the  cuticle  has  been  removed,  and  which 
appears  some  hours  after  the  receipt  of  the  injury  as  a  red 
border  to  the  wound.  A  little  later,  this  ring,  as  well  as  the 
actual  hole,  is  covered  with  a  dark  scab,  which  consequently 
is  larger  than  the  hole  which  it  covers.  The  bullet  in  its 
passage  inwards  pushes  in  front  of  it  the  skin,  which  is  thus 
brought  into  contact  with  the  sides  of  the  bullet  and  bruised 
by  it.  The  projectile,  then  passing  on,  stretches  and  per- 
forates theskin,  and  gains  admission  through  a  hole  which  is 
smaller  than  the  actual  diameter  of  the  bullet. 

Typical  Wounds  Caused  by  Normal  Small-Bore 
Bullets. — When  the  axis  of  flight  of  the  bullet  is  inclined  at 
less  than  a  right  angle  to  the  surface,  the  wound  in  the  skin 
becomes  oval,  and  the  breach  of  surface,  therefore,  is  slightly 
bigger.  When  the  angle  is  very  oblique  the  bullet  traverses 
a  certain  track  of  skin,  depressing  it  more  and  more  until 
actual  perforation  takes  place.  The  skin,  therefore,  is  bruised 
and  the  cuticle  destroyed  for  some  distance  from  the  aperture 
of  (entrance.  This  damaged  area  of  skin  shows  as  a  red  raw 
place  when  the  wound  is  recent.  The  shape  of  the  contused 
area  is  roughly  that  of  an  isosceles  triangle  with  a  rounded 
apex,  and  the  sides  are  slightly  bent  outwards.  The  base  is 
formed  by  the  perforation  in  the  skin.  The  breadth  is  often 
more  than  that  of  the  actual  bullet.  Bullets  passing  out 
through  the  skin  obliquely  make  an  oval  aperture  of  exit, 
and  this,  if  the  line  of  flight  is  greatly  inclined  to  the  skin,  is 


20  SURGERY. 

often  of  large  size,  but  still  remains  oval.  The  skin  is 
evidently  pushed  out  and  then  burst.  The  width  of  such  a 
wound  is  rather  striking,  and  is  due  to  the  skin  being  un- 
supported and  to  the  natural  elasticity  of  the  cutis  causing 
retraction  and  gaping. 

Ricochet  Bullet  Wounds. — In  these  cases  the  wounds 
lose  more  or  less  of  their  typical  character  according  to  the 
amount  and  kind  of  distortion  the  bullet  has  undergone.  The 
round,  oval  or  slit-like  wound  becomes  irregular,  torn  or 
jagged,  for,  even  if  not  greatly  distorted  after  striking  the 
ground,  the  bullet  no  longer  continues  to  have  its  long  axis 
in  the  axis  of  flight,  and  so  may  strike  the  body  with  its  side, 
or  partly  with  its  side  and  base.  In  such  cases  the  length  of 
the  wound  will  vary  according  to  the  actual  position  of  the 
projectile  at  the  moment  of  its  impinging  on  the  skin.  Frag- 
ments of  stones  struck  by  bullets  will  also  cause  jagged  ir- 
regular wounds.  This  is  especially  the  case  when  the  bullet 
strikes  the  body  where  it  is  in  contact  with  the  ground. 

The  So-called  Explosive  Bullet  Wounds. — These  are 
nearly  always  met  with  in  connection  with  fractures  of  bone. 
The  extent  of  the  exit  wound  has  no  invariable  definite 
relation  to  the  underlying  damage,  although  it  may  alTord 
valuable  indications  thereof.  The  introduction  of  a  finger 
will  often  show  that  although  the  exit  aperture  may  be  large, 
the  skin  is  so  undermined  and  the  muscles  so  torn  that  a  still 
larger  irregular  cavity  is  formed  into  which  the  ends  of  the 
fractured  bone  protrude,  and  this  is  especially  well  shown  in 
cases  of  fractured  fernur.  Another  form  of  wound  is  that  in 
which  the  skin  is  blown  away  to  a  great  extent.  This  is 
likely  to  happen  if  the  bullet  emerges  from  a  subcutaneous 
bone,  as  the  shin,  and  then  there  is  a  definite  loss  of  substance 
so  that  a  crater-like  wound  results.  A  third  form  is  that  in 
which  the  muscles  and  tendons  are  torn,  and  at  the  same 
time  extruded  through  the  skin  wound  and  form  a  protruding 
mass  above  the  level  of  the  skin  resembling  in  some  degree  a 
fungating  sarcoma,  especially  if  seen  for  the  first  time  some 
days  after  the  infliction  of  the  wound. — Brit.  Med.  Jour. 

ABORTING     BUBOES. 

Dr.  Christian,  in  a  recent  article  in  the  Therapeutic 
Gazette,  declares,  after  quite  an  extensive  experience  in  the 
Philadelphia  Polyklinik,  that  he  believes  that  fully  fifty  per 
cent,  of  buboes,  due  to  gonorrhoea,  chancroid,  or  herpes,  can 
be  aborted  if  proper  treatment  is  undertaken  before  pus  has 
begun   to  form.      He    thinks   that   the    matter  of  aborting 


SURGERY.  21 

buboes  has  not  received  the  attention  it  deserves  in  modern 
works  on  surgery.  His  plan  is  to  prepare  the  following 
ointment:  K  Vug.  Hydrargyri,  Ung.  Belladonnae,  Ichthyol, 
Lanolin,  each  ci^ht  parts,  A  piece  of  surgical  lint  spread 
with  the  omtmeiit  is  applied  directly  to  the  swollen  gUnd, 
and  over  this  is  placed  a  piece  of  oiled  silk  of  the  same  size. 
The  next  essential  is  to  insure  constant  pressure  over  the 
gland,  and  this  is  accomplished  by  placing  a  large  pad  of 
cotton  over  the  oiltd  silk.  Last,  a  wide  spicaof-ihe-groin 
is  next  applied,  two  bandages  being  employed.  This  treat- 
ment IS  reiieued  every  second  day,  and  at  the  end  of  two 
weeks  the  b welling  has  usually  disappeared.  Out  of  twenty 
cases  ol  buboes,  treated  by  this  plan,  twelve  were  cured.  Ot 
course,  if  the  bubo  is  due  to  tuberculous  infection,  this  treat- 
ment will  be  of  no  use. —  ^our.  Medicine  atid  Science, 

imm£;dzat£  and  remote  effects  of  brain  injury. 

D.  S.  Fairchild,  Clinton,  Iowa,  concludes  from  his  study 
of  a  series  of  cases  that  : 

1.  Violence  of  no  great  intensity  when  applied  to  a 
limited  area  of  skull  may  cause  a  fracture  with  only  mo- 
mentary displacement  with  a  rupture  of  a  meningeal  artery, 
or  a  rupture  oi  an  artery  without  fracture. 

2.  A  localizing  injury,  which  may  lead  to  a  fracture 
w.thout  displacement  and  hemorrhage,  does  not  as  a  rule, 
cause  a  serious  permanent  brain  lesion  if  early  and  judi- 
cious treatment  is  employed. 

3'  A  fracture  may  occur  without  apparent  displace- 
ment, yet  a  real  localized  pressure  on  the  brain  exists  which 
may  cause  irritative  changes  involving  a  more  or  less  ex- 
tended sclerosis  and  remote  secondary  results,  as  epilepsy 
or  mental  impairment. 

4.  A  blow  may  be  received  on  the  head  which  may 
produce  a  more  or  less  extensive  laceration  of  the  scalp 
which  in  itself  is  not  serious.  But  the  fall  from  a  height 
or  from  a  rapidly  moving  train  may  produce  more  or  less 
extensive  contusion  or  laceration  of  brain  tissue  leading  to 
serious  immediatfe  or  remote  effects. 

5.  A  fall  from  a  height  or  moving  train  may,  without 
a  fracture,  cause  directly  or  indirectly  a  contusion  or  lacera- 
tion of  brain  tissue  or  so  disturb  the  cerebrospinal  fluid  as 
to  primarily  bring  about  such  changes  and  cause  immediate 
results  or  secondary  serious  remote  effects  by  inducing 
degeneration  and  final  interstitial  changes  producing  in- 
sanity. 

6.  An  injury  may  be  of  such  a  character  as  to  produce 
a  localized  wound  of  the  brain  that  may  heal  with  the  pro- 


22  SURGLRY. 

duction  of  scar  tissue  which  may  extend,  may  or  may  not 
undergo  cystoid  or  other  degeneration  with  serious  remote 
effects. 

7.  In  the  absence  of  localizing  or  other  definite  symp- 
toms, to  indicate  the  nature  of  the  lesion,  the  character  of 
the  accident  and  the  manner  in  which  the  force  is  applied 
is  of  great  value  in  reaching  a  conclusion  as  to  the  prob- 
able nature  of  injury  to  the  brain — Jour.  A.  M.  A. 

THE  TREATMENT   OF  TRAUMATIC  INFLAMMATIONS  OF 
THE  JOINTS. 

A  time-honoured  procedure  in  the  management  of  the 
traumatic  synovitis,  is  to  place  the  joint  at  rest.  Strict 
immobilization,  with  the  use  of  hot  fomentations,  is  the  ac- 
cepted method  of  treatment.  As  soon  as  the  pain  subsides 
the  patient  is  commonly  allowed  to  get  about  ;  if  there  is 
much  rtuid  in  the  joint  it  is  slowly  absorbed  away,  and 
there  is  usually  more  or  less  thickening  of  the  peri-articular 
structures  with  the  formation  of  bands  of  adhesion  in  the 
joint,  seriously  interfering  with  its  motion,  A  joint  in  the 
condition  here  described  is  subject  to  subacute  exacerba- 
tion, brought  on  by  slight  strains  or  twists,  which  would  be 
absolutely  unnoticed  in  a  healthy  joint,  and  which  are  ac- 
companied by  an  increase  in  the  fluid  and  some  exaggera^ 
tiou  in  pain.  These  subside  with  rest,  and  the  patient 
again  gets  about,  to  have  the  process  reiieated  in  endless 
succession.  Stimulating  linaments,  anti-rheumatics  and 
other  applications  are  employed  in  vain,  until  in  sheer 
desperation  the  physician  puts  the  patient  to  bed  and  again 
immobilizes  the  joint  for  a  period  of  two  or  three  weeks. 
This  is  followed  by  improvement,  but  later  on  with  the  in- 
evitable relapse.  In  young  persons,  and  those  whose  cir- 
culation is  good,  as  time  passes  and  there  is  a  vigorous 
effort  to  resume  the  use  of  the  limb,  there  is  greater  im- 
provement, followed  by  ultimate  recovery.  Thnt  this  is 
due  more  to  the  persistence  of  the  patient  and  a  determined 
effort  to  use  the  limb,  rather  than  under  the  advice  and 
treatment  of  the  physician,  is  apparent  to  one  who  carefully 
studies  the  history  of  one  of  these  cases.  The  error  in  the 
treatment  of  a  joint  by  rest  has,  we  think,  come  about  in 
two  ways  :  First,  the  improvement  and  cure  which  some- 
times results  in  tubercular  and  other  infected  joints  by 
rest,  and  the  improvement  which-  is  noted  in  traumatic 
non-infected  joints  by  brief  period  of  rest.  This  latter  has 
undoubtedly  led  physicians  to  employ  rest,  thinking  that,  if 
a  joint  was  improved  by  a  few  days'  rest,  that  it  would  only 
be  necessary  to  continue  long  enough  to  have  a  perfect 
cure.      The  later  theories  regnrding  the  treatment  of  such 


SURGERY.  23 

joints  tend  toward  just  the  opposite  treatment.  The  first 
few  days  after  a  joint  injury  rest  may  be  employed  with 
advantage,  but  very  soon  it  is  important  to  place  the  joint 
in  active  use,  even  though  it  is  pamful  and  there  is  consider- 
able fluid  remaining  in  the  joint  cavity.  This,  is  to  pre- 
vent adhesions.  If  the  adhesions  have  already  formed  it  is 
absolutely  necessary  that  they  be  broken  up  and  full 
motion  must  be  given  to  the  joint,  otherwise  the  recurrent 
inflammations  and  accumulations  of  fluid  will  inevitably 
take  place.  Instead  of  rest,  therefore,  the  latest  treatment 
of  traumatic  injuries  to  joints  includes  a  thorough  and  deep 
massage,  which  should  be  so  vigorous  as  to  stimulate  the 
synovial  membrane  to  absorption,  and  of  passive  motion 
which  should  include  the  whole  range  of  joint  movement. 
In  this  way  joint  adhesions  are  avoided,  or  if  already 
formed  are  broken  up  and  stretched.  Joints  treated  in 
this  way  show  a  much  higher  percentage  of  recoveries  and 
much  less  danger  of  secondary  inflammation  than  those 
treated  by  rest,  in  which  the  peri-articular  surfaces  become 
edematous,  the  sjnovia  eroded,  together  with  the  destruc- 
tion of  tissue  which  results  frcrm  long  chronic  inflammation. 
A  quick  cure  is  essential  to  a  permanent  one  in  these  ca^es. 
— St.  Louis  Med.  Rev. 

THE    TREATMENT    OF    THROMBOSED    VARICOSE    VEINS 

OF  THE  LEG. 

C.  Mansell  Moulin  discusses  in  the  Clinical  Journal  of 
July  31,  1901,  the  treatment  of  thrombosis  of  superficial 
varicose  veins.  This  condition  is  especially  frequent  in 
that  part  of  the  internal  saphena  at  the  side  of  the  knee 
and  in  the  lower  third  of  the  thigh.  The  condition  is  a 
grave  one  because  of  the  liability  of  a  portion  of  the  throm- 
bus separating  and  reaching  the  heart.  The  diagnosis  of 
this  condition  is  easy  ;  the  soft  purplish  masses  along  the 
course  of  the  veins,  standing  out  underneath  the  skin  and 
more  or  less  adherent  to  it,  cannot  be  mistaken.  There  is 
always  inflammation  around  a  thrombosed  vein,  and 
secondarily  a  certain  amount  of  tenderness  and  redness  of 
the  skin  and  swelling  of  the  surrounding  cellular  tissue- 
It  is  advisable  before  coming  to  a  decision  as  to  the  method 
of  procedure  to  carefully  note  how  this  superficial  inflam- 
mation spreads.  Now  and  again  the  inflammation  of  the 
cellular  tissue  involves  the  walls  of  the  vein,  and  a  phle- 
bitis is  secondary  to  the  infective  inflammation  of  the  sur- 
rounding tissues.  These  cases  must  be  carefully  distin- 
guished from  those  in  which  the  primary  trouble  is  a 
thrombosis  and  the  inflammation  to  it  secondary  and  com- 
paratively slight. 


24  SURGERY. 

The  causes  which  give  rise  to  thrombosis  in  veins  vary 
in  individual  cases.  In  most  cases  the  thrombosis  starts 
from  a  dilitation  in  which  presumably  the  blood  is  almost 
stagnant,  or  from  behind  a  valve.  Impaired  vitality  of  the 
endothelial  lining  of  the  vein  is  another  cause.  Some- 
times this  may  arise  from  prolonged  stasis,  the  nutrition 
of  the  lining  cells  growing  more  and  more  feeble  until  at 
last  some  fibrin  ferment  is  set  free-  More  frequently  the 
cause  is  traumatic — a  blow  or  the  compression  of  a  band- 
age. The  third  cause  of  thrombosis,  more  difficult  to  esti- 
mate, is  the  difference  in  the  constitution  of  the  blood. 
In  a  recent  case  on  which  the  writer  operated  the  throm- 
bus extended  from  below  the  knee  to  the  saphenous 
opening,  a  condition  which  could  not  have  arisen  from  a 
local  cause.  What  this  alteration  in  the  constitution,  of 
the  blood  may  be  it  is  not  easy  to  say.  It  occurs  in  such 
wasting  diseases  as  phthisis,  and  is  not  infrequent  in  ty- 
phoid. It  sometimes  occurs  after  severe  surgical  opera- 
tions which  pursue  a  perfectly  aseptic  course.  After 
severe  abdominal  operations  it  is  well  to  raise  the  foot  of 
the  bed  from  nine  to  twelve  inches  to  prevent  venous 
stasis  in  the  lower  extremities-  It  is  possible  that  these 
cases  may  be  of  bacterial  origin,  the  germs  having  been 
taken  in  during  operation,  but  not  being  sufficiently 
numerous  to  cause  a  general  reaction  in  the  system,  but 
only  a  disturbance  in  the  blood  which  is  nearly  stagnant. 
Such  a  condition  has  been  experimentally  proved  in 
animals. 

The  routine  treatment  of  thrombosed  veins  is  to  en- 
force absolute  quiet  of  the  affected  limb,  covering  it  with 
lead  lotion  or  extract  of  belladonna,  and  wait  until  all 
pain  and  tenderness  have  gone,  and  the  vein  has  either  re- 
gained its  natural  condition  or  feels  hard  and  cord-like. 
In  the  meanwhile  the  patient  is  liable  to  sudden  embolism, 
which  may  occur  at  any  moment,  and  to  extension  of  the 
thrombus  until  it  has  spread  through  the  saphenous  open- 
ing into  the  femoral  vein,  or,  what  is  nearly  as  serious, 
until  it  extends  through  some  of  the  communicating 
branches  into  the  deep  veins.  Such  prolonged  treatment 
is  unsatisfactory,  as  it  may  take  weeks  or  even  monthsi  for 
a  blood-clot  to  become  organized  and  obliterate  the  vein. 
Surgical  treatment  should  be  undertaken  early.  All  that 
is  necessary  is  to  make  an  incision  down  upon  the  vein, 
turn  out  the  thrombus,  and  ligate  it  above  and  below-  In 
most  cases  it  is  wise  to  put  a  ligature  around  the  vein  im- 
mediately below  the  saphenous  opening,  to  prevent  the  clot, 
if  it  is  accidentally  displaced  during  the  operation,  being 
carried  into  the  general  circulation.      Where  the  thrombus 


SURGERY.  25 

is  SO  long  that  it  cannot  be  removed  entire,  segments 
should  be  taken  away  and  the  .divided  ends  of  the  vein 
closed  by  ligature,  or  better  still  by  torsion.  In  some  cases 
where  there  is  a  large  mass  on  the  inner  side  of  the  thigh 
and  the  wall  of  the  vein  is  more  or  less  adherent  to  the  sur- 
rounding structures,  a  flap  of  skin  is  removed  and  the  mass 
of  veins  slit  in  every  direction.  The  clot  is  turned  out,  and 
so  much  of  the  wall  as  can  be  readily  removed  is  taken 
away,  the  skin  afterward  being  replaced. 

In  cases  involving  the  superficial  veins  nothing  better 
than  these  methods  of  operating  can  be  employed.  The 
redness  of  the  skin,  tenderness,  and  all  other  signs  of  in- 
flammation disappear  at  once,  and  union  takes  place  within 
a  week.  In  a  fortnight  the  patient  is  up  and  about-  Un- 
fortunately, in  thrombosis  of  the  deep  vessels,  operation  is 
out  of  the  question  ;  nothing  but  unlimited  time  and 
patience  are  of  service. — Medicine. 

A  STUDY  or  BURNS. 

Frederick  Griffith,  in  the  Medical  News  of  August  24, 
1901,  says  that  burns,  which  are  the  commonest  of  all 
injuries,  should  be  treated  upon  accepted  surgical  prin- 
ciples. They  may  be  divided  into  two  classes  :  the  first, 
which  involves  the  skin  only,  and  a  second  group  including 
the  deeper  structures.  Early  death^and  internal  complica- 
tions after  burns  are  due  to  the  direct  action  of  the  heat, 
causing  fragmentation  and  vital  changes  in  the  blood- 
corpuscles.  The  constitutional  disturbance  is  probably 
due  to  infection  originating  in  the  burned  area-  Contrac- 
tion in  burns  and  subsequent  deformity  is  determined  by 
the  granulations.  The  greater  the  friction,  from  whatever 
source,  the  more  extensive  the  granulations,  followed  by  a 
larger  amount  of  connective  tissue,  and  hence  greater  con- 
traction. The  early  methods  of  treating  burns  had  for 
their  basis  the  prevention  of  irritation  and  the  excessive 
formation  of  connective  tissue. 

In  the  early  treatment  of  a  burn  all  dead  and  charred 
tissue  should  be  removed  as  far  as  possible.  The  thorough- 
ness with  which  this  is  done  determines,  in  great  measure, 
the  amount  of  discharge  and  the  probable  presence  of  in- 
fecting organisms.  The  best  antiscT^tic  for  immediate 
application  is  hydrogen  dioxide.  After  the  wound  is 
cleansed,  rubber  tissue  should  be  placed  over  it  to  prevent 
contact  with  absorbent  dressings-  Splints  should  be  em- 
ployed to  secure  relaxation  and  retention  in  obtaining  rest 
for  the  burned  part.  This  is  quite  as  important  as  it  is  in 
fractures.      The  internal  treatment  of  burns  should  be  by 


26  THERAPEUTIC  NOTES. 

stimulation  until  reaction   from    shock   has    taken   place, 
when  the  treatment  should  be  supportive. 

Utto  L.  Muench  (ibid.)  recommends  carbolic  acid  in 
the  treatment  of  burns.  He  has  employed  it  in  several 
cases,  in  one  of  which  the  amount  of  surface  involved  was 
considerable-  The  application  of  pure  carbolic  acid  is 
followed  by  an  immediate  cessation  of  pain  and  a  prompt 
and  rapid  healing  of  the  part.  The  carbolic  acid  is  applied, 
using  the  ordinary  95  per  cent.,  and  is  immediately  washed 
away  with  alcohol.  Not  only  does  it  give  instant  relief 
from  pain,  but  it  effectually  antiseptisizes  the  surface  of 
the  burn  and  seals  all  the  avenues  of  infection. 


Therapeutic  Notes. 


Bed  Sores. — If  the  nurse  is  competent,  this  painful 
complication  will  rarely  require  treatment.  It  is  advisable  to 
rub  the  parts  upon  which  the  patient  rests  with  alcohol,  and 
daily  sponging  of  the  entire  body  with  warm  water  and  then 
with  alcohol  will  add  greatly  to  comfort.  Should  a  suspicious 
spot  of  redness  present  itself,  remove  the  pressure  there- 
from by  an  air-cushion,  and  prevent  the  folds  of  linen  press- 
ing upon  the  patient.  Dry  dressings  are  preferable  to  moist 
ones  for  bed-sores,  and  oxide  of  zinc  in  powder  or  ointment 
is  one  of  the  most  valuable  remedies  ;  acetate  of  aluminum 
has  also  a  very  beneficial  effect.  At  times,  considerable  loss 
of  substance  is  found,  giving  rise  to  a  very  foul  odor ;  in 
these  cases  a  charcoal  poultice  acts  remarkably  well. — Rotch. 

Chloroform  is  now  very  seldom  used  in  the  Dublin 
hospitals.  The  patient  is  first  part  under  the  influence  of 
nitrous  oxide,  and  when  anaesthesia  is  secured  it  is  prolonged 
by  means  of  ether. 

Dr.  Munde  recommends  vaginal  injections  of  bromide 
of  potash,  I  dr.  to  a  pint  of  water,  in  cases  of  so-called  irrit- 
able uterus,  diffuse  pelvic  pains  and  hysterical  neurosis  in 
various  parts  of  the  body. 

In  the  Philippines  the  insurgents  dress  wounds  with  dry 
salt  or  strong  brine,  for  lack  of  th.e  usual  antiseptics,  and 
wounds  from  firearms  heal    under  it   in  four  or  five  days. 


THERAPEUTIC  NOTES.  27 

Peanuts  have  the  faculty  of  absorbing  alcohol  and 
preventing  it  from  demoralizing  the  nerves  and  upsetting 
the  thinking  machine,  without  entirely  curtailing  its  exhil- 
arating effects.  The  large  proportion  of  oil  in  the  peanuts 
accounts  for  the  result.  A  good  wineglass  of  olive  oil  has 
the  same  effect. 

The  passage  of  the  catheter  inurinary  diseases  is  a  surgical 
operation,  and  should  be  considered  as  such.  It  is  not 
merely  a  manoeuvre,  rashly  and  indiscriminately  to  be  un- 
dertaken. 

In  Biliary  Lithiasis,  Dr.  Stanley  M.  Ward  finds  that 
if  the  patient  will  eschew  fats  and  take  1  dr.  of  phosphate 
of  soda  in  hot  water  three  times  daily  for  six  months,  then 
twice  for  three  months,  and  then  continue  the  dose  before 
breakfast  for  the  balance  of  the  year,  recurrence  is  very  rare. 
The  injection  of  a  glass  syringeful  of  lemon  juice  into  the 
nose,  after  it  has  been  cleansed  of  clots,  will  stop  bleeding 
after  everything  else  has  failed.  —  Massachusetts  Medical 
Journal,  September,  1901. 

In  Incontinence  of  Urine  in  children,  antipyrine  has 
proved  to  be  useful  in  large  doses.  Take  2  dr.  of  antipyrine 
and  dissolve  it  in  i  oz.  of  water  and  add  i  oz.  of  alcohol. 
Take  one  teaspoonful  at  bedtime. 

Balsam  of  copaiba  is  an  excellent  remedy  for  chilblains  ; 
paint  it  on  once  a  day  or  more. 

The  following  is  Vidal's  formula  for  seborrhoea  sicca  of  the 
scalp  :  Precipitated  sulphur,  fifteen  parts  ;  castor  oil,  fifty 
parts  ;  cocoa  butter,  twelve  parts ;  balsam  of  Peru,  two  parts. 
Thoroughly  mix  the  sulphur  and  castor  oil,  add  the  cocoa 
butter  with  the  aid  of  a  gentle  heat,  and  finally  the  balsam. 
Rub  into  the  scalp. 

Agaricin  in  doses  of  ^/^  to  ^  gr.  is  a  valuable  remedy 
in  the  night-sweats  of  phthisis. 

A  thin  paste  made  by  mixing  iodoform  in  balsam  of  Peru 
is  an  excellent  application  to  chronic  indolent  ulcers.  Over 
this,  place  a  dressing  of  bichloride-of-mercury  gauze. 

Dr.  Sidlo,  long  ago,  claimed  to  have  cured  many  cases 
of  ozjena  by  daily  washing  out  the  nasal  cavities  with  a  2 
per  cent,  solution  of  chloride  of  potassium,  to  which  10  per 
cent,  of  glycerine  has  been  added.  This  is  followed  by  in- 
serting ro'ls  of  cotton  soaked  in  a  mixture  of  one  part  of 
glycerine  and  three  parts  of  water,  the  tampons  to  remain  in 
place  for  one  hour. 


28  THERAPEUTIC  NOTES. 

Phosphorus  in' full  doses  is  said  to  be  very  beneficial 
in  the  treatment  of  some  cases  of  goitre. 

A  lotion  made  of  i  dr.  of  permanganate  of  potassium  to 
one  pint  of  water  is  very  effective  in  counteracting  the  odor  of 
sweating  feet. 

Chapman  calls  attention  to  a  diagnostic  sign  in  myx- 
cedema  which  has  often  proved  useful.  As  is  well  known, 
puffiness  of  the  eyelids  is  a  sign  of  Bright's  disease.  So,  too, 
is  it  a  symptom  of  myxoedemadue  to  the  collection  of  mucin. 
So  that  when  the  urine  is  normal  and  puffiness  of  the  lid  is 
a  sympton,  the  possibility  of  myxoedema  being  the  cause 
should  be  kept  in  mind. 

Dr.  Ry  reports  thirty-two  cases  of  night-terrors  in  children, 
in  all  of  which  adenoids  were  present  in  the  naso-pharyngeal 
vault,  and  when  these  vere  removed,  the  nightmare  ceased. 
He,  therefore,  concluded  that  adenoids  area  common  under- 
lying cause  of  this  trouble. 

In  Acute  Gonorrhceal  Epididymitis,  Setz  has  great 
faith  in  guaiacol.  He  first  washes  the  parts  with  soap  and 
ether,  and  then  applies  a  lo  per  c^nt.  ointment  of  guaiacol 
in  vaseline. 

Many  physicians  prefer  the  bromide  of  strontium  to  any 
other  form  of  bromide  in  the  treatment  of  epilepsy,  because 
it  can  be  continued  for  months  without  any  of  the  deleteri- 
ous effects  which  attend  the  use  of  the  potassium  salt,  and 
can  therefore  safely  be  given  in  doses  large  enough  to  con- 
trol the  fits. 

Lime  in  the  Eye. — Wash  the  eye  thoroughly  with  a 
large  quantity  of  warm  water — for  a  little  water  but  adds  to 
the  trouble  by  slacking  the  lime — and  then  introduce  a  solu- 
tion of  sugar  and  water.  This  is  superior  to  solutions  of 
vinegar  or  dilute  acids,  because  sugar  forms  an  insoluble 
compound  with  lime. 

Whatever  else  you  do  in  internal  carbolic-acid  poisoning, 
give  at  once  a  large  dose  of  alcohol — whisky,  brandy,  rum, 
or  gin  will  answer — and  repeat  it  often. 

The  Treatment  of  Oz/ENA  with  antidiphtheritic 
serum  seems  to  have  many  prominent  advocates.  Such  spe- 
cialists as  Mgyind,  Cathetin,  Kyle  and  King  report  good 
results  following  this  plan. 

The  Treatment  of  Pneumonia  by  serum  therapy 
has  not  been  attended  with  sufficiently  marked  results  except 
to  give  encouragement  for  its  further  trial. 


THERAPEUTIC  NOTES.  29 

Strychnine  is  the  drug  most  commonly  used  to  sustain 
the  heart,  and  many  advise  that  it  be  given  in  full  doses 
hypodermically  because  the  stomach  is  often  so  disturbed  as 
to  delay  its  absorption.  —  Journal  of  Medicine  and  Science, 
August,  1 90 1. 

Fissure  of  the  Nipple  has  been  very  successfully 
treated  by  many  physicians  with  orthoform.  A  few  drops 
of  a  saturated  solution  of  orthoform  in  80  per  cent,  alcohol 
is  applied  directly  to  the  crack,  and  a  dry  compress  is  then 
placed  above. 

SuLHUR  Cream  for  Dandruff. 

Dr.  Geo.  T.  Jackson  says  the  following  will  make  an 
elegant  sulphur  ointment,  which  he  uses  extensively  in  the 
treatment  of  dandruff:  — 

R  White  wax 3  iiiss. 

01.  petrolati f,  iiss. 

Rose  water 3  j. 

Sod.  biborate "gr.  xv. 

Precipitated  sulphur .3  iiiss. 

This  is  an  elegant,  smooth,  white  preparation  without 
sulphur  odour.  It  keeps  perfectly,  does  not  separate,  and  is 
as  perfect  an  ointment  as  can  be.  Dr.  Jackson  has  tried  on 
his  scnlp  all  sorts  of  lotions  in  the  treatment  of  seborrheal 
dermatitis,  and  invariably  comes  back  to  the  sulphur  cream 
with  pleasure  and  profit.  Used  once  or  twice  a  week,  it 
keeps  the  scalp  comfortable,  does  not  make  the  hair  too 
greasy,  when  properly  applied,  and  checks  the  dandruff. — 
Jour.  Cnt.  and  Gen,  Ur.  Dis. 

For  Toothache. 

Under  the  name  of  Swedish  toothache  drops,  the  Ohio 
Dental  Journal  quotes  the  following: — 

^  Clove-oil. 

Cajuput-oil,  of  each,  10  parts. 

Chloroform. 

Acetic  ether,  of  each,  5  parts. 

Menthol,  3  parts. 

Camphor,  i  part. 

Dissolve.  For  application  to  the  tooth. — {^New  York 
Medical  Journal.) 


30  jottings 

The  Cleansing  of  Teeth. 

M.  H.  Fletcher,  M.  D.,  D.  D.  S.  (Cincinnati  Lancet- 
Clinic),  gives  as  the  result  of  elaborate  investigations,  the 
following  formula  : — 

R   Pulv.  cereal,  75  per  cent. 
Sodium  borate,  18  per  cent. 
Potass,  chlorate,  7  per  cent. 
Orris  and  menthol  to  flavour,  and  saccharine  to  sweeten 
to  taste. 

Dr.  Fletcher  says  that  it  requires  at  least  five  grains  at  a 
time  of  any  powder  to  be  at  all  efficient  in  cleansing  the 
mouth  and  teeth,  and  double  or  triple  the  portion  is  better  ; 
in  every  five  grains  of  the  above  formula  there  is  one  and 
one-quarter  grains  of  the  combined  remedies ;  this  is  suffi- 
cient to  keep  the  saliva  decidedly  alkaline  for  some  time 
after  using  and  to  counteract  the  ill  effects  of  sweets. 

Caffeine  in  the  Treatment  of  Whooping-cough. 
The  Agenda-Medical  gives  the  following  formula  : — 
^  Caffeine  valerianate,  3  parts. 
Brandy,  40  parts. 
Syrup  of  coffee,  500  parts. 
M,   From  a  coffeespoonful  to  a  tablespoonful,  according 
to  the  patient's  age,  is  to  be  given    morning  and   evening. 
— {New  York,  Medical  Journal^ 

Venereal  Sores. 

R   Hydrgr.  Chloridum  Mite i  drachm. 

Listerine c I  ounce. 

Aqua  Calcis 5  ounces. 

M.  Sig.  : — Mop  the  surface  night  and  morning  with 
gauze  or  absorbent  cotton. 


Jottings, 

BUTTERMILK. 

Buttermilk  as  a  remedial  agent  can  not  be  praised  too 
highly.  The  lactic  acid,  the  sour  of  the  buttermilk,  attacks 
and  dissolves  every  sort  of  earthy  deposit  in  the  blood  ves- 
sels. Thus  it  keeps  the  veins  and  arteries  so  supple  and  free 
running  there  can  be  no  clogging  up  ;  hence  no  deposit  of 


JOTTINGS.  31 

irritating  calcareous  matter  around  the  joints,  nor  of  poi- 
sonous waste  in  the  muscles.  It  is  the  stiffening  and  harrowing 
of  the  bloodvessels  which  bring  on  senile  decay.  Buttermilk 
isjikely  to  postpone  it  ten  to  twenty  years,  if  freely  drunk. 
A  quart  a  day  should  be  the  minimum,  the  maximum  ac- 
cording to  taste  and  opportunity.  Inasmuch  as  gouty  diffi- 
culties usually  arise  from  sluggish  excretion,  buttermilk  is  a 
blessing  to  all  gouty  subjects.  It  gently  stimulates  all  the 
excretories — liver,  skin  and  kidneys.  It  also  tones  the 
stomach  and  furnishes  it  the  material  from  which  to  make 
rich,  red,  healthy  blood.  If  troubled  with  gout  avoid  meat, 
sweets,  pastry,  wines,  spices,  hot  rolls,  bread  of  all  sorts,  and 
everything  belonging  to  the  tribe  of  ferments.  Eggs,  game, 
fresh  fruit,  vegetables,  especially  salads,  may  be  eaten  with 
impunity.  If  any  one  has  a  creaky  joint  or  a  swollen  and 
aching  one,  he  .should  drink  all  the  buttermilk,  he  can  relish 
whenever  and  wherever  he  can,  but  it  should  be  fresh 
churned  and  wholesome. — Health  Culture. 

TO  CURE  INSOMNIA. 

A  very  simple  method  of  inducing  sleep  in  ca  es  of  per- 
sistent insomnia,  and  one  that  has  succeeded  where  many 
drugs  have  failed,  is  :  Simply  administer  a  moderate  amount 
of  liquid  food  before  the  patient  goes  to  bed.  This  diverts 
the  blood  from  the  brain  to  the  abdominal  organs,  and  takes 
away  the  cerebral  excitement  that  precludes  sleep. — New 
York  Med.  Jour. 

MISTAKEN  NOURISHMENT. 

No  patient  with  chronic  Bright's  disease  should  use 
beef  tea  or  bouillon,  or  the  so-called  beef  extracts,  as  a  diet. 
Over  and  over  again  it  has  been  shown  that  these  substances 
are  concentrated  solutions  of  the  very  salts  which  go  to 
make  up  the  solids  of  the  urine  itself,  in  addition  to  a  certain 
amount  of  albumin.  Yet  I  am  constantly  consulted  in  cases 
where  the  physician  is  nourishing  his  patients  on  such  food 
with  the  impression  that  he  is  doing  a  good  thing,  whereas 
he  is  either  overworking  the  kidneys  or  overcharging  the 
blood  with  toxic  substances,  or  both.  Whenever  there  is  an 
aggravation  of  symptoms  a  recourse  must  be  had  to  a  milk 
diet.  Diluted  milk  is  to  be  preferred  to  skim  milk,  because 
in  the  latter  the  proportion  of  proteid  remains  unchanged, 
and  the  fat,  harmless  fat,  is  removed,  while  in  dilute  milk  the 
proteid  is  reduced  and  much  of  the  fat  is  retained,  as  is,  of 
course,  desirable. — Med.  Standard. 


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IMPURE     VrATER. 

Chemists  and  bacteriologists  attached  to  the  health  de- 
partments of  civic  corporations  occasionally  give  us  con- 
siderable food  for  thought.  Whether  that  thought  produces 
the  effect  which  those  gentlemen  think  some  of  their  state- 
ments will  have  is,  however,  open  to  serious  question. 
Attached  to  the  corporation  of  the  City  of  Montreal  is  a 
chemist  of  no  mean  ability  and  whose  chemical  knowledge 
no  one  would  question.  Whether  he  understands  human 
nature  quite  as  well  is,  in  our  opinion,  exceedingly  doubtful. 
Within  the  last  few  months  we  have  had  from  him  reports 
on  the  water  supply  of  Montreal  which  he  asserts  is  chemi- 
cally and  bateriologically  a  healthy  water  to  drink.  He, 
however,  admits  that  it  is  occasionally  off  color  and  of  a 
somewhat  brownish  hue,  still  will  not  occasion  any  un- 
toward results.  We  believe  he  is  perfectly  correct  in  this 
statement.  As  we 'draw  our  supply  from  the  Ottawa  river, 
which  at  best  is  in  bulk  of  a  brownish  hue,  it  requires  but  a 
small  increase  in  the  amount  coming   from  swamp  land  to 


EDITORIAL.  33 

make  this  color  very  decided.  We  find  it  so  in  the  spring 
nearly  always.  Now,  if  there  is  any  drink  which  a  human 
being  craves  it  is  water,  and  he  desires  it  clear  and  limpid* 
It  is  only  such  water  that  he  relishes.  Let  us  give  an  ex- 
ample. Pour  water  into  a  glass  which  has  contained  milk, 
and  at  once  it  becomes  whitish  blue.  That  water  can  never 
be  drank  with  the  same  relish  as  if  it  had  been  placed  in  a 
clean  glass.  So  often  then  is  our  Montreal  water  dis- 
coloured that  we,  with  many  others,  have  not  drank  a  drop 
of  it  for  a  long  time.  Hundreds  have  given  up  its  use  as  an 
unadulterated  beverage,  and  have  supplied  themselves 
with  Laurentian  water  from  the  Laurentian  Springs  which 
is  beautifully  clear  and  v  absolutely  free,  we  believe,  from 
organic  matter.  While  the  report  of  our  Montreal  water 
supply  is  satisfactory,  save  in  the  part  we  have  noted,  we 
find  that  the  bacteriologist  of  the  Buffalo  Health  Depart- 
ment has  thrown  the  citizens  of  that  place,  especially  those 
who  use  filters,  into  a  somewhat  excited  state.  He  reports 
that  in  water  taken  from  the  ordinary  tap  he  found  from 
i6o  to  560  bacteria  per  cubic  centimeter,  while  in  the  water 
from  a  mechanical  filter  he  found  from  1,180  to  3,800  per 
cubic  centimeter.  The  Philadelphia  Medical  Journal  com- 
menting on  this  statement  says  •• 

•' '  This  is  not  surprising  ;  it  is  astounding  ' !  The  tests 
clearly  show  that  in  many  instances  filters  will  clarify  the 
water  very  nicely,  also  add  tremendously  to  its  bacterial 
contents.  This  they  do  by  reason  of  the  filtering  material 
becoming  a  culture-medium  for  bacteria,  after  it  has  become 
a  little  dirty.  This  is  a  very  serious  matter,  as  it  shows  that 
people  who  trust  a  mechanical  filter  to  purify  their  drinking- 
water  are  the  victims  of  misplaced  confidence.  A  filter  that 
is  not  frequently  and  thoroughly  cleansed  may  become  a 
vastly  more  dangerous  source  of  infection  than  the  water 
that  it  is  supposed  to  purify." 

Really  one  is  almost  compelled  to  exclaim  :  "  How  in 
the  world  do  we  exist  with  so  many  bacteria  in  our  food  and 
drink."     It  is  indeed  wonderful. 


34  EDITORIAL 

MESICAI.  TEACHING. 

The  method  of  teaching  Medicine  has  changed  greatly 
during  the  last  twenty-five  years.  The  work  ^is  now  more 
minutely  done,  and,  as  a  consequence  and  necessity,  there 
has  been  a  vast  increase  in  the  number  of  teachers.  This  is 
a  self-evident  fact  patent  to  every  medical  man  who  has  fol- 
lowed the  gradual  development  of  the  medical  schools  not 
only  of  Canada,  but  of  the  United  States  and  Europe.  Even 
as  late  as  fifteen  years  ago  the  professorial  staff  of  most 
medical  colleges  was  filled  ;by  men  engaged  in  general  prac- 
tice. Then  began  the  day  of  commencing  specialism,  and 
there  was  a  gradual  introduction  of  specialists  on  the  teach- 
ing staff,  replacing  men  who  in  their  day  had  done  their 
duty  and  done  it  well.  But  the  world  is  ever  moving 
onward,  and  within  a  comparatively  few  years  many  colleges 
found  that  several  subjects  embraced  in  the  curriculum, 
especially  those  of  a  theoretical  character,  demanded  men 
whose  whole  time  must  be  devoted  to  their  work.  This  de- 
mand has  been  met  by,  we  may  say,  every  teaching  medical 
body,  though  in  the  minor  schools,  that  is  minor  as  regards 
the  number  of  students,  it  has  been  a  severe  strain  on  their 
financial  resources.  To  their  credit,  however,  we  must  say 
there  has  not  been  any  holding  back,  and  that  all  have  risen 
to  the  situation  with  an  enthusiasm  infinitely  to  their  credit. 
But,  with  the  march  of  time,  other  changes  will  be  demanded, 
and  the  financial  strain  will  surely  become  greater.  How  is 
this  to  be  met  ?  Endowments  have  already  reached  some 
of  our  older  Canadian  schools,  and  more  will  doubtless 
come.  The  junior  schools  with  increasing  age  will  find 
friends  who,  recognizing  the  good  work  they  are  doing,  will 
come  to  their  jiid. 

But  we  ask,  has  the  country  not  a  duty  to  perform, 
of  placing  in  the  hands  of  our  medical  teaching  bodies  an 
annual  grant  which  would  be  but  a  slight  recognition  of  the 
enormous  work  gratuitously  performed  by  the  medical  pro- 
fession .''  No  other  profession  performs  gratuitous  work  to 
anything  approaching  that  of  the  profession  of  medicine. 
This  work  the  government  should  recognize  in  the  way  we 


EDITORIAL.  3  5 

have  suggested.  This,  we  presume,  was  the  view  taken  by 
the  government  of  this  province  when  it  for  years  gave  the 
medical  schools  an  annual  grant  somewhere  in  the  ueigh- 
bourhood  of  one  thousand  dollars.  When  the  finances  of 
the  province  were  reduced  to  a  low  ebb  this  annual  grant 
was  cut  off,  but,  now  with  an  income  showing  a  small  sur- 
plus, it  is  worth  while  to  raise  the  question  whether  it  would 
not  be  wise  policy  to  again  give  small  grants  to  the  various 
medical  schools  in  the  Province  of  Quebec.  We  have  said 
that  great  changes  have  taken  place  in  teaching  medicine 
during  the  last  two  decades,  but  there  arc  not  a  few  who 
feel  that  some  of  the  changes  are  of  a  questionable  char- 
acter. The  amount  of  time  devoted  to  laboratory  work  is 
considered  by  some  to  be  too  great,  while  practical  medicine, 
surgery  and  midwifery,  to  learn  to  practice  which  students 
go  to  college,  do  not  receive  that  attention  which  it  is  essen- 
tial they  should.  Mere  individual  attention  seems  to  be  a 
direction  toward  which  the  thought  of  many  is  turning. 
Harvard,  one  of  the  leading  medical  schools,  would  seem  to 
believe  in  it,  for  they  have  one  hundred  and  thirty-one 
teachers,  or  one  to  every  five  students.  Teaching  by  small 
sections  instead  of  class  teaching  is  thus  made  practicable. 
The  Medical  Alumni  Association  of  that  school  has,  through 
a  committee,  been  investigating  its  method  of  teaching 
medicine,  and  the  report  was  presented  at  a  meeting  held  in 
June  last.  It  strongly  endorses  this  method  of  individual 
teaching  and  urges  its  extension,  and,  of  necessity,  a  large 
increase  in  the  staff  of  instructors.  It  also  declares  that 
visits  to  the  hospitals  of  thirty  or  more  students  fail  in  their 
object.  That  such  visits  should  cea  e  and  make  way  for 
smaller  numbers  in  sections  where  the  student  should  take 
an  active  part  in  the  visits  and  be  questioned.  This  has 
already  been  done,  so  far  as  Fourth  Year  men  are  con- 
cerned, who  are  divided  into  sections  of  five  wno  make 
eighteen  visits  in  the  wards,  when  the  after-treatment  of 
operations  and  the  routine  care  of  the  patients  is  illustrated 
and  discussed  with  the  students  by  the  assistant  surgeons. 
One  might  imagine  that  a  number  of  such  visits  daily  would 


36  EDITORIAL. 

interfere  with  the  recovery  of  patients,  but  we  are  assured  by 
a  graduate  nurse  of  one  of  the  largest  Boston  hospitals  that 
such  is  not  the  case,  only  about  three  hours,  and  that  in  the 
morning,  is  occupied  by  these  visits.  Such  modes  of  con- 
densed and  individual  teaching  are  applied  in  clinical  medi- 
cine and  in  obstetrics  with  some  necessary  variation  in  de- 
tail. Both  the  great  Boston  City  Hospital,  the  Dispensary 
and  Lying-in  Hospital  and  its  out-patient  relief  service  are 
employed  in  this  work.  Students  have  each  a  fracture,  a 
minor  surgical  case,  a  medical  case,  six  cases  of  labour  to 
treat  themselves  and  to  report  on,  but  always  near  a  con- 
sultant if  unexpected  emergencies  arise.  The  opinion  of 
men  experienced  in  teaching  is  that  didatic  lectures  should 
be  less  frequent,  but  never  abandoned.  The  proportion  sug- 
gested is  to  clinical  and  laboratory  teaching  of  one  to  three 
or  even  one  to  four  in  some  subjects.  This  is  especially  im- 
portant in  gynaecology,  threapeutics,  laryngology,  ophthal- 
mology and  dermatology.  It  is  especially  important  in 
the  last  two  where  our  knowledge  is  based  on  what  we  see 
and  feel.  Specialties  should  be  relegated  to  the  Fourth 
Year,  and  should  be  almost  entirely  taught  by  clinics.  The 
touch,  the  sight,  the  use  of  instruments  of  precision,  absolute 
contact  with  a  case  should  be  the  means  of  examination. 
In  the  case  of  operative  surgery  there  should  be  didactic  de. 
monstration,  a  repetition  of  all  operations  by  the  student — 
no  examination  paper.  The  weekly  grinds,  we  think,  are 
very  important  and  ought  to  be  regularly  carried  out,  and 
the  students  encouraged  to  answer.  Many  we  know  through 
either  timidity  or  fear  decline,  but  this  difficulty  might,  we 
believe,  be  entirely  overcome.  It  is  the  only  way  to  secure 
active  mental  participation  instead  of  passive  receptivity. 
This  Harvard  Committee  believes  that  medicine  and  sur- 
gery should  be  taught  together  and  not  as  now,  disassociated. 
Nature  draws  no  such  line,  and  we  cannot  draw  any  such 
line  in  practice.  Pathological  processes  may  be  first  medical 
and  later  surgical,  or  the  opposite.  It  is  important  that  in- 
stead of  rare  diseases  forming  part  of  too  many  clinical  lec- 
tures that  the  student  should   be   made  familiar  with  com- 


EDITORIAL.  37 

mon  maladies  such  as  are  likely  to  make  up  the  bulk  of  his 
practice.     The  former  is  of  most  interest  to  the  teacher,  the 
latter  to  the  student.     It  is  here  that  the  out-door  depart- 
ment of  our  hospitals  offer   a   rich   field,  and  we  regret  it  is 
not   more  fully  taken  advantage    of.     Many  of  those  who 
have  done  so  have   repeatedly    written  us  stating  how  con- 
stantly in  practice  they  have  found   the   knowledge  gained 
there  come   to   their  aid.     Teachers  we  fear  do  not  realize 
how  much  of  general  medicine  and  how  little  surgery  and 
specialties  form  the  practice  of  general   practitioners  in  even 
fairly  sized  towns.     Seven  physicians   in  general  practice  in 
as  many  such   places  recently  tabulated  a  year's  work  and 
found  they  had   1,594  cases.     Of  these   1,230  were  medical 
and  364  surgical  and  specialties.     Of  the  medical  cases  two- 
thirds  were  of  ten  common  types,  such  as  grippe,  digestion, 
bronchitis,    rheumatism,  pneumonia,  colds,  etc.     The   com- 
mon we  have  with  us  always ;  on  this  we  must  stand  or  fall 
in  daily  practice.     It  is,  therefore,  impossible  for  students  to 
see  too   much   of  it.      Finally,  as  regards  the  examination, 
these,  in   our  opinion,  are  often   unfair   to   the  student,  the 
oral  is  too  short  to  give   the  student  a  fair  chance  to  show 
his  knowledge,  which,  extensive   as   it  may  be,  cannot    be 
universal.     The  teacher  may,  unfortunately,  light  upon  the 
student's  weakest  point,  and,  finding  that  out,  should  drop 
it  at  once,  and  give  him  an   opportunity  of  showing  what  he 
does  know.     Hence,  many  students  who  have  been  rejected 
are  eventually  our  best  practitioners,  and  rise  to  high  profes- 
sional   standing.     In   the    written    examination    too    many 
questions  are  often   given  for   the  time  allowed.     The  stu- 
dent cannot  do  himself  justice,  and  he  feels  it  so.     Then  the 
labour  and  exhaustion  in  reading  the  papers  are  too  onerous 
for  the  examiner.     In  schools  with  large  classes  examination 
of   papers   by  one  man   is   well-nigh  impossible,  and  manv 
papers  are  handed  over  to  subordinates.     This  is  not  fair,  for 
different    men   judge    from    different   standpoints,    and    the 
students  suffer  in  their  marks.     It  becomes  clear,  therefore, 
that  as  far  as  possible  the  standing  of  students  should  be  the 
result  of  work  done  and  its  result  shown  at  the  time.     This 


3^  EDITORIAL. 

could  be  arranged  for  at  short  intervals  throughout  each 
course.  It  should  be  the  object  of  the  examinations  to  test 
the  student's  power  to  deal  with  cases  of  disease,  to  make  a 
thorough  physical  examination,  take  an  intelligent  his- 
tory and  reason  from  these  to  a  rational  diagnosis,  prognosis 
and  treatment,  and  this  can  alone  be  done  by  a  clinical  ex- 
amination. That  he  should  be  able  to  give  a  written 
account  of  a  disease  in  an  examination  room,  and  under  ex- 
amination pressure  is  of  secondary  importance.  The  living 
case  is  the  one  that  he  ought  to  examine,  diagnose  and 
write  a  report  of.  We  have  been  induced  to  throw  together 
these  few  lines,  based  upon  personal  experience  as  a  teacher 
for  over  thirty  years  and  from  the  opinions  gathered  from 
articles  published  in  various  medical  journals,  but  more 
especially  from  the  report  of  the  Alumnia  Association  of 
Harvard  University.  This  was  published  lately  in  the  pro- 
ceedings of  that  body. 


COLLEGE    OF    PHYSICIANS    AND    SURGEONS^    PROVINCE 
OF  QUEBEC. 

In  the  November  number  of  the  Record   we   gave   the 
result  of  the  election  of  the  new  Board  of  Governors.     We 
neglected,  however,  to  give  the  names  of  those  elected  by 
the  Universities  to  represent  them  on  the  Board. 
They  are  as  follows: — 

Universihj  of  McGill: — Drs.  Craik  and  Lafleur. 

Laval  University,  Quebec: — Drs.  Simard  and  Catellier. 

Laval    University,  Montreal: — Drs.    E.    P.    Lachapelle 
and  Demers. 

University  of   Bishop- s    College,  Montreal: — Drs.  F.  W. 
Campbell  and  J.  B.  McConnell. 


The  report  of  Major  Gagas,  Chief  Sanitary  Officer  of 
Havana,  states  that  for  the  first  time  in  over  a  hundred 
years  that  city  had  not  a  single  case  of  typhoid  fever  in 
June,  1901.     This  is   a   feather  in  the  cap  of  our  American 


BOOK  REVIEWS  39 

cousins,  whose  occupation  of  that  city  has   brought    about 
this  wonderful  result. 


The  Medical  Department  of  the  University  of  Penn- 
sylvania is  the  oldest  Medical  College  in  the  United  States. 
It  was  organized  in  1765,  and  has  graduated  12,201  physi- 
cians. 


Book   Reviews. 


The  Physician's  Visiting  List.— (Lindsay    &  Blakistons) 
for  1902  ;    fifty-first    year    of  its    publication.     Philadelphia, 
P.  Blakiston,  Son  &  Co. 
In  acknowledging  the  receipt  from  the  publishers  of  the  above 

Visiting  List,  we  have  pleasure  in    again  expressing    the   opinion, 

that  it  stands  at  the  head  of  all  visiting  lists. 

F.  W.C. 

The  Practice  of  Obstetrics,  by  American  Authors. 

Edited  by  Charles  Jewett,  M.  D.,  Professor  of  Obstetrics  and 
Gynecology  in  Long  Island  College  Hospital,  Brooklyn,  New- 
York.     New    (2d)    edition,    revised   and    enlarged.     In   one 
handsome  octavo  volume  ot  775  pages,  with  445  engravings  in 
colors  and  black,  and  35  full  page  coloured  plates.     Cloth,  net, 
$5.00;    leather,    net,    $6.00;  half  morocco,    net,  $6.50.     Lea 
Brothers  &  Co.,  Publishers,  Philadelphia  and  New  York,  1901. 
That  the  first  edition  has  been  so  rapidly  exhausted  is  proof 
that  this  work  has  been  appreciated.     This  edition  has  been  brought 
thoroughly  up  to  date  and  much  added  to  it.  The  teaching  is  most 
modern  and  full  of  good  common  sense,  the  only  exception  perhaps 
in  the  work  is  the  advice  given  in  the  management  of  the  birth  of 
the  head  in  simple  labour  which  is  undoubtedly  bad  practice.    Per- 
sonally, I  recommend    two   works  on   obstetrics    to  my  class  in 
College,  one  of  which  is  Jewett,  and  it  is  perhaps  the  best  one  of 
the  two- 

H.  L.  R. 

The  Pocket  Gray,  or  Anatomist's  Vade  Mecum— By 

the  late  Edward  Cotterell,  F.R.C.S.  Fifth  edition  revised  and 
edited  by  C.  H.  Fagge,  M.B.,  M.S.,  Lond.,  F.R.C.S.,  Senior 
Demonstrator  of  Anatom  Guy's  Hospital.  Wil  am  Wood, 
&  Co.,  New  York,  1901. 

This  excellent  little  manual  on  anatomy,  now  for  the  first  time 
published  in  America,  is  a  very  welcome  contribution  to  the  litera- 
ture of  the  science.     The  term  "Pocket  Gray"  is  presumably  an 


40  BOOK  REVIEWS. 

euphemism,  as  the  editor,  Mr.  Fagge,  has  evidently  studied  many 
other  authorities  than  the  late  Henry  Gray,  and  like  his  distinguished 
father,  Dr.  Hilton  Fagge,  of  Guy's  Hospital,  is  certainly  an 
accomplished  and  able  anatomist. 

The  book  has  the  three  essential  qualities  of  a  scientific  work, 
accuracy,  clearness  and  conciseness,  and  should  be  a  valuable  aid 
to  the  student  preparing  for  his  final  examinations  and  to  the  busy 
practitioner  seeking  some  necessary  and  desired  or  desirable  de- 
tails on  the  subject.  This  is  the  purpose  of  the  author  and 
editor,  for  the  work  is  not  designed  to  compete  with  the  i  \  1 
works  on  anatomy. 

C.  A.  H. 

The  Diagnostics  of  Internal  Medicine.  A  Clinical 
Treatise  upon  the  Recognized  Prmciples  of  Medical  Diagnosis. 
Prepared  for  the  use  of  Students  and  Practitioners  of  Medi- 
cine by  Glentworih  Reeve  Butler,  A.M.,  M.D.,  Chief  of  the 
second  Medical  division.  Methodist  Episcopal  Hospital ; 
attending  Physician  to  the  Brooklyn  Hospital  ;  Consulting 
Physician  to  the  Bushwick  Central  Hospita  formerly  Asso- 
ciate Physician,  Department  of  Diseases  of  the  Chest  and  Dis- 
eases of  Children,  St.  Mary's  Hospital,  Brooklyn,  New  York  ; 
Fellow  of  the  New  Yc  rk  Academy  of  Medicine  ;  Member  of 
the  Medical  Society  of  the  County  of  Kings,  etc.  New  York  : 
D.  Appleton  &Co.,  1901.  Canadian  Agents  :  Tue  Geo.  N. 
Morang  Co.,  Ltd.,   ("oronto. 

This  work  being  written  from  the  point  of  view  of  a  practical 
clinical  work  proves  most  interesting  and  highly  instructive  read- 
ing ;  the  farther  you  pr(  gress  in  its  perusal  the  more  intensely  en- 
grossed do  you  become.  This  volume  presents  some  unusual 
features,  and  will  doubtless  find  numerous  readers  who  will 
appreciate  the  novel  method  by  which  the  author  treats  his  sub 
ject.  He  divides  the  work  into  two  parts  :  first,  a  study  of  symp- 
toms and  their  indications  ;  and,  second,  a  study  of  diseases  and- 
their  characteristics.  The  evidences  of  disease  occupy  the  greater 
part  of  the  space  and  are  dealt  with  in  a  highly  satisfactory  manner. 
In  the  examination  of  his  patient  the  embryo  physician  is  instruct- 
ed by  what  routine  to  proceed  in  order  to  arrive  at  a  preliminary 
opinion  as  to  what  may  be  at  fault,  so  that  important  indications 
may  be  later  examined  in  greater  detail.  The  advice  herein  given 
by  the  author  and  his  method  of  diagnosis  deserves  the  highes 
commendation,  the  most  minute  details  being  pointed  out  and 
their  import  designated.  Dr.  Butler  has  given  us  an  eminently 
practical  book  full  of  what  the  busy  doctor  is  daily  in  need  of,  and 
dealing  at  length  with  symptoms  and  their  diagnostic  importance. 
The  general  plan  of  the  work,  the  arrangement  of  subjects,  the 
coloured  plates,  the  illustrations  and  diagrams,  are  alike  excellent. 
The  book  contains  between  two  covers  practically  all  that  is  es- 
sential for  the  making  of  a  diagnosis,  and  apparently  no  helpful 
clew  in  obscure  cases  has  been  overlooked.     The  value  of  modern 


BOOK  REVIEWS.  41 

laboratory  methods  has  also  been  fully  appreciated.  The  volume 
as  a  whole  is,  consequently,  a  reliable  guide  for  students  and  prac  - 
titioners  in  this  important  field  of  medical  practice.  While  every 
chapter  of  the  book  is  good,  the  subject  of  cerebral  localization 
and  of  the  diagnosis  of  diseases  of  the  nervous  system  seems  to  us 
to  be  especially  well  treated — full,  complete  and  up  to  date.  The 
publishers  have  done  their  part  of  the  work  in  a  highly  creditable 
manner.  The  book  is  especially  well  printed,  well  bound  and 
artistically  illustrated,  and  we  would  recommend  all  in  need  of  a 
thoroughly  practical  book  and  one  which  will  be  a  valuable  ad- 
dition to  their  library  to  purchase  a  copy  without  delay. 

R.  C  . 


Libertinism  and  Marriage.— By  Dr.  Louis  Julien  (Paris), 
Surgeon  of  Saint  Lazare  Prison  ;  Laureate  of  the  Institute  of 
the  Academy  of  Medicine,  and  of  the  Faculty  of  Medicine  of 
Paris.  Translated  by  R.  B.  Douglas-  Size  of  page  S/^  by 
7j^  inches.  Pages  v- 169.  Extra  cloth,  $100  net,  delivered. 
Philadelphia,  F.  A.  Davis  Company,  publishers,  1914-16 
Cherry  Street. 

This  little  book  deals  in  a  most  happy  and  frank  manner  with 
the  important  subject  of  libertinism  and  marriage.  Each  paragraph 
shows  earnest  thought  and  an  extended  and  intimate  knowledge 
of  the  subject.  One  could  wish  that  a  copy  might  find  its  way 
into  the  hands  of  every  physician  and  student  of  medicine,  for 
ignorance  of  the  great  importance  on  later  married  life  of  the  so- 
considered  trivial  chronic  affections  of  the  urethra  is  not  confined 
alone  to  the  laity. 

In  the  introduction  "  professional  discretion  "  is  carefully  re- 
viewed and  ethical  conduct  strongly  uphfld,  but  there  is  also  a 
strong  plea  to  the  effect  that  the  Doctor  has  not  done  all  his  duty 
by  remaining  silent,  but  that  he  should  use  his  utmost  influence 
to  protect  the  innocent  party  in  case  of  intending  marriage.  To 
insure  good  health  in  the  contracting  parties  the  suggestion  is 
advanced  that  a  certificate  of  good  health,  from  a  recognized  spe- 
cialist, would  greatly  facilitate  matters-  In  the  succeeding  chapters 
the  evolution  of  Blennorrhoea  and  its  various  stages  are  carefully 
considered- 

In  the  light  shed  by  our  present  clinical  methods  for  investi- 
gating Blennorrhoea  some  measure  of  the  responsibility  in  treating 
this  deceptive  disease  has  dawned  upon  us. 

To  the  specialist,  however,  the  truth  appears  in  more  vivid 
colours,  and  the  lessons  he  is  enabled  to  draw  from  a  larger  ex- 
perience cannot  fail  to  impress  the  thoughtful  reader.  We  take 
much  pleasure  in  recommending  this  little  work  to  all  labourers  in 
the  field  of  medicine 

G.  F. 


42  BOOK   REVIEWS. 

Annual  and  Analytical  CyclopsBdia  of  Practical 
Medicine.  By  Charles  de  M.  Sajous,  M.D.,  and  one 
hundred  associate  editors,  assisted  by  corresponding  editors, 
collaborators  and  correspondents,  illustrated  with  chromo- 
lithographs, engravings  and  maps.  Vol.  vi.  F.  A.  Davis 
Company,  publishers,  Philadelphia,  New  York  and  Chicago, 
1901. 

As  previously  intimated,  this  annual  and  cyclopaedia  was  to 
be  issued  in  six  volumes  at  stated  intervals,  and  to  represent  the 
progress  in  all  branches  of  medicine  of  the  last  ten  years,  a 
monthly  journal  being  sent  to  each  subscriber.  This  volume 
is  the  last  of  thi«  series,  and  contains  the  matter  from  R.  to  Z. 
The  articles  are  very  comprehensive  and  contain  the  most  recent 
information.  That  on  Typhoid  Fever  in  this  volume  covers  thirty- 
five  pages,  and  is  a  fine  representation  of  the  treatment  of  the 
various  subjects.  One  need  not  go  further  than  this  article  to  gain 
a  full  knowledge  of  this  subject,  and  this  applies  to  most  of  the 
articles.  While  the  work  is  arranged  alphabetically,  it  is  not 
strictly  so;  thus,  under  urinary  system  we  find  most  of  the  surgical 
affections  of  the  kidney,  bladder  and  urethra.  In  discussing 
therapeutic  articles  many  agents  which  are  described  in  regular 
text-books,  but  which  have  become  almost  obsolete,  are  omitted, 
and  only  those  of  generally  recognized  virtue  and  tried  efficacy  are 
considered. 

Among  the  many  important  articles  in  this  volume  are  those 
on  Rheumatism,  by  Dr.  Levison,  of  Copenhagen  ;  Surgery  of  the 
Srtomach  and  Intestines,  by  Prof.  W.  W.  Keen  and  Dr.  M.  B. 
Tinker,  of  Philadelphia;  Surgery  ot  the  Spine,  by  Prof.  R.  H. 
Sagre,  of  New  York  ;  Surgery  of  the  Urinary  System,  by  Prof. 
J.  \V.  White  and  Dr.  A.  C.  Wood,  of  Philadelphia;  Diseases  of 
the  Uterus,  by  Prof.  H.  T.  Byford.  of  Chicago;  Wounds  and  In- 
juries of  ihe  Chest,  by  Prof.  L.  A.  Siimson  and  Dr.  E.  L.  Kyes, 
jun.,  of  New  York;  Typhoid  Fever,  by  Dr.  Jas.  E.  Graham, 
Toronto. 

A  very  complete  general  index  covering  over  one  hundred 
pages   concludes  the  volume. 

J.  B.  McC. 

The  Transactions  of  the  American  Electro-Thera- 
peutical Association  of  1899  19  30,  published  by  F. 
A.  Davis  &  Co.,  Philadelphia. 

There  is  no  doubt  that  the  different  elect  o-therapeutical  agents 
are   taking  a    larger  place  than  ever  in  the    management  of  patho- 
ogical  conditions,  and   justly    so.  "Particularly    is  this  true   of  the 
c    and  X-ray  methods. 

In  fact,  we  have  now  arrived  at  that  stage  where  certain  classes 
of  disease  can    only    be   successfully   managed   in   this  way,    and 


BOOK  REVIEWS,  43 

it  will  be  necessary  for  the  modern  physician  to  equip  himself 
accordingly  if  he  wishes  to  keep  pace  in  the  march  of  scientific 
therapeutical  progress. 

As  the  workers  in  this  field  hitherto  have  been  comparatively 
few,  we  therefore  look  upon  the  results  of  their  experience  with 
no  small  amount  of  interest. 

Every  year  shows  distinct  steps  in  advance,  not  only  in  the 
variety  of  conditions  treated,  but  also  in  the  manner  of  dealing 
with  them.  The  transactions  in  the  numerous  topics  referred  to 
and  the  attendant  discussions  offer  many  suggestions  of  interest 
and  worthy  of  the  careful  consideration  of  the  electro-therapeutic 
student.  The  treatment  of  such  affections  as  rheumatism,  sciatica, 
neurasthenia,  hysteria,  hypertrophied  prostate,  certain  forms  of 
cancer,  etc.,  have  always  baffled  the  medical  practitioner,  and  it  is 
to  this  class  of  conditions  particularly  that  electricity  in  its  newer 
methods  of  application  is  peculiarly  adapted,  bringing  certainly 
more  or  less  relief  if  not  absolute  cure. 

The  Transactions  are  well  worthy  of  perusal,  and  we  look  for- 
ward with  interest  to  similar  publications  in  the  future. 

W.   E.  D. 

A  Text  Book  of  Physiological    Ohemistry.    For  Stud- 
ents  of  Medicine   and  Physicians,  by  Charles  E.  Simon,  M.D., 
of  Baltimore,  author   of     ''Simon's   Clinical   Diagnosis."     In 
one  octavo    volume   of  452    pages.      Cloth  $3.25  net.     Lea 
Brothers  Si  Co.,  Philadelphia  and  New  York. 
This  work,   from  the  pen  of  Dr  Simon,  is  the  first  systematic 
text-book  of  Physiological    Chemistry  that   has    appeared  in  the 
United  States.     The  production  of  such    a  work  was  desirable    in 
view  of  the  rapid  strides  made,  of  late  years,  in  that  department  of 
science. 

The  arrangement  of  the  subject-matter  of  the  work  impresses 
us  favourably.  Its  first  section  treats  of  the  origin  and  ciiemical 
nature  of  food-substances,  and  c)f  ihe  products  of  their  decompo- 
sition. The  recent  advances  in  our  knowledge  of  the  chemistry 
of  the  carbohydrates  and  of  the  nitrogenous  derivatives  of  the 
albumins  are  here  clearly  presented.  The  second  section  deals 
with  the  processes  of  digestion,  resorption  and  excretion.  The 
various  digestive  fluids  concerned  in  the  transformation  of  food- 
stuffs into  material  which  can  be  utilized  for  the  needs  of  the 
tissues,  thtir  action  on  food  substances  and  the  resorption  of  the 
final  products  of  digestion  are  considered  in  detail. 

This  section  is  written  with  a  thorough  knowledge  of  the 
requirements  of  students  in  this  department  of  physiological 
chemistry.  Only  the  more  important  tests  are  given,  and  the 
methods  of  quaniitaiive  estimations  are  clearly  and  accurately 
described.  Exception  ir.ight  be  taken  to  the  statement  that  organic 
acids  in    concentrations    met  with    in    stomach    contents  do  not 


44  BOOK   REVIEWS. 

Strike  a  pink  culour  with  dimethyl-amido-azobenzol.  This  reagent, 
introduced  by  Topfer  for  the  detection  of  free  hydrochloric  acid, 
reacts  with  lactic  acid  in  a  concentration  of  i  in  1,500,  and  this 
acid  fometiines  occurs  in  stomach  contents  in  the  ab  )ve  propor- 
tion. Would  it  not  be  advisable  to  extract  all  organic  acids  likely 
to  occur  in  stomach  contents  with  ether  before  iipplying  Topfer's 
test  for  free  hydrochloric  acid? 

The  third  section  of  the  work  is  devoted  to  the  chemical  study 
of  the  tissues  and  organs  of  the  body  and  to  the  products  of 
their  action. 

Dr.  Simon's  work  is  well  adapted  to  the  needs  of  students,  and 
we  commend  it  as  a  thoroughly  practical  guide  to  workers  in  the 
Physiological  Laboratory. 

A.  B. 

International  Clinics- — A  quarterly   of  clinical  lectures  and 
especially  prepared  articles  on  all  branches  of  Med  nd 

Surgery  and  other  topics  of  interest  to  students  and'pracii- 
tioner.^.  By  leading  members  of  the  Medical  profession 
throughout  the  world.  Edited  by  Henry  W.  Catiell,  A.M., 
M.D.,  Philadelphia,  U.S..-^.,  with  the  collaboration  of  John 
B.  Murphy,  M.D.,  Chicago  ;  Alex.  1).  Bl  ickader,  M.D..  Mont- 
real; H.  C.  Wood,  M.D.,  Philadelphia;  I".  M.  Kotcli,  M.U., 
Boston;  E.  Landort,  M.D.,  Paris;  Thus.  G  M  irton,  M.D  , 
of  Philadelphia,  and  Chas.  H.  Reed,  M.D.;  J.  B.  Billantyne, 
M. D.,  of  Edinburgh;  and  John  Harold,  M.D.,  of  London;  with 
regular  correspondents  in  Montreal,  London,  Paris,  Leip^ic 
and  Vienna  ;  volume  li ;  eleventh  series.  J.  B.  Lippincott  & 
Co.,  Philadelphia,  lyor.  Canadian  Agent :  Charles  Roberts, 
1524  Ontario  Street,  Montreal 

The  present  number  of  this  popular  quarterly  of  clinical 
lectures  is  one  of  exceptional  interest,  owing  to  the  nimiber  of  ex- 
cellent articles  it  contains,  the  eminence  of  many  of  the  contributors 
and  the  timeliness  of  most  of  the  articles  Readeis  of  this  pcrio. 
dical  are  kept  in  touch  with  the  real  progress  in  medical  science. 
The  clinical  lectures  and  prepared  articles  represent  mostly  the 
experience  and  accumulation  <>{  knowledge  of  teachers  connected 
with  colleges  and  large  hospitals,  and,  being  presented  in  the 
the  clinical  rather  than  text-book  style  of  article,  is  at  once  attrac- 
tive to  the  reader,  as  well  as  being  laden  with  the  present  views 
and  representing  the  experience  and  practical  suggtstions  of  ripe 
thought  and  observation.  There  are  twenty-eigiii  articles  in  this 
number,  all  of  them  being  of  more  than  ordinary  interest.  Among 
the  more  important  are  the  following: — Surgical.Analgesis  by  Injec- 
tion of  Cocaine  into  the  Spinal  Column,  by  T.  A.  Taffin,  Paris;  The 
Oxytocic  Effect  of  Lumbar  Injection  of  Cocaine,  particularly  to  in- 
duce Labour,  by  A-  Dt)leris,  M-D-,  Paris;  The  Treatment  of  Putr- 
perai  Eclampsia,  by  Saline  Diuretic  Infusion  based  on  Ttventy-Two 
Cases,  Robert  Jardine,  M.D  ,  Edin.  ;  The   Treatment  of  Malignant 


BOOK    REVIEWS.  45 

Tumours  by  an  *Anticellular  Serum,  Dr.  Wlaeff,  of  Petersburg ; 
Smallpox,  with  Particular  Reference  to  the  Prevailing  Epidemic, 
Jaq.  '1'.  Schamberg,  M.D.,  Philadelphia — this  article  is  well  illus- 
trated ;  Actinomycosis  of  the  Respiratory  Tract,  by  Ludvi},'  Hek- 
toen,  M.D.,  Chicago  ;  The  Diagnosib  and  Prognosis  of  Some  Forms 
of  Blood  Disease  in  Infancy,  by  J.  S.  Fowler,  M.D-,  F.R.C.P-,  Kdin. ; 
Abortions,  by  J.  W.  Ballantyne,  M.D.,  F.R.CP.E.,  F.D.,  Edin., 
also    article    by  A.    Blackader,  M.D,,  Montreal.        J.  B.  McC. 

Progressive  Medicine.  A  quarterly  digest  of  advances,  discov- 
eries and  improvements  in  the  Medical  and  Surgical  sciences. 
Edited  by  Hobart  Amory  Hare.  M.D.,  Prof,  of  Therapeutics 
and  Materia  Medica  in  the  Jefferson  Medical  College  of  Phila- 
delphia, assisted  by  H.  R.  M.  Landis,  M.  D.,  Assistant  Physi- 
cian to  the  out-patient  Medical  Department  of  the  Jefferson 
Medical  College  Hospital.  Volume  IV.,  December,  1901. 
Lea  Brothers  &  Co.,  Philadelphia  and  New  York,   1901. 

This  volume  is  out  on  time  and  keeps  up  its  reputation  as  a 
first-class  digest  of  the  best  medical  and  surgical  literature  of  the 
preceding  three  months.  Where  so  many  subjects  are  embraced 
it  is  impossible  to  allude  to  them  in  detail,  btill  we  cannot  but 
draw  attention  to  the  article  on  Anaesthetics  by  Dr.  Bloodgood, 
which  occupies  fifty  pages  of  the  book.  It  is  a  complete  review  of 
all  that  is  known  on  this  most  important  question,  and  it  ought  to 
be  read  and  digested  by  every  operating  surgeon.  Ether  and 
chloroform,  of  course,  remain  the  drugs  of  choice  in  the  vast 
majority  of  instances  in  which  a  general  anaesthetic  must  be  given. 
Nevertheless,  other  general  anaesthetics  have  entered  the  field  in 
com  etition  and  are  rapidly  finding  iheir  proper  place,  such  as 
nitrous  oxide,  in  combination  with  oxygen,  ethyl-chloride  and 
ethyl-bromide.  All  the  anatsihetics  are  discussed,  and  the  conclu- 
sion drawn  is  that  it  is  unjustifiable  for  any  surgeon  to  tise  any 
one  anaesthetic  exclusively.  Stomach  surgery  has  several  impor- 
tant items,  and  though  they  do  not  occupy  much  space,  yet  oper- 
ating surgeons  will  read  them  with  satisfaction — for  the  indica- 
tions for  operating  are  definitely  laid  down  by  men  who,  from  ex- 
perience and  success,  have  a  right  to  speak  with  no  uncertain 
sound.  In  Dr.  Belfield's  section  on  genito-urinary  diseases,  the 
subject  of  general  infection  by  the  gonococcus  is  fully  discussed, 
and  tuberculosis  of  the  genito-urinary  tract  receives  the  attention 
which  its  importance  demands. 

The  various  pathological  conditions  of  the  kidneys  are  ably 
treated  by  Dr.  John  Rose  Brandford.  Particularly  instructive  is 
his  discussion  of  the  various  forms  of  albuminuria  and  the  varieties 
of  uremia.      Dr.   Brubaker's   section  on  Physiology  presents  the 


46  BOOK   REVIEWS. 

recent  advances  in  the  physiology  of  the  glandular  system  with 
special  reference  to  the  therapeutic  value  of  gland  extracts  in  their 
therapeutic  application.  He  also  presents  the  most  recent  conclu- 
sions on  the  study  of  artificial  fertilization.  The  section  on  Hy- 
giene by  Dr.  Baker  is  notable  because  of  the  universal  interest 
excited  by  the  discussion  aroused  by  Dr.  Koch's  statement  that 
bovine  tuberculosis  is  not  dangerous  to  man,  and  the  recent  re- 
searches as  regards  the  transmission  of  yellow  fever.  The  Prac- 
tical Therapeutic  referendum,  by  Dr.  E.  Quin  Thornton,  although 
placed  last  in  the  book,  possesses  the  greatest  general  interest  and 
value  to  all  practicing  physicians.  All  the  recent  therapeutic 
methods  and  remedies  are  presented  and  their  merits  and  demerits 
impartially  discussed.  It  constitutes  a  therapeutic  manual  of  the 
most  advanced  methods  of  treatment. 

In  this  brief  synopsis  of  the  contents  only  the  most  prominent 
features  are  touched  upon.  In  each  section  every  recent  advance 
of  value  in  relation  to  the  dis'eases  described  is  fully  written  of  and 
from  the  most  practical  standpoint.  The  contributors  are  all  au- 
thorities of  the  highest  standing.  The  book  is  not  a  mere  com- 
pilation of  recent  literature,  but  a  series  of  critical  reviews  and 
original  papers  by  masters  of  the  subjects  whereof  they  threat. 

F.  W.  C. 

A  Treatise  on  the  Acute  Infectious  Exanthemata, 

Including  Variola,  Rubeola,  Scarlatina,  Rubella,  Varicella, 
and  Vaccinia,  with  especial  reference  to  Diagnosis  and  Treat- 
ment. By  William  Thomas  Corlett,  M.D.,  L.R.C.P.,  London, 
Professor  of  Dermatology  and  Syphilology  in  Western  Re- 
serve University  ;  Physician  for  diseases  of  the  skin  to  Lake- 
side Hospital;  Consulting  Dermatologist  to  Charity  Hospital, 
St.  Alexis  Hospital  and  the  City  Hospital,  Cleveland;  Mem- 
ber of  the  American  Dermatological  Association  and  the 
Dermatological  Society  of  Great  Britain  and  Ireland.  Illus- 
trated by  12  coloured  places,  28  half-tone  plates  from  life, 
and  2  engravings.  Pages  viii-392.  Size,  6J  by  gj  inches. 
Sold  only  by  subscription.  Price^  extra  cloth,  $4.00  net,  de- 
livered Philadelphia,  F.  A.  Davis  Company,  publishers, 
1914-16  Cherry  Street. 

This  volume  is  in  my  opinion  unique,  and  fills  a  want  which 
is  constantly  being  felt,  owing  to  the  class  of  diseases  of  which  this 
book  deals,  being  now  treated  in  special  hospitals,  very  generally 
in  cities  under  civic  control.  Medical  students  but  seldom  have  the 
opportunity  of  seeing  them.  This  is  a  matter  of  regret,  for  it  is  of 
the  utmost  importance  that  the  acute  infectious  exanthema  should 
be  promptly  recognized.  The  public  are  constantly  being  made 
sufferers  from  the  want  of  this  early  recognition.  As  a  proof  of 
this  I  may  mention  that  much  of  the  smallpox  which  is  now  pre- 
valent in  this  province  is  due  to  the   fact  that  a  number  of  cases 


BOOK  REVIEWS.  47 

which  recently  occurred  in  a  village  near  Montreal  were  diagnosed 
as  chicken-pox.  In  reality  they  were  cases  of  smallpox,  and, 
though  of  a  mild  character,  produced  some  severe  cases.  The 
obstacles  then  in  the  way  of  bedside  instruction  makes  this  sub- 
ject one  of  the  most  difficult  departments  of  medicine  in  which  it 
is  possible  to  obtain  a  sufficient  degree  of  familiarity. 

The  coloured  plates  and  photo-engravings  are  simply  superb. 
They  could  not  be  truer  to  nature.  This  book  should  be  in  the 
hands  of  every  undergraduate  and  practitioner  in  medicine,  for  a 
careful  study  of  the  plates  will  enable  a  correct  diagnosis  to  be 
be  made,  even  though  a  case  has  never  been  seen.  The  text  is 
quite  up  to  date. 

F.  W.  C- 

The  Life    of  Pasteur.     By   Rane   Vallery-Radot,    translated 
from  the  French  by  Mrs.  K.  L.  Devonshire,  in  two  volumes. 
Price,    thirty-two    shillings.      Westminster:    Archibald    Con- 
stable &  Co.,  Ltd.,  2  Whitehall  Gardens,  1902. 
These  two  volumes  are  produced  in  beautiful  style.     Volume 
one  has  as  a  frontispiece  a  likeness  of  Pasteur,  which  is  admitted 
by   his  friends  to  be   an  admirable  one.     The  biographer  traces 
Pasteur's  career  from  his  birth,  on  Dec.  27,  1822,  down  to  his  death. 
It  can  well  be  imagined  that  the  life  of  a  man  so  distinguished  in 
the  scientific  world  must  contain   much   of  great  interest,  and  it 
certainly  does.     No  one  can  read  these  two  volumes  without  being 
struck  with  the  simple  home-like  nature  which  Pasteur  possessed, 
associated  with  an  independence  and  perseverance  which  was  little 
short  of  marvellous.     His  departure   from  Arbois  to  attend  school 
in  Paris  (and  travelling  in   those  days  was  no  small  undertaking) 
was  a  home  picture  which   illustrated  strongly  his  devotion  to  his 
parents.     Twenty  times  were  farewells  repeated  while  the  horses 
were  being  harnessed.     His  arrival  in  Paris  and    sojourn  there, 
although  he  was  accompanied  by  his  greatest  boy  friend,  was  not 
such  as  inspired  him   to  his  work.      He  became  low-spirited  and 
excessively   homesick,    and,    his    father    being   notified,  came    to 
Paris  and  took  him  home.     There  he  became  annoyed  at  his  want 
of  courage  in  giving  way  to  his  feelings.      For  a  time  he  tried  to 
bury    these   by    occupying    his    time    in    pastel    drawings,    but   a 
nature  such  as  his  could  not  live  in  the  quiet  of  his  old  home,  and 
his  ambition   to  pursue   his  education  induced  him  to  consent  to 
again  go  away  from   it.     This  time   he  did   not  go  so  far  as  Paris, 
but  to  the  Coll-ge  at  Besangon,  which  he  entered  to  prepare  for 
the  Ecole  Normale.     This  was  the  turning  point  in  his  life,  for  his 
progress  afterwards  was  steadily  onward  and  upward.     "  Onward  ' 
was  his  motto,  from  an  insatiable  thirst  for  knowledge.     Many  suc- 
cesses and  honours,  the  result  of  his   chemical   research   in  the 
laboratory,  reached  him,  but  his  first  marked  honour  came  to  him 
in  1854  when  he  was  made  Professor  and  Dean  in  the  new  Faculte 


48  PUBLISHERS'   DEPARTMENT. 

des  Sciences  at  Lille.  From  this  time,  till  stricken  with  haeraa- 
plegia  at  the  age  of  46  years,  his  work  had  been  of  immense  service 
to  the  various  French  industries.  Though  temporarily  laid 
aside  from  work,  his  convalescence  continued,  and  when  the 
Franco-Prussian  war  broke  out  he  was  so  improved  that  he  looked 
forward  to  an  early  resumption  of  his  laboratory  work.  But  it  was 
not  to  be  till  the  war  ended,  by  which  time  he  had  regained  much 
of  his  strength  and  was  able  to  move  about.  It  was  in  1873  that 
Pasteur  wrote :  "Howl  wish  I  had  enough  health  and  sufficient 
knowledge  to  throw  myself  body  and  soul  into  the  experimental 
study  of  one  of  our  infectious  diseases."  From  this  date  more 
markedly  is  shown  his  more  intimate  relations  with  the  medical 
profession.  His  views  on  germination,  Lord  Lister  says, 
demonstrated  to  him  the  truth  of  the  germ  theory  of  putrefacation, 
and  this  furnished  him  with  the  principle  upon  which  alone  the 
antiseptic  system  can  be  carried  out.  He  was  invited  to  visit 
Edinburgh  by  Lord  Lister  "  to  see  at  our  hospital  how  largely 
mankind  is  being  benefited  by  your  labours."  From  this  time  his 
work  in  the  field  of  serum  injections  as  preventative  of  certain  dis- 
eases is  well  known  to  the  majority  of  medical  men.  In  hydro- 
phobia his  labours  are  known  to  lay  and  medical  public  alike. 

Volume  two  is  the  most  interesting  10  ihe  medical  practi- 
tioner, and  will  more  than  repay  perusal.  On  the  28th  of  Sept., 
1895,  Pasteur  died,  leaving  behind  him  a  name  which  will  endure, 
I  was  going  to  say,  forever.  Few  men  have  done  more  for  his 
generation  than  he  has.  H'is  biography  will  well  repay  perusal, 
and  we  commend  it  to  all  our  readers. 

F.  W.  C. 


PUBIvISHKRS  DKPARTMBNT, 


LITERARY  NOTE. 
"No.  3000." 

Not  many  magazines  live  to  print  their  three-thousandth  number,  yet  the 
issue  of  The  Living  Age  for  January  4,  1002,  bears  that  number  on  its  title- 
]iage.  Founded  by  the  late  Mr.  E.  Littell,  in  1844,  this  magazine  has  carried 
to  its  readers  every  Saturday  for  nearly  fifty  eight  years  whatever  was  freshest, 
most  important  and  most  interesting  in  the  whole  field  of  foreign  periodical 
literature.  It  has  retained  its  essential  characteristics  through  this  long  period, 
and,  while  other  magazines  have  come  andgone,  has  strengthened  its  hold,  year 
by  year,  upon  the  intelligent  constituency  to  which  it  ministers.  Art,  science, 
travel,  biography,  literary  criticism  and  appreciation,  poetry,  fiction,  politics 
and  international  affairs — whatever  is  of  broad  human  interest  finds  a  place  in 
its  well -filled  and  clearly  printed  pages;  and  despite  the  multitude  of  younger 
magazines,  competing  for  the  public  favour,  there  never  was  a  time  when  this 
venerable  eclectic  was  more  nearly  indispensable  to  alert  readers  than  to-day. 
It  is  published  by  The  Living  Age  Company,  Boston. 


CANADA 

MEDICAL  RECORD 


FEBRUARY,     t902. 


Original  Communications. 

RETROSPECT  OF  liARYNGOLOGY.     " 

UNDEK  THE  CHARGE  OF 

GEO.  T.  ROSS,  M.  D..  D.  C.  L. 

Fellow  American  Laryiigological,  Otological  and  Rhinological  Society.  Laryngologist 

Western  Hospital,  &c..  Lecturer  on  Laryngology  and  Rhinology 

Medical  Faculty    University    of     Bishop's    College. 

TUBERCULAR    LARYNGITIS. 

St.  Clair  Thomson  concludes  an  article  on  this 
subject  as  follows : — Early  diagnosis  can  only  be  made 
by  watching  the  development  of  successive  pictures  by 
prolonged  observation,  not  that  of  to-day  alone,  but  that 
of  yesterday  and  to-morrow,  in  order  to  decide  for  or  against 
laryngeal  tubercle,  including  careful  examination  of  the  entire 
body. 

Pathology  and  clinical  experience  show  that  in  the  ma- 
jority of  cases  the  focus  of  infection  is  near  or  in  the  cryco- 
ary  tenoid  joint.  Early  diagnosis  should  be  made  while  the 
disease  is  in  an  incipient  stage.  Any  persistent  or  suspicious 
laryngeal  catarrh  should  be  treated  seriously.  Once  diag- 
nosed the  patient  should  be  treated  on  the  principles  laid 
down  in  the  modern  method  of  sanitorium  treatment. 
Symptomatic  treatment  should  be  directed  to  any  irritative 
catarrhal  or  obstructive  state  of  the  air  passages,  and  silence 
should  be  enjoined  to  rest  the  parts. 

Ewart  gives  the  result  of  protargol  injections,  and  says 
the  method  has  yielded  by  itself  satisfactory  results,  but  it  is 
not  claimed  to  be  more  than  the  first  and  most  important 
instalment  in  an  extensive  system  of    active    treatment.     He 


50  RETROSPECT  OF   LARYNGOLOGY. 

has  found  that  ichthyol  is  the  best  internal  remedy,  although 
a  place  is  still  to  be  found  for  the  old  remedies  as  necessary 
adjuncts.  The  continuous  inhalation  of  oxygen,  for  instance, 
is  stated  as  compatible  with  the  most  useful  forms  of  medica- 
tion. Idithyol  is  given  after  meals,  a  few  drops  in  pepper- 
mint water  with  a  daily  increase  of  one  minim  till  ten  minims 
are  taken.  In  some  cases  as  much  as  twenty  minims  have 
been  taken  with  advantage. 

RONTGEN  RAY  IN  THE  DIAGNOSIS  OF  TUBERCLE  OF  LUNGS. 

Bonnet-Leon  publishes  his  results  in  diagnosis  of  pul- 
monary tuberculosis  in  early  stage.  In  over  600  observations 
where  he  employed  the  fluorescent  screen  he  was  able  to  make 
a  precise  diagnosis  of  tuberculosis  in  98  per  cent,  of  the  cases 
even  at  the  commencement  of  the  disease.  In  the  very  earli- 
est stage  a  diagnosis  could  be  arrived  at  by  observing  the 
diaphragm  and  the  inspiratory  muscles.  Anomalies  in  the 
synchronism,  or  the  amount  of  displacement  of  the  two  halves 
of  the  diaphragm,  one  might  always  diagnose  a  predisposi- 
tion to  tuberculosis  or  a  commencing  tuberculosis.  In  this 
way  a  number  of  persons  apparently  in  good  health  had  be- 
come suspected,  in  whom  some  months  or  years  afterwards 
unmistakable  evidence  of  this  disease  had  manifested  itself. 

THE  NASO-PHARYNX  IN  SCARLATINA- 

Seibert  says  that  to  clean  and  to  disinfect  the  infiltrated 
mucosa  in  the  naso-pharyngitis  of  this  disease,  irrigations 
with  I  to  5  per  cent,  warm  solutions  of  ichthyol,  repeated 
every  six  hours,  have  been  successfully  used.  A  half  pint  is 
allowed  to  flow  through  the  nares  and  the  naso-pharynx 
from  a  fountain  syringe  suspended  about  three  feet  above  the 
patient.  When  the  infiltration  is  so  far  advanced  as  to  ob- 
struct the  passage-way  between  the  nose  and  throat,  irriga- 
tions will  be  found  insufficient,  for  the  fluid  then  returns 
through  the  other  nostril  without  coming  in  contact  with 
this  cavity.  During  the  past  year  six  cases  of  scarlatinous 
naso-pharyngitis,  in  which  irrigations  were  insufficient,  have 
been  treated  in  a  manner  which  readily  overcame  the  obstruc- 
tion ;  this  consists  of  local  applications  of  a  50  per  cent,  resorcin 
solution  in  alcohol.     These  resorcin-alcohol  applications  have 


INFANT  FEEDING.  5^ 

proved  themselves  to  be  perfectly  harmless,   and  are  indicated 
in  scarlatina  as  soon  as  the  naso-pharynx  becomes  involved. 

CHLORIDE   OF   ETHYL   IN    NASAL  SURGERY. 

Mackie  says  this  anaesthetic  greatly  simplifies  and  facili- 
tates his  work  in  nasal  and  throat  treatment.  Two  thousand 
cases  are  quoted  wherein  it  has  been  employed,  in  which  no 
dangerous  symptoms  manifested  themselves.  He  claims 
that  if  this  anaesthetic  is  used  carefully  it  is  an  ideal  one  for 
the  narcosis  of  minor  surgery.  The  principal  advantage  of 
it  is  the  rapidity  with  which  patients  come  under  its  influ- 
ence, while  the  apparatus  for  giving  it  is  not  as  cumbersome 
as  that  for  nitrous  oxide.  Goldan,  in  the  Medical  News 
dififers  from  these  conclusions,  but  does  not  set  forth  the  data 
furnished  by  Mackie. 

ACUTE  TONSILLITIS. 

Floersheim  claims  remarkable  results  from  the  applica- 
tion of  tincture  of  iodine  in  this  disease.  A  camel's  hair 
brush  with  the  tincture  is  rapidly  passed  over  all  the  inflamed 
area.  Should  intense  burning  result,  a  gargle  of  plain  warm 
water  is  enough  to  relieve  the  condition.  While,  if  no  burn- 
ing is  felt,  the  remedy  is  applied  a  second  time,  from  three  to 
five  minutes  after  the  first  application.  The  results  are  said 
to  be  marvellous,  for  in  five  minutes  the  pain  and  difficulty 
in  swallowing  are  relieved.  Ordinary  measures  were  used 
subsequently,  but  in  many  cases  it  seemed  to  abort  the  trouble, 
and  nothing  else  was  done. 


Selected  Articles. 


INFANT   FEEDING. 

"  In  reviewing  the  immense  amount  of  literature  which 
has  accumulated  on  the  subject  of  infant  feeding  we  find 
that  the  superiority  of  breast  feeding  is  acknowledged  so 
generally  that  it  may  be  said  to  have  become  a  scientific 
truth.  On  the  other  hand,  the  opinions  expressed  regarding 
artificial  feeding    are    so    diverse,  and  so    opposed  to  one 


52  INFANT  FEEDING- 

another,  that  it  is  evident  that  much  which  has  for  years 
been  taught  must  be  unlearned,  or  rather  admitted  to  be 
untrue,  before  we  can  expect  to  make  any  intelligent  advance 
in  this  most  difficult  subject." — Rotch. 

In  the  decade  which  has  elapsed  since  the  above  state- 
ment appeared  (Cf.  "  Keating's  Cyclopcedia  of  the  Diseases 
of  Children"  Vol.  i,  270)  no  subject  has  received  greater 
attention  at  the  hands  of  the  profession,  in  the  way  of 
scientific  study  and  clinical  experiment,  than  has  that  of 
"  infant  feeding,"  whose  generous  bibliography  is  unequalled 
by  that  of  any  other  branch  of  medicine  ;  and,  while  im- 
portant advances  have  been  made  in  our  knowledge  of  the 
composition  and  preparation  of  substitute  foods,  especially 
from  a  chemical  and  bacteriological  standpoint,  yet  a  critical 
review  of  recent  text-books  and  magazine  articles  reveals  the 
fact  that  the  same  diversity  of  opinion,  regarding  details  in 
the  methods  of  artificial  feeding,  exists  to-day  among 
specialists  as  well  as  the  rank  and  file  of  the  profession,  as 
that  which  was  complained  of  by  Prof  Rotch  ten  years  ago  ; 
therefore,  we  feel  justified  in  heading  our  article  with  the 
above-quoted  expression  of  this  author's  pessimistic  views. 
In  other  words,  we  believe  now  as  did  he  then,  that  much 
which  has  been  taught  and  accepted  as  truth  (even  during 
the  past  ten  years)  "  must  be  unlearned,  or  rather  admitted 
to  be  untrue,"  ere  we  shall  come  to  an  intelligent  under- 
standing and  agreement  upon  this  important  subject. 

Concurrence  of  Opinions. — It  is  agreed  that,  inasmuch  as 
breast  milk  is  the  child's  natural  food,  it  should  serve  as  the 
standard  by  which  to  judge  artificial  foods  ;  and  it  is  the 
generally  accepted  opinion,  that,  if  for  any  sufficient  reason 
the  babe  cannot  be  nursed,  the  most  practical  substitute  food 
is  cow's  milk.  The  only  mooted  question  is — how  shall  it 
be  prescribed  ?  Regarding  this  point,  there  is  great  dis- 
cordance of  views;  but  we  believe  it  is  now  admitted  by 
pediatric  specialists  and  by  every  general  practitioner  of 
experience  that  the  milk  should  be  diluted  or  modified  so 
as  to  correspond  as  nearly  as  possible  with  mother's  milk  in 
the  proportion  and  amount  of  its  chief  constituent  parts — 
i.  e.,  its  proteids,  fat  and  sugar.  The  analysis  of  breast  milk 
shows  that  these  three  essential  ingredients  are  present  in  the 
following  approximate  proportion  :  proteids  2,  fat  4,  sugar 
7  ;  while  in  cow's  milk  they  are  found  as  follows  :  proteid? 
4,  fat  4,  sugar  45^. 


INFANT  FEEDING.  53 

It  will  be  seen  that  in  modifying  cow's  milk  the  proteid 
must  be  reduced  one-half  by  diluting  the  milk.  This  reduces 
the  fat  and  sugar  also.  Hence  fat  and  sugar  must  be  added. 
The  theoretical  problem,  therefore,  is  simple  :  Reduce  the 
proteid  by  diluting  the  milk  ;  increase  the  fat  and  sugar  by 
adding  those  elements.  To  accomplish  this  purpose  it  has 
been  customary  to  dilute  one  pint  of  milk  with  au  equal 
quantity  of  water ;  but  as  the  already  deficient  amount  of 
sugar  has  then  become  still  further  reduced  (to  2^)  the 
deficiency  is  made  up  by  adding  a  tablespoonful  of 
granulated  sugar  or  milk  sugar  to  one  pint  of  the  mixture. 
As  fat  has  also  been  reduced  one-half  (to  2)  a  small  quantity 
of  cream  is  generally  added. 

Another  point  upon  which  physicians  agree  is,  that  milk 
from  the  herd  is  better  than  one  cow's  milk,  on  the  ground 
that  it  is  less  likely  to  vary  in  its  composition  from  day  to 
day.  Again,  it  is  admitted  that  sanitary  conditions  should 
be  insisted  upon  at  the  dairy  and  due  precautions  be  taken 
to  prevent  bacterial  infection.  Not  only  should  the  cows  be 
kept  clean  and  healthy,  but  cleanliness  should  be  observed 
by  the  men  themselves  at  the  time  of  the  milking,  while  the 
various  pails,  cans,  bottles,  etc ,  should  be  made  perfectly 
sterile-  In  other  words  the  profession  is  now  awakening  to 
the  importance  of  obtaining  c/ean  milk — that  which  is  fresh 
from  spore-bearing  bacteria. 

The  majority  of  physicians  are  now  convinced,  from 
clinical  experience,  that  diluted  "condensed"  milk  is  unfit 
for  infant  feeding — its  prolonged  use  very  frequently  pro- 
ducing rickets.  A  dilution  of  i  to  12,  the  one  most  com- 
monly used,  contains  but  )/%  the  amount  of  fat  and  ^^  the 
amount  of  proteid  of  average  breast  milk.  Double  that 
strength  contains  but  ^  the  proper  amount  of  fat,  but  the 
amount  of  sugar  is  so  excessive  as  to  soon  upset  the  stomach. 
It  is  evident,  therefore,  that  a  food  so  wide  of  the  standard 
is  not  a  proper  one  for  the  infant.  The  practice,  too,  observed 
now  at  some  dairies,  of  using  chemical  preservatives  in  milk 
such  as  borax,  boric  acid,  formaldehyde,  etc. — is  universally 
condemned  as  harmful. 

Diversity  of  Views. — Concerning  the  best  mode  of 
modifying  cow's  milk  so  that  it  may  resemble  breast 
milk,  not  only  in  the  proportion  of  its  constituents,  but  in  its 
digestibility — even  our  most  eminent  pediatricians  are  at 
loggerheads — one  advocating  "  laboratory"  and  the  other 
*'home"  modification,  in  both  of  which  methods  the  strength 


54  INFANT  FEEDING- 

of  the  mixture  may  be  varied  according  to  the  '  percentage" 
of  ingredients.  Among  those  prominent  in  pedriatic  circles 
who  have  advocated  laboratory  feeding  will  be  found  the 
names  of  Thomas,  Meigs,  Rotch,  Zahorski.  etc.,  while  on  the 
other  hand,  Crandall,  Chapin,  Kischer  and  others  suggest 
certain  methods  of  home-feeding  which  are  considered 
equally  scientific  and  far  more  practical. 

It  will  be  found,  too,  that  while  some  authorities  favour 
the  adoption  of  a  process  which  effectually  destroys  bacteria, 
and  inhibits  certain  fermentative  changes — i.  e.,  by  sterih'zing, 
pasteurizing,  etc. — the  majority  of  specialists  are  opposed  to 
this  procedure  and  recommend  feeding  upon  fresh  "raw" 
milk,  which  has  been  immediately  cooled  and  kept  at  a 
temperature  below  50*^  F.  Then,  too,  many  physicians 
believe  it  is  unwise  to  add  to  the  mixture  any  ingredient 
(especially  of  a  vegetable  nature)  not  found  in  normal  breast 
milk,  while  others  recommend  the  employment  of  certain 
cereal  infusions  as  diluents.  Again,  while  certain  proprietary 
milk-foods  are  advocated  by  the  general  practitioner,  the 
majority  of  specialists  condemn  each  and  all  such  foods  in 
unmeasured  terms. 

From  the  foregoing  observations  it  will  be  seen  that  the 
problem  of  "infant-feeding"  is  still  in  a  maze  of  doubt  and 
perplexity,  and  the  physician  who  is  anxiously  searching  for 
the  correct  solution  will  be  the  greater  confounded  the  more 
he  investigates  the  subject.  It  is  our  purpose,  therefore,  to 
present  as  briefly  as  may  be  the  suggestions  offered  by 
certain  prominent  specialists,  whose  opinions  must  command 
respect,  and  leave  it  to  the  judgment  of  each  individual 
reader  which  method  he  selects  as  being  likely  to  prove  most 
effective  in  actual  practice. 

Laboratory  Feeding. — Since  the  establishment  of  the 
first  modified  milk  laboratory,  in  Boston,  in  i8yi,  similar 
laboratories  have  been  established  in,  twelve  other  cities  of 
the  United  States,  besides  three  in  Canada  and  one  in 
London.  Under  the  management  of  Messrs.  Walker  and 
Gordon  (whose  names  these  institutions  bear),  working  under 
the  scientific  direction  of  Prof.  Rotch,  the  system  has  been 
developed  to  an  extent  little  dreamed  of  in  the  beginning, 
so  that  it  is  now  possible  for  a  physician  to  obtain  any  com- 
bination he  may  wish,  and  to  have  his  directions  carried  out 
with  the  same  care  and  accuracy  with  which  his  prescriptions 
are  filled  at  the  drug  store.  That  is  to  say,  the  different 
constituents  of  milk  may  be  varied  at  pleasure  according  to 


INFANT  FEEDING.  55 

the  judgment  of  the  physician — accuracy  in  the  modification 
being  thus  assured.  The  chief  function  of  the  laboratory, 
then,  is  to  fill  prescriptions  calling  for  certain  percentages  of 
fat,  sugar  and  proteids,  or  anything  else  which  the  physician 
may  desire  to  add — e.  g,  cereals,  mineral  matters,  malt, 
pancreatin,  patent  foods,  etc., — or  the  milk  may  be  ordered 
sterilized,  pasteurized  or  raw. 

The  general    principles  to    be    observed    in    laboratory 
feeding  are,  of  course,  those  of  percentage  feeding  in  general. 
The  most  important  indications    according  to  which  the  per- 
centages of  fat,  sugar  and  proteids  are  to  be  varied   may  be 
summarized  as  follows  :     Habitual  vomiting  or  regurgitation 
is   almost    always  due  to  an  excess  of  fat  or  to  over-feeding  ; 
and,  for  an  infant  with  such  symptoms,  the  percentage  of  fat 
must  be  reduced   as   well  as  the  quantity    of  milk.      If  the 
patient  is  not  gaining  in  weight,  and  yet  has  no  special  signs 
of  indigestion,  the  rule   is  to  increase  the  percentages  of  all 
the   ingredients.     "  Habitual  colic,"    says    Holt  (Cf.  N.  Y. 
Med.  Jour.,  Jan.  12,  1901),  "  is  nearly  always  from  an  excess 
of  proteids.      For  such  a  condition  one  should  not  give  more 
than  one  third  as  much  proteids  as  fat,  and  usually  at  first 
very  low  percentages.     This    condition  is  commonly  asso- 
ciated with  the  presence  of  curds  in  the  stools,  which  requires 
the    same  treatment."     For  obstinate  constipation   increase 
both  'at  and  proteids.     Something    should  be  said,  however, 
regarding  the  changes  required  in   milk  modification  during 
very  hot  weather.     At  such  times  both  the  proteids  and  fat 
must  be  reduced,  but  particularly  the  latter.     It  is  seldom 
wise  in    any   case,  even    with    perfectly  healthy  children,  to 
have  the  fat    in   the  summer  months  over  3  per   cent,  and 
during  short  periods  of  excessive   heat  it  should  be  reduced 
to  2  per  cent.     It  is  a  good    rule  to  begin  with   very  young 
infants,  with  low  percentages,  especially  of  the  proteids,  which 
should  not  be  above  .50  per  cent,  for  the  first  two  weeks  of 
life,  and  some  authorities  say  .25  per  cent.     Fats  and  sugars 
should   also  be   moderately   low,  about  2   per  cent,   for  the 
former  and  5  per  cent,  for  the  latter.     Of  course,  much  older 
children  sometimes  require  these  low  percentages  ;    but  for  a 
short  time  only. 

Home  Feeding. — The  prime  object  in  modifying  milk  is 
to  obtain  a  mixture  upon  which  the  infant  will  thrive,  and 
many  prominent  pediatrists  have  become  satisfied  from 
clinical  experience  that  if  care  be  taken  to  select  good  cow's 
milk,  in  which  the  growth  of  bacteria  has  been  prevented  by 
cooling,  and    due    observance    has   been    had    in    regard   to 


56  INFANT  FEEDING. 

cleanliness,  etc, — that  the  modification  of  milk  (with 
reference  to  percentages)  may  be  employed  with  the  same 
accuracy  and  much  more  practically  at  the  home  of  the 
patient  by  devoting  attention  to  certain  important  points. 
It  is  well  known,  for  instance,  that  the  fat  in  milk,  which  has 
stood  a  short  time,  rises  gradually  toward  the  surface  and 
eventually  forms  cream  ;  so  that  there  is  a  period  during 
which  the  percentage  of  fat  exists  in  regularly  increasing 
ratio,  advancing  from  the  bottom  toward  the  top.  Advantage 
has  been  taken  of  this  fact,  and  the  following  plan  adopted 
for  obtaining  certain  percentages  : 

The  milk  (rapidly  cooled  and  strained  after  milking)  is 
put  in  steriHzed  quart  bottles,  such  as  dairymen  use,  and 
kept  so  until  used — standing  in  the  ice-chest  from  12  to  24 
hours.  The  upper  portion  of  the  milk  is  now  richest  in  fat, 
which  has  disseminated  itself  from  below  upwards,  and  any 
percentage  desired  may  be  calculated  from  the  following 
table : 

9  ounces  top  milk,  I2  per  cent,  fat,  4  per  cent,  proteid. 

II        «'         "       "  10        "  "     4        "  " 

ic        c«         it        <<  g        <i  "4         "  " 

2Q  «  <c         «  6         "  "      d  "  " 

The  top  9  ounces  (or  more,  as  the  case  requires)  of 
cream  and  milk  are  removed  by  using  Chapin's  one-ounce 
dipper  ;  and,  after  proper  dilution  with  water  or  otherwise 
and  the  addition  of  sugar,  it  is  ready  for  feeding.  If  we 
wish  to  make  a  mixture  containing  proteid,  fat  and  sugar, 
in  the  proportion  of  2,  4,  7  (the  proportion  found  in  breast 
milk),  we  require  a  top  rnilk  containing  twice  the  amount  of 
fat  desired— /.  ^.,  15  ounces  top  milk.  The  method,  then, 
is  exceedingly  simple.  The  top  fifteen  ounces  are  dipped 
out,  diluted  one-half,  and  the  required  amount  of  sugar 
added  (usually  a  tablespoonful  to  the  pint  or  one  ounce  to 
twenty  ounces  of  the  mixture).  The  mixturethen  contains 
proteid,  fat  and  sugar  in  the  proportion  of  2,  4,  7. 

The  importance  of  procuring  clean  milk  cannot  be 
overestimated,  and  if  the  same  care  be  taken  that  only  the 
best  shall  be  used,  as  is  observed  in  the  Walker- Gordon 
laboratories,  there  is  no  reason  why  the  proportions  should 
not  be  made  as  accurate  in  home-feeding  as  in  laboratory 
feeding.  The  fitness  of  milk  for  infants'  food  depends 
largely  on  the  percentage  of  lactic  acid  present  and  on  the 
number  of  bacteria  to  the  cubic  centimetre.  In  the  words 
of  a  prominent  chemist:  "Lactic  acid  is  due  to  the  20 
varieties  of  bacteria  out  of  200  that  may  be  present  in  milk. 


INFANT  FEEDING.  57 

The  lactic  acid  bacteria  come  froai  the  teat  of  the  cow,  and 
can  be  largely  eliminated  by  throwing  away  the  first  few 
streams  when  milking.  Pathogenic  bacteria  get  into  the 
milk  through  the  water  used  in  cleaning  the  vessels  or  from 
persons  who  handle  the  milk.  Putrefactive  bacteria  come 
from  the  manure.  Great  care  should  be  taken  in  cleansing 
the  udder  and  teats  before  milking,  as  well  as  the  hands  and 
finger  nails  of  the  milker,  who  should  wear  a  duster  over  his 
working  clothes.  The  stables  should  also  be  clean."  The 
general  practitioner  is  now  awakening  to  the  supreme  im- 
portance of  this  subject,  and  the  future  is  likely  to  witness 
improved  methods  in  the  production  as  well  as  in  the  dis- 
tribution of  milk  throughout  the  country. 

Sterilization. — Pediatrists  are  now  practically  agreed 
that  sterilized  milk  is  unfit  to  be  used  for  any  length  of 
time  as  an  infant's  food  ;  but  the  general  practitioner,  who 
is  somewhat  rusty  in  his  chemical  knowledge,  has  been  slow 
to  recognize  the  fallacy  of  the  method,  and  many  physicians 
have  yet  to  learn  that  heating  milk  to  a  degree  necessary  to 
effect  its  sterilization  {i.  <?.,  to  destroy  existing  bacteriaj  must 
necessarily  produce  chemical  changes  therein,  which  will 
seriously  interfere  with  its  nutritive  properties  as  well  as  its 
digestibility.  Recent  investigations  have  shown  that  milk 
raised  to  a  temperature  of  loo"  C.  is  altered  in  the  following 
particulars  : 

1.  Its  proteids  are  modified  and  rendered  less  diges- 
tible, i.  e.,  the  lactalbumin  and  globulin  are  coagulated,  and 
the  casein  so  altered  as  to  increase  its  resistance  to  the  dis- 
integrating action  of  the  gastric  ferments. 

2.  The  combination  of  its  saline  ingredients  with  the 
proteids  is  more  or  less  broken,  and  the  salts  assume  a  con- 
dition in  which  they  are  less  readily  absorbed,  i.  e.,  the 
lactose  is  partially  changed  and  the  organic  phosphorus  is 
converted  into  an  inorganic  phosphate,  both  of  which 
changes  interfere  with  the  digestibility  of  the  milk.  Wrob- 
lewski  has  shown,  too,  that  certain  of  the  calcium  salts, 
necessary  for  the  coagulation  of  the  milk  in  the  stomach 
(and  which  in  raw  milk  are  in  a  soluble  state)  are  made  to 
enter  into  insoluble  combifiations  by  a  high  temperature. 

3.  Natural  ferments  which  are  present  in  milk,  and 
which  naturally  assist  its  digestion  in  the  infant's  stomach, 
are  destroyed  ;  Russell  and  Babcock  having  proved  that 
unsterilized  milk  undergoes  a  self-digestion  owing  to  the 
presence  of  a  trypsine  ferment  readily  destroyed  by  heat. 


58  INFANT  FEEDING. 

4.  Alteration  in  the  normal  emulsion  in  the  milk  also 
takes  place  from  the  action  of  heat  lessening  its  digestibility. 

5.  Observations  point  to  the  fact  that  immunity  to  dis- 
ease may  be  conveyed  through  the  mother's  milk,  and  that 
such  immunity — conferring  substances  (present  in  raw  milk) 
are  destroyed  by  a  heat  of  60"  C.  or  over,  thus  rendering 
children,  fed  exclusively  on  milk  sterilized  at  a  high  tem- 
perature, more  liable  to  certain  infections  leading  to  disturb- 
ances in  general  nutrition. 

6.  Clinical  experience  has  shown  that  such  affections 
as  scurvy  and  rickets,  and  other  disorders  of  malnutrition, 
may  result  from  a  diet  from  which  raw,  fresh  food  is  ex- 
cluded. 

In  his  work  on  "  Infant  Feeding,"  recently  published, 
Prof.  Louis  Fischer  devotes  conr^.i  'erable  space  to  and  em- 
phasizes the  necessity  of  feeding  with  cow's  milk  in  its 
"natural  state,"  i.  e., feedittg  uith  raw  milk.  "This,"  sa\s 
one  prominent  author,  "  seems  ofif  liand  like  a  broad  state- 
ment, but  when  we  consider  that  breast  milk  is  'raw  milk' 
and  that  we  are  simply  copying  from  nature  by  feeding, 
then  we  can  readily  see  the  vast  importance  of  this  methi  d 
of  feeding.  Clinical  evidence  is  certainly  in  favour  of  fee  i- 
ing  milk  in  its  raw  state  owing  to  its  anti-scorbutic  qualitii  •=, 
and  besides  it  does  not  cause  that  terrible  bugbcarer  of  the 
beginner  and  possibly  also  the  older  practitioner,  viz.,  cc  n- 
stipation." 

Does  it  not,  then,  seem  better  to  aim  in  securing  cle  .11 
milk  and  applying  the  principles  of  sterilization,  or,  if  yiu 
prefer  the  term,  pasteurization,  to  the  stable,  to  the  milkt  's 
hands  and  to  all  utensils  coming  in  contact  with  the  mlk 
from  the  beginning  to  the  end  of  the  milking?  In  t  is 
manner  we  do  away  with  the  possible  contamination  of  I  le 
milk,  with  stable  and  other  filth,  and  avoid  infection  w)ih 
micro-  organisms. 

Diluents. — No  phase  of  the  infant-feeding  problem  h  is 
been  studied  so  assiduously  or  created  so  much  controver-^y 
as  has  the  vexed  question  of  "diluents";  and,  while  ;  II 
authorities  are  agreed  that  cow's  milk  should  be  diluted  \sx\\ 
something  to  bring  down  the  excess  of  proteid,  yet  there  is 
great  diversity  of  opinion  as  to  which  is  the  best  agent  to 
use  for  this  purpose.  Simple  dilution  with  water  has  been 
recommended  by  some;  others  suggest  the  addition  of  an 
alkali,  such  as  plain  or  saccharated  lime-water  ;  one  prominent 
pediatrist  favours  a  decoction   of  gum-arabic  or  solution  of 


INFANT  FEEDING.  59 

gelatine  as  a  diluent  for  very  young  infants,  and  another 
equally  noted  specialist  argues  strongly  in  favour  of  cereal 
infusions.  It  is  our  purpose  here  to  call  attention  to  the 
latter  method,  which  is  probably  more  extensively  em- 
ployed than  any  of  the  others,  and  give,  in  brief,  the 
reasons  advanced  for  its  use,  by  its  chief  promoter,  whose 
name  is  favourably  known  in  pediatric  circles  over  the  en- 
tire world. 

In  a  paper  entitled  "The  Place  of  Cereals  in  Infant 
Feeding,"  read  before  the  American  Pediatric  Society,  at 
Niagara  Falls,  May  28,  1901,  Henry  Dwight  Chapin, 
M.D.,  of  New  York,  recommends  for  use  as  a  diluent  in 
home  modifications  a  predigested  cereal  gruel  made  as  fol- 
lows :  "  Make  into  a  paste  two  tablespoonfuls  of  wheat  or 
barley  flower  with  cold  water,  and  add  to  a  quart  of  water. 
Boil  fifteen  minutes  ;  add  a  pinch  of  salt.  When  cool  add 
to  this  a  preparation  of  diastase.  Cereo  (a  glycerite  of 
diastase)  is  especially  recommended,  two  teaspoonfuls  to  the 
quart.  Of  this  diluent,  now  dextrinized,  add  three  parts  to 
one  part  of  the  'nine  ounces  of  top  milk';  add  the  sugar, 
one  part  to  twenty,  and  you  have  a  humanized  milk."  "  On 
the  theoretical  side,"  says  this  author,  "it  must  be  con- 
fessed that,  at  first  sight,  the  employment  of  a  material  in  a 
form  not  found  in  human  milk  may  appear  unwarranted  to 
those  who  desire  a  strictly  scientific  reason  for  all  pro- 
cedures." But,  we  may  add,  if  it  can  be  shown  that  the 
curd  of  cow's  milk  is  thus  rendered  more  digestible,  a  strong 
reason  appears  for  its  employment. 

The  introduction  of  system  into  infant  feeding  has 
been  a  great  advance  and  has  doubtless  come  to  stay,  but  it 
has  also  emphasized  the  fact  that  changing  the  percentages 
in  cow's  milk  to  correspond  with  those  in  breast  milk  dees 
not  change  cow's  milk  into  woman's  milk.  Changing  the  per- 
centages of  proteid,  fat  and  sugar,  in  cow's  milk  to  equal 
those  of  woman's  milk  simply  records  the  quantities  of  those 
ingredients  in  cow's  ihilk.  While  we  must  admit  the  im- 
portance of  efifecting  this  agreement  (/.  e.,  in  the  percentages 
of  these  three  essential  ingredients),  and  believe  that  it 
should  always  be  accomplished,  yet  we  must  not  remain 
blind  to  the  fact  that  one  of  these  ingredients  of  cow's  milk, 
viz.,  the  proteid,  is  not  of  the  same  nature  as  that  of  mother's 
milk.  In  other  words,  the  proteid  in  the  latter  is  one  part 
casein  to  two  parts  albumin  and  globulin,  while  in  cow's 
milk    the   proteid    is  composed  of  four  fifths  casein.     Inas- 


60  INFANT  FEEDING. 

much  as  albumin  and  globalin  are  readily  soluble  and  easily 
digested  and  absorbed,  while  casein  is  insoluble  and  must 
undergo  certain  transformations  before  it  can  be  absorbed, 
it  will  be  seen  that  the  proteid  of  cow's  milk  ( 4  casein)  re- 
quires more  digestive  effort  than  the  proteid  of  woman's 
milk  (^  casein). 

It  may  be  seen  the  amount  of  curd  formed  in  milk  de- 
pends upon  the  proportion  of  casein  present,  and  the  le  s 
bulky  the  curd  the  more  easily  digested  is  the  milk.  White 
and  Ladd,  of  Harvard,  as  a  result  of  their  experiments, 
have  arrived  at  the  conclusion  that,  by  the  use  of  whey  as 
a  diluent  of  creams  of  various  strengths,  they  are  able  to 
modify  cow's  milk  so  that  its  proportions  of  casein  and 
soluble  (whey)  proteids  will  closely  correspond  to  the  pro- 
portions present  in  human  milk — thus  rendering  it  much 
more  digestible  and  suitable  for  infant  feeding.  They  claim 
that  whey  cream  mixtures  yield  a  much  finer,  less  bulky 
and  more  digestible  coagulum  than  plain  modified  mixture 
with  the  same  total  proteids.  They  admit,  however,  that 
barley  water  mixtures  yield  a  coagulum  equally  fine.  It 
will  be  seen,  ttierefore,  that  it  is  to  break  up  the  curd  of 
cow's  milk,  and  thus  furnish  a  small  quantity  of  easily  ab- 
sorbable food,  that  cereal  gruels  (in  which  the  starch  has 
been  converted  into  dextrin  and  maltose)  are  advocated  as 
diluents;  it  having  already  been  shown  that  the  curd  of 
cow's  milk,  with  a  digested  gruel  diluent,  passed  through  a 
sieve  having  900  meshes  to  the  square  inch,  while  those 
with  water  diluent  remained  on  the  sieve.  How  much 
effect  a  digestive  gruel  has  on  the  curd  of  milk  depends,  of 
course,  on  the  strength  of  the  gruel  and  the  dilution  of  the 
milk. 

Thus,  after  years  of  careful  study  and  experiment,  it 
has  been  found  that  cow's  milk  may  be/  so  modified  as  to 
correspond  very  closely  to  mother's  milk,  not  only  in  the 
relative  proportions  of  its  total  constituents  (proteid,  fat  and 
sugar),  but  also  in  the  composition  of  the  proteid  itself — the 
casein  being  so  reduced  that  a  much  less  bulky  curd  is 
formed  which  is  more  easily  digested.  It  is  for  this  latter 
purpose  that  White  and  Ladd's  "whey  mixtures"  and 
Chapin's  "cereal  infusions"  have  been  recommended  ;  and, 
though  experience  has  proven  that  they  are  advantageous 
in  many  cases,  yet  the  fact  remains  that,  though  the  curd 
has  been  reduced  in  amount,  it  is  not  of  the  same  character 
as  that  formed  from  mother's  milk,  i.  e.,  it   is  still  often   re- 


INFANT  FEEDING.  6 1 

gurgitated  from  the  infant's  stomach  in  hard,  lumpy  masses. 
To  overcome  this  latter  difficulty,  after  many  expedients 
have  been  tried  and  nothing  found  that  the  patient  will 
tolerate  (and  where  there  is  little  time  for  further  experi- 
ment), the  following  plan  may  always  be  adopted  and  for 
the  reasons  hereinafter  given  : 

Caroidization. — There  are  two  great  classes  of  milk: 
I.  Those  that  form  hard,  solid  curds  with  rennet — 
cow's  milk.  2.  Those  that  form  soft,  flaky  curds  with 
rennet — woman's  milk  In  other  words,  the  rule  seems 
to  be  that  animals  that  ruminate  furnish  their  young 
with  milk  that  curds  in  solid  lumps  and  animals  that 
masticate  their  food  before  swallowing  it  furnish  their 
young  with  milk  that  curds  in  soft  flakes.  The  human 
stomach  receives  food  in  a  finely  divided  state,  and  woman's 
milk  curds  in  loose  flakes. 

Dr.  Brush  has  explained  this  property  of  forming  hard 
curds  as  belonging  to  the  milk  of  all  cud-chewers  in  contra- 
distinction to  the  softer  and  more  flaky  curds  of  the  milk  of 
those  animals  which  are  not  cud-chewers.  He  says  :  "  The 
young  of  the  former  all  chew  the  cud  soon  after  birth,  there- 
fore the  milk  designed  for  their  use  contains  a  variety  of 
casein  which  coagulates  into  a  mass  sufficiently  hard  and 
consistent  to  be  regurgitated  and  chewed,"  Furthermore,  it 
has  been  shown  by  analysis  (Cf.  Richmond's  "  Dairy  Che- 
mistry ")  that  the  milks  that  form  solid  curds  with  rennet 
are  furnished  by  animals  whose  normal  digestion  \s  prolojiged 
and  whose  elimentary  canals  are  relatively  very  much 
longer  than  those  animals  whose  milk  forms  soft  flaky  curds. 
It  is  evident,  therefore,  that  the  human  infant's  stomach  is 
likely  to  find  difficulty  in  digesting  the  casein  of  cow's 
milk  (even  when  present  in  the  same  proportion  as  in 
mother's  milk)  unless  it  is  first  partially  broken  up  so  as  to 
form  a  fine  flocculent  curd — easily  disintegrated  and  ren- 
dered fit  for  absorption; 

It  has  been  found  that  during  digestion  there  is  an  in- 
creased elimination  of  nitrogen  from  the  system  which  is 
proportional  to  the  intensity  ot  digestive  work  ;  also  an  in- 
crease of  about  fifteen  per  cent,  in  the  quantity  of  oxygen 
consumed  and  a  larger  increase  of  carbon  dioxide  thrown  ofif.- 
This  shows  an  immediate  demand  for  proteids  and  carbo- 
hydrates at  the  beginning  of  a  meal  ;  and  it  is  known  that 
when  milk  is  taken  into  the  stomach  the  first  step  in  its 
digestion  is  a  separation    of  the  easily  absorbable  albumins 


62  INFANT  FEEDING. 

and  sugars  from  the  casein  and   fat,  which  require  digestion 
as  they  are  left  in  a  semi-solid  state. 

It  will  thus  be  seen  that  the  increased  demand  for  pro- 
teids  and  carbohydrates,  during  digestion,  is  met  by  a 
separation  of  the  soluble  constitutents  of  the  milk  as  soon  as 
it  is  swallowed.  Furthermore,  the  secretion  of  all  the  diges- 
tive juices  is  promoted  by  this  absorption  at  the  beginning 
of  the  msal,  i.  e.,  the  normal  digestive  process  is  ushered  in. 
This  is  what  happens  when  woman's  milk  is  taken.  But 
when  cow's  milk  diluted  with  water  is  given  to  an  infant  the 
quantity  of  readily  absorbable  food  is  reduced  to  almost 
nothing,  and  the  proteids  and  fat  form  a  solid  curd  which  is 
either  regurgitated  or  passes  on  into  the  intestines  to  fer- 
ment and  serve  as  a  source  of  irritation.  The  result  of  this 
process,  if  continued,  is  to  interfere  with  the  secretion  of  the 
digestive  ferments ;  and  milk  which  enters  the  stomach 
finally  meets  with  the  same  reception  that  it  would  if  it  were 
injected  into  the  rectum,  i.  <?.,  it  remains  unabsorbed  because 
its  insoluble  constituent  (casein)  has  not  been  changed  into 
(soluble)  peptone.  Every  practitioner  of  any  experience 
knows  that  in  feeding  by  the  rectum  the  milk  must  first  be 
peptonized  —  or  it  will  not  be  absorbed. 

For  the  same  reason  in  many  cases  of  infantile  mal- 
digestion the  casein  of  cow's  milk  must  be  put  into  a  partially 
digested  or  soluble  condition  before  its  administration,  i,  e.^ 
it  must  be  acted  upon  by  a  ferment.  The  value  of  barley 
water  and  other  cereal  infusions,  in  breaking  up  and  making 
the  curd  soften,  is  due  to  the  action  of  the  starches  and 
diastasic  ferments  vhich  they  contain.  The  food  that  is 
most  finely  divided  and  can  most  easily  leave  the  stomach  is 
the  most  suitable  for  weak  digestions.-  Digestive  enzymes 
act  by  contact  and  neither  take  away  nor  add  anything  to 
the  substance  acted  upon.  For  this  reason,  a  pure  vegetable 
ferment,  like  caroid,  is  superior  to  a  cereal  infusion  which 
adds  starch,  cellulose  and  other  constituents  to  the  food, 
which  must  themselves  be  dige-^ted. 

In  all  cases  of  faulty  digestion,  therefore,  caused  by  the 
formation  of  insoluble  curds  in  the  infant's  stomach,  caroidized 
milk  prepared  as  follows  will  be  found  of  the  greatest 
utility:  Heat  the  purest,  freshest  cow's  milk  obtainable 
(modified  as  suggested  under  "home  feeding")  until  luke- 
warm, then  stir  two  or  three  grains  of  caroid  into  it,  and 
when  the  curd  has  set  (which  will  be  within  two  or  three 
minutes)  beat  it  up  until  it  is  almost  re-liquefied.  Re-warm 
this  if  necessary,  and   feed   through  a  nipple  as  in  ordinary 


A  PLEA  FOR  LARGER  DOSES  OF  ANTITOXIN.  63 

bottle  feeding.  After  the  caroid  has  been  added  the  milk 
must  not  be  allowed  to  stand  very  long,  as  it  will  acquire 
the  bitter  taste  characteristic  of  the  formation  of  peptone. 
Each  feeding  should  be  prepared  separately,  therefore,  and 
should  be  fresh. 

The  advantages  of  the  above  method  are  :  i.  That  it  is 
impossible  to  re-curdle  milk  thus  treated,  hence  tough  and 
indigestible  curds  are  avoided.  2.  Digestion  will  go  on  in 
both  the  stomach  and  intestines  until  the  casein  is  entirely 
absorbed,  the  process  being  assisted  partially  by  the  diges- 
tive apparatus  of  the  infant. 

As  hyperacidity  usually  prevails  in  the  infant's  stomach 
in  cases  of  maldigestion  some  physicians  prefer  to  neutralize 
this  condition  by  adding  lime  water  to  the  milk  in  the  pro- 
portion of  one  to  four.  This  may  also  be  done  with 
caroidized  milk.  An  efficient  substitute  for  lime  water  is 
the  "liquor  calcis  saccharatus "  of  the  British  Phar- 
macopoeia, from  five  to  fifteen  drops  of  this  solution  being 
added  to  each  half  pint  of  the  milk  mixture. 

REFERENCES. 

1.  "Practical  Hyoiene,"  Charles  Harrington,  Phil.,  1 90 1. 

2.  "Therapeutics  of  Infancy  and  Childhood,"  A.  Jacobi,  Phil.,  1898 

3.  "  Manual  of  Diseases  of  Children,"  John  Madison  Taylor,  Phil.,  1901. 

4.  "Infant  Feeding,  etc,"  Louis  Fischer,  Phil,  and  Chicago,  190I. 

5.  "  The  Feeding  of  Infants,"  Joseph  E.  Winters,  New  York,  1901. 

6.  "  Diseases  of  Children,"  Wm.  M.  Powell,  Phil.,  1901. 

7.  "Artificial  Feeding  of  Infants,^'  Blackader,  Ret.  Handbook  of  the 
Med.  Sciences,  VIII.  ;  92-102. 

8.  While  and  Ladd,  Phil  Med.  Jotir.^  Feb.  2,  1901. 

9.  Practical  Food  Prescribing,  Crandall,  Dominion  Med.  Mo.,  June,  1901. 

10.  Percentage  and  Laboratory  Feeding,  Griffith,  PhiL   Med.   jfour.^  Mar. 
16,  1901. 

11.  Laboratory  Feeding,  Thomas,  The  Cleveland  Med.  Gazette ,  Aug. ,  1901. 

12.  Cereals  in  Infant  Feeding,  Chapin,  Med,  /?iv.,  July  6,  1931. 

13.  Whey  Cream  Modifications  in  Infant  Feeding,  Med.  Age,  Feb.  25,  190I. 
14    Sterilization  of  Milk,  Blackader,  N.  \.  Med.  Juur,,  Feb.  2,  1901. 

15.   Substitute  Infant  Feeding,  Chapin,  A'.  Y.  Med.  Jour  .^  XXIII.  ;  No.  8. 
10.  The  Artificial  Feeding  of  Infants,  Holcombe,  The  Med.  Council,  Mar., 
1899. 


A  PI^EA  FOR  UVRGER  DQSES   OF  ANTITOXIN  IN   THE 
TREATMENT   OF  DIPHTHERIA. 

BY   JOHN    H.   MCCOLLOM,   M.D. 

Dr.  McCollom  first  calls  attention  to  the  statistics  prov- 
ing the  fact  that,  in  the  time  previous  to  the  use  of  anti- 
toxin, diphtheria  was  more  prevalent  and  yielded  a  higher 
mortality  rate   in  Boston  than    in  London,    Paris.  Berlin, 


64  A  PLEA  FOR  LARGER  DOhES  CF  ANTITOXIN 

Liverpool  and  Glasgow.  He  also  quotes  statistics  which 
prove  that  in  no  other  American  city  has  the  mortality 
rate  from  diphtheria  undergone  such  "marked  and  con- 
tinue us  diminution"  as  has  occurred  in  Boston,  and  states 
that  "a  diminution  from  18  per  10,000  to  4,99  in  five  years 
cannot  be  attr.buted  to  good  fortune  nor  to  the  mild  types 
of  ihe  disease.  This  diminution  can  only  be  explained  by 
the  u^e  of  antitoxin  and  treatment  in  hospital"  .... 
"In  the  prehistoric  days,  previous  to  1895,  in  the 
Boston  City  Hospital  the  rate  (of  mortality)  was  40  per 
cent.  In  the  same  hospital,  since  1895,  during  which  time 
7,657  patients  were  treated  with  antitoxin,  the  percentage 
of  mortality  was  12.9.  It  must  be  borne  in  mind  that  these 
were  all  cases  of  diphtheria  both  from  a  clinical  and  from 
a  bacteriological  point  of  view." 

Dr.  McOollom  quctes  statistics  which  prove  that  in  the 
Boston  City  Hospital,  where  very  large  doses  of  antitoxin 
were  employed,  the  mortality  rate  is  much  lower  than  in  the 
other  three  large  contagious  disease.hospitals,  viz-,  those  of 
London.  Glasgow  and  Philadelphia.  'Tor  instance,  com- 
lare  the  ho>pital  in  Philadelphia  with  a  percentage  of 
mortality  of  63  in  children  under  one  year  of  age,  with  that 
of  the  Boston  City  Hospital  (contagious-disease  depart- 
ment), with  a  percentage  of  26."  This  difference  is  all  the 
more  striking  when  one  considers  that  the  mortality  rate 
in  very  young  children  is  extremely  high. 

Dr.  McCollom  quotes  figures  which  show  that  this 
difference  in  mortality  between  the  Boston  City  Hospital 
and  other  contagious-disease  hospitals  is  equally  pro- 
nounced among  patients  of  all  ages,  and  in  the  laryngeal 
types  of  the  disease,  and  in  the  cases  requiring  intubation 
or  tracheotomy. 

These  statistics,  based  upon  thousands  of  cases,  prove 
conclusively  that,  by  large  doses  of  antitoxin,  many  thou 
sands  of  patients,  who  now  die  when  only  small  or  mod- 
erate doses  are  employed,  could  be  saved  by  employing 
antitoxin  in  the  quantities  used  in  the  Boston  City  Hos- 
pital. In  the  following  quotation  from  Dr.  McCollom's 
paper,  the  proper  adaptation  of  the  quantity  of  antitoxin 
to  the  individual  case  is  tersely  urged: 

"No  hard  and  firm  rule  can  be  made  regarding  the  use 
of  the  serum.  The  agent  must  be  given  until  the  charac- 
teristic effect  is  produced  on  the  diphtheritic  membrane. 
In  sonie  cases  4,000  units  will  accomplish  this;  in  other 
instances  60,000  or  70,000  units  may  be  required.  When  a 
guinea  pig  is  inoculated  at  the  laboratory  with  a  certain 
definite  amount  of  the  toxin  of  diphtheria,  it  is  a  very  easy 
matter  to  antagonize  this  with  a  certain  amount  of  antl- 


IN  THE  TREATMENT  OF  DIPHTHERIA.  6$ 

toxin.  In  the  case  of  a  patient  ill  with  diphtheria,  there  is 
no  way  of  estimating  the  quantity  of  toxin  generated  by 
ihv^  nienibiane,  and,  therefore,  one  must  administer  the 
agent  until  the  characteristic  etfect  is  produced,  viz..  the 
shiiveling  of  the  membrane,  the  diminution  of  the  nasal 
discharge,  the  correction  of  the  fetid  odor  and  a  general 
improvement  in  the  condition  of  the  patient.  In  the  opera- 
tive cases  the  beneficial  ettect  of  large  doses  of  antitoxin 
has  been  marked,  preventing,  in  many  instances,  the  exten- 
sion of  membrane  to  the  smaller  ramifications  of  the 
bronchi — a  most  important  factor  in  raising  the  death 
rate  in  this  class  of  cases.  In  the  operative  cases,  it  is 
safe  to  say  that  nearly  twenty  per  cent,  of  the  deaths  were 
caused  by  blocking  of  the  bronchi  with  diphtheritic  mem- 
brane. At  the  South  Department  the  autopsies  proved  this 
fact. 

"No  case  of  diphtheria  should  be  considered  hopeless. 
Antitoxin  should  be  administered  in  each  and  every  in- 
stance. It  has  been  my  experience  during  the  past  few 
years  to  see  so  many  jiatients  apparently  hopelessly  ill 
recover  that  my  convictions  are  very  firm  on  this  subject. 
When  one  sees  a  patient  with  membrane  covering  the  ton- 
sils and  uvula.  ]>rofuse  sanious  discharge  from  the  nose, 
spots  of  ecchymosis  on  the  body  and  extremities,  cold, 
clammy  hands  and  feet,  a  feeble  pulse  and  the  nauseous 
odour  of  diphtheria,  and  finds  that  after  the  administration 
of  10000  units  of  antitoxin,  in  two  doses,  the  condition  of 
the  patient  improves  slightly,  that,  after  10,000  units  more 
have  been  given,  there  is  a  marked  abatement  in  the  se- 
verity of  the  symptoms;  that,  when  an  additional  10.000 
units  have  been  given,  the  patient  is  apparently  out  of 
danger,  and  eventually  recovers,  one  must  believe  in  the 
cuKitive  powder  of  antitoxin.  When  one  sees  a  patient  in 
whom  the  intubation  tube  has  been  repeatedly  clogged — 
w^hen  the  hopeless  condition  of  the  patient  changes  for  the 
better  after  the  administration  of  50-000  units,  one  cannot 
help  but  be  convinced  of  the  importance  of  giving  large 
doses  of  antitoxin  in  the  very  severe  and  apparently  hope- 
less cases.  In  the  majority  of  instances  these  large  doses 
are  not  required,  particularly  if  the  patients  are  seen  early 
in  the  attack,  4,00(T  to  6,000  units  being  enough  to  produce 
the  charactei-istic  effect  on  the  membrane.  As  illustrating 
the  advantage  of  the  early  administration  of  antitoxin,  an 
allusion  to  the  cases  of  diphtheria  occurring  in  the  staff  of 
the  South  Department  may  be  of  interest.  There  have  been 
since  September.  1895.  104  instances  of  diphtheria  contrac 
ted  in  the  line  of  duty,  and  not  a  single  death      Each  pa- 


65  A  PLEA  FOR  LARGER  DOSES  OF  ANTITOXIN 

tient  received  a  full  dose  of  antitoxin  (4,000  units)  at  the 
outset,  or  as  soon  as  there  were  any  symptoms  of  the 
disease.  In  some  instances  it  was  not  necessary  to  repeat 
the  dose;  in  others  the  doses  were  repeated  two  or  three 
times.  It  is  of  interest  to  note  that  in  this  series  of  cases 
there  were  no  marked  symptoms  of  paralysis;  that  heart 
complications  did  not  occur,  and  that  the  duration  of  the 
illness  was  comparatively  short.  It  must  be  borne  in  mind 
that  th?se  were  genuine  cases  of  diphtheria,  contracted 
under  unfavourable  conditions. 

"In  the  study  of  any  particular  line  of  treatment  for 
a  special  disease,  the  clinical  picture  presented  by  patients 
ill  with  that  disease  is  always  of  interest,  and  is  frequently 
more  conclusive  than  a  simple  array  of  figures.  A  short 
history  of  a  few  of  the  extremely  severe  cases  of  diphtheria, 
in  which  antitoxin  was  administered  in  large  dosea.  will 
Le  given. 

"■Case  1. — A  boy,  six  years  of  age.  When  admitted  he 
had  been  ill  three  days;  there  was  a  large  patch  of  mem- 
brane on  each  tonsil;  the  uvula  was  edematous;  there  was 
a  profuse  nasal  discharge.  Dyspnoea  was  very  great,  and 
there  was  marked  cyanosis.  The  cultures  were  positive. 
Pulse  feeble  and  rapid.  Temperature,  99.5.  There  was  a 
slight  trace  of  albumin  in  the  urine.  He  was  intubed  at 
once,  and  given  4,000  units  of  antitoxin.  The  intubation 
tube  not  giving  relief,  it  was  removed  in  ten  minutes,  when 
the  patient  expectorated  a  quantity  of  thick,  tough,  tena- 
cious mucus,  and  the  breathing  immediately  became  easier. 
On  the  second  day  after  admission  the  dyspnoea  was  urgent, 
and  the  boy  was  re-intubed  with  marked  relief.  In  four 
days  this  patient  had  5G,000  units  of  antitoxin  without  any 
injurious  effect  and  with  positive  relief.  He  was  discharg- 
ed well.  He  had  none  of  the  usual  sequelae  of  diphtheria. 
He  did  have  a  troublesome  urticaria.  The  heart  did  not 
at  any  time  have  an  irregular  action;  there  was  no  indica- 
tion of  paralysis. 

"Case  2. — A  girl,  six  years  old.  She  had  been  ill  three 
days  when  admitted.  The  tonsils  and  uvula  were  covered 
with  a  thick  membrane.  Pulse  rapid  and  weak.  The  mem- 
brane commenced  to  disappear  in  three  days,  but  on  the 
fourth  it  commenced  to  re-form,  and,  therefore,  large  doses 
of  antitoxin  were  given.  In  all  this  patient  received  80,000 
units  of  antitoxin.  The  cervical  glands  suppurated.  At  one 
fme  during  the  course  of  the  attack  the  action  of  the  heart 
was  irregular.  There  was  a  slight  palatal  paralysis.  At  one 
time  there  was  a  slight  trac^^  of  albumin  in  the  urine.  She 
made  a  good  recovery. 


IN  THE  TREATMENT  OF  DIPHTHERIA.  6^ 

"Case  3. — A  man  eighteen  years  old.  He  had  been  ill 
one  week  at  the  time  of  admission.  There  was  great  pros- 
tration; a  profuse  nasal  discharge  with  a  foul  odour;  there 
was  a  very  extensive  membrane  covering  the  tonsils,  uvula 
and  palate.  The  action  of  the  heart  was  feeble;  the  sounds 
indistinct.  Pulse  feeble.  The  general  condition  indicated 
speedy  death.  He  had  on  entrance  an  initial  dose  of  6,000 
units  of  antitoxin,  repeated  in  five  hours.  The  next  day  he 
had  four  doses  of  6,000  units  each,  and  on  the  third  and 
fourth  days  a  like  quantity.  On  the  fifth  day  after  entrance 
the  throat  was  clear  and  the  mucous  membrane  normal  in 
appearance.  For  the  first  four  days  delirium  was  a  marked 
symptom.  The  patient  was  unable  to  swallow,  and  food 
and  stimulants  were  given  by  the  rectum.  At  one  time 
there  was  a  slightly  nasal  voice,  but  there  was  no  marked 
paralysis.  The  action  of  the  heart  was  regular  at  the  time 
oli  discharge.  A  slight  trace  of  albumin  was  found  in  the 
urine-  Urticaria  was  an  annoying  complication,  but  not 
a  grave  one.  There  was  no  arthralgia-  Brandy  and 
strychnia  were  given  in  large  doses.  It  is  cases  of  this 
class  that  swell  the  mortality  ratio  of  hospitals.  "The 
patient  was  moribund  when  admitted;  he  left  the  hospital 
well,  and  has  been  well  up  to  the  present  time.  It  is  pos- 
sible that  the  man  might  have  recovered  with  a  slightly 
diminished  dose;  it  is  certain  that  the  usual  doses  of  anti- 
toxin would  not  have  saved  his  life,  and  it  is  also  certain 
that  no  injurious  effect  followed  the  large  dose. 

"Case  4. — A  coloured  boy,  seven  years  old.  On  admission 
this  patient  had  a  very  weak  pulse;  the  heart  sounds  were 
feeble;  the  tonsils,  uvula  and  hard  palate  were  covered 
with  a  dirty  necrotic  membrane;  there  was  a  profuse  nasal 
discharge;  the  cervical  glands  on  the  right  side  had  slough- 
ed; there  was  an  intolerable  odour-  His  condition  was  as 
unfavourable  as  it  could  well  be.  The  boy  had  84,000  units 
of  antitoxin  in  five  days.  He  was  discharged  well  in  sixty- 
six  days.  At  the  end  of  the  sixth  day  after  entrance  the 
condition  of  the  patient  had  improved  so  much  that  no 
one  who  bad  not  seen  him  on  entrance  would  have  believed 
that  he  had  been  so  critically  ill.  He  made  a  good  recovery, 
which  was  somewhat  delayed  by  post-diphtheritic  paraly- 
sis. He  was  nourished  during  part  of  the  time  by  the  rec- 
tum. At  one  time  during  convalescence  he  had  one-eighth 
of  one  per  cent,  of  albumin  in  the  urine.  This  albuminuria 
could  not,  however,  be  attributed  to  the  antitoxin,  as  it  is 
one  of  the  most  frequent  symptoms  in  severe  attacks  of 
diphtheria,  and  was  recognized  and  described  long  before 
the  davs  of  antitoxin. 


68  A  PLEA  FOR  LARGER  DOSES  OF  ANTITOXIN 

'•Many  more  cases  might  be  cited  iu  which  large  doses 
of  antitoxin  were  given  with  satisfactory  results,  but 
enough  has  been  said  to  prove  that  small  doses  of  anti- 
toxin are  of  little  avail  in  the  treatment  of  grave  types  of 
the  disease;  that,  iu  order  to  obtain  the  best  results,  the 
serum  must  be  heroically  administered.  It  is  true  that  all 
of  the  patients  to  whom  large  doses  of  antitoxin  have 
been  given  have  not  recovered,  but  so  many  of  them  have 
that  one  must  be  convinced  that  large  doses  are  impera- 
lively  demanded  in  very  severe  cases.  When  death  has 
occurred  it  has  been  from  nerve  degeneration  or  from 
sepsis.  In  no  instance  was  there  any  injurious  effect  pro- 
duced by  either  the  large  or  small  doses  of  antitoxin.  Albu- 
minuria, although  present  in  many  cases,  cannot  be  attri- 
buted to  the  serum,  as  albuminuria  is  one  of  the  most  fre- 
([uent  symptoms  in  diphtheria.  Heart  complications  of  a 
serious  nature  have  not  been  so  frequent  in  the  7,657 
patients  treated  at  the  South  Department  as  would 
have  been  the  case  in  a  like  number  treated  withouL 
antitoxin.  Paralysis,  although  occurring  in  the  severer 
cases,  has  not  been  so  prominent  as  it  would  have  been  in 
an  equal  number  of  cases  treated  without  antitoxin. 
Urticaria  and  arthralgia  are  certainly  very  annoying  com- 
plications, but  they  do  not  imperil  the  life  of  the  patient, 
and  are,  therefore,  not  worthy  of  being  considered  an  argu- 
ment against  the  use  of  the  serum. 

''Although  different  remedies  were  used  to  prevent 
tlie  extension  of  membrane  before  the  advent  of  antitoxin, 
the  death  rate  from  diphtheria  remained  about  the  same 
until  the  introduction  of  antitoxin.  Before  tlie  days  of 
antitoxin  there  was  no  method  of  limiting  the  extension 
of  the  membrane.  The  number  of  different  applications 
to  the  diphtheritic  membiane  was  so  great  as  to  prove 
that  no  one  of  them  was  satisfacory.  No  germicide  can 
be  of  sufficient  strength  toi  effectually  destroy  the  bacilli 
of  diphtheria  without  causing  destruction  of  the  mucous 
membrane,  and  thus  opening  a  fresh  field  for  the  growth 
of  the  organism. 

"From  a  comparison  of  the  health  reports  of  Boston 
(before  and  after  the  introduction  of  the  anti-diphtheritic 
serum),  from  a  comparison  of  the  health  reports  of  other 
cities,  from  a  study  of  hospital  reports,  from  a  clinical 
observation  of  nearly  8,000  cases  of  diphtheria,  the  follow- 
ing conclusions  are  justifiable: 

"1.  That  the  ratio  of  mortality  of  diphtheria,  per 
10.000  of  the  living,  was  very  high  in  Boston  previous  to 
189^. 

"2.  That  the  ratio  of  mortaliH  per  10.000  has  been 
very  materially  reduced  since  the  introduction  of  anti- 
toxin. 


DISEASES  OF  INFANCY  AND  CHILDHOOD.  69 

"3.  That  the  percentage  of  mortality  in  the  South 
Department  is  lower  than  that  of  any  of  the  hospitals 
taken  for  comparison. 

"A.  That,  since  larger  doses  of  antitoxin  have  been 
given,  the  death  rate  has  been  materially  reduced,  the 
reduction  having  occurred  in  the  apparently  moribund 
casts, 

"5.  That  no  injurious  effect  has  followed  the  use  of 
the  serum. 

^'6.  That,  to  arrive  at  the  most  satisfactory  results 
in  the  treatment  of  diphtheria,  antitoxin  should  be  given 
at  the  earliest  possible  moment  in  the  course  of  the 
diseas?.'' 

THE    FOUR   ESSENTIALS    IN    THE   TREATMENT    OF      DIPHTHERIA. 

1.  Use  antitoxin  early — soon  as  diphtheria  is  sus- 
pected. For  immunizing,  500  to  1,000  units  are  recom- 
mended. 

2.  Curative  dose:  Where  the  attack  of  diphtheria  is 
slight  and  the  patient  is  treated  on  first  day  of  disease. 
2,01  0  units  is  invariably  sufficient;  when  treated  on  second 
or  third  day  of  disease  give  3,000  units.  Where  the  ad- 
ministration of  antitoxin  is  delayed  or  disease  is  severe, 
never  administer  less  than  3,000  units.  In  all  cases  repeat 
or  double  the  initial  dose  if  favourable  results  do  not 
follow  within  six  or  eight  hours  after  first  injection — no 
bad  results  can  follow  its  use.  Remember  the  only  danger 
is  in  insufficient  dosage.     Keep  patient  quiet  and  in  bed. 

3.  Children  require  larger  doses  than  adults,  since 
they  are  more  susceptible  to  the  disease.  Remember  anti- 
toxin is  an  antidote,  and  sufficient  must  be  given  to  fully 
neutralize  the  toxins  of  diphtheria.  There  is  no  danger  of 
giving  too  much,  but  of  using  too  little. 


DIAGNOSIS   IN  DISEASES   OF  INFANCY  AND 
CHILDHOOD. 

B/ JOHN  Za^HORSKY,  M.D.St  Louis. 

Clinical  Lecturer  on  Children's  Diseases.  Wasliington  riiiversity.  Medical  Department; 
Attending  Physician  to  the  Bethesda  Foundling  Home. 

CONVULSIONS. 

infantile  convulsions  or  eclampsia  is  that  group  of 
symptoms  characterized  by  general  or  partial,  irregular, 
clonic  muscular  contractions.  Loss  of  consciousness  ac- 
com])anie3  these  contractions. 

The  underlying  pathologic  condition  is  a  heightened 
irritability  of  the  central  nervous  system  which  results  in 


70  DISEASES  OF  INFANCY  AND  CHILDHOOD. 

a  series  of  motor  discharges  induced  by  a  peripheral  or 
cential  excitant. 

It  is  assumed  that  the  practitioner  will  recognise 
these  clonic  muscular  spasms. 

Having  administered  chloroform  or  utilized  any  other 
appro]  riate  means,  and  the  severity  of  the  spasms  having 
been  subdued,  the  causation  of  the  symptoms  must  be 
sought.     Take  the  rectal  temperature. 

I. A  VERY  HIGH   FEVER  IS   PRESENT. 

In  the  majority  of  cases  a  very  high  fever  or  hyper- 
pyrexia will  be  found  to  exist.  Further  inquiry  must  then 
be  instituted  as  to  the  cause  of  the  fever.  The  principles 
laid  down  in  the  former  articles  on  fever  are  perfectly  ap- 
propriate in  this  condition.  The  same  care  must  be  ob- 
served in  examining  the  various  organs  of  the  bodj'  for 
evidences  of  infection. 

Affections  of  the  respiratory  tract,  which  are  initiated 
with  a  high  temperature,  must  be  considered.  Among 
these  influenza  and  pneumonia  are  the  most  frequent. 
During  an  epidemic  of  influenza  convulsions  are  exceed- 
ingly common  among  infants. 

Infections  of  the  gastroenteric  tract  are  the  common 
causes  of  this  group  of  symptoms.  But  no  doubt  in  the 
past  there  has  been  too  great  a  stress  laid  on  intestinal 
irritants.  Toxemia  from  decomposing  food  may  excite 
fever  and  convulsions.  At  the  onset  of  fermental  or  in- 
flammatory diarrhoea  and  dysentery  convulsions  may 
arise.  But  it  is  not  rational  to  assume,  as  many  practi- 
tioners seem  to  do,  that  the  majority  of  cases  are  caused 
by  eating  some  indigestible  food. 

Eclampsia  is  a  common  symptom  in  all  acute  infec- 
tions of  the  nervous  system.  When  the  attacks  are  re- 
peated very  frequently  in  twenty-four  hours  and  the 
patient  is  over  two  years  of  age,  cerebral  infections  must 
be  ^ti'ongly  suspected.  In  infants,  on  account  of  the  open 
cranial  sutures  and  fontanelles,  eclamptic  seizures  are  less 
common  even  in  grave  cerebral  diseases  than  might  be 
expected. 

The  blood  infections  to  be  considered  are  malaria  and 
the  acute  exanthemata.  In  malarious  countries  the 
former  di?ea?'e  must  invariably  be  given  first  place. 
Scarlet  fever  among  the  infectious  diseases  is  the  most 
apt  to  cause  spasms. 

Acute  suppurative  inflammations  in  any  of  the  inter- 
nal organs,  as  the  bones,  muscles,  cellular  tissue,  liver, 
kdney,  etc.,  may  serve  as  the  exciting  cause. 


DISEASES  OF  INFANCY  AND  CHILDHOOD.  7  I 

In  summer,  during  the  very  hot  weather,  thermic 
fever  is  not  rare.  When  the  temperature  reaches  107 
degrees  convulsions  are  imminent. 

II- LITTLE  OR  NO   FEVER  IS   PRESENT. 

When  little  or  no  rise  in  temperature  exists  one  is 
compelled  to  assume  that  some  hereditary  or  acquired  in- 
.stability  of  the  nervous  system  is  present. 

Under  congenital  or  hereditary  influences  must  be 
classed  defects  of  the  ceretral  structure,  cerebral  par- 
alysis, epilepsy  and  various  neuropathic  states  not  classi- 
fied. A  lepeated  afebrile  convulsion  in  the  absence  of 
demonstrable  organic  disease  always  suggests  epilepsy. 

Among  the  acquired  conditions  are  acute  diseases  and 
chronic  diseases  of  the  central  nervous  system,  which  pro- 
duce alterations  in  its  structure  and  functions.  Acute 
encephalitis,  cerebral  hemorrhage,  meningitis,  etc.  Each 
of  these  ma^  have  changes  which  thereafter  leave  the 
motor  area  in  an  unstable  condition. 

Nutritive  disturbances,  so  common  in  infancy,  must 
always  be  studied.  Kickets  is  a  condition  which  enhances 
the  irritability  of  the  nervous  system,  and  slight  excitants 
may  initiate  a  motor  discharge.  The  most  characteristic 
is  that  form  of  tonic  spasms  called  tetany,  which  must  be 
sharply  differentiated  from  the  clonic  spasms  of  eclampsia. 
Laryngo-spasm  is  rather  similar  to  tetany. 

Various  forms  of  malnutrition  may  create  an  'unstable 
nervous  system.  The  starvation  following  disease  of  the 
stomach  and  intestines,  tuberculosis,  laryngeal  stenosis 
and  syphillis  can  so  change  the  function  of  the  nervous 
system  as  to    result  in  great  irritability. 

Having  determined  the  existence  of  this  nervous  in- 
t-tability  the  peripheral  excitant  must  still  be  sought.  In 
the  presence  of  a  slight  fever  some  mild  infection,  such  as 
influenza,  tonsilitis,  stomatitis  ard  gastroenteric  disease 
should  be  suspected. 

Simple  iiritation  of  the  end  organs  of  certain  afferent 
nerves,  whether  this  irritation  is  caused  by  thermal,  me- 
chanical or  chemical  agents  may  serve  as  the  exciting 
cause.  The  skin,  the  alimentary  mucous  membrane,  the 
genito  urinary  tract  and  the  respiratory  tract  must  each 
be  separated,  studied.  The  baby  must  be  stripped  and 
examined.  Inquiry  must  be  made  as  to  the  recent  diet. 
The  genitive  organs  should  be  examined  as  to  the  presence 
of  phimosis.  The  urine  should  be  studied  for  uric  acid 
crvstals. 


T2  TONSILITIS. 

Sudden  changes  in  the  intracranial  pressure,  whether 
induced  bj  a  paroxysm  of  pertussis,  a  severe  straining,  as 
in  constipation,  enhirged  thymus  gland  or  other  tumour 
pressing  on  the  large  vessels  leading  to  the  cranium,  each 
of  these  may  serve  as  a  factor  in  the  etiology. 

When  all  our  efforts  fail  to  locate  the  cause  outside  of 
the  brain,  and  the  convulsions  are  repeated,  the  brain  must 
become  the  point  of  continued  study.  Epilepsy  is  the 
most  common.  But  cerebral  tumour,  abscess,  chronic 
hydrocephalus,  cerebral  syphilis,  hemorrhage  and  chronic 
meningitis,  each  must  be  carefully  excluded. 

Many  times  severe  injuries  to  the  cranial  vault,  or  to 
other  parts  of  the  body  result  in  convulsions.  But  here  the 
immediate  history  or  the  signs  of  injury  at  once  suggest 
the  cause. 

Hysterical  convulsions  occur  also  in  childhood.  They 
are  often  puzzling,  and  only  careful  study  will  reveal  their 
true  nature. 

But  often  a  convulsion  will  come  and  pass  away 
harmlessly,  and  the  physician  will  not  have  been  able  to 
make  a  positive  diagnosis. — Mfd.  Fortnif/htli/. 


TONSILLITIS. 


Diagnosis. — Dundas  Grant  says  that  occasionally  the  med 
ical  attendant  and  friends  of  patients  affected  with  acute  ton- 
sillitis are  considerably  alarmed  by  the  appearance,  on  the 
upper  and  posterior  part  of  the  tonsil,  of  what  seems  to  be  a 
deep  excavated  ulcer  of  oval  shape,  the  floor  of  which  is 
covered    with  a  white,  slough-like  membrane. 

Killian  points  out  that  in  rhe  new-born  child  the  tonsil 
consists  ot  three  masses  of  tonsil-tissue,  between  which  are 
two  furrows;  the  uppermost  mass  and  the  furrow  next  to  it 
are  the  most  persistent ;  the  lower  furrow  gradually  disappears, 
and  the  tissue,  which  forms  the  bulk  of  the  adult's  tonsil,  is 
covered  to  a  considerable  extent  by  a  triangular  fold  of 
membrane  running  downward  and  backward  from  the 
anterior  pillar  of  the  fauces. 

Killian  recommends  for  the  better  examination  of  the  ton- 
sil that  the  head  should  be  turned  toward  the  affected  side, 
the  tongue  pulled  out  toward  that  side  and  the  opposite 
angle  of  the  mouth  retracted  while  the  patient  utters  the 
sound  "hay."  In  this  position  the  tonsil  is  looked  at  more 
nearly  from  the  middle  line,  so  that  the  furrow  and  the 
marginal  cushion    above  and  behind  it  can  be  readily  recog 


TONSILITIS.  73 

nized.  It  is  extremely  probable  that  the  furrow  has  been 
frequently  mistaken  for  excavating  ulcers  by  others,  as  they 
have  been  personally. 

Etiology. — Follicular  tonsillitis  and  peritonsillitis  are 
believed  by  Joseph  Meyer  to  be  due  to  the  infection  of 
toxins  or  bacteria,  the  latter  probably  made  active  by  what 
is  commonly  called  a  cold,  setting  the  bacteria  into  action, 
upon  a  field  which  they  before  may  have  occupied,  but, 
through  said  cold,  the  field  has  become  a  field  of  less  resist- 
ance and  a  most  suitable  soil  for  bacterial  activity  and 
absorption  of  toxins.  The  tonsils  may  have,  as  claimed  by 
some,  anti-bactericidal  properties,  but  because  of  their  peculiar 
conformation  they  also  have,  in  a  high  degree,  the  capacity 
for  storing  bacteria  and  putrefactive  matter,  either  of  which 
may  become  active  through  a  cold  or  of  their  own  accord 
at  any  time  that  conditions  are  favourable. 

Prophylaxis. — W.  Freudenthal  says  that  it  is  impossible  to 
prevent  acute  lacunar  inflammation  by  the  use  of  any  drug, 
but  it  can  be  done  by  attention  to  the  climatic  factors,  which 
play  an  important  role  in  the  etiology  of  this  affection.  To 
prevent  acute  lacunar  amygdalitis  one  should  not  bundle  up 
•children  in  cloths,  but  harden  them  to  changes  of  temper- 
ature. Mucus  dropping  down  into  the  naso-pharynxand  dry- 
ing, acts  as  a  foreign  body,  and  causes  an  irritation  which 
predisposes  to  lacunar  inflammation.  The  obvious  indica- 
tion is  to  treat  the  naso-pharynx. 

Treatmant. — Joseph  Meyer  thinks  that  the  abortive 
treatment  of  follicular  tonsillitis  and  peritonsillitis  consists  of 
two  things,  viz.: — 

1.  Treatment  of  the  initial  stage. 

2.  Cleansing  the  lacunae  by  syringing  them  with  bi- 
chloride solution  I  to  I  coo. 

If  the  patient  is  seen  early  enough  and  the  preceding 
symptom  of  a  cold  are  present,  a  uniform  temperature,  also 
rest  in  bed,  with  hot  beef-tea  or  milk  as  a  drink,  getting  up 
a  good  sweat  followed  by  a  hot  towel  rub-down,  will  often 
abort  or  anieliorate  an  attack  of  follicular  tonsillitis  or  quinsy 
by  bringing  about  less  favourable  condition  for  bacterial 
action. 

A  simple  one  fourth  or  one-half  ounce  syringe  of  the 
laryngeal  type  is  personally  used  for  syringing  the  lacunae. 
If  the  mouths  of  the  lacuna  are  narrow,  one  of  the  lips  may 
be  lifted  up  with  a  cotton-carrier  or  blunt  curette,  stretched 
slightly,  or  opened  with  a  small  knife,  and  then  the  syringe 


74  TONSILITIS. 

can  be  introduced  with  ease.  The  nozzle  of  the  syringe 
should  be  introduced  deeply  into  the  lacunse  and  the  fluid 
injected ;  often  one  will  be  surprised  to  see  a  plug  come  out 
of  a  neighbouring  lacuna  or  the  fluid  injected  from  a  number  of 
lacunar.     The  relief  often  is  immediate. 

In  cases  where  most  of  the  inflammatory  trouble  has 
passed  over,  but  one  or  two  lacunje  are  filled  with  cheesy 
matter,  leaving  still  a  sore  sensation,  some  pain  on  swallow- 
ing, with  some  swelling  of  the  tonsil;  this  method  is  admir- 
ably adapted.  The  syringing  must  be  thoroughly  done  with 
a  proper    syringe,  and   quite  warm    bichloride  solution    (i  to 

lOOOj. 

According  to  Samuel  Floersheim,  the  local  appHcation  of 
tincture  of  iodine  in  acute  tonsillitis  is  of  value.  The  method 
of  application  is  simply  to  saturate  a  long  camel's-hair 
brush  with  the  tincture  of  iodine,  and  rapidly  brush  over  the 
inflamed  area  i.e.,  tonsils,  pharynx,  u/ula,  fauce=,  etc. 
Should  the  patient  experience  intense  burning  after  two 
minutes,  a  gargle  of  plain,  warm  water  suffices  to  relieve  the 
condition.  If  the  patient  does  not  experience  the  burning 
the  remedy  is  usually  applied  a  second  time,  from  three  to 
four  minutes  after  the  first  application.  The  results  have 
been  marvelou=.  Patients  who  had  considerable  pain  were 
relieved,  and  those  who  could  not  sleep,  eat  or  drink  were 
also  relieved  within  five  minutes. 

In  68  cases  of  acute  catarrhal  and  follicular  amygdalitis 
treated  by  this  method  within  the  past  two  years  the  most 
gratifying  results  have  been  noted.  Relief  from  the  distress- 
ing symptoms  was  observed  within  five  minutes  after  the 
application  of  the  remedy  to  the  inflamed  area  in  every  case 
observed.  The  intense  redness  and  swelling  nlso  became 
considerably  decreased  within  five  minutes. 

When  the  inflamed  area,  after  twenty-four  hours,  had 
shown  much  improvement  with  a  tendency  toward  a  rapid 
cure,  the  application  of  the  tincture  of  iodine  was  not  re- 
peated. In  some  of  the  cases  nothing  else  was  done  ;  in  others 
the  usual  throat  remedies  appropriate  to  the  disease- were 
prescribed. 

M.  R,  Ward  says  the  treatment  of  acute  lacunar  inflam- 
mation should  be  both  local  and  constitutional.  The  local 
application  of  guaiacol  is  alleged  by  some  to  have  the  power 
to  abort  the  process.  Small  pieces  of  cracked  ice  or  ice  water 
are  decidedly  useful  in  the  early  stages.  The  patient  should 
be  freely  purged  with  calomel  or  with  effervescent  phosphate 


MEDICINE   AND   NEUROLOGY.  75 

of  sodium.  The  value  of  tincture  of  chloride  of  iron  cannot  be 
over-estimated,  and  it  should  be  given  throughout  the  acute 
stage.  Codeine,  salol  and  phenacetin  relieve  the  headache 
and  other  pains.  The  tonsils  should  be  removed  in  the  inter- 
val of  the  attacks. — Monthly  Cyclopcedia  of  Medicine, 


Progress  of  Medical  Science. 

MKDICINB    AND     NEUROI^OQY 


IN   CHARGE   OP 

J.  BRADFORD  McOONNELL,  M.D. 


Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College ;  Physician  Western  Hospital . 


USES  AND  ABUSES  OF  ARSENIC. 

'  Arsenic  is  one  of  our  most  valuable  medicines,  and 
one  that  is  not  as  popular  as  it  should  be  among  the  pro- 
fession generally.  Many  practitioners  who  do  not  see 
much  of  skin  diseases  seem  to  have  an  idea  that  arsenic  is 
a  remedy  which  can  be  administered  in  almost  every  lesion 
of  the  skin  with  advantage,  and  fail  to  recognize  that,  as 
a  rule,  it  is  contra-indicated  whenever  the  layers  of  the 
skin  are  inflamed,  being  most  useful  when  the  epiderm  is 
dry  and  improperly  nourished,  and  of  very  little  use  when 
the  corlum  is  inflamed.  Psoriasis  is  a  typical  disease  of 
the  former  class,  and  in  its  treatment  arsenic  is  a  standard 
remedy.  As  stated  above,  the  medicine  should  not  be  pre- 
scribed during  the  inflammatory  stage  of  a  skin  disease. 
When  used,  it  should  be  kept  up  for  weeks,  even  months- 
As  a  result  of  the  constant  employment  of  arsenic  when  it 
ought  not  to  be  used,  we  see  cases  where  great  damage  is 
done  by  its  too-free  administration.  We  must  also  remem- 
ber that  the  drug  given  in  large  doses  is  capable  of  pro- 
ducing some  renal  irritation  as  well  as  irritation  of  the 
stomach  and  intestines,  and  that  a  condition  of  irritability 
of  the  mucous  membranes  of  the  body  generally  are  some- 
times caused  by  too  large  a  dose.  Dr.  Hare  calls  our 
attention  to  the  use  of  arsenic  as  a  valuable  appetizer  in 
doses  of  a  minim  of  Fowler's  solution  with  ten  grains  of 
bicarbonate  soda  and  a  tablespoonful  of  infusion  of 
genitan  taken  before  meals.  I  have  used  it  this  way  and 
certainly  found  it  a  very  valuable  tonic.  It  is  also  useful 
in  certain  forms  of  morning  diarrhoea  and  nausea;  also  it 


76        '  PROGRESS   OF  MEDICAL  SCIENCE. 

is  valuable  in  tlie  treatment  of  various  forms  of  anaemia, 
in  which  case  it  must  be  given  over  long  periods. 

It  is  hardly  necessary  to  remind  you  that  it  is  almost 
a  specific  in  the  treatment  of  chorea,  and  its  value  as  a 
blood  tonic  in  malaria,  and  its  great  value  in  diabetes  and 
asthma.  It  is  held  by  Murray  and  others  that  it  is  useful 
in  those  asthmatic  cases  which  are  young,  and  the  old  with 
marked  emphysema.  It  is  also  valuable  in  cases  that 
have  nasal  disorders  due  to  hyperemia  of  the  respiratory 
mucous  membrane.  While  recognizing  the  value  of 
arsenic,  we  must  not  forget  that  it  is  possible  for  it  to  pro- 
duce evil  influences;  that  it  is  capable,  when  administered 
too  long  a  time  in  large  doses,  of  causing  pigmentation  of 
the  skin,  irritation  of  the  stomach  and  of  the  respiratory 
iract,  and,  more  serious  still,  peripheral  neuritis. 

In  the  treatment  of  choresi  I  find  it  of  the  greatest 
value.  You  must  use  it  in  increasing  doses,  and  this  is 
one  of  the  few  disease.^  in  which  arsenic  is  so  valuable 
that  you  have  to  give  it  in  ascending  doses,  even  to  toler- 
ance. I  find  it  of  the  greatest  value  in  anemia;  even  the 
obstinate  and  often  incurable  cases  of  pernicious  anemia 
yield  better  to  arsenic  than  to  any  other  known  remedy; 
it  is  to  be  given  in  small  doses  and  kept  up  for  months. 
In  the  small  dose  you  are  not  so  likely  to  produce  stomach 
disturbances  The  effect  of  the  drug  in  this  disease  is  not 
due  to  its  increasing  the  nVimber  and  quality  of  the  red 
blood  corpuscles,  but  rather  to  its  preventing  or  delaying 
their  destruction  in  the  portal  circulation.  By  timely  use 
of  laxatives  and  careful  watching  the  dosage  you  may 
easily  adjust  the  blood-making  forces. 

Dysmenorrhoea,  frequently  noticed  in  women  with  a 
tendency  to  asthma  or  subject  to  chronic  skin  diseases,  is 
often  cured  or  benefited  by  arsenic. 

Arsenic  ranks  next  to  quinine  in  treatment  of  malaria; 
foi-  instance,  chronic  cases,  where  quinine  has  lost  its 
power,  are  markedly  benefited  by  arsenic. 

Neuralgic  headaches  and  anaemia  of  malarial  origin 
ara  very  amenable  to  the  drug.  Fowler  first  reported  the 
remarkable  efficiency  of  arsenic  in  neuralgia  of  the  inter- 
costal and  fifth  pair  of  nerves. 

It  is  equally  as  valuable  in  these  cases,  whether  the 
disease  be  due  to  malaria  or  general  debility-  I  have  fre- 
quently gotten  very  good  results  in  pulmonary  phthisis,  es- 
pecially in  those  cases  where  there  is  excessive  expectora- 
tion and  slow  degenerative  processes.  The  good  effect  of 
the  arsenic  is  shown  by  the  rapid  improvement  of  their 
general  condition,  there  being  a  lesser  pulmonary  secre- 
tion, a  general  improvement  in  the  appetite,  and  increase 


MEDICINE   AND    NEUROLOGY.  'J'J 

in  the  body  weight.  It  is  contm-iiidieated  in  phthisis 
where  the  cough  is  hoarse  and  paroxysmal,  with  but 
scanty  secretions  and  tendency  to  hemorrhage.  When  I 
want  to  improve  the  nutrition  of  my  patients  I  tind  it  the 
most  valuable  of  tonics.  It  has  not  the  power  of  increas- 
ing red  blood  cells,  but  it  stops  the  destruction  of  the  cell 
and  thereby  shows  its  great  influence  on  the  general  nutri- 
tion. I  do  not  know  of  an}-  tonic  that  we  can  expect  to 
give  us  better  results  than  arsenic  when  administered  in 
the  proper  way.  In  regard  to  the  preparation  used,  it  is 
just  a  matter  of  preference-  I  find  Fowler's  solution  to  be 
the  most  useful  in  a  general  way,  and  use  this  preparation 
more  than  any  other.  I  believe  that  failure  follows  so 
many  because  they  do  not  persist  in  its  use  for  a  long  time. 
— P.  G.  Simpson,  M.  D.,  in  Am    Practitioner. 

TREATMENT  OF  CERTAIN  FORMS  OF  CANCER  BY  THE 

X-RAY. 

Williams  [Jour.  Amer.  Med.  Ass-n.,  September  14,  1901) 
divides  cancers,  from  the  standpoint  of  X-ray  treatment, 
into  internal  and  external  forms,  of  which  he  discusses 
only  the  latter  class  in  regard  to  the  therapeutic  ett'ect  of 
the  X-ray.  This  class  includes  epidermoid  cancers,  typi- 
cal epitheliomas  and  rodent  ulcers,  "and  also  cases  which 
had  the  clinical  appearance  of  beginning  cancers,  but 
which,  under  the  microscope,  were  found  to  be  i)lasmona. 
or  s'mple  cases  of  ulceration  and  necrosis,''  .  .  .  situated 
particularly  about  the  face  and  hands.  They  are  the 
forms  that  have  been  amenable,  in  a  measure,  to  other 
therapeutic  proceedings,  but  the  present  method  has  the 
advantage  ( f  painlessness,  harmlessness,  and  that  it  yields 
good  cosmetic  effects.  Great  care  is  to  be  taken  to  pre- 
vent X-ray  burns.  The  advantages  of  this  new  method 
are:  ''The  treatment  causes  no  pain;  healing  is  produced 
without  creating  a  burn;  some  cases  improve  after  a  few 
sittings  without  further  renewal  of  treatment;  the  treat- 
ment can  be  carried  on  without  interfering  with  the  work 
of  the  patient." 

OXYGEN      AND      STEAM      W^ITH      THE     VAPOURS     OF      A 
SPECIAIi    INHALATION    MIXTURE    IN    PULMONARY 

DISEASES. 

Penrose  {Jolins  Hopkins  Host).  Bull..  November,  1900) 
advocates  the  use  in  catarrhal  affections  of  the  nose. 
pharynx,  larynx,  in  grip,  chronic  bronchitis  and  pulmonary 
tuberculosis  with  secondary  infection,  of  steam  or  oxygen, 
or  both,  which  has  been  passed  thi'ough  a  mixture  of  creo 
sote,  turpentine  and    compound    tincture   of  benzoin  in    r, 


78  SURGERY. 

pint  of  boiling  water.  He  details  a  case  of  tuberculosis 
with  beginning  cavity  formation  in  which  the  sputum  de- 
creased rapidly  and  pus  organisms  disappeared  entirely 
within  a  few  weeks.  Patient  gained  weight,  and  the 
tubercle  bacilli  disappeared  after  three  months  of  the 
inhalation  treatment;  another  case,  one  of  purulent  bron- 
chitis, in  which  the  sputum  and  the  pus  organisms  rapidly 
disappeared  and  the  cough  ceased;  finally  a  case  of 
chronic  infantile  purulent  bronchitis,  which  yielded 
rapidly,  and  permitted  a  rapid  development  of  the  child. 

The  method  may  be  applied  by  passing  oxygen  or 
steam  through  the  mixture,  utilizing  a  "Benzoinal  In- 
haler" or  "Hynson  and  Westcott  Inhaler,"  or,  more  simply 
and  less  expensively,  especially  for  home  Use,  by  inhaling 
the  fumes  as  they  rise  from  the  boiling  water.  To  be 
eflPective,  inhalations  should  be  of  ten  to  fifteen  minutes' 
duration,  and  taken  systematically  three  or  four  times  a 
day.     To  begin  with  the  following  formula  is  used: 

I^  Creosote  (Beecliwood) 

Olei  terebinthinae aa  3  iv 

Tr,  benzoini  CO §  iij 

M.  Sig. — Di'am  of  this  mixture  to  a  pint  of  boiling  water. 

A  greater  proportion  of  creosote  and  oil  of  turpentine 
may  gradually  be  added  until  finally  the  formula  contains 
equal  parts  of  each  ingredient. 


STJRQKRY. 

IN   CHARGE    OF 

ROLLO  CAMPBELL,  M.D., 

Lecturer  on^Sargery,  University  of  Bishop's  College  ;  Assistant  Surgeon,   Western  Hospital  ; 

AND 

GEORGE  PISK,  M.D., 
Instructor  in  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeon,  Western  Hospital. 


A  NE"W  METHOD   FOR  THE  RADICAIi  CURE  OF  HYDRO- 
CELE    OF     THE     TUNICA    VAGINALIS     TESTIS. 

The  method  herein  described  of  evacuation  of  the  sac 
and  subsequent  inversion  of  it  is  by  no  means  a  new  one. 
Looking  over  the  literature  of  the  subject  we  see  that  it 
was  first  proposed  some  ten  years  ago  by  Vautrin,  of 
Nancy.  The  French  surgeons  have  used  it  largely,  and 
in  that  country  it  is  called  Longuet's  operation.  Of  late 
it  has  been  introduced  into  Germany,  where  it  goes  by  the 


SURGERY.  79 

name  of  Winkelman's  operation.  The  author  makes  a 
transverse  incision  on  the  affected  side,  and  the  sac  is  de- 
fined and  incised  longitudinally.  The  fluid  is  evacuated 
and  the  cavity  irrigated  with  sterile  water  or  a  bichloride 
solution.  The  testicle  and  collapsed  sac  are  now  drawn 
through  the  skin  incision,  the  sac  split  from  top  to  bottom 
and  turned  inside  out,  the  edges  being  stitched  in  their 
new  position  by  a  few  catgut  sutures.  The  testicle  and 
tunica  are  returned  to  the  scrotum,  so  now  the  entire  se- 
rous surface  of  the  tunica  vaginalis  proper  is  in  apposition 
with  the  loose  connective  tissue  of  the  tunica  vaginalis, 
with  which  it  very  shortly  fuses.  The  testicle  now  lies 
between  the  tunica  and  scrotal  wall.  The  skin  wound  is 
closed  in  the  usual  fashion.  Usually  the  testicle  is  dislo- 
cated upward  as  a  result  of  the  operation.  The  sac  in  its 
new  position  is  unable  to  secrete,  and  speedily  atrophies. 
The  operation  commends  itself  for  its  simplicity,  lack  of 
hemorrhage,  freedom  from  complications  and  attainment 
of  a  radical  cure.  Conclusions  cannot  yet  be  drawn  as  to 
whether  it  causes  any  changes  in  the  testicular  function — 
1'.  H.  Lewis.  M.  U.,  Therapeutic  Gazette. 

PERFORATION  IN  TYPHOID  FEVER  FROM  AN 
OPERATIVE  STANDPOINT. 

Davis  {Amer.  Jour.  Surg,  and  Gynec.)  says:  The  diag- 
nosis of  perforation  is  not  always  easy.  A  decided  and 
sudden  increase,  especially  of  pain,  in  the  abdominal  symp- 
toms, associated  with  an  abrupt  fall  of  temperature,  is 
diagnostic  of  perforation.  Leucccytosis  is  a  confirmatory 
sign.  Hemorrhage  is  accompanied  with  a  sudden  fall  of 
temperature,  but  not  by  a  sudden  increase  of  abdominal 
symptoms.  Dullness  in  the  right  iliac  region  is  not  to  be 
expected  in  cases  of  perforation.  Localized  impairment 
of  resonance  may  be  due  to  free  abdominal  fluid;  change 
of  position  causes  it  to  disappear.  Localized  pain  and  dull- 
ness may  be  due  to  a  plastic  peritonitis  around  the  site  of 
perforation.  This  may  be  observed  perhaps  in  one  case  in 
ten,  possibly  one  in  five.  It  is  impossible  to  recognize  that 
a  perforation  is  about  to  occur.  It  is  not  necessary  to 
operate  before  a  perforation  occurs,  but  it  is  necessary  to 
operate  before  collapse  is  marked.  Typhoid  fever  patients 
when  not  in  total  collapse  bear  operation  much  better  hhan 
was  formerly  expected.  Patients  operated  on  in  marked 
collapse  are  liable  to  die  on  the  table.  I  know  of  some 
such  cases.  Washing  out  the  abdominal  cavity  with  hot 
normal  salt  solution,  even  if  no  perforation  is  present, 
seems  to  improve  the  condition  of  the  patient  at  the  time  of 


8o  SURGERY. 

operation,  and  to  favourably  influence  the  subsequent 
course  of  the  disease.  Operate  as  soon  as  the  diagnosis  of 
perforation  is  made.  It  is  less  dangerous  for  the  patient 
to  run  the  risk  of  having  an  operation  done  during  the  first 
period  of  depression  than  to  wait  and  run  the  risk  of  having 
collapse  preclude  all  operative  measures.  In  operating, 
incise  as  for  appendicitis,  and  not  in  the  median  or  semi- 
lunar line.— Memphis  Medical  Monthly. 

THE  USE  OF  NORMAL  SALT  SOLUTION. 

John  G.  Clark  (Progressive  Medicine)  says  the  more 
extensive  one's  experience  becomes  in  the  use  of  normal 
salt  solution  as  a  stimulant  in  abdominal  operations,  the 
more  convincing  is  the  evidence  of  the  benefits  to  be  ob- 
tained by  its  use.  During  the  past  four  years  he  has  made 
it  a  practice  to  leave  at  least  one  liter  in  the  peritoneal 
cavity,  after  even  the  simplest  operations.  It  increases 
the  volume  of  the  blood,  lessens  its  specific  gravity,  stimu- 
lates the  cardiac  ganglia  and  accelerates  the  circulation. 
The  skin,  kidneys  and  intestines  are  stimulated,  and  all  the 
organs  of  the  body  functionate  better  under  its  influence. 
The  number  of  red  blood  corpuscles  is  distinctly  increased. 
Its  special  use  in  abdominal  casesi  is  to  prevent  shock,  to 
lessen  the  elfects  of  hemorrhage  and  decrease  the  virulence 
of  infection.  Next  to  the  Trendelenburg  posture,  the 
author  regards  the  introduction  of  the  normal  salt  solution 
as  one  of  the  greatest  benefitsi  which  have  been  conferred 
upon  modern  surgery  in  the  last  five  years.  Its  most 
marked  advantages  are  claimed  to  be  a  lessening 
of  the  thirst  and  an  increase  in  the  urinary  ex- 
cretion. Drainage  from  the  peritoneal  cavity  the 
author  regards  as  a  problematic  benefit,  because 
of  the  rapidity  with  which  absorption  takes  place  by  the 
lymphatics  and  peritoneum.  In  these  cases  he  employs  an 
infusion  of  large  quantities  of  normal  salt  solution  com- 
bined with  the  elevated  dorsal  posture.  In  moribund 
patients  he  has  seen  a  marvellous  stimulation  from  this 
treatment,  which  safely  tided  them  over  the  critical  period. 
Submammary  infusions  are  quite  as  beneficial;  they  act 
almost  as  rapidly  as  intravenous  transfusions,  and  are  de- 
void of  some  of  the  complications  which  attend  the  latter. 
The  writer's  plan  is  to  leave  at  least  one  or  two  quarts  of 
salt  solution  in  the  abdominal  cavity  after  every  abdominal 
operation,  and  in  addition  to  this  a  quart  may  be  given  be- 
neath the  mammary  glands,  in  case  the  patient  shows 
immediate  shock.  As  a  routine  practice  in  all  operations, 
either  minor  or  major,  one  or  two  liters  of  salt  solution  is 
given  per  rectum  for  the  purpose  of,  alleviating  thirst. — 
Medicine. 


SURGERY.  8 1 

TREATMENT  OF  SIMPLE  ERACTURES. 

Bennett  (British  Medical  Journal)  concludes  a  discus- 
sion of  this  question  as  follows: 

1.  The  treatment  of  simple  fractures  at  present,  al- 
though less  stereotyped  than  hitherto,  is  still  conducted 
generally  too  much  upon  lines  which  are  traditional  rather 
than  rational.. 

2.  The  use  of  splints  for  long  periods  is  disadvantage- 
ous, especially  in  the  form  of  irremovable  appliances,  such 
as  plaster  of  Paris  and  the  like. 

3.  Speaking  generally,  the  earlier  movements  of  the 
joints  above  and  below  the  fracture  in  a  long  bone  are  used 
the  shorter  is  the  time  occupied  in  recovery. 

4.  The  legitimate  scope  of  the  operative  treatment  of 
simple  fracture  is  limited,  and  should  be  confined  to  (a) 
cases  which  are  otherwise  unmanageable;  (b)  special  cases, 
such,  for  example,  as  certain  spiral  and  oblique  fractures, 
mainh'  of  the  tibia;  and  (c)  certain  fractures  near  joints  in 
adults,  notably  of  the  humerus  at  the  elbow. 

5.  The  operative  treatment  of  recent  fracture  of  the 
patella  is  by  no  means  so  generally  satisfactory  or  so  free 
from  risk  as  published  cases  would  tend  to  show;  and 
further,  in  cases  in  which  the  separation  of  the  fragments 
does  not  exceed  half  or  even  three-quarters  of  an  inch,  as 
good  results  for  practical  purposes  are  usually  obtainable 
without  operation,  although  less  rapidly. 

6.  The  use  of  massage  and  passive  movements  immedi- 
ately in  simple  fracture  when  the  circumstances  of  the 
patient  and  of  the  practitioner  admit  of  it,  either  in  its 
entirety  or  with  modifications,  is,  in  the  majority  of  cases, 
the  best  means  of  effecting  a  rapid  and  useful  recovery. 

7.  The  tendency  of  late  has  been  to  exaggerate  the  de- 
gree of  disability  and  diminution  in  wage-earning  capacity 
following  upon  simple  fractures. 

8.  Although  no  pains  should  be  spared  in  obtaining 
perfect  position  of  the  fractured  ends,  moderate  displace- 
ment, provided  it  is  not  rotary,  is  not  necessarily  followed 
by  any  disability  if  care  be  taken  by  the  use  of  early  move- 
ments to  prevent  any  matting  of  the  parts  around  the  frac- 
ture; in  other  words,  the  disability  which  follows  in  certain 
cases  in  which  the  position  of  the  united  fragments  is  not 
ideal  is  due,  not  to  the  bony  deformity,  but  to  the  adhesion 
of  the  soft  parts  around,  which  is  easily  preventable. 

9.  Having  regard  to  the  unavoidable  modifications 
which  must  be  dictated  by  the  circumstances,  social  and 
otherwise,  of  the  patient,  and  by  the  facilities  possessed 
by  the  practitioner,  no  one  method  of  treatment  for  simple 
fractures  can  be  insisted  upon  for  routine  use,  even  in 
cases  in  which  the  local  conditions  are  precisely  alike. — 
Medical  Standard. 


Therapeutic  Notes. 


Bronchitis. 

R   Perpinol. 

Sodii  Benzoatis aa  gr.  2 

Sach  alb ,. q.  s. 

M.  at  ft.  pil  No.  i.     Take  six  to  12  daily. 

Night  Sweats  of  Phthisis. 

I^  Agaricin .   gr.  7^ 

Dwen  Powder dr.  2 

Powd.  Marshmallow. 

Mucilage  of  acacia aa  dr.  i 

M.  Div.  in  pil  No.  c.     One  or  two  pills  at  night. 

Treatment  of  Acute    Albuminuria  After  Scarlet 

Fever. 

The  following  is  recommended  by  Otto  Maier,  in  the 
Post  Graduate : — 


B  Pilocarpin  hydrochlor gr.  i 

Infusion  digitalis ^iii    96 


06 


M.  Sig.  : — One  teaspoonful  every  three  hours. 

He  also  recommends  that  a  hot  bath  he  given  daily  and 
a  diet  consisting  of  milk  and  ice  cream.  To  promote  alimi- 
nation  by  the  bowels,  gives  the  following  : — 


B   Hydrarg.  chloridi  mitis gr.  iiss 

Pul.jalapae ,.  gr.  ivss. 


IS 
28 


M.  Ft.  chart.  No.  i,  Sig.: — One  such  to  be  taken  twice  a 
week. —  Journ.  of  the  American  Med.  Assn. 

'Sf  Heroin gr.  tV 

Ammon   Hopophos gr.   3 

Hyoscyami gr.     i 

Pin  Alb  Corb gr.  3J^ 

Bols  Toluban g"*-  /^ 

Glycerin!  puri dr.    i 

For  each  dose. 


Jottings, 


Salicylic  acid  in  a  salve  applied  to  developing  boils 
will  abort  them. 

Strong,  hot  coffee  will  quickly  overcome  uterine  in- 
ertia if  drank  freely. 

Sulphur  in  an  ointment  applied  just  within  the  anus  is 
said  to  rapidly  destroy  pinworms. 

A  1-20  solution  of  potassium  permanganate  is  power- 
fully effective  in  toothache. 

Pyrogallic  acid,  fifteen  grains,  in  one  ounce  of  col- 
lodion will  cure  ringworm  very  speedily  wherever  located. 

Nitroglycerine  has  a  wonderful  effect  in  postpartum 
hemorrhage  ;  it  is  ^Iso  excellent  in  vomiting  of  a  reflex 
character. 

Sodium  phosphate  increases  the  functional  activity  of 
the  liver  and  stimulates  the  glandular  organs  concerned  in 
digestion. 

For  diarrhoea  with  large  watery  movements  with 
sharp,  spasmodic,  colicky  pains,  the  arsenite  of  copper  is  a 
good  remedy. 

For  tapeworm  give  eight  grains  of  salicylic  acid  every 
hour  until  five  or  six  doses  have  been  taken,  then  give  a 
good,  big  dose  of  castor  oil. 

In  spasmodic  stricture  of  the  urethra,  in  spasms  of  the 
ureter,  in  spasms,  or  in  the  tenesmus  of  dysentery,  we  have 
no  remedy  superior  to  full  doses  of  gelsemium. 

Hair-cap  moss  (Polytrichum)  it  is  claimed  is  of  benefit 
in  ascites  or  anasarca.  It  largely  increases  the  urinary 
secretion  and  reduces  the  weight  of  the  body  within  a  few 
days. 

A  lotion  prepared  by  dissolving  one  grain  of  the  bi- 
chloride of  mercury  in  four  ounces  of  the  peroxide  of 
hydrogen  is  said  to  be  a  most  excellent  topical  application 
in  the  treatment  of  diphtheria. 

In  the  treatment  of  orchitis,  first  treat  the  temper- 
ature ;  second,  administer  Phytolacca  for  its  specific 
infiiience  ;  and  third,  assist  in  general  elimination  by  ad- 
ministering an  occasional  dose  of  acetate  of  potassium. 

The  date  at  which  the  rashes  appear  in  the  various 
diseases  is  as  below  : — Typhoid  fever,  seventh  to  ninth 
day  ;  typhus  fever,  fourth  or  fifth  day  ;  smallpox,  third  or 
fourth  day  ;  measles,  third  or  fourth  day  ;  scarlatina,  first 
or  second  dav. 


TrHE? 


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"MTBSTERN    GENERAIi    HOSPITAIi,    MONTREAL. 

The  Western  Hospital  has  had  a  somewhat  varied  history. 
In  1873  a  gentleman  from  the  Southern  States,  named  Major 
Mills,  who  had  resided  in  Canada  for  about  ten  years, 
donated  $12,000  to  erect  a  wing  to  be  used  as  a  Western 
General  Hospital.  Through  the  exertion  of  two-  or  three 
gentlemen  there  was  collected,  towards  the  purchase  of  land, 
about  $40,000.  The  ground  first  purchased  formed  the 
corner  of  Mountain  and  Osborne  Streets.  It  was  soon  felt 
that  this  site  was  not  sufficiently  far  West,  and  that  it  was 
not  large  enough.  It  was,  therefore,  sold,  and  a  property 
about  half  a  mile  or  so  further  west  was  secured.  This  con- 
sisted of  about  82,000  square  feet  and  is  bounded  by  four 
streets,  and  on  one  side  has  a  fairly  large  public  square. 
Those  who  at  that  period  took  a  deep  interest  in  the  hospital 
scheme  considered  the  site  unique  for  a  hospital  building, 
and  events  have  proved  their  wisdom.  Atwater  avenue,  a 
very  wide  street,  leads  directly  to  it,  from  a  lower  section  of 
the  city  in  which  manufactories  have  greatly  multiplied 
within  the  last  few  years.     In  1874  an  Act  of  Incorporation 


EDITORIAL.  85 

was  obtained,  and  in  18;  6  Major  Mills  began  the  erection  of 
his  building.  Owing  to  a  variety  of  events,  this  building  was 
not  fully  completed  and  ready  for  occupation  till  about  1880. 
During  this  period  great  depression  had  fallen  upon  Mon- 
treal, and  the  friends  of  the  institution  also  found  that  a 
strong  opposition  had  developed  from  a  quarter  which  they 
had  not  anticipated.  The  result  was  that  the  Western  Hos- 
pital Corporation  did  not  consider  the  time  opportune  for 
opening  it,  especially  as  its  completion  by  Major  Mills  made 
it  his  property  to  do  with  it  what  he  pleased  till  he  had  re- 
couped himself  for  the  additional  siim,  above  his  original 
subscription,  expended  in  finishing  the  building.  The 
Women's  Hospital,  the  charter  of  which  was  purchased 
by  the  Medical  Faculty  of  Bishop's  College,  and  which  was 
in  operation  in  small  quarters,  offered  to  lease  the  new 
Western  building  from  Major  Mill$.  Their  offer  was  ac- 
cepted and  the  Women's  Hospital  took  possession  and 
opened  Maternity  and  Gynaecological  departments.  For 
about  ten  years  this  Faculty  conducted  therein  the  most  sue 
cessful  Women's  Hospital  in  Canada,  and  were  able  to  supply 
their  students  with  maternity  cases,  so  numerous  as  to  make 
them  the  envied  of  the  students  of  all  other  medical-  schools  in 
Canada.  In  1894  they  moved  out  of  the  Western  Hospital 
and  are  now  in  possession  of  a  building,  which  still  enables 
them  to  supply  almost  unlimited  midwifery  cases  for  their 
students.  This  exodus  of  the  Women's  Hospital  enabled  the 
Western  Hospital  Corporation  to  open  the  building,  now 
their  property,  as  a  General  Hospital.  In  the  twenty  years 
which  had  elapsed  since  its  incorporation  death  had  carried 
away  many  of  its  early  and  warm  supporters — others  who 
remained  threw  themselves  actively  into  the  work.  But  the 
work  required  for  a  General  Hospital  was  found  so  arduous 
that  the  early  friends,  who  remained,  found  the  task  an  up- 
hill one,  and  looked  for  younger  blood  to  assist  them.  Why 
this  was  not  forthcoming  it  is  perhaps  best  not  to  say ;  but  it 
was  not  forthcoming,  and  the  result  was,  that  although  much 
good  work  was  done  in  the  Hospital,  debt  accumulated 
rapidly.     With  accumulating  debt  the   friends   began  to  lose 


85  EDITORIAL. 

interest — bad  health  deprived  the  Hospital  of  several  of  its 
best  collectors,  and  meetings  of  the  Committee  could  only  be 
had  at  long  intervals.  Such  a  state  of  things,  if  allowed  to 
continue,  could  have  but  one  end,  that  is  closing  of  the  Hos- 
pital. Fortunately,  a  few  staunch  friends  still  remained,  and 
these  determined  to  make  an  efifort  to  place  the  Hospital  under 
a  new  organization.  The  gentleman  who,  for  a  number  of 
years,  had  filled  the  office  of  President  was  most  anxious  to 
resign,  and  it  was  felt  that  if  a  gentleman,  possessing  power 
of  organization,  and  other  qualifications  essential  in  a  Hos- 
pital President,  could  be  obtained,  the  first  step  in  a  successful 
reorganization  would  be  secured.  Happily,  this  was  done  by 
inducing  Alderman  C.  F.  Smith  to  accept  the  Presidency. 
He  has  done  wonders  in  placing  the  Hospital  in  a  better  con- 
dition than  it  has  ever  been,  and  the  work  now  done  within 
its  walls  is  not  excelled  by  any  hospital  in  Montreal.  He 
has  surrounded  himself  with  an  active  and  energetic  Com- 
mittee of  Management,  who  meet  regularly  every  week.  The 
Hospital  has  a  Medical  Superintendent  and  a  Lady  Superin- 
tendent, who,  under  the  medical  staff,  has  charge  of  one  of  the 
best  training  schools  for  nurses  in  the  city.  The  debt  has 
been  reduced  by  several  thousands  of  dollars,  and  the  yearly 
receipts  are  equal  to  the  yearly  expenditure.  Nearly  fifty 
new  governors  have  been  obtained  during  the  last  year  and 
a  half,  and  scarcely  a  week  passes  without  one  or  two  of 
Montreal's  well-known  citizens  qualifying  for  this  position. 
In  fact  the  aspect  of  everything  is  changed  for  the  better. 
This  was  well  indicated  at  the  annual  meeting  of  the  gover- 
nors which  was  held  on  the  21st  of  January,  when  the  attend- 
ance was  the  largest  in  the  history  of  the  Hospital,  and 
great  interest  was  evinced  in  the  proceedings.  The  Secre- 
tary in  his  report  made  allusion  to  an  offer  discussed  at  the 
last  quarterly  meeting  of  the  governors,  for  the  purchase  of  a 
portion  of  the  Hospital  ground.  This  had  been  voted  down  by 
a  large  majority  as  it  was  felt  it  would  all  be  necessary  for 
hospital  purposes  in  the  near  future.  The  Governors  in 
rotation  had    visited    the    Hospital    weekly,  and  in  many  in- 


EDITORIAL.  87 

Stances  it  had  proved  an  agreeable  surprise  to  learn  the  good 
work  it  was  doing.  Their  appreciation  of  this  was  shown  by 
many  specially  contributing  toward  some  of  the  most  urgent 
needs  of  the  institution.  The  financial  condition  was  con- 
sidered most  satisfactory,  considering  it  only  represented  a 
hospital  year  of  seven  and  a  half  months.  This  was  caused 
by  the  decision  of  the  previous  annual  meeting  to  have  the 
hospital  year  run  concurrent  with  the  actual  year.  The  re- 
ceipts from  subscriptions  and  donations  average  $432  per 
month  as  compared  with  $244  per  month  the  pieceding  year. 
The  medical  report,  which  was  read  by  Dr.  Fisk,  Medical 
Secretary,  showed  marked  increase  in  both  the  Outdoor  de- 
partment and  the  Indoor  department.  The  attendance  at  the 
former  had  been  increased  from  a  daily  average  attendance 
in  1900  of  11.02  to  15.95  in  1901.  The  increase  of  intern 
patients  for  the  year  was  33  per  cent.  The  report  was  fully 
discussed,  and  was  considered  eminently  a  satisfactory  one. 
Mr.  G.  B.  Burland  spoke  encouragingly  of  the  work  which 
was  being  done  under  most  adverse  circumstances.  He  con- 
sidered the  present  building  unfit  for  a  modern  hospital — 
a  new  one  was  a  necessity.  He  would  be  one  of  ten  to  erect 
an  up-to-date  building  costing  $100,000,  which  he  thought 
would  build  such  a  one — but,  if  not,  he  would  be  one  of  the 
same  number  to  erect  one  costing  $200,000.  This  announce- 
ment was  received  with  great  applause.  Subsequently,  four 
gentlemen  intimated  that  they  would  join  a  party  of  twenty 
to  wipe  out  the  debt  of  the  Ho&pital.  Both  these  offers  were 
referred  to  the  incoming  Committee  of  Management.  Al- 
together, the  stock,  so  to  speak,  of  the  Western  Hospital,  was 
never  so  high  as  it  is  to-day.  This  has  resulted  from  two 
causes:  — ist,  the  evident  need  of  such  an  institution  in  the 
rapidly  growing  Western  part  of  Montreal,  and,  2nd,  the 
opening  of  its  private  wards  to  all  reputable  physicians,  quite 
independent  of  their  being  in  any  way  connected  with  the 
Hospital.  Many  of  our  readers  we  know  have  special  inter- 
est in  this  Hospital  and  will  be  pleased  to  hear  of  its  bright 
prospects. 


88  EDITORIAL. 

JEFFREY  HALE  HOSPITAL,  QUEBEC. 

The  annual  meeting    of    this    Hospital  was  held  on  the 
i6th  of  January,  when  the  reports  of  the  Secretary  and  the 
Treasurer  were  read.     Both  of  these  are  of  a  most  satisfac- 
tory character.     During  the  year  359  patientsi  were  admitted, 
of  whom  24  died.     The  report  states  that  the  new  Hospital 
had  been    completed    during   the   year    and    was    now    fully 
equipped  and  in  use.     The  building  for  contagious  patients 
is  also  finished  and  is  ready  for  use.     The  Lady ,  Superintend- 
ent is  Miss  Blakie,  a  graduate  of  the  Montreal  General  Hos- 
pital training  school,  and  the  House  Surgeon  is  Dr.  Stevenson. 
The    Treasurer's    report   shows    that   the    receipts    from   all 
sources  were  $73,750.51.     This  includes  a  donation  of  $25,000 
and  one  year's  interest  on  same  of  $1,250,  a  total  of  $26,250, 
also  $1,500  from  Father  O'Leary.     Donations  and  subscrip- 
tions were  $3,265.     Interest  on  invested  funds,  $5,914.10,  and 
on  deposits,  $622.73.    The  cost  of  the  Hospital  during  the  year 
was  $13,140.45.     There    was    disbursed    to   contractors   and 
architects    for    construction,    $33,400.     There    was     invested 
$10,000,  and  there  is  a  cash  balance  on  hand  of  $17,210.05. 
This  report  is  a  satisfactory  one,  but  only  a  general  summary 
is  given.     A  more  detailed  report  will  doubtless  be  published 
shortly,  and  will  be  of  deep  interest  to  all  who  are  engaged  in 
hospital  work. 

We  had  the  pleasure  of  visiting  this  Hospital  last  Sep- 
tember, in  company  with  a  friend  who  takes  a  very  deep 
interest  in  it.  We  were  more  than  pleased  with  what  we  saw. 
Indeed,  in  many  ways  it  was  a  revelation  to  us.  Every 
possible  convenience  is  in  evidence,  and  we  are  of  opinion  that 
Quebec  has  reason  to  be  proud  of  its  Jeffrey  Hale  Hospital. 
Its  situation  is  most  desirable,  and  the  view  from  its  windows 
and  galleries  simply  magnificent  and  not  to  be  excelled  any- 
where. If  scenery  and  splendid  air  contribute  to  recovery,  as 
we  believe  they  do,  then  the  death  rate  of  this  Hospital  ought 
to  be  small. 


EDITORIAL.  89 

THE  ROYAI.  VICTORIA  HOSPITAL. 

The  annual  meeting  of  the  governors  of  the  Royal  Vic- 
toria Hospital  was  held  on  the  21st  of  January.  This  insti- 
tution, as  our  readers  are  doubtless  aware,  is  endowed  and 
receives  but  little  support  from  the  outside  public.  The 
ground  on  which  it  is  built  was  purchased,  the  buildings 
erected,  and  the  Hospital  endowed  by  Lord  Strathcona  and 
Mount  Royal  and  Lord  Mount  Stephen.  A  few  thousand 
dollars  were  contributed  toward  the  object  by  outsiders,  but 
practically  it  is  as  stated.  Patients  are  admitted  from  every 
part  of  the  Dominion  on  terms  similar  to  those  enjoyed  by 
residents  of  Montreal,  The  city  gave  a  piece  of  land  on 
which  to  build  the  Hospital,  but,  owing  to  circumstances  need- 
less to  recall,  it  was  placed  on  adjoining  land.  The  original 
site  is  used  as  breathing  space.  From  the  report  of  the  Secre- 
tary we  learn  that  during  the  year  1901  2,579  patients  were 
admitted,  of  these  1,605  were  Protestants,  879  Roman 
Catholics,  68  Jews  and  27  of  other  faiths;  1,254  were  free 
patients,  904  public  ward  patients  paying  50  cents  a  day ;  421 
private  ward  patients;  1856  were  residents  of  Montreal  and 
723  were  from  districts  outside  of  Montreal.  The  death  rate 
for  the  year  was  4.42  or  3.54,  deducting  those  who  died 
within  forty-eight  hours  after  entering  the  Hospital. 
In  the  out-patient  department  the  number  treated  was 
3,601.  The  number  of  visits  of  these  patients  was 
18,906.  The  income  for  the  year  was  $130,738.40,  while 
the  ordinary  expenditure  was  $112,280.20,  the  balance  being 
applied  towards  the  cost  of  the  new  power  house  and  isolation 
pavilion.  Already  in  many  ways  the  magnificent  buildings 
and  annexes  are  being  found  inadequate.  Plans  are  being 
prepared  for  needed  extensions  and  improvements  in  oper- 
ating theatre.  Mr.  R.  B.  Angus  was  re-elected  President. 
Many  of  the  governors  hold  office  on  account  of  the  public 
positions  which  they  hold.  For  instance,  the  Mayor  of  Mon- 
treal, the  President  and  Manager  of  the  Canadian  Pacific, 
the  Manager  of  the  Grand  Trunk  Railway,  President  of 
the     Board    of    Trade,    are    governors    in    virtue    of    the 


90  EDITORIAL 

office.  The  Royal  Victoria  Hospital  is  excelled  by 
few  hospitals  in  the  world.  It  will  forever  be  a  magni- 
ficent monument  to  the  liberality  and  public  spirit  of  its 
most  generous    donors. 


Dr.  Lapthorn  Smith,  of  Montreal,  has  received  a  letter 
from  Professor  Pestalozza,  of  Florence,  on  behalf  of  the 
Committee  of  Organization  of  the  Fourth  International  Con- 
gress of  Gynaecology,  begging  him  to  announce  to  the  Pro- 
fession of  Canada  that  the  Congress  will  meet  in  Rome  from 
the  15th  to  the  21st  of  September  of  this  year.  The  Com- 
mittee of  Organization  consists  of  Professors  Pasquali, 
Morosani  and  Mangiagelli,  who  wish  to  extend  a  hearty 
welcome  to  their  Canadian  brethren.  The  subscription  fee  is 
five  dollars  for  gentlemen  and  two  dollars  for  the  ladies  ac- 
companying them.  The  Treasurer  is  Dr.  La  Torre,  8  Via 
Venti  Septembre,  Rome.  The  subjects  chosen  for  discussion 
are: — i.  The  medical  indications  for  the  induction  of  labour. 
2.  Genital  tuberculosis.  3.  Hysterectomy  in  puerperal  sep- 
ticaemia. 4.  Inflammatory  changes  in  the  neck  of  the  uterus. 
5.  The  surgical  treatment  of  cancer  of  the  uterus. 

•   It  is  the  earnest  wish  of  the  Committee  to  have  a  large 
attendance  of  Gynaecologists  and  Obstetricians  from  Canada. 


Dr.  James  Patterson,  who  had  charge  of  a  large  outbreak 
of  smallpox,  numbering  1,500  cases,  in  the  west  of  Canada, 
n  ports  that  the  disease  was  most  prevalent  among  the 
unvaccinated  French  half-breeds  ;  was  less  prevalent  among 
the  Indians,  who  were  fairly  well  vaccinated,  and  did  not 
appear  at  all  among  the  Dhoukobor  and  Gallician  villages- 
whose  inhabitants  had  all  been  vaccinated  in  childhood,  and 
revaccinated  on  board  ship  before  entering  the  country. 


Personals. 


Dr.  Robillard  (McGill  i860)  has  resigned  his  position  as 
Medical  Health  Officer  for  the  City  of  Ottawa,  Ont. 

Dr.  Albert  A.  Macdonald,  of  Toronto,  has  commenced 
to  use  an  automobile  in  making  his  visits.  The  Doctor 
pronounces  it  a  distinct  success  and  says  that  he  can  at  least 
save  an  hour  in  his  afternoon  work  alone. 

Dr.  Francis  J.  E.  Tetreault  (M.  D.,  Bishop's,  1880),  of 
Orange,  New  Jersey,  United  States,  was,  on  the  17th  of 
January,  elected  President  of  the  Orange  Mountain  Medical 
Society.  We  congratulate  Dr.  Tetreault  on  this  manifestation 
of  the  high  regard  in  which  he  is  held  by  his  confreres. 

Dr.  Douglas  Macrae  (M.  D.,  Bishop's,  1893),  who  has 
been  for  several  years  Surgeon  on  the  Red  Star  Line  of 
Steamships  sailing  between  Philadelphia  and  Liverpool  was 
in  Montreal  during  January  last. 

Dr.  Tutill  (M.  D.  Bishop's,  1901),  has  been  appointed 
one  of  the  House  Surgeons  of  the  Western  General  Hospital 
in  place  of  Dr.  Baird  resigned  owing  to  ill  health.  Dr.  Tutill 
entered  upon  his  duties  early  last  January.  He  had  pre- 
viously served  nine  months  as  House  Surgeon  of  the  Women's 
Hospital. 

Dr.  Charles  A.  Hebbert,  M.  R.  C.  P.,  of  London,  has  been 
elected  Professor  of  Anatomy  in  the  Medical  Faculty  of 
Bishop's  College.  He  has  for  several  years  been  Lecturer 
on  the  subject  at  this  College  and  previously  held  a  similar 
appointment  at  the  Westminister  Hospital  Medical  School, 
London,  England.  Dr.  Hebbert  is  an  exceptionally  good 
teacher,  and  is  not  engaged  in  general  pratice,  devoting  him- 
self to  consultations  in  medico-legal  cases,  in  which  he  is  an 
expert. 


Book    Reviews, 

The  Four  Epochs  of  Woman's  Life.  A  study  in  Hy- 
giene, by  Anna  M.  Galbraith.  M.D.,  Author  of  "  Hygiene 
and  Physical  Culture  for  Women  ;  "  Fellow  of  the  New  York 
Academy  of  Medicine,  etc.       With  an    Introductory  Note  by 


92  BOOK  REVJEWS. 

John  ,H.  Musser,  M.D,,  Professor  of  Clinical  Medicine,    Uni- 
versity of  Pennsylvania.      12  mo  volume  of    200  pages.  Phila- 
ladelphia   and    London,  W.    B.   Saunders  &  Company,  1901. 
Cloth,  $1.25,  net.    Carvelh  &  Co.,  Toronto,  Canadian  agents. 
Women  have  at  last  awakened  to  a  sense  of  the  penalties  they 
have    paid    for  their  ignorance  of   those    laws    of  nature  which 
govern  their  physical  being,  and  to  feel  keenly  the  necessity  for 
instruction    in  the    fundamental    principles    which    underlie    the 
epochs  of  their  lives. 

This  is  pre  eminently  the  day  of  preventive  medicine.  The 
physician  who  can  prevent  the  origin  of  disease  is  a  greater  bene- 
factor than  he  who  can  lessen  the  mortality  or  suffering  after  the 
disease  has  occurred.  Any  contribution,  therefore,  to  the  piiy- 
sical,  and  hence  the  mental,  perfection  of  woman  should  be  wel- 
come alike  by  her  own  sex,  by  the  thoughtful  citizen,  by  the 
political  economist  and  by  the  hygienist. 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing 
and  conclusive  manner,  those  truths  of  which  every  woman  should 
have  a  thorough  knowledge.  Written  as  it  is  for  the  laity,  the  subject 
is  discussed  in  clear,  comprehensible  language,  readily  grasped 
even  by  those  most  unfamiliar  with  medical  subjects.  A  valuable 
and  commendable  feature  of  this  handy  volume  of  instructive 
information  is  a  comprehensive  glossary  of  those  medical  terms 
necessary  to  a  thorough  understanding  of  the  subject  under  discus- 
sion. Without  doubt,  it  is  a  book  that  should  receive  he  thought- 
ful consideration  of  every  woman. 

F.  W.  C. 

A  Text-Book  of  Pharmacology,  and  some  allied  sciences 
(Therapeutics,  Materia  Medica,  Pharmacy,  Prescription- 
Writing,  Toxicology,  etc.),  by  Torald  SoUman,  M.D.,  Assist- 
ant Professor  of  Pharmacology  in  the  Medical  Department  of 
Western  Reserve  University,  Cleveland,  Ohio.  Illustrated. 
W,  B.  Saunders  &  Co.,  Philadelphia;  Carveth&Co,  Toronto, 
TQor,  $3.75.  ^ 

It  is  seldom  a  volume  is  issued  by  one  author  aimmg  to  cover 
as  much  ground  as  Is  attempte'd  in  the  book  under  review.  I  say 
attempted,  advisedly,  because  in  the  894  pages  in  the  book  the  field 
of  pharmacy,  phajmacognosy,  j-harroacology,  therapeutics,  toxi- 
cology and  experimental  pharmacology  have  been  brought  under  ob- 
servation with  varying  degrees  of  completeness,  so  that  it  is  rather 
more  than  a  text-book  and  something  less  than  a  system  ;  with  the 
exception  of  Part  I.  dealing  with  the  preparation  and  prescribing  of 
medicine  and  toxicologic  analysis,  and  Parts  III  (practical  exercises 
in  chemistiy  and  experiments  on  animals),  and  IV  (methods  of 
analyzing  the  cause  of  pharmacological  action),  The  bi-ok  appeals 
to  one  as  more  of  a  teacher's  or  graduate's  book  than  one  fitted  for 
the  student ;  because  the  condensation  essential  to  keeping  the 
volume  within  bounds  necessarily  induces  to  a  terseness  and  a  dog- 
maticism  of  style  that  is  foreign  to  the  fuller  scientific  discussion 
of,  as  yet,  undecided  questions  in  pharmacology,  and  they  are  many 


BOOK    REVIEWS.  93 

—while  it  pre-supposes  a  prior  knowledge  that  is  not  necessarily 
possessed  by  the  student,  and,  unfortunately,  often  not  by  the  gra- 
duate. The  question  of  immunity,  for  example,  as  discussed  by 
the  late  Kanthik  and  by  the  author,  will  serve  to  show  my 
meaning.  The  author  has  condensed  into  some  seven  pages  a 
subject  worthy  of  a  monograph.  The  judicious  use  of  display 
type,  however,  has  enabled  him  to  work  to  good  advantage,  and 
on  the  whole  the  work  will  hi  very  acceptable  to  the  teacher,  and 
parts  of  it  to  the  student.  In  common  with  most  teachers  of  the 
English  school,  I  deprecate  the  attempt  to  cover  too  wide  a  field 
at  one  sitting  and  prefer  the  more  careful  (if  slower),  process  of 
spading  and  sowing  one  section  thoroughly  at  a  time.  The  distinc- 
tion of  the  British  pharmacopeal  preparations  from  those  of  the 
United  States,  and  the  use  of  metre,  as  well  as  the  usual  weights 
and  measures,  is  of  the  greatest  use  and  marks  the  transition  stage 
from  arbitrary  to  scientific  standards.  The  printing  and  binding 
are  in  Saunders'  well-known  style  and  call  for  no  comment,  while 
the  price  places  it  well  within  reach  of  every  one. 

R.  W. 

Saunders'  Question  Oompends.  Essentials  of  Phy- 
siology. Prepared  especially  for  Students  of  Medicine, 
and  arranged  with  questions  following  each  chapter.  By 
Sydney  P.  Budgect,  M.  D  ,  Professor  of  Physiology,  Medical 
Department  of  Washington  University,  St.  Louis.  i6  mo 
volume  of  233  pages,  illustrated.  Philadelphia  and  London, 
W.  B.  Saunders  &  Company,  1901.  Carveth  &  Co  ,  Toronto. 
Cloth,  $1.00  net. 

This  is  an  entirely  new  work  and  a  worthy  accession  to 
Saunders'  excellent  series  of  Question  Compends.  It  aims  to 
furnish  material  with  which  students  may  lay  a  broad  foundation 
for  later  amplification,  and  to  serve  as  an  aid  to  an  intelligent  con- 
sultation of  the  more  elaborate  text- book.  The  subject  of  Physio- 
logy is  covered  completely,  and,  the  author  of  the  work  being  a 
teacher  of  wide  experience,  the  salient  points  are  particularly  em- 
phasized. An  important  feature  is  the  series  of  well-selected 
questions  following  each  chapter,  summarizing  what  has  previously 
been  read,  and  at  the  same  time  serving  to  fix  the  essential  facts  in 
the  mind.  In  every  way  the  work  is  all  that  could  be  desired  as 
a  students'  aid. 

F.  W.  C. 

New  Remedies  and  Therapeutic  Measures,  Wainwright's, 
G.  P.  Engelhard  &  Company,  Chicago,  1901. 

The  volume  before  me  is  a  very  welcome  addition  to  the  phy- 
sician's armamentarium.  As  the  author  truthfully  says  in  his  preface 
(and  the  admission  is  rather  humiliating)  the  part  of  the  physician's 
practice  with  which  he  is  least  familiar  is  pharmacology,  and  equally 
apt  is  his  statement  that  the  average  general   practitioner  has  not 


94  BOOK   REVIEWS. 

the  time  to  read  the  reports  of  the  never  ending  list  of  new  syn- 
thetic drugs  placed  on  the  market  appearing  in  the  various  journals. 
While  the  vast  majority  of  these  new  compounds  sink  into  perhaps 
a  well-merited  oblivion,  there  are  always  a  few  that  stand  the  test 
of  time  and  experience.  It  is  to  cull  these  for  the  benefit  of  the 
busy  practitioner  ihat  Mr.  Wainwright  has  issued  his  booklet,  and 
well  has  he  done  his  work.  I  note  the  omission  of  the  cocodyls 
from  the  arsenical  preparations,  and  adrenalin  from  the  animal 
extracts,  although  the  extract  of  the  suprarenals  is  mentioned.  A 
very  welcome  addition,  and  one  which  may  be  profitably  extended 
in  the  next  edition,  is  the  department  of  newer  therapeutics — 
excellent  articles,  models  of  condensation,  appearing  as  the 
Nauheim  treatment  of  heart  diseases,  general,  regional  and  local 
anaesthesia  both  by  Schleich  and  spinal  methods.  The  notes  on 
Nirvanin  deserve  the  consideration  of  those  enthusiasts  of  the 
spinal  method  of  anaesthesia.  The  volume  contains  224  pages  of 
printed  matter,  in  clear  type,  on  dull-finished  paper,  deckled  edge, 
gilt  top,  and  is  a  credit  to  the  bookmaker.  It  should  be  on  the 
desk  of  every  physician. 

R.  W. 

A  Texlt-Book  of  Pharmacology  and  Therapeutics,  or 

the  action  of  drugs  in  health  and  diseases,  by  Arthur  R. 
Gushing,  M.A.,  M.D.  (Aberdeen),  Professor  of  Pharmacology 
and  Therapeutics  in  the  University  of  Michigan — second 
edition  revised  and  enlarged,  47  engravings.  Lea  Bros.  & 
Co.,  Philadelphia  and  New  York,  1901. 

Cushing's  work  is  too  widely  and  favourably  known  to  call  for 
more  than  the  briefest  notice.  The  first  edition  of  his  work  was 
fully  reviewed  in  this  journal  on  its  appearance  over  a  year  ago  — 
and  it  is  gratifying  alike  to  his  friends  and  himself  that  a  work 
"  which  endeavours  to  explain  the  reason  for  drug  action  and  to 
"  offer  a  corrected  and  rational  body  of  knowledge  concerning 
"  Therapeutics"  has  met  with  the  measure  of  success  it  deserves. 
The  last  edition  contains  a  few  new  articles  and  some  necessary 
■  corrections  of  clerical  errors.  Not  the  least  pleasing  feature  of  the 
book  is  its  literary  style,  a  form  of  writing  that  finds  perhaps  its 
highest  expression  in  the  workings  of  Lauder  Brunton,  and  which 
makes  the  reading  a  pleasure  instead  of  a  toil,  while  the  bibliographic 
index  at  the  end  of  the  sections  is  valuable  to  those  wishing  to 
delve  deeper  into  any  subject  than  could,  of  necessity  be  expected 
in  a  text-book  of  its  avowed  objects. 

R.  W. 

Venereal  Diseases.  A  Manual  for  Students  and  Practitioners, 
by  James  R.  Hay  den,  M.D.  Third  and  revised  edition.  Lea 
Bros.  &  Co.,  publishers,  Philadelphia,  1902. 

Much  of  the  text  of  this  edition  has  been  re-written  and  many 
new  illustrations  added.  New  sections  on  Vegetations  and  Herpes 
have  appeared  for  the  first  time  and  are  certainly  a  valuable  addi- 


BOOK  REVIEWS.  95 

tion.  The  arrangement,  printing,  illustrations  and  general  make-up 
of  the  book  is  excellent.  The  text  is  very  concise  and  not  too 
short  to  be  clear.  Much  practical  advice  is  noticed  throughout, 
and  conflicting  theories  are  conspicuous  by  their  absence. 

A  very  sensible  section  is  that  on  the  care  of  urethral  instru- 
ments. The  note  of  warning  that  too  zealous  sterilizing  often 
renders  the  instruments  rough  and  harmful  to  the  patient  may  well 
bo  remembered. 

Students  will  find  this  work  very  useful,  and  the  busy  practi- 
tioner may  review  the  subject  without  loss  of  time  in  reading  this 
book. 

G.  F. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James 
M.  Anders,  M.D.,Ph.D.,  LL.D.,  Professor  of  the  Practice 
of  Medicine  and  of  Clinical  Medicine  iu  the  MedicoChirurgical 
College  of  Philadelphia,  Attending  Physician  to  the  Medico- 
Chirurgical and  Samaritan  Hospitals,  Philadelphia.  W.  B. 
Saunders  &  Co.,  Philadelphia  and  London,  1901  ;  J.  A. 
Carveth  &  Co.,  Toronto,  Canadian  Agents. 

We  have  in  this  volume  the  fifth  edition  of  a  valuable  and 
useful  treatise  on  the  Practice  of  Medicine.  It  has  been  carefully 
revised  and  brought  into  harmony  with  the  most  recent  develop- 
ment in  practical  medicine.  Differential  diagnosis  and  treat- 
ment have  been  especially  well  worked  out.  The  bacteriology  of 
the  book  is  up  to  date. 

The  volume  consists  of  over  twelve  hundred  pages  and  is 
divided  into  eleven  parts.  Infectious  diseases,  constitutional 
diseases,  diseases  of  the  blood  and  ductless  glands,  diseases  of 
the  respiratory  system,  diseases  of  the  digestive  system,  diseases  of 
the  urinary  system,  diseases  of  the  nervous  system,  diseases  of  the 
muscles,  the  intoxications,  obesity  and  heat  stroke,  animal  parasitic 
diseases.  In  the  present  edition  extensive  changes  have  been 
made  in  the  infectious  diseases,  bringing  the  subject  up  to  the  most 
modern  ideas.  A  few  nevv  articles  have  been  introduced — fatty 
infiltration  of  the.  heart,  streptococcus,  pneumonia  and  acute 
diffuse  interstitial  nephritis. 

This  volume  represents  a  very  large  amount  of  well  classified 
labour.  It  is  replete  with  useful  information.  Its  worth  is  such  that 
it  should  be  in  the  hands  of  every  student  and  worker  in  the 
realm  of  general  medicine. 

W.  G.  S. 

The  Medical  News  Pocket  Formulary  for  1902.  By  E. 

Reim  Thornton,  M.D.  Demonstrator  of  Therapeutics,  Phar- 
macy and  Materia  Medica  in  the  Jefferson  Medical  College, 
Philadelphia.  Fourth  edition,  revised.  Lea  Bros.  &  Co., 
Philadelphia  and  New  York,  287  pages,  wallet  size,  leather 
bound,  with  pocket  and  pencil,  $1.50  net. 

That  this  little  pocket  vade-mecum  should  have  reached  its 
fourth  edition  must  be  a  source  of  gratification  to  its  author  who 


96  BOOK   REVIEWS. 

has  succeeded  in  getting  together  some  1,700  formulae  for  the 
different  conditions  and  ills  to  which  the  flesh  is  heir.  It  may  be 
said  of  this  volume  as  was  once  said  of  a  certain  story,  "To  those 
who  hke  that  sort  of  thing  it  is  just  the  sort  of  thing  they  would 
like,"  and  doubtlessly  it  fills  a  want  in  a  certain  field.  It  has 
always  appealed  to  me,  however,  that  its  very  existence  is  a 
reflection  on  the  teaching  of  any  university  whose  graduates  find 
they  need  it.  That  there  is  need  for  it,  this  fourth  edition  bears 
mute  but  forcible  testimony.  When  will  our  universities  insist  on 
the  vast  importance  of  Pharmacology  and  Therapeutics  in  quali- 
fications of  a  graduate  in  Medicine. 

R.  W. 

A  Brief  Manual  of  Prescription  Writing  in  Latin  or 
EngUsh  for  the  use  of  Physicians,  Pharmacists  and  Medical 
and  Pharmacal  Students,  by  M.  L.  Neff,  A.M.,  M.D.,  Cedar 
Rapids,  la.  Pages  v-152.  Size,  8  x  5^  inches.  Extra 
cloth  75  cents,  net,  deUvered.  Philadelphia,  Pa.  F.  A. 
Davis  Co.,  publishers,  1914-16  Cherry  street.  . 

This  lit  le  volume  is  a  compendium  of  his  notes  in  teaching 
prescription  writing.  There  was  no  need  of  the  statement  in  the 
preface  that  he  "disclaimed  any  attempt  to  teach  the  Latin  lang- 
uage, or  such  ''  ;  the  fact  is  self-evident.  Just  so  long  as  the 
matriculation  standards  of  certain  schools  of  medicine  are  main- 
tained at  their  present  level,  just  so  long  will  such  a  booklet  find 
sale.  .Of  its  utility  after  purchase  there  is  room  for  personal 
opinion.  Like  the  Biblical  description  of  man,  it  is  "  fearfully 
and  wonderfully  made."  Latin  may  sufier  from  the  stigma  of  a 
dead  language,  malgie  de  foel,  that  it  is  spoken  as  an  every-day 
tongue  by  some  30,000  people  on  the  Eastern  coast  of  the  Adriatic, 
but  a  knowledge  of  it  does  polish  the  mind  and  broaden  the 
intellect,  hence  its  retention  as  a  matriculation  subject  for  entrance 
to  the  study  of  Medicine — the  broadest  of  all  sciences.  It  is  hard 
to  see  how  a  matriculant,  passing  his  latin  exam.,  should  need  such 
a  help.  Should  he  do  so,  however,  the  low  price  will  atone. 
Verily,  of  the  making  of  books  there  is  no  end. 

R.  W. 

A  Practical   Treatise   on   Diseases    of  the  Skin,  by 

John  V.  shoemaker,  M.D.,  LL  D.  Fourth  edition  revised 
and  enlarged  with  chromogravure  plates.  D.  Appleton  & 
Co.,  New  York,  1901. 

This  volume  groups  in  a  concise  and  systematic  form  all  the 
essentials  of  dermatoli  gy  ;  the  hypographical  work  and  engravings 
are  very  good. 

This  edition  has  been  thoroughly  revised  and  contains  many 
important  changes  an  t  additions. 

The  author's  classification  is  very  complete,  and  the  formulary 
for  internal  and  external  treatment  most  useful. 

J.  M.  J. 


CANADA 

MEDICAL  RECORD 


MARCH.     1902. 


Original  Communications. 


NOTES  FROM  THE  CASE  BOOK  OF  A  GENERAL 
PRACTITIONER. 

By  FRANCIS  W.  CAMPBELL,  M.D.,  L.R.C.P.  L . ,  D.CL. 

Dean  and  Professor  of  Medicine,  Faculty  of  Medicine,  UnlTersity  of  Biihop'a 

College. 

EPILEPSY. 

How  little  we  know  of  this  disease.  Theories,  we 
have  many,  but  they  do  not  help  us  to  a  cure.  Of  its 
patholo^'j,  we  may  be  said  to  be  profoundly  ignorant. 
Persons  who  have  been  epileptics  for  years  die  from  some 
inter-current  disease,  and  on  post  mortem,  the  brain,  spinal 
cord  and  nerves  are  found  in  a  healthy  condition.  McLane 
Hamilton,  in  his  article  on  Epilepsy,  in  Pepper's  System  of 
Medicine,  says:  "An  epileptic  attack  is  nothing  more  or 
less  than  a  discharge  of  nervous  energy  from  an  over- 
excited, or  what  may  be  called  a  dynamo  pregnant  nerve 
centre  or  collection  of  nerves."  That  is  simply  a  theory, 
and  makes  no  impression  on  my  mind  of  any  therapeutic 
value.  Hamilton  says  heredity  plays  a  most  important 
part;  fifty  per  cent,  of  his  cases  had  hereditary  history. 
Osier,  in  his  last  edition,, says  it  plays  but  a  minor  role, 
and  that  French  physicians,  with  whom  he  has  conversed 
on  the  subject,  hold  the  same  opinion.  My  experience  is 
not  large  but,  such  as  it  is,  I  endorse  Hamilton's  views. 
After  repeatedly  reading  articles  on  this  disease,  in  all  our 
standard  works  on  practice,  I  ris^  from  their  perusal,  con- 
vinced that  I  have  not  learned  anything  of  practical 
benefit.  These  articles  are  written  by  men,  who,  if  I  may 
say   it,   seem   to   be   writing    to   earn   their  money.     The 


98  EPILEPSY 

divisions  and  sub-divisions  which  they  make  of  the  disease 
are  not  met  with  in  ordinary  practice.     It  would  seem  as 
if  they  lived  in  a  world  of  their  own,  where,  possibly,  be- 
cause they  do  a  large   consulting   practice,  peculiar   cases 
are  sent  to  them.     So  far  as  my  experience  enables  me  to 
observe,  and  it  has  extended  over  forty  years,  I  have  not 
been  able  to  diagnose  any  special    features   in    the   cases 
which  have  come  under  m}^  observation.     Practically,  all 
have  had  the  same  symptoms,  the  only  difference  being  one 
of  degree.     Until  the  introduction  of  the  treatment  of  this 
disease  by  the  bromide  of  potash,  the  unfortunate  sufferer 
received  little  or  no  benefit  from  the  drugs  employed.    The 
routine  was  the  administration    of    antispasmodics,  such 
as  valerian,  ether  ffnd    musk.     It    was   about    fifty   years 
ago  that  the  bromide  of  potash  was  recommended  to  the 
profession,  and,  even  when  ten  years  later   I   entered  the 
profession,  it  was  the  drug  which    apparently    had    given 
the  best  results.     Some  absolute  cures  were  recorded.     I 
well  remember    the  late  Dr.    Waburton  Begbie,  of  Edin- 
burgh, telling  me  that  one  of  the  brightest  intellects  at  the 
Scotch  Bar,  who  had  developed  epilepsy    in    early   youth, 
had  been  cured  by  this  medicine.     From  that   day   up  to 
the  present  time  it  has  been  the  drug  which  has  been  pre- 
scribed in  seventy-five  per  cent,  of  all   cases.     Bromide  of 
sodium  has,  with  some,  taken  its  place,  while  a  combina- 
tion of  bromide  of  potash,  bromide  of   soda   and  bromide 
of  ammonium,  in  the  proportion  of  1.  1.  1-2  is  the  favourite 
of  a  few.     There  are,  of  course,  others  which    are   recom- 
mended, such  as  belladonna,  ergot,  hydrobromic  acid,  nitro 
glycerine.     But    to-day  the  bromides  are  still  the  stand- 
byes  of  the  profession  in  this  disease,  and  yet  I  fail  to  learn 
that  many  absolute  cures  are    recorded,  though    I    freely 
admit  that  in  many  cases  they  have   diminished   the   fre- 
quency and  severity  of  the   attacks.     If  they    have   done 
more.  1  do  not  know  it.     I  have  prescribed  it  sometimes 
alone   and    sometimes    in    combination     with    the    other 
bromide  salts,  because,  pterhaps,  to  be  honest,  I  knew    no 
better  treatment.  My  experience  extends  to  about  twenty- 
five  cases ;  some  have  died  from   some  inter-current  disease 
(I  never  have  had  a  death  during  a  convulsion),  and  some 


EPILEPSY.  99 

1  have  lost  track  of.  At  the  present  time  I  have  under 
observation  and  treatment  four  cases,  the  last  having  been 
under  my  care  only  a  few  weeks;  the  other  three  for 
periods  varying  from  forty  years  to  ten  years  and  two 
years.  I  bring  them  before  the  profession,  because,  since 
1898  I  have  placed  them  on  a  preparation  to  which  my 
attention  was  drawn  by  an  advertisement  in  one  of  my 
''Medical  Exchanges,"  I,  being  editor  of  the  "Canada 
Medical  Kecord."  That  preparation  is  Pil  Ferri  Hydrocy- 
anate,  and  it  is  manufactured  by  the  Tilden  Company,  of 
New  Lebanon,  N.  Y.  The  following  is  its  composition: 
B  Hydrocynate  of  Iron  (Tilden)  60  grains,  Extract  of 
Hyoscyamis,  60  grains,  Mucilage,  q.  s.  Divide  into  120 
pills,  one  to  be  given  night  and  morning,  and  increased 
one  pill  every  three  weeks,  until  three  pills  are  taken  at 
a  dose.     A  pill  double  this  strength  is  also  made. 

A.  C.  was  married  in  1861,  at  the  age  of  22  years. 
!So  far  as  I  can  ascertain,  previous  to  marriage,  she  never 
had  an  attack  of  grand  mal.  She,  undoubtedly,  had  many 
attacks  of  petit  mal,  occuring,  so  to  speak,  in  clusters. 
They  would  be  absent  for  months,  and  then  recur,  many 
occurring  in  a  day,  and  then  disappear  again.  Her  hus- 
band did  not  know  this  at  the  time  of  his  marriage,  nor  for 
some  time  after.  It  was  not  till  the  spring  of  1862  that 
she  became  pregnant,  and  in  August,  when  quickening 
occurred,  she  was  one  night  seized  with  a  severe  convul- 
sion. I  saw  her  immediately,  and  recognized  at  once  its 
character,  that  of  a  severe  epileptic  fit.  It  was  at  this 
time  I  discovered  the  patient's  history,  as  I  have  briefly 
stated  it.  I  also  learned  that  she  had  been  wet  nursed  by 
one  who  had  had,  at  long  intervals  epileptic  attacks,  and 
whose  son  had  developed  the  disease.  From  this  on- 
ward she  had  occasional  attacks,  but  went  to  her  full 
period,  and  was  delivered  of  a  healthy  child.  She  also 
made  a  good  convalescence,  and  her  baby  was  nursed  by 
a  healthy  wet  nurse.  The  treatment  adopted  was  15 
grains  of  bromide  of  potash  three  times  a  day,  with  a  half 
drachm  at  bed-time.  It  is  needless  to  give  minutely  the 
history  of  this  case,  extending  over  so  many  years. 
Briefly,  however,  it  is  as  follows:     She  subsequently  bore 


100  EPILEPSY. 

three  children  at  full  term,  all  of  whom  are  alive  and  in 
good  health.  She  also  was  delivered  of  three  children, 
about  the  seventh  month,  all  of  whom  died  within  a  few 
days  of  birth.  During  the  interval  between  the  first  at- 
tack and  the  year  1875,  a  period  of  some  thirteen  years, 
she  had  severe  attacks,  generally  about  the  menstrual 
period,  and  they  invariably  occurred  at  night.  An  attack 
during  the  day  only  took  place  two  three  times  during 
that  period.  This  fact  enabled  her  to  move  about  freely, 
going  to  church,  social  gatherings,  etc.,  and  did  not 
necessitate  a  companion  being  with  her.  The  night  at- 
tacks varied  in  severity,  but,  generally,  were  very  severe, 
indicated  constantly  by  minute  extravasations  after  a  fit, 
over  the  face,  down  the  side  of  the  neck  and  en- 
croaching on  to  the  upper  part  of  the  chest.  On 
one  occasion,  during  the  fit,  she  got  the  heel  of 
the  left  foot  over  the  nail  of  the  right  big  toe,  and 
forced  it  so  loose,  that  it  was  the  following  day  re- 
moved by  Dr.  Roddick.  She  visited  Scotland  several  times 
and  consulted  eminent  men,  who  made  no  change  in  treat- 
ment, beyond  increasing  the  dose  to  20  grains  three  times 
a  day,  and  40  grains  at  bed-time.  Special  attention  was 
directed  to  be  given,  the  bowels,  so  as  to  have  one  good 
motion  daily.  She,  up  to  this  time,  had  taken  the  bromide 
very  regularly,  but  her  intellect  and  spirits  continued 
perfect.  In  1875  there  gradually  developed  a  singular 
change,  the  night  seizures  took  place  at  longer  intervals, 
and  day  seizures  took  their  place,  until  1880,  during  which 
year  no  night  seizures  occurred,  and  day  seizures  alone 
occurred.  It  had  been  rare  for  mare  than  two  fits  to  take 
place  on  the  same  night,  but  four  and  five  seizures  during 
the  day  was  now  common.  This  was  a  serious  change  for 
the  patient  and  her  friends,  and  necessitated  the  employ- 
ment of  a  companion  to  be  constantly  with  her.  It  pre- 
vented her  going  to  evening  amusements,  or  for  walking 
out,  except  after  a  week  succeeding  a  fit,  when  this  was 
permitted  for  two  weeks.  During  this  time  the  chances 
were  against  the  patient  having  an  attack,  as  there  was 
generally  about  a  month  between  the  fits.  As  a  matter 
of  fact,  during  several  years,  only  one  severe  attack  and 


EPILEPSY.  lOI 

two  or  three  slight  ones  occurred,  while  the  patient  was 
thus  allowed  out.  At  this  time  a  change  was  made  in  the 
treatment — that  is  in  the  autumn  of  1883.  The  patient 
was  placed  on  one  drop  of  a  one  per  cent,  solution  of  nitre 
glycerine  in  a  teapoonful  of  water,  3  times  a  day  after 
meals.  Bromide  of  soda  was  now  given  instead  of  potash, 
in  a  20  grain  dose,  morning  and  evening.  The  nitro 
gh'cerine  was  increased  gradually,  till  in  six  months,  five 
drops  were  taken.  Within  six  months  of  commencing  the 
nitro  glycerine  there  was  evidence  of  its  doing  good;  the 
frequency  of  the  attacks  were  diminished,  two  months 
elapsing  between  attacks,  and  their  severity  was  less. 
Twice  four  months  elapsed  during  1888  and  1889  without 
a  fit,  and  the  patient  and  her  friends  were  most  hopeful. 
But  in  1890  the  attacks  were  more  frequent,  and  the 
patient  was  discouraged.  Still  the  nitro  glycerine  was 
continued,  and  once  more  in  1891  the  attacks,  though 
hardly  less  frequent,  were  certainly  again  less  severe,  and 
she  seldom  had  more  than  one  fit  on  the  same  day. 
During  the  time  intervening  between  1892  and  1897,  the 
bromide  of  soda  was  discontinued,  and  a  mixture  of 
bromide  of  potash  and  sodium,  with  bicarbonate  of  potash 
and  tincture  of  columba  substituted.  The  nitro  glycerine 
was  continued  at  intervals,  though  not  regularly,  as  the 
patient's  stomach  began  to  rebel  and  show  a  certain 
amount  of  irritation.  In  November,  1897,  my  attention 
was  accidentally  drawn  to  thej  benefit  said  to  be  derived 
in  this  disease  from  a  pill  of  the  hydrocyanate  of  iron,  manu- 
factured by  the  Tilden  Company  of  New  Lebanon,  N.  Y. 
I  sent  for  some  literature  on  this  subject,  and  in  January 
of  1898,  I  placed  the  patient  on  this  pill,  the  composition 
of  which  I  have  already  given. 

Within  four  months  from  commencing  this  remedy,  a 
decided  improvement  was  noticed.  The  patient  had,  dur- 
ing this  time  only  two  attacks,  and  they  were  decidedly 
less  severe,  the  epileptic  sleep  was  much  shorter,  and  the 
patient ,  regained  her  faculties  sooner.  The  pills  were, 
during  the  last  six  months  of  1898,  increased  to  six  daily, 
during  which  time  only  three  fits  occurred,  with  occasional 
attacks  of  petit  mal.    In  1899  she  was  placed  on  the  double 


102  EPILEPSY 

strength  pill,  commencing  with  three,  which  was  practio- 
ally  the  same  dose,  and  was  increased  every  two  months 
by  another  pill,  till  five  were  taken.     This  dose  the  patient 
has    continued   to   take    night  and   morning   ever   since. 
During  1899  she  had  only  five  attacks.     In  January,  1900, 
she  had  a  slight  fit,  and  on  the  21st  February   she  had   a 
severe  fit.     From  that  date,  up  to  the    first    of   February, 
1902,  she  was  absolutely  without  a  fit,  though  there  ■  was 
occasionally  slight  attacks  of  petit  mal,  but  on  the  2nd  of 
February,  1902,  while  at  dinner,  she  was  seized  with  an 
attack,  which  at  first  seemed  as  if  it  would  only  be  a  slight 
threatening,  but  it  developed  into  a  fairly  severe  fit,  though 
not  as  severe,  by  any  means  as  those  she  generally  took 
before  commencing  the  Hydrocyanate  of  Iron.     Looking 
back  over  the  history  of  this   case,  which   is  but  a   mere 
outline  of  forty  years,  I  have  no  hesitation    in  saying  that 
this  pill  has  done  far  more  for  my  patient  than  any  other 
drug  she  has  taken.     I  had  hoped  when  I  began  writing 
this  case,  that  I  would  have  been  able  to  state  that    she 
was  absolutely  cured  of  the  grand  mal,  having  been  nearly 
two  years  without  a  fit,  but  the  attack  on  February  first 
makes   it    impossible.     Still,  when    we   consider   that    for 
nearly  two  years,  she  had  been  practically  absolutely  free 
from  the  disease,  the  influence  of  the  Hydrocyanate  of  Iron 
must  be  admitted   as   being  most   powerful   for   good    in 
this  disease. 

Case  II. — Miss  W.,  a  woman  of  about  28  years  of  age, 
unmarried,  consulted  me  in  March,  1900,  for  epilepsy. 
Had  been  subject  to  the  disease  since  the  age  of  15  years. 
Had  occasional  treatment  without  relief.  No  hereditary 
history.  She  took  the  fits  always  at  night,  generally  two 
and  they  came  on  every  month,  occasionally  two  or  three 
times  in  a  month.  I  placed  her  on  the  1-2  grain  Hydro- 
cyanate of  Iron  pills — one  night  and  morning,  and  increas- 
ing one  pill  every  three  weeks  till  five  were  taken,  when  I 
changed  to  the  one  grain  pill  of  which  she  is  now  taking 
four  night  and  morning.  I  prescribed  half  a  drachm 
of  bromide  of  potash  at  bedtime.  The  effect  of  the  pills 
were  very  marked,  as  during  the  first  three  months  she  had 
only   one    attack   and   mild.     Then    four   months   elapsed 


EPILEPSY  103 

without  a  fit,  and,  believing  herself  cured,  stopped  the 
pills,  when  the  disease  returned  as  severe  as  ever.  On 
their  resumption,  the  beneficial  effect  was  again  marked. 
Two  or  three  times  since,  not  having  the  money,  she  was 
unable  to  get  the  pills,  and  their  discontinuance  was  in- 
variabl}'  followed  by  return  of  the  attacks  in  a  severe 
form.  At  the  time  of  writing,  she  had  taken  them  steadily 
for  nearly  four  months,  and  has  only  had  one  mild  fit. 

Case  III. — A.  L.,  aged  about  27,  a  blacksmith  by  trade, 
and  a  patient  of  mine  from  birth,  developed  the  disease 
about  the  age  of  17.  No  cause  could  be  ascertained, 
except  that  about  that  time  he  seriously  abused  himself 
with  liquor.  The  fits  came  on  every  two  or  three  weeks, 
and  he  has  had  as  many  as  five  in  one  night.  ^  I  placed  him 
on  the  nitro  glycerine  treatment,  with  moral  treatment 
added.  He  certainly  was  benefited  by  it,  as  their  frequency 
and  severity  was  diminished.  In  1899  he  married,  and 
shortly  after  the  fits  returned  as  bad  as  ever.  I  then  put 
him  on  the  Hydrocyanate  of  Iron,  when  he  went  nearly 
five  months  without  one,  but,  going  on  spree  of  some  two 
weeks,  they  again  returned,  but  not  so  bad.  I  cannot  get 
the  patient  to  take  the  pills  regularly,  so  that  he  does  not 
give  them  a  fair  chance.  His  family,  however,  recognize 
the  great  power  they  have  over  the  disease. 

Case  lY. — K.  W.,  clerk  in  an  insurance  office,  aged 
about  35  years,  was,  in  1890,  referred  to  me  for  epilepsy. 
The  attacks  came  on  irregularly,  night  and  day,  and  were 
a  mixture  of  both  the  grand  mal  and  the  petit  mat.  I  put 
him  on  the  nitro  glycerine  treatment,  with  bromide  of 
potash,  night  and  morning.  No  apparent  beneficial  result 
followed.  In  fact,  the  attacks  rather  increased,  till  he  was 
discharged  from  his  situation  in  1895,  on  account  of  having 
several  severe  attacks  in  the  office.  Before  this,  he  had 
been,  singular  to  sa3%  free  from  any  severe  attack  while  at 
work,  though  petit  mal  attacks  had  been  numerous.  At 
this  time  the  nitro  glycerine  was  discontinued,  and  the 
patient  put  on  bromide  of  potash  alone,  which  seemed  to 
diminish  the  frequency,  but  not  the  severity  of  the  fits. 
LTpon  one  occasion  during  this  year,  after  an  attack,  he  was 


104  EPILLPSY 

SO  violently  insane  that  I  was  sent  for,  and  only  succeeded 

in  getting  him  quiet  by  a  hypodermic  of  morphia.     In  1896 

he  came  to  my  office,  but  seldom,  and,  I  think,  only  once 

in  1897,  when  the  report  says    "no   improvement."     I  did 

not  see  him  again  till  the  first  week  in  October,  1901,  when 

he  came  to  my  office,  and  I  have  the  following  entry  in  my 

note  book :  "Patient  continued  my  treatment  till  the  spring 

of  1900,  when,  seeing  no  benefit,  upon  the  advice  of  some 

friend,  he  began  to  take  a  medicine  which  was  said  to  have 

completely    cured    a   prominent    gentleman    in    St.    John, 

N.B.     I  cannot  find    out    what    this    medicine    was.     The 

patient,  however,  says  it  not  only    did   him   no   good,  but 

under  it,  he  became  much  worse,  till,  at  this  time,  he  had  a 

severe  fit  every  ten  or  fifteen  days.     I  placed  him  on  the 

Hj'drocyanate  of  Iron,  giving  the  one  grain  pill,  and  with 

instructions  to  increase  one  pill  every  three  weeks.     The 

patient  has  reported  me  once  a  month,  since  he  began  this 

remedy.      The    following    are    the    reports,    up   to   date 

(March  18).     October  31, 1901. — No  attack  since  commencing 

the  pills.     iVoy.  30. — Only  one  v  slight    seizure.     This    was 

taken  in  church,  and  was  simply  a  shadow.     He  sat  in  the 

last  seat,  and  few,  I  am  told  by  his  brother,  recognized 

anything  unusual.     Dec.  30. — One  slight  seizure  at  night, 

during  this  month.     Jan.  30,  1902. — No  attack  this  month. 

March    18. — No     fit     since     early    in    December.      These 

reports    show     a     marked    improvement,    and  his    friends 

recognize  a  general  improvement  in  his  condition.     There 

can  be  no  doubt  of  the  beneficial  effect  of  the  Hydrocyanate 

of  Iron  in  this  case. 

I 

Cass  V. — A.  R.,  aged    15,  came   to   my   Clinic   at   the 

Montreal  Gneneral  Hospital,  on  the  23rd  of  January  last. 

Had  his  first  epileptic  fit  at  the  age  of  eleven  years.     They 

recurred  at  first  at  intervals  of  five  or  six  weeks,  but  for 

the  last  year  they  came  on    more   frequently,  till   at    the 

time  he  came  to  the  Hospital,  he  took   a   severe  fit  every 

four  days.     He  was  placed  on  the  Hydrocyanate  pills,  one 

night  and  morning.      He  was  then  two  weeks  without  a  fit, 

■when    one   occurred    on   the   6th   of   February.     About    a 

month  elapsed  without  a  fit,  when  he  had  one  on  the  street 


INJURY  TO  THE  EYEBALL.  IO5 

on  the  4th  of  March.  He  was  left  lying  in  the  snow,  and 
the  following  day,  developed  a  pneumonia  of  the  base  of 
the  right  lung.  On  the  26th  of  the  present  month  he  is 
convalescent,  and  has  not  had  another  fit.  While  this  case 
is  not  cured,  it  is  cited  to  show  that  the  Hydrocyanate  of 
Iron  has  already  vastly  improved  the  patient.  He  had 
been  under  other  treatment  before  coming  to  the  Hospital, 
and  not  only  had  there  not  been  any  improvement,  but  the 
patient  had  steadily  grown  worse. 


THREE  CASES  OF  GRAVE  INJURY  TO  THE  EYEBALI. 
W^ITH  ULTIMATE  RECOVERY  OF  USEFUL  VISION. 

By  George  H.  Mattewson.  B.&.,  M.D., 

Lecturer  on  Ophthalmology,  Medical  Faculty,  University  of  Bishop's  College, 
Oculist  to  the  Western  General  Hospital. 

As  most  of  the  readers  of  the  Record  are  general  prac- 
titioners who  are  so  situated  that  they  must  often  treat 
serious  injuries  of  the  eye,  whether  they  will  or  no,.  I  need 
make  no  apology  for  citing  the  following  instructive  cases : 

Case  I. —  On  Nov.  4,  1900,  Carl  A.,  a  Swede  from 
Radnor  Forges,  was  sent  to  me  by  Dr.  W.  H.  Drummond 
for  treatment.  Seven  days  previous  to  his  visit  to  me  he 
had  (while  working  with  a  sledge-hammer)  been  struck  on 
the  right  eye  by  a  fragment  of  steel.  He  consulted  imme- 
diately a  local  physician,  who  ordered  him  to  stop  work  and 
prescribed  atropin  drops.  After  the  first  shock  of  the  in- 
jury had  passed  away  the  eyesight  was  good,  and  the  eye 
gave  little  trouble  until  the  fifth  day,  when  it  became  very 
red  and  painful,  and  vision  was  greatly  reduced.  Two  days 
later  he  came  to  Montreal.  On  examining  the  eye  I  found 
it  very  red  (from  intense  scleral  and  conjunctural  inflamma- 
tion), the  pupil  widely  dilated  (from  atropin).  In  the  bot- 
tom of  the  anterior  chamber  was  a  small  deposit  of  yellow 
exudate,  i.  e.,  hypopyon.  The  eye  was  very  tender  to  the 
touch,  and  gave  patient  considerable  pain.  No  red  reflex 
could  be  obtained  when  light  was  thrown  into  the  pupil,  nor 
could  the  fundus  be  seen  with  the  ophthalmoscope.  By 
oblique  illumination  a  yellowish  reflex  was  produced,  a  mass 


I06  INJURY  TO  THE  EYEBALL 

of  yellowish  gray  exudate  could  be  seen  lying  in  the  vitreous, 
filling    the  whole  pupillary  area.     Vision   was   reduced    to 

counting  fingers  at  a  distance  of 
three  feet.  The  site  of  the  wound 
was  marked  by  a  scar  in  the 
median  horizontal  line  near  the 
caruncle. 

Here,  you  see,  is  a  condition 
of  severe  irido-cyclo-chorioiditis 
resulting  from  a  wound,  just  the  condition  to  produce 
sympathetic  ophthalmia.  The  patient  was  sent  to  the 
Western  General  Hospital  and  put  to  bed. 

Both  eyes  were  protected  by  a  large  shade  (if  one  eye  is 
diseased  both  must  be  shaded,  if  you  wish  to  derive  any  good 
from  the  shading).  Hot  fomentations  and  subsequent 
irrigations,  with  a  solution  of  bichloride  of  mercury,  1/6000, 
were  ordered  to  be  given  q.  3  h.  Drops  consisting  of  a 
combination  of  atropin  sulph.  i  per  cent,  and  cocain  mur, 
2  per  cent.,  were  instilled  into  the  eye  t.i.d.,  and  after  the 
fourth  day  a  pill  consisting  of  one  grain  each  of  Pulv. 
Hydrarg.  c  Creta  and  Pulv.  Ipecach  Co.  was  given  t.i.d. 

I  feared  the  worst,  but  felt  that  he  should  be  given 
every  chance  before  enucleation  of  the  diseased  eye  was 
resorted  to. 

Next  day  the  inflammatory  symptoms  were  less  severe, 
and  on  the  third  day  the  hypopyon  had  quite  disappeared. 

A  radiograph  of  the  eye  was  taken  on  the  third  day  (by 
our  radiographer,  Dr.  Robt.  Wilson),  and  showed  that  there 
was  no  steel  or  other  foreign  body  in  the  eye. 

November  14,  ten  days  after  the  patient's  admission  to 
the  hospital,  I  made  out  for  the  first  time  the  optic  nerve 
and  details  of  the  fundus. 

By  this  date  the  tenderness  had  quite  disappeared. 

On  December  24,  R.V.  =  6-18,  and  with  +  3.50  spher. 
(to  compensate  for  cycloplegic  effect  of  the  atropin,  which  he 
was  still  using)  he  could  read  Jaeger  No.  I.  at  25  cm. 

On  this  day,  at  his  urgent  and  persistent  demand,  he 
was  allowed  to   return   to  Radnor  Forges,  on  condiiion  that 


INJURY  TO  THE  EYEBALL.  10/ 

he  report  in  a  month's  time  or  sooner,  if  the  eye  troubled 
him  in  the  least.  He  was  given  atropin  sulph,  i  per  cent, 
drops  for  local  application  and  the  same  pill  as  before  for  in- 
ternal use. 

On  Jan.  21,  1901,  he  came  to  see  me  and  I  found  the 
R.V.  =  6-12,  and  that  the  opacities  in  the  vitreous  had 
largely  disappeared.  He  had  been  working  at  the  iron 
furnaces  for  three  weeks. 

On  April  2,  1902,  he  reported  once  more,  R.V.  =  6/12. 
I  stopped  the  mercury  and  gave  him  atropin  sulph.  drops 
I  per  cent.,  to  be  used  every  second  day,  with  the  idea  of 
preventing  relapse,  which  is  very  common  in  this  disease. 
On  this  occasion  he  was  very  drunk  and  said  he  was  going 
to  Cape  Nome  to  find  gold,  and  I  have  never  been  able  to 
find  trace  of  him  since,  which  is  unfortunate,  as  one  cannot 
be  certain  the  cure  was  permanent,  though  after  five  months 
without  relapse  it  is  likely  the  eye  remained  well. 

Case  II. — On  Feb.  13,  1901,  I  was  consulted  by  Miss 
D.,  who  had  injured  her  eye  while  attempting  to  open  a  bottle 
of  ginger  ale.  The  bottle  broke  at  the  shoulder,  and  a  frag- 
ment of  glass  struck  the  patient  on  the  right  eye.  I  saw  her 
half  an  hour  after  the  accident,  and  found  the  condition  of 
the  right  eye  to  be  as  follows  : 

Running  across  the  cornea  from  below  upwards,  and 
slightly  to  the  temporal  side  of  its  centre,  was  a  wound 
that  involved  the  whole  thickness  and  breadth  of  that  struc- 
ture, and  extended  into  the  sclera  about  0.5  mm.  above,  and 
I  mm.  below.  A  second  short  cut  began  in  the  sclera  below, 
extending  into  the  cornea  and  joining  the    larger  wound 

so  as  to  make  a  short  corneal 
flap.  The  anterior  chamber  was 
empty,  and  there  was  a  slight 
prolapse  of  vitreous,  while  the 
iris  lay  against  the  cut  cornea, 
and  was  caught  between  the  lips 
of  the  wound  in  nearly  its  whole 
extent,  though  it  did  not  prolapse  as  far  as  the  anterior  sur- 


I08  INJURY  TO  THE  EYEBALL. 

face  of  the  cornea.     Right  vision  =  counting  fingers  at  three 
feet. 

I  had  the  patient  removed  to  the  Western  General 
Hospital,  where  I  excised  the  prolapsed  vitreous  under 
cocaine,  and  sprinkled  the  wound  with  iodoform  instilled  a 
drop  or  two  of  i  p.c.  atropin  solution,  applied  a  firm  band- 
age and  had  patient  put  to  bed,  and  atropin  drops  t.i.d. 
were  ordered,  while  the  eye  was  kept  bandaged. 

The  next  day  the  anterior  chamb^r  was  restored,  but 
the  iris  was  found  to  be  still  firmly  caught  in  nearly  the 
whole  length  of  the  wound,  in  such  a  way  that  the  temporal 
part  of  the  iris  was  tense  while  the  nasal  part  with  most  of 
the  pupillary  border,  was  in  its  normal  position.  The  temporal 
part  of  the  anterior  chamber  was  thus  largely  obliterated 
and  cut  ofif  fron^  the  other  part. 

On  Feb.  25  the  corneal  wound  burst  open  during 
sleep,  but  closed  again  in  a  few  hours. 

On  Feb.  27  Vision  Right  Eye.  =  Fingers  at  18  ft. 
Tension  rather  high. 

On  March  3  corneal  wound  again  burst  open,  this  time 
from  patient  starting  up  violently  from  sleep  in  fright. 
Wound  again  closed  in  a  few  hours. 

On  March  5  the  corneal  wound  again  burst  open,  this 
time  quite  spontaneously,  so  I  decided  that  the  trouble  was 
due  to  the  pressure  of  the  aqueous  fluid  against  the 
adherent  iris,  which  pressure  did  not  act  equally  on  both 
lips  to  the  wound. 

I  performed  an  iridotomy,  therefore,  the  same  day, 
making  a  corneal  incision  above,  introducing  iris  scissors  and 
cutting  oft"  that  part  of  the  iris  which  was  caught  in  the  lips 
of  the  wound,  keeping  the  blades  as  close  as  possible  to  the 
cornea. 

The  new  wound  healed  kindly  and  the  old  wound 
closed  and  remained  so. 

For  some  time  the  eye  remained  sensitive  to  light,  but 
finally  became  quiet  and  the  patient  left  the  hospital  on 
March  26  six  weeks  after  her  admission. 


INJURY  TO  THE  EYEBALL.  IC9 

On  April  6,  1901,  R.  Vision  6-60  and  she  could 
read  Jaeger,  No.  8  at  25  cm.,  i.e.,  ordinary  print  at  the  usual 
distance. 

On  Feb.  26,  1902,  patient  could  read  Jaeger,  No.  5, 
quite  fine  print  and  her  distant  vision  R.  V.  6-24. 

Here  we  have  a  case  of  perforating  wound  in  the  ciliary- 
region  and  of  large  size,  with  vision  very  much  reduced,  and 
still  it  was  not  necessary  to  enucleate  the  eye,  but  by  proper 
care  the  patient  has  a  very  serviceable  eye. 

Case  III.  Mr.  V. — While  chipping  out  rivets  on  April 
3,  1 90 1,  patient  was  struck  on  the  right  eye  by  a  flying 
fragment  of  iron.  When  I  examined  his  eye  next  day  I 
found  a  small  corneal  wound  already  closed,  considerable 
pericorneal  congestion  and  a  beginning  tramuatic   cataract. 

The  lens  swelled  up  so  rapidly  that  in  a  few  days  the 
tension  was  dangerously  high  and  the  iris  was  seriously 
inflamed  from  the  pressure  of  the  swollen  lens,  that  I 
decided  to  remove  part  of  the  disintegrated  lens. 

The  patient  was  a  very  powerful  man  and  did  not 
behave  well  during  the  operation,  and  just  as  the  corneal 
section  was  completed,  closed  his  eyelids  together  with  such 
force  that  a  large  part  of  the  softened  lens  tissue,  and  a  very 
large  amount  of  vitreous  humour  were  forced  out  of  the 
wound, 

I  feared  at  first  that  the  retina  had  been  detatched,  but 
finding  the  patient  could  count  fingers  I  filled  the  globe 
with  normal  saline  solution  and  bandaged  the  eye  in  the 
usual  way, 

I  was  much  gratified  next  day  to  find  the  wound  firmly 
closed  and  the  chamber  restored.  The  further  course  of  the 
case  was  uneventful  and  the  patient  was  discharged  JVIay 
18. 

When  seen  about  a  month  later  Vision  R.  Eye  c+  10.00 
Spherical  =  6-60  and  could  have  been  easily  improved  as  the 
pupil  was  largely  closed  by  secondary  cataract,  which,  how- 
ever, it  was  thought  not  advisable  to  operate  on  at  the  time, 
as  patient  had  to  support  a  family  and  could  see  with  left 
ey,- 


no  ABSTRACTS. 

The  conclusions  I  would  have  you  draw  from  these 
cases  are  : 

First. — Do  not  be  too  hasty  in  deciding  to  enucleate  a 
wounded  eye,  even  though  the  wound  be  large  and  vision 
bad.  Treat  the  condition  for  some  days  expectantly,  always 
being  on  the  lookout  for  "shrinking  tenderness"  to  touch, 
which  is  the  chief  danger  signal  in  these  cases  as  it  proves 
the  existence  of  iridocyclitis  in  the  injured  eye. 

Second. — Filling  the  globe  with  saline  solution  in  the 
last  case,  undoubtedly  saved  the  eye,  as  it  made  possible  an 
exact  coaptation  of  the  lips  of  the  wound,  which  could  not 
have  been  had  in  the  previous  collapsed  condition  of  the 
globe. 

GEO.  H.  MATHEWSON,  B.A.,  M.D., 

56  Crescent  St. 


Abstract  of  several  papers  recently  published  by  William 
S.  Gottheil,  M  D.,  of  New  York. 

(Communicated  by  the  author  to  the  Canada  Medical  Record.) 
ACTINOTHERAPY,  GOTTHEIK 

{Author's  Abstract^ 

In  a  preliminary  communication  upon  the  use  of  con- 
centrated light  in  the  treatment  of  dermal  affections  W.  S. 
Gottheil  briefly  reviews  the  work  done  by  Finsen,  Kime  and 
others  in  this  field,  and  describes  the  arc  light  that  he 
employs  for  the  purpose.  This  is  at  present  the  only  avail- 
able source  for  the  actinic  rays  of  sufficient  volume  and  in- 
tensity for  therapeutic  employment.  Sunlight  is  of  course 
the  best,  and  is  costless  ;  but  it  is  too  uncertain  for  satis- 
factory use.  No  combination  of  incandescent  bulbs,  run  on 
the  ordinary  continuous  or  alternating  commercial  current,  is 
sufficiently  actinic,  and  the  apparatuses  arranged  with  them 
practically  give  us  heat  and  no  light  baths. 

The  author  employs  an  apparatus  called  the  Actino- 
lyte,   made  by  Kliegl   Bros.,  of  New  York,    which    can  be 


ABSTRACTS.  1 1 1 

adopted  to  either  the  continuous  or  the  alternating  current, 
uses  from  25  to  55  amperes  and  gives  a  concentrated  circle 
of  light  of  from  20,000  to  30,000  candle  power.  He  is  not 
prepared  as  yet  to  publish  his  results,  but  the  progress  of 
cases  of  lupoid  and  syphilitic  ulceration  has  been  most  en- 
couraging. The  cosmetic  results  of  this  non-operative  and 
painless  method  of  treatment  are  especially  good  ;  a  point  of 
the  greatest  importance,  of  course  when  the  face  is  involved. 
{The  Medical  News,  July  6,  1901.) 

DUHRING'S   DISEASE  IN   CHILDHOOD,   GOTTHEIL. 
[Author's  Abstract.) 

Dermatitis  herpetiformis,  first  described  by  Professor 
Duhring,  of  Philadelphia,  is  probably  of  commoner  occurrence 
than  is  generally  supposed,  more  especially  in  children. 
Two  cases  are  described  by  William  S.  Gottheil,  of  New 
York,  in  the  June  number  of  the  Archives  of  Pediatrics. 
The  resemblance  at  first  sight  to  an  ordinary  eczema,  der- 
matitis, or  impetigo  is  marked,  and,  doubtless,  cases  of  the  di- 
sease are  not  infrequently  so  classified.  The  points  which 
distinguish  the  less  common  affection  are  : — 

1.  The  extreme  obstinacy  and  chronicity  of  the  ma- 
lady ;  it  being  prolonged  almost  indefinitely  by  successive 
exascerbations  or  relapses. 

2.  Its  original  herpetic  character  and  subsequent  multi- 
formity of  lesion. 

3.  The  intense  pruritus. 

4.  Its  recalcitrancy  to  treatment. 

Any  apparent  eczema,  dermatitis  or  impetigo  in  children 
presenting  these  features  should  be  carefully  observed  ;  a 
certain  number  of  them  will  undoubtedly  be  found  to  be 
cases  of  Duhring's  disease. 

THE  CTJREABII.ITY  OF  SYPHII/IS,  GOTTHEIL. 

{Author's  Abstract.) 

Speaking  of  the  cureability  of  syphilis  in  the  sym. 
posium  upon  that  disease  in  the  October  number  of  the  In- 
iernational  Medical  Magazine^  William  S.  Gottheil,  of  New 


112  ABSTRACTS. 

York,  takes  exception  to  the  opinion  of  its  practical  incura- 
bility which  is  prevalent  in  certain  quarters.  Every  day 
experience  shows  that  the  great  majority  of  cases  are  cured 
in  every  practical  sense,  the  occasional  late  relapses  and 
accidents  to  the  contrary,  notwithstanding,      He  concludes  : 

1.  Syphilis  is  a  curable  disease,  and  may  even,  with 
restrictions,  be  called  a  self-limited  one. 

2.  Whilst  cure  in  a  given  case  canmt  be  affirmed  with 
scientific  accuracy,  the  chances  of  its  being  the  fact  after  a 
certain  time  under  proper  treatment  are  so  great  that  it  may 
be  properly  claimed  to  have  been  affected. 

3.  Practically,  a  patient  who  has  been  properly  treated 
throughout  the  active  stages  of  the  disease,  and  who  has  had 
no  manifestations  of  its  persistance  for  several  years  there- 
after, may  be  regarded  as  cured,  and  may  be  told  so. 

THE    UNRECOGNIZED     CHANCRE,    GOTTHEIL. 

{Author's  Abstract.) 

In  the  International  Medical  Magazine  for  October 
William  S,  Gottheil  calls  attention  to  the  frequent  insigni- 
ficance and  fugacity  of  the  syphilitic  initial  lesion,  which 
leads  to  its  non-recognition  in  quite  a  large  proportion  of 
cases.  Ignorance  of  its  occurance,  and  not  voluntary  falsifica- 
tion, is  the  cause  of  the  frequent  absence  of  a  syphilitic 
history  in  undoubtedly  specific  cases.  The  author  calls 
attention  to  the  following  points   of  diagnosis:  — 

1.  The  presence  of  a  tumor  as  the  original  lesion.  In 
its  essence,  and  invariably  at  the  beginning,  the  chancre  is  a 
small  round  cell  accumulation  in  the  skin  or  subucutaneous 
tissue.  Ulceration  may  occur,  and  usually  does,  or  even 
phagadaenism  ;  but  these  are  accidental,  and  epiphenomena, 
and  almost  invariably  the  specific  induration  is  appreciable 
at  the  base  of  the  lesion. 

2.  The  tumor  is  indolent,  painful  and  recalcitrant  to 
treatment. 

3.  A  peculiar  and  characteristic  "  stony  "  induration  of 
the  nearest  lymphatic  glands  accompanies  it,  different   from 


GALLSTONES  113 

the  general  adenopathy  that  occurs  later  as  a  consequence  of 
the  systemic  ^^infection.  Other  lesions,  as  gummata,  do  not 
show  it. 

4.  Chancre  runs  its  full  course  in  a  few  weeks,  whilst 
tuberculosis  takes  months,  and  carcinoma  even  years,  for  its 
development. 

5.  The  well  known  signs  of  general  luetic  infection, 
osteocopic  pain,  cephalalgia,  synovitis,  general  lymphaden- 
itis, exanthem,  etc.,  must  be  carefully  and  persistently 
searched  for  in  every  suspicious  case.  They  may  be  so 
slight  as  to  entirely  escape  careless  examination. 


Selected  Articles. 


GAIiliSTOXES. 


According  to  recent  statistics,  it  has  been  found  that  in 
round  numbers  about  one  person  in  every  fifteen  has  gall- 
stones ;  and  furthermore,  that  of  those  so  afflicted,  death  was 
attributed  to  the  presence  of  gallstones  in  over  1 1  per  cent, 
of  the  cases — that  is  to  say,  in  every  1,000  deaths,  'j6  are  attri- 
buted to  gallstones.  The  disease  is  first  mentioned  (as  occur- 
ring in  man)  some  time  in  the  fifth  century,  although  at  a 
much  earlier  date  the  Egyptian  priests  observed  that  dom- 
estic animals  were  afflicted  with  it. 

Age  is  a  prominent  etiological  factor,  the  disease  being 
most  common  after  the  age  of  forty.  Women  are  more  often 
affected  than  men,  some  writers  giving  the  proportion  of 
three  to  two,  while  others  give  as  high  as  five  to  one.  The 
greater  liability  of  women  in  this  respect  has  been  attributed 
to  their  more  sedentary  habits  and  the  abdominal  constric- 
tion caused  by  tight  fitting  clothing  and  corsets  ;  but  we  be- 
lieve that  ''criminal  neglect  of  the  bowels"  should  be  con- 
sidered as  playing  an  important  role  in  the  etiology  of  this 
complaint.  Furthermore,  it  has  been  unquestionably  proven 
that  gallstones  are  most  frequently  found  in  the  gouty, 
lithaemic  and  obese.  In  other' words,  the  same  constitutional 
factors  favouring  the  production  of  uric  acid  excess  are  favour - 
able  to  the  production  of  gallstones.  Indeed,  the  term  "chole- 
lithiasis "  is  itself  indicative  of  the  uric  (lithic)  acid  dysarasic. 

A  diminution  of  the  sodium  salts  in  the  bile  is  consid- 


II4  GALLSTONES 

ered  one  of  the  chief  causes  which  lead  to  a  separation  of  its 
elements,  making  stone  formation  possible.  The  fact,  too, 
that  most  stones  are  composed  of  from  seventy  to  eighty  per 
cent,  cholesterin  would  indicate  inspissation  and  viscidity  of 
this  fluid  caused  by  a  loss  of  its  alkaline  ingredients  and  the 
consequent  inability  to  oxidize  the  colloid  waste  brought  to 
it  by  the  circulation.  Again,  although  no  change  takes 
place  in  healthy  bile,  excreted  from  a  healthy  liver  and  con- 
tained in  healthy  biliary  passages,  yet,  if  prevented,  for  an}' 
reasons,  from  escaping  for  a  considerable  period  of  time,  as 
in  chronic  constipation,  the  bile  becomes  altered  in  character 
decomposition  ensues,  and  the  bile  elements  are  deposited. 

The  treatment  may  be  considered  from  two  stand- 
points—  medical  and  surgical.  If  the  stone  is  sufficiently 
large  to  be  detected  by  palpation  or  otherwise,'  and  excites 
inflammation,  violent  pain,  icterus,  or  other  pain  signs  of  oc- 
clusion, an  immediate  operation  may  be  desirable.  But  in 
that  vast  majority  of  cases  in  which  the  diagnosis  has  been 
made  from  more  obscure  symptoms — e,  g.,  malaise,  bitter 
taste  in  the  mouth,  constipation,  dull  pain  in  the  hypochon- 
riac  region  (accompanied,  perhaps,  by  nausea  and  other  gas- 
trio  disturbances),  occasional  chills,  fever  and  sweats,  slight 
jaundice,  migraine,  etc.,  or  sometimes  from  the  more  definite 
biliary  colic, —  then,  the  results  of  internal  treatment  may 
often  be  found  efficacious.  While  it  is  doubtless  inexpedient 
to  attempt  to  dissolve  stones  of  considerable  size  already 
formed  (and  too  large  to  pass  through  the  common  duct),  yet, 
it  is  frequently  the  case  that  stones  are  repeatedly  formed 
which  are  expelled  into  the  bowel,  and  it  is  to  prevent 
further  formation  of  these  that  our  efforts  may  well  be  direct- 
ed. 

The  success  obtained  from  the  use  of  thialion  in  these 
cases  is  doubtless  owing  partly  to  the  cholagogue  and 
laxative  effects  of  its  soda  salt  in  preventing  inspissation  of 
bile,  and  partly  to  its  alkalising  and  solvent  virtues  in  clear- 
ing the  blood  of  uric  acid  and  its  congeners  and  preventing 
obstruction  of  the  capillaries  from  colloid  waste.  By  its  in- 
fluence the  bowels  are  kept  open  and  free,  and  a  more  gen- 
erous flow  of  bile  instituted  from  the  gall  passages  ;  the 
liver,  as  well  as  kidneys,  is  stimulated  to  greater  activity, 
their  respective  secretions  become  greater  in  amount  and 
more  alkaline,  and  thus  more  capable  of  oxidizing  and  hold- 
ing in  solution  the  waste  products  of  tissue  metabolism.  In 
other  words,  like  the  blood  itself,  the  bile  and  urine  are  ren- 


MEDICINE  AND  NEUROLOGY.  II5 

dered  more  nearly  normal  in  character  owing  to  the  influence 
of  the  remedy  in  removing  the  ''ashes  and  clinkers"  from  the 
system  which  clog  up  its  grates  and  prevent  free  oxygena- 
tion. The  same  treatment,  therefore,  which  prevents  the 
deposition  of  urates  from  the  blood  (causing  gout),  or  from 
the  urine  (causing  gravel  or  renal  calculi),  will  prove  equally 
efficacious  in  preventing  deposits  from  the  bile  and  the  for- 
mation of  gallstones.—  Uric  Acid  Monthly. 


Progress  of  Medical  Science. 


MKDICINB    AND     NEUROI^OGY 

IN  CHARGE  OF 

J.  BRADFORD  McCONNELL,  M.D. 

Associate  Professor  of  INIedicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College;  Physician  Western  Hospital. 


RECENT  VIEWS  OF  THE  EFFECTS  OF  ALCOHOL. 

The  conclusion  reached  by  Professor  Atwater,  as  a  re- 
sult of  experiments  conducted  by  him  last  year  to  determine 
the  effects  of  alcohol  on  the  human  system,  that  the  substance 
taken  in  small  quantities  and  under  certain  conditions  is  a 
food,  has  given  rise  to  much  and  bitter  discussion.  The 
garbled  accounts  given  in  the  newspapers  of  Dr.  Atwater's 
findings  are  chiefly  responsible  for  the  state  of  affairs.  Many 
of  these  journals  proclaimed  that  the  professor  had  proved 
alcohol  as  a  beverage  to  be  harmless,  whereas,  in  fact,  he  went 
no  further  than  to  declare  that  it  is  oxidized  in  the  same 
manner  as  any  other  food  materials,  and  is  transformed  into 
heat  and  muscular  energy.  The  experiments  were  not 
sufficiently  prolonged  to  demonstrate  what  the  effects  might 
be  upon  the  human  organism  of  the  habitual  use  of  alcohol, 
nor  was  any  attempt  made  to  show  that  such  use  would  be 
any  thing  but  harmful. 

Another  pronouncement  on  the  same  question  has  been 
recently  made  by  the  well-known  Viennese  clinician.  Prof. 
Max  Kassowitz,  who  asserts  that  the  dogma  concerning  the 
nourishing  and  strengthening  character  of  alcohol  is  one  of 
the  fatal  errors  of  science.  .  He  holds  the  view  that  the 
majority  of  physicians  take  up  an  inconsistent  position  with 
regard  to  the  use  of  alcohol,  for  the  reason  that  while  they 


1 16  PROGRESS   OF  MEDICAL  SCIENCE. 

are  well  aware  of  its  dangerous  and  poisonous  qualities,  they* 
nevertheless,  contribute  to  making  permanent  the  false  ideas 
concerning  the  value  and  effects  of  alcohol  which  are  so  gen- 
erally disseminated.  Kassowitz  explains  these  incon- 
sistencies on  the  ground  that  the  teaching  which  considers 
alcohol  a  food  because  it  is  burned  in  the  organism,  has  held 
its  ground  in  spite  of  many  disregarded  newer  investigations 
which  have  shown  its  indefensibility.  He  is,  therefore,  of  the 
opinion  that  the  assumption  ascribing  food  properties  to  al- 
cohol based  on  simple  theoretical  consideration  is  a  grave 
scientific  error,  the  removal  of  which  is  the  most  important 
preliminary  condition  to  an  effectual  battle  against  alcoholism. 

Dr.  Hermann  Blocher,  of  Basle,  Switzerland,  in  an 
article  in  the  Internationale  Monatsschrift  fur  die  Bekampsung 
der  Jrinksitten  for  April,  comments  very  favourably  upon  Pro- 
fessor Kassowitz's  utterances,  and  discusses  the  matter  from 
the  standpoint  of  physiological  experiment.  He  refers  to 
the  investigations  of  Miura,  which  indicate  that  alcohol  be- 
longs to  the  same  group  of  substances  as  glycerin,  lactic  acid, 
butyric  acid,  and  so  forth,  which  are  indeed  burned  in  the 
animal  body,  but  which,  nevertheless,  are  not  fit,  even  to  the 
smallest  extent,  to  take  the  place  of  necessary  food  in  the 
preservation  of  the  body.  Miura  found  that  the  addition  ot 
alcohol  to  the  food  before  its  being  taken  not  only  causes  no 
diminution  of  the  nitrogen  output,  and  does  not  prevent  the 
loss  of  body  material  (as  is  the  case  with  the  addition  of  sugar 
or  fat),  but  that  on  the  contrary  the  nitrogen  output  follow- 
ing this  addition  of  alcohol  may  become  yet  greater  than  it 
had  been  without  this  addition. 

Professor  Atwater  did  not  pretend  in  his  experiments  to 
prove  the  innocuousness  of  alcohol  as  a  beverage,  and  it  was 
due  to  the  newspapers  that  such  a  belief  was  disseminated. 
Whether  alcohol  in  small  amounts  and  used  with  discretion 
is  harmful  has  yet  to  be  clearly  proved. — Editorial  in  Medi" 
cat  Record, 

RESULTS  OF  TESTING  OF  THE  RENAL  FUNCTIONS 
WITH  METHYLENE  BLUE. 

Achard  and  Castaigne,  who  have  in  the  past  contributed 
a  number  of  papers  upon  this  new  diagnostic  resource,  have 
now  published  a  small  monograph  on  the  same  subject  (Paris, 
1900). 

The  results  thus  far  yielded  by  this  method  to  date  are 
as  follows  (it  will  be  remembered  by  the  reader  that  a   solu- 


MEDICINE   AND   NEUROLOGY.  1 17 

tion  of  methylene  blue  is  injected  hypodermatically,  and  the 
interval  noted  before  the  colour  appears  in  the  urine,  as  well 
as  the  duration  of  the  period  of  elimination): 

In  interstitial  nephritis  there  are  evidences  of  imper- 
meability, such  as  delayed  appearance  (frequently),  and 
habitually  prolonged  elimination  period.  The  authors  have 
often  made  the  diagnosis  when  other  phenomena,  such  as  al- 
buminuria, were  not  in  evidence.  Considering  the  insidious 
nature  of  this  disease,  the  test  should  be  of  great  practical 
value. 

In  acute  and  chronic  diffuse  nephritis  it  is  quite  different. 
Ptrme.ibility  appears  to  be  retained  for  a  long  time.  The 
same  holds  good  for  amvloid  kidney. 

In  functional  albuminuria  a  slight  prolongation  of  the 
period  of  elimination  has  been  observed. 

In  passive  congestion  of  the  kidneys  from  cardiac  weak- 
ness the  elimination  of  the  blue  does  not  appear  to  be  inter- 
fered with.  After  the  condition  is  of  long  standing  irregu- 
larities of  elimination  will  appear. 

In  diabetes  elimination  appears  to  be  almost  normal. 
If  this  disease  coincides  with  actual  organic  disease  of  the 
kidney,  impermeability  is  readily  apparent. 

In  urinary  surgery  operators  have  employed  the  blue  in 
doubtful  cases  to  determine  whether  or  not  thd  kidneys  are 
sufficiently  impaired  to  contraindicate  operations  on  the 
urogenital  tract.  The  method  has  been  combined  with 
urethral  catheterization,  so  that  the  permeability  of  each  kid- 
ney may  be  ascertained. 

It  was  thought  that  the  blue  might  prove  of  service  in 
obstetrical  practice,  and  foretell  the  possibility  of  eclampsia 
through  evidences  of  renal  inadequacy ;  but  these  hopes 
have  not  been  reaHzed.  An  eclamptic  may  eliminate  the 
blue  normally,  while  a  case  which  eliminates  badly  will 
present  no  evidence  of  likelihood  of  eclampsia. — Medical 
Review  of  Reviews. 

HOW  CAN  W^E  TELL.  ViTHETHER    PLEURISY  IS  TUBER- 
CULOUS OR  NOT?  r\    , 

Given  a  case  of  acute  pleurisy,  can  we  possibly  tell  whe- 
ther the  patient  will  be  free  from  or  subject  to  tuberculosis 
ultimately  ?  Positively  so,  in  those  who  have  personal  or 
hereditary  taints,  for  they  are  certaintly  prone  to  tubercu- 
losis. As  regards  those  who  have  no  taints,  who  are  ap- 
parently in  a  most  favourable  condition,  we  can  tell  by  tests, 


Il8  PROGRESS   OF   MEDICAL   SCIENCE. 

which  are  to  be  here  considered.  But  in  the  first  place,  let 
it  be  asserted  that  such  is  the  case,  namely,  in  spite  of  the 
most  favour,! ble appearances,  acute  pleurisy  with  effusion  from 
a  cold,  a  frigore,  may  be  of  tuberculous  nature.  In  proof  of 
this,  we  recall  the  common  occurrence  of  a  young  and  pre- 
viously healthy  man,  without  any  personal  or  hereditary 
taint,  recovering  in  all  likelihood  from  a  case  of  acute  pleurisy 
due  to  cold,  and  seemingly  primary,  after  25  or  28  days, 
the  effusion  having  been  aspirated  or  resolved  according  to 
circumstances.  Yet,  should  this  patient  be  kept  under 
observation,  it  also  occurs  quite  often  that  after  two  or  three 
years,  sometimes  later,  sometimes  earlier,  his  health  changes 
and  he  is  found  to  be  attacked  by  tuberculosis,  which  runs  a 
more  or  less  rapid  course.  Again,  we  recall  the  large  number 
of  autopsies  of  cases  of  acute  pluerisy,  seemingly  primary,  in 
which  is  was  found  that  tuberculosis  existed,  and  we  give  as 
examples,  the  following  brief  reports  ; 

In  1884,  a  man  aged  34  years,  in  good  health  up  to 
that  time,  no  tainted  previous  history,  is  taken  sick  with 
acute  pleurisy,  a  frigore,  and  dies  suddenly.  Post  mortem  ; 
2,2Co  can.  of  good  fluid  ;  apex  of  one  lung  presents  chalky 
tuberculous  mass. 

In  1887,  a  man  aged  50  years,  robust,  in  good  health 
up  to  the  time  of  admission  into  the  hospital,  is  found  to 
have  a  large  effusion  in  pleura,  necessitating  immediate 
aspiration.  He  does  well  for  a  time,  then  dies  suddenly. 
Post  mortem  :  2,300  cent,  of  good  fluid  ;  apex  of  one  lung 
presents  tuberculous  mass  in  the  stage  of  repair,  containing 
bacilli ;  tubercles  of  recent  formation  in  pleura. 

But,  while  it  can  thus  be  said  that  in  the  great  majority 
of  cases  of  acute  pleurisy,  with  effusion  there  is  a  latent 
tuberculosis  and  that  acute  pleurisy  a  frigore  is  not  primary, 
but  actually  secondary  to  tuberculosis,  yet,  it  must  also  be 
asserted  as  a  clinical  truism,  chiefly  in  the  country  where 
cases  can  be  more  easily  kept  under  observation,  that  there 
area  number  of  cases  of  acute  pleurisy  with  effusion  that  do 
get  entirely  well.  For  instance,  Corivaud  states  that  out  of 
27  cases  in  his  own  practice,  only  four  died  in  a  period  of 
twenty  years.  So,  on  the  one  hand  we  have  cases  of  acute 
pleurisy,  due  to  latent  tuberculosis,  on  the  other,  cases  inde- 
pendent of  it.  How,  then,  can  we  differentiate?  Clinical 
investigation  is  obviously  inadequate,  since  auscultation 
gives  very  variable  and  very  uncertain  results.  We  therefore 
have  to  depend  on  laboratory  tests.     Of  these  (a)  incocula- 


MEDICINE  AND  NEUROLOGY.  II9 

tion  of  animals  with  the  pleural  fluid  is  not  entirely  reliable, 
since  40  per  cent,  of  tests  in  evident  cases  of  tuberculosis  give 
no  positive  results  ;  (J?)  injection  of  tuberculin  is  dangerous  ; 
{c)  agglutination,  as  in  typhoid  fever,  lacks  precision  ;  {d) 
cultures,  though  made  on  the  best  gelose-blood,  are  too  deli- 
cate to  be  used  in  a  general  way ;  {e)  Finally,  the  cytodia- 
gnosis  introduced  by  Widal  and  Ravant,  is  by  far  the  most 
accurrate.  The  following  is  the  information  we  gather  from 
the  procedure,  based  on  the  histologic  examination  of  the 
pleural  fluid. 

When  we  examine  the  fluid  of  a  pleurisy  in  Bright's 
disease,  we  find  endothelial  cells  in  sheets,  and  should  there 
be  in  the  history  the  occurrence  of  hemoptysis,  the  latter  is 
accounted  for  by  the  circulatory  disturbances  of  Bright's 
disease.  ^ 

When  we  examine  the  fluid  of  a  pleurisy  consequent 
upon  pneumonia,  typhoid  fever  or  other  infections,  we  find 
large  mono  or  polynuclar  leucocytes. 

When  we  examine  the  fluid  of  a  pleurisy  oi  a  fri^ore^vjQ 
find  on  the  one  hand  red  blood  cells,  on  the  other  small 
white  cells,  lymphocytes. 

Summing  up  we  have  the  following  formulas  in  cito- 
diagnosis  : 

(a)  Endothelial  sheets  in  mechanical  pleurisy  due  to  cir- 
culatory disturbances. 

(6)  Large  mono  or  polynuclear  leucocytes  in  pleurisy  of 
infectious  origin,  not  tuberculous. 

{c)  Red  blood- cells  associated  with  lymphocytes  in 
tuberculous  pleurisy. 

As  these  results  in  cystodiagnosis  have  been  confirmed 
by  the  culture,  inoculation  and  agglutination  procedures,  it 
is  therefore  certain  that  the  presence  of  erythrocytes  and 
lymphocytes  in  the  same  field  shows  that  the  fluid  examined 
is  of  turberculous  nature. —  Journal  de  Medecine  et  de  Chi- 
rurgie  pratiques,  August    10,    1901. 

HINTS   FOR  DYSPEPTICS. 

Eat  slowly,  masticating  the  food  very  thorougly,  even 
more  so,  if  possible,  than  is  required  in  health.  The  more 
time  the  food  spends  in  the  mouth,  the  less  it  will  spend  in 
the  stomach.  Avoid  drinking  at  meals  ;  at  most  take  a  few 
sips  of  warm  drink  at  the  close  of  the  meal,  if  the  food 
is  very    dry    in  character.     In  general  dyspeptic    stomachs 


120  PROGRESS  OF  MEDICAL  SCIENCE. 

manage  dry  food  better  than  that  containing  much  fluid. 
Eat  neither  very  hot  nor  cold  food.  The  best  temperature 
is  about  that  of  the  body.  Avoid  exposure  to  cold  after 
eating.  Be  careful  to  avoid  excess  in  eating.  Eat  no  more 
than  the  wants  of  the  system  require.  Sometimes  less  than 
is  really  needed  must  be  taken  when  digestion  is  very  weak. 
Strength  depends  not  on  what  is  eaten,  but  on  what  is 
digested.  Never  take  violent  exercise  of  any  sort,  either 
mental  or  physical,  either  just  before  or  just  after  a  meal.  It 
is  not  good  to  sleep  immediately  after  eating,  nor  within 
four  hours  of  a  meal.  Never  eat  more  than  three  times  a 
day,  and  make  the  last  meal  very  light.  For  many  dyspep- 
tics, two  meals  ,are  better  than  more.  Never  eat  a  morsel 
of  any  sort  between  meals.  Never  eat  when  very  tired, 
whether  exhausted  from  mental  or  physical  labour.  Never 
eat  when  the  mind  is  worried  or  the  temper  ruffled,  if  pos- 
sible to  avoid  doing  so.  Eat  only  food  that  is  easy  of  diges- 
tion, avoid  complicated  and  indigestible  dishes,  and  taking 
but  one  to  three  kinds  at  a  meal.  Most  persons  will  be 
benefited  by  the  use  of  oatmeal,  wheat  meal,  cracked  wheat, 
and  other  whole  grain  preparations,  though  many  will  find  it 
necessary  to  avoid  vegetables,  especially  when  fruits  are 
taken. — Public  Health  Journal. 

VERATRUM  VIRIDE  IN  MANIA. 

Any  physician  who  has  not  employed  veratrum  viride 
in  acute  mania  has  missed  the  best  agency  which  is  available 
for  the  cure  of  these  distressing  cases.  It  is  one  of  the 
greatest  advantages  a  physician  can  have  to  see  the  feverish 
sufferer,  under  the  application  of  this  remedy,  pass  from 
absolute  sleeplessness  into  a  state  of  quiet  rest.  That  many 
cases  which  would  otherwise  go  on  to  death  are  saved  by 
the  use  of  this  remedy  is  a  fact  beyond  question.  The  fear 
which  many  practitioners  have  of  using  veratrum  viride,  on 
account  of  the  varying  strength  of  its  various  preparations, 
must,  of  course,  be  met  when  the  drug  is  employed,  by 
the  use  of  Norwood's  tincture. — American   Medical  Journal. 

THE  TREATMENT  OF  RECTAL  PROLAPSE  IN  CHILDREN. 

Hajech  recommends  the  use  of  ice  in  prolapse  of  the  rec- 
tum. A  tapering  piece  of  ice,  about  three  inches  long  and 
about  an  inch  in  diameter  at  the  thick  end  is  wrapped  with 
iodoform  gauze,  and  its  point  is  pressed  gently  against  the 
center  of  the  prolapsed  mass  until  it  is  replaced.     The    ice 


MEDICINE   AND  NEUhOLOGY.  121 

tampon  remains  in  the  rectum  without  the  use  of  any  reten- 
tive bandage,  provided  it  is  pushed  in  far  enough.  A  fresh 
piece  of  ice  is  employed  in  this  way  after  each  act  of  defeca- 
tion. This  treatment  soon  cures  the  prolapse.  It  seems  to 
act  by  emptying  the  blood-vessels  in  heightening  the  con- 
tractility of  the  rectum.  —  Courier  of  Medicine. 

THE  SCIENTIFIC  STUDY  OF  THE  CRIMINAIi  AND 
DEFECTIVE    CLtA-SSES. 

It  is  some  years  since  Lombroso,  the  eminent  Italian, 
began  his  studies  in  criminology  and  endeavoured  to  trace 
the  impulse  of  the  criminal  to  an  anatomical  peculiarity 
of  the  brain.  Pauline  Tarnowsky,  the  well-known  Russian, 
also  contributed  to  this  subject,  her  principal  contribution 
being  a  book  relating  to  the  anatomical  peculiarities  of  the 
ears,  eyes,  etc.,  of  a  number  of  criminal  women,  including 
thieves,  prostitutes,  etc.  The  first  hints  thrown  out  did 
not  fall  on  fallow^  ground,  and  the  results  so  far  obtained 
have  been  both  interesting  and  satisfactory. 

The  Fifth  International  Congress  of  Criminal  Anthrop- 
ology, in  its  meeting  at  Amsterdam,  September  9-14,  1901, 
passed  the  following  resolution,: 

''The  members  of  the  Fifth  International  Congress  of 
Criminal  Anthropology  are  in  favour  of  the  establishment 
of  psycho-physical  laboratories  for  the  practical  applica- 
tion of  physiological  pscyhology  to  sociological  and  abnor- 
mal or  pathological  data,  especially  as  found  in  institu- 
tions for  the  criminal,  pauper  and  defective  classes  and  in 
hospitals,  and  also  as  may  be  observed  in  schools  and  other 
institutions." 

This  Congress  consists  of  distinguished  specialists 
from  all  over  Europe,  and  it  is  the  highest  authority.  In 
our  country  up  to  date  the  following  associations  have 
passed  the  same  resolution,  but  referred  it  to  the  Depart- 
ment of  the  Interior:  Four  National  Medical  Societies 
and  Associations,  the  American  Medical  Association,  the 
Association  of  American  Medical  Editors,  American 
Medico-Psychological  Associations  and  the  Association  for 
the  Study  and  Cure  of  Inebriety;  thirteen  State  Medical 
Societies:  Connecticut,  Indiana,  Kansas,  Kentucky, 
Louisiana,  Minnesota,  Mississippi  Valley  Medical  Associa- 
tion, North  Dakota,  New  Jersey,  Pennsylvania,  Texas  and 
Wisconsin;  three  City  Medical  Societies:  St.  Louis, 
Chicago  and  Syracuse. 

Now  that  such  wide-spread  interest  has  been  excited 
in  regard  to  criminal  anthropology,  we  may  expect  that  the 
combined  studies  and  records  of  those  who  are  preparing 


122      .  PROGKESS  OF  MEDICAL  SCIENCE. 

themselves  to  enter  this  field  will  be  rich  in  results  and 
furnish  solutions  to  many  of  the  intricate  and  complicated 
problems  of  modern  sociology.  An  editorial  in  the  Ameri- 
can Lawyer,  of  New  York,  gives  the  best  view  yet  published 
on  the  Scientific  Study  of  the  Criminal  and  Defective 
Classes.     It  is  as  follows: 

''An  effort  is  being  made  to  establish  a  laboratory   in 
the  Department  of  the    Interior    at    Washington    for    the 
practical  application  of  physiological  psychology  to  socio- 
logical and  abnormal  or   pathological    data,  especially    as 
found  in  institutions  for  the  criminal,  pauper  and  defective 
classes  and  in  hospitals,  and  also  as  may   be  observed   in 
schools  and  other  institutions.     The  defect  in  our  present 
cr'minal  law  is,  as  we  have   before   remarked,  that   it   re- 
gards the  crime  and  not  the  criminal.     It  presupposes  that 
all  mankind  possess  an  equal  power  of  resistance  to  anti- 
social tendencies.     It  practically  lays  down  as  an  axiom 
that  the  child  born  of  criminal  parents,  brought  up  in  an 
environment  of  crime,  is,  until  he  has  actually  come  within 
the  jurisdiction  of  a   magistrate's    court,  as  equally  desir- 
able a  citizen  to  all  intents  and   purposes   as  he  who  has 
been  reared  in  the  atmosphere  of  the  law-abiding.     Until 
an  offence  has  been  committed,  the  law  does  not  recognize 
the  offender.     For  it   the   prospective    criminal    does    not 
exist.      Unfortunately,   there    are    some    beings   who    are 
moral    imbeciles.     To    confine    our    efforts    to    punishing 
crime  when  committed  rather  than  to  preventing  its  com- 
mission, is  like  the  proverbial  locking  of  barn  after  steal- 
ing of  horse.     Nothing  has  been  done  by  government  as 
vet  to  treat  the   matter   scientifically,  and  when  it  is  con- 
sidered that    1600,000,000    is    the    annual    tribute    which, 
statisticians  assure  us,  society  pays  to  crime,  and  that  the 
United  States  has  the  highest  murder  rate  of  any  civilized 
country  in  the  world,  one  is  almost  tempted  to  long  for  a 
return  to  the  condition  of  tilings  when    one   hundred   and 
^nxty  offences  were  punishable  by  death,  though  it  be  con- 
ceded that  the  death   penalty   is    one  of  the   slightest   of 
deterrents  to  crime."     The  promoters  of  the  measure  have 
our  best  wishes.     As  put  by  the  well-known  writer:  *  *  * 
'The  study  of  man,  to  be  of  most  utility,  must  be  directed 
first  to  the  causes  of    crime,    pauperism,  alcoholism    and 
other  forms  of  abnormality.     To  do  this    the   individuals 
themselves   must  be   studied.     As   the   seeds   of  evil   are 
usually  sown  in  childhood  and    youth,  it    is  here  that   all 
investigation  should  commence,  for  there  is  little  hope  of 
making  the  world  better  if  we  do  not  seek  the  causes    of 
social  evils  at  their  beginnings." — Tlie  ^t.  Louis  Medical  and 
Surqical  Journal. 


SURGKRY. 


IN   CHARGE    OP 

EOLL.O  CAMPBELL.  M.D., 

Lecturer  on  Surgery,  University  of  Bishop's  College  ;  Assistant  Suri;eon,  Western   Hospital  ; 

AND 

GEORGE  P]SK,  M.D. , 
Instructor  in  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeon,  Western  Hospital. 


i,aboratory  aid  in  surgical  technique. 

By  GEORGE  B.  BROAD,  M.  D., 
Syracuse,  N.  Y. 

Instructor  in  Pathology  and  Bacteriology,  Syracuse  University,  CoUesre  of  Medicine  ; 

Gynaecologist,  Syracuse  Free  Dispensary  :  Assistant  Gynsecologist 

St.  Joseph's  Hospital,  Syracuse. 

Wound  infection  is  a  matter  of  such  grave  moment 
that  I  feel  I  need  no  apology  for  presenting  a  few  facts 
learned  in  the  laboratory  bearing  upon  this  all-important 
subject. 

It  has  occurred  to  everyone  engaged  in  surgical  work  to 
any  extent  to  have  now  and  then  a  case  of  suppuration, 
where  apparently  the  utmost  care  was  used  in  preparation 
and  during  the  surgical  procedure.  Suppuration  cannot 
occur  without  infection  from  some  source,  and  to  trace  this 
source  has  been  my  endeavour. 

My  first  work  along  this  line  dates  back  to  1897,  when 
a  series  of  experiments  with  hands  known  to  be  infected  was 
undertaken.  Prior  to. that  time,  rubber  gloves  had  not  been 
generally  used,  and  the  operator  was  sometimes  compelled 
to  work  in  virulent  pus,  both  during  the  operation  and  at 
.subsequent  dressings.  1  hese  hands  by  culture-testing  were 
known  to  be  infected  by  the  staphylococcus  pyogenes  aureus. 
Then  began  a  systematic  effort  to  rid  the  hands  of  this  in- 
fection. Strong  antiseptics  were  used,  and  culture  tests  made 
after  their  use,  to  note  the  effect  of  antiseptics  on  hands 
known  to  be  infected. 

First,  bichloride  of  mercury  was  used  in  strengths  of 
1-2000  and  1-4000,  the  hands  being  first  scrubbed  with  green 
soap  and  water.  The  hands  were  soaked  in  bichloride  of 
the  above  strengths  for  periods  varying  from  five  to  fifteen 
minutes.  In  every  instance,  after  these  washings,  culture- 
testing  always  developed  the  staphylococcus. 

After  two  weeks'  work  with  bichloride,  the  infection 
still  persisting,  this  was  dropped  and  the  permanganate-oxalic- 
acid  method  tried.      This  method   was  used    for  two  weeks, 


124  SURGERY. 

cultures  being  taken  after  the  washings.  Here,  as  with  the 
bichloride  method,  finger  scrapings  and  pieces  of  skin  in 
culture  media  always  developed  the  staphylococcus  aureus. 
Formalin  was  next  used  in  strengths  varying  from  i  to  4 
per  cent.  With  it  results  were  at  first  more  gratifying.  No 
growth  would  appear  until  about  forty- eight  hours,  when  the 
bouillon  would  begin  slowly  to  cloud.  But  with  the  formalin, 
as  with  the  other  antiseptics  at  no  time  did  the  growth  of 
the  micro-organism  fail  to  appear.  Then  followed  scrubbings 
with  green  soap  and  water,  no  antiseptics  being  used,  but 
still  the  microbes  developed.  Then  followed  a  rest  of  several 
weeks,  our  victim  going  out  of  town.  On  his  return  culture- 
testing  still  proved  that  the  staphylococcus  pyogenes  aureus 
was  present,  but  guinea  pig  inoculations  showed  it  to  be  of 
lessened  virulence.  Disgusted  with  our  findings,  the  subject 
refused  further  experiment. 

Here  was  an  infection  which  extended  over  a  period  o 
three  months  and  persisted  in  spite  of  strong  antisep  c 
How  much  longer  it  remained  I  do  not  know.  I  think  we 
have  a  right  to  say  that  the  unprotected  hands  can  be,  and 
often  are,  a  source  of  infection  to  our  patients,  even  though 
washed  in  strong  antiseptic  solutions.  The  culture  medium 
used  was  bouillon  and  agar-agar. 

The  possibility  of  silk  being  sometimes  the  cause  of  in- 
fection led  to  some  work  with  it,  to  see  just  when  it  was 
rendered  sterile  by  boiling.  Different  sizes  of  silk  from  one 
up  to  twenty  were  first  infected  with  a  pure  culture  of  the 
staphylococcus  pyogenes  aureus.  This  organism  was  chosen 
because  by  far  the  larger  number  of  cases  of  suppuration 
are  due  to  its  presence. 

The  silk  was  boiled  up  to  seventy  minutes,  pieces  being 
removed  under  aseptic  precautions  every  five  minutes.  The 
water  was  brought  to  a  boil  before  the  silk  was  dropped  in, 
temperature  212°  F.,  without  pressure.  We  found,  as  might 
be  expected,  the  larger  the  silk  the  longer  the  time  required 
to  render  it  sterile. 

Number  20  silk  was  boiled  sixty  minutes  before  becom- 
ing sterile;  No.  16,  forty-five  ;  No.  12,  forty  ;  No,  8,  thirty- 
eight  ;  No.  6,  thirty-five;  No.  4,  thirty  minutes,  and  all  be- 
low No.  4  was  boiled  twenty-five  minutes,  except  No.  i,  in 
which  no  growth  was  obtained  after  eighteen  minutes'  boil- 
ing. 

I  admit  this  is  a  pretty  hard  test,  for  some  silk  may  not 
be  badly  infected,  and  perhaps  no  silk   would   be   as   badly 


SURGERY.  125 

infected  as  was  the  silk  used  for  these  tests.  Still,  I  know 
of  no  other  ground  on  which  to  work,  for  we  must  assume 
that  silk  is  infected  unless  we  know  otherwise,  and  must 
sterilize  on  this  assumption. 

Silkworm  gut  as  a  means  of  infection  was  »lext  consi- 
dered. The  silkworm  was  used  as  it  came  trom  the  factory. 
Work  was  done  also  with  silkworm  gut,  which  had  been 
infected  with  the  staphylococcus  aureus.  No  growth  could  be 
obtained  from  either  after  forty-five  minutes'  boiling.  We  had 
previously,  as  routine,  boiled  our  silkworm  gut  five  or  six 
hours  for  two  or  three  consecutive  days.  This  long  boiling 
may  be  necessary  with  some  silkworm  to  render  it  sterile, 
still  I  know  of  no  pyogenic  micro  organisms  that  can  with- 
stand anything  like  that  amount  of  boiling.  Certainly,  in  an 
experimental  way,  no  growth  could  be  obtained  after  silkworm 
had  been  boiled  for  the  time  above  stated.  1  am  strongly 
inclined  to  believe  that  much  of  the  infection  laid  at  the 
door  of  silkworm  gut  is  really  an  infection  from  the  skin  of 
the  patient,  or  may  even  be  a  post- operative  infection. 

The  sterilization  of  catgut  is  a  question  of  extreme  im- 
portance. During  1896  and  1897  most  of  the  catgut  with 
which  we  worked  was  prepared  by  the  bichloride  method. 
The  gut,  after  the  fat  had  been  dissolved  out,  was  put  in  a  i- 
100  alcoholic  solution  of  bichloride  and  preserved  in  alcohol 
or  glycerin  alcohol.  This  method  was  a  fairly  good  one, 
and  it  was  exceptional  that  any  infection  was  found  on  cul- 
ture-testing. 

Formalin  was  next  used  in  catgut  preparation  in  strengths 
varying  from  2  to  8  per  cent.,  following  somewhat  closely 
the  method  of  VoUmer  and  Kossman,  who  made  strong 
claims  for  this  method.  With  me  it  was  not  satisfactory.  I 
found  I  could  sterilize  the  smaller  gut  as  Nos.  o,  i  and 
2,  but  anything  larger  than  No.  2  was  uncertain. 

I  have  had  some  experience  with  the  ammonium-sulphate 
method  as  described  by  Elsberg.  This  method  is  based  on 
the  chemical  fact  that  animal  tissue  can  be  boiled  in  a  solu- 
tion of  ammonium  sulphate  without  disintegrating,  which 
fact  is  true.  The  catgut  would  not  disintegrate,  but  its 
strength  with  me  was  much  impaired.  It  could,  of  course, 
be  rendered  perfectly  sterile  by  boiling.  The  method  which 
seems  to  me  the  most  perfect  is  the  sterilization  of  catgut 
by  dry  heat.  The  gut,  after  the  fat  is  dissolved,  is  placed 
in  parchment  or  bond  envelopes,  doubly  sealed.  These 
envelopes  when  sealed  are  subjected  to  a  heat  of  300°  F. 


126  SURGERY. 

or  practically  150°  C,  for  three  hours,  and  on  the  following 
day  to  the  same  heat  for  one  hour,  to  kill  any  spore  which 
may  have  resisted. 

Culture-tests  have  shown  that  catgut  prepared  in  this 
way  is  absolutely  sterile.  When  this  heat  is  maintained  in 
a  proper  oven,  asbestos-lined,  to  prevent  strong  radiation, 
we  have  a  gut  which  is  strong,  sterile,  and  in  every  way 
desirable.  These  facts  are  borne  out  by  clinical  experience. 
It  has  been  used  by  Dr.  A.  B.  Miller,  of  Syracuse,  as  well  as 
myself  for  the  past  two  years  in  both  hospital  and  private 
practice  without  a  single  case  of  suppuration  in  the  line  of 
suture  from  its  use.  It  seems  to  me  in  this  method  we 
approach  nearest  the  ideal,  for  we  can  produce  a  gut  strong 
and  absolutely  sterile  by  the  simplest  and  best  of  all  agents, 
viz.,  heat,  without  the  use  of  a  single  chemical.  It  is  also 
convenient  and  can  be  carried  in  the  surgeon's  grip  without 
fear  of  contamination. 

Rubber  gloves  and  their  sterilization  were  next  under- 
taken. Rubber  gloves  were  first  infected  with  the  staphy- 
lococcus aureus.  These  gloves  were  boiled  and  portions  of 
them  removed  under  strict  asepsis,  at  intervals  of  five  minutes 
up  to  thirty  minutes.  Rubber  boiled  fifteen  minutes  gave  a 
growth,  while  rubber  boiled  eighteen  minutes  was  sterile. 

One  other  source  of  infection  which  may  or  may  not  be 
of  much  practical  importance  is  the  expired  air,  A  few 
limited  experiments  have  convinced  me  that  bacteria  are 
given  out  from  mouth  and  nose.  Whether  these  bacteria 
are  given  out  during  respiration  or  during  speech  is  a  matter 
of  little  moment  to  the  surgeon.  A  crude  mask  was  devised 
and  worn  for  one  hour,  at  the  end  of  which  time  pieces  of 
gauze  through  which  the  wearer  had  been  compelled  to 
breathe  were  removed.  This  gauze  was  contained  in  a  little 
chamber  held  from  the  face  so  that  any  contamination  from 
prespiration  could  be  excluded.  Examination  of  this  gauze 
has  always  given  a  growth. 

The  bacterial  growth  from  this  gauze  was  made  up  largely 
of  staphylococci,  diplococci  and  an  occasional  bacillus.  My 
work  along  the  line  of  expired  air  is  so  limited  that  it  can 
count  for  but  little  as  yet.  Still,  in  this  way  we  may  be  able 
to  explain  an  occasional  case  of  suppuration,  when  an  assist- 
ant or  observer  has  been  present  who  was  suffering  at  the 
time  from  some  suppurative  disease  of  the  nose  or  mouth. — 
JS/.  V.  Medical  Record. 


SURGERY.  •  127 

UPON    THE    DIAGNOSIS    OF    ABDOMINAL    DISEASES. 

CHARLES  C.  ALLISON,   M.  D., 

Professor  of  Surgery  at  Creiglitoii  Medical  College,  Surgeon  to  Presbyterian  and  St 
Joseph  Hospitals,  UniaUa,  Neb. 

Methods  to  be  of  the  greatest  value  as  diagnostic  aids 
in  the  interpretation  of  abdominal  diseases  must  be  com- 
paratively simple.  They  must  be  based  upon  anatomical 
considerations,  and  upon  the  most  reasonable  pathology. 
In  other  words,  we  should  suspect  the  most  probable  con- 
ditions, and  bear  in  mind  all  of  the  possibilities  which 
may  obtain  in  a  given  case.  It  is  this  latter  feature  I 
take  it  which  is  most  frequently  neglected;  that  is,  the 
cultivation  of  the  habit  of  bearing  in  mind  all  of  the  pathic 
changes  that  can  occur  in  a  given  case  rather  than  look- 
ing for  a  few  of  the  more  common  diseases. 

A  smple  working  method  which  has  been  found  prac- 
tical of  utility  by  the  writer  is  the  elimination,  when  pos- 
sible, of  functional  disturbances;  but  this  can  be  done 
only  by  the  most  painstaking  examination;  when  this  has 
been  done  we  may  classify  pathology  of  the  abdomen  into 
three  groups,  namely:  (a)  Inflammatory;  (&)  Neoplastic; 
(c)  Gynaecologic. 

Taking  the  inflammatory  as  the  most  common  type  of 
trouble  in  this  classification,  it  will  be  well  to  decide 
whether  there  is  a  localized  peritonitis  or  an  inflammatory 
catastrophe,  which  involves  the  entire  peritoneum. 

We  would  not  aim  to  attribute  an  undue  proportion 
of  inflammator}-  expressions  to  the  appendix,  but  we  be- 
lieve it  to  be  generally  admitted  that  in  the  male  septic 
peritonitis  has  its  origin  in  this  organ  in  ninety-five  per 
cent,  of  all  cases. 

We  will  not  point  out  at  this  time  that  left-sided  pain, 
even  in  the  upper  quadrant  of  the  abdomen,  is  not  unusual 
in  its  disease.  Taken  as  a  whole,  medical  and  surgical 
minds,  we  believe,  have  attributed  too  much  uniformity 
to  the  location  of  the  appendix. 

If  it  be  deep  seated  with  its  apex  pointing  towards  the 
left,  the  septic  peritonitis  may  be  practically  limited  to  the 
left  side,  the  tip  of  the  appendix  lying  to  the  left  of  the 
inferior  attachment  of  the  mesentery,  and  the  initial  in- 
fection in  such  a  case  would  be  limited  to  the  left  side  of 
the  abdomen,  muscular  rigidity  will  be  general  and  prob- 
ably most  to  the  left  of  the  median  line,  the  pain  will  be 
radiating,  the  tenderness  general,  the  most  acute  exacerba- 
tion in  these  cases  will  be  sinister  in  character. 

Next  in  frequency  of  inflammatory  conditions  of  the 
lethal  type  is  perforating  gastric  ulcer.     The  antecedent 


128  '  SURGERY. 

history  of  the  individual's  health  will  usually  avail  in  sug- 
gesting this  condition,  but  the  shock  which  attends  the 
actual  perforation  is  so  great  that  the  diagnosis  may  gener- 
ally be  suspected  when  clammy  skin,  hurried  respiration, 
thready  pulse,  subnormal  temperature,  acute  pain  and  in- 
eflScient  emesis  are  found  to  have  suddenly  developed. 

Rupture  of  the  intestine  or  perforation  of  the  duo- 
denum will  assume  in  a  measure  this  clinical  picture,  but 
the  combined  symptoms  will  be  somewhat  less  pronounced, 
duodenal  ulcer  occurring  more  frequently  in  men,  while 
gastric  ulcer  occurs  most  frequently  in  women.  The 
duodenal  ulcer  is  longer  after  the  ingestion  of  the  food 
than  the  gastric,  and  is  more  often  associated  with  some 
septic  process  in  the  bod}'  which  invites  septic  thrombosis 
in  the  vessels  near  the  liver. 

The  biliary  diverticulum  is  responsible  for  many  cases 
of  peritoneal  inflammation,  yet  thq  onset  will  usually  be 
less  acute,  the  danger  of  general  infective  peritonitis  not 
so  great  as  in  the  conditions  which  we  have  named. 
Sudden  rupture  of  the  gall  bladder  is  very  uncommon,  al- 
though a  severe  lethal  infection  may  so  promptly  destroy 
the  gall  bladder  in  the  gangrenous  type  of  cholecystitis, 
that  the  result  may  be  a  peritonitis  as  acute  and  dangerous 
in  character  as  has  been  described  as  following  an  acute 
perforation  of  the  stomach.  Eliminating  this  somewhat 
rare  type  of  trouble,  however,  diseases  of  the  biliary 
channels  will  not  be  essentially  difficult  to  diagnose  if  we 
but  remember  that  there  are  two  sets  of  symptoms  in 
cholelithiasis;  first,  when  the  stones  and  the  attendant 
infection  are  limited  to  the  gall  bladder  and  cystic  duct, 
in  which  jaundice  will  either  be  entirely  absent,  or  of  but 
short  duration;  second,  when  the  stones  or  infection  is 
limited  to  the  hepatic  or  common  duct,  when  recurrent 
jaundice,  associated  with  rigour  and  fever,  will  suggest 
obstruction  to  the  essential  biliary  canal. 

Another  point  which  it  seems  to"  the  writer  is  not 
uniformly  borne  in  mind  is,  that  a  continuously  distended 
gall  bladder  associated  with  persistent  jaundice  should 
always  suggest  malignant  disease. 

Localized  peritonitis  having  origin  in  the  appendix, 
stomach  or  in  the  intestine  may  run  a  comparatively  mild 
course,  due,  first,  to  slow  leaking  from  these  organs,  and, 
secondly,  to  the  less  infective  bacterial  agent  in  the  given 
case. 

Instead  of  the  general  muscular  rigidity,  rapid  pulse 
and  general  symptoms  of  collapse,  there  may  be  some  local- 
ized pain,  a  local  area  of  muscular  rigidity,  moderate 
elevation  of  temperature,   and,   probably,  sharp,  remittent 


SURGERY.  129 

pain.  In  these  cases  it  will  usually  be  possible  to  cause  an 
evacuation  of  gas  from  the  bowel,  which  may  be  looked 
upon  as  a  symptom  of  very  considerable  security,  particu- 
larly if  vomiting  has  ceased,  and  the  mental  condition, 
facial  expressions  and  the  sum  total  of  symptoms  begin  to 
subside. 

Turning  to  the  neoplastic  class  of  abdominal  lesions, 
we  consider  also  two  features;  first,  the  most  probable 
points  of  origin  of  malignant  disease,  and,  secondly,  the 
intrinsic  displacement  which  these  growths  produce. 

It  may  be  said  that  carcinoma  of  the  pylorus  producea 
earlier  symptoms  than  a  malignant  development  involving 
the  small  intestine;  that  is  to  say,  malignant  involvement 
of  the  intestine  frequently  produces  inconsiderable  symp- 
toms until  an  acute  obstruction  has  occurred. 

Malignant  diseases,  certainly  of  the  purely  carcino- 
matous type,  comes  move  frequently  after  the  middle 
period  of  life,  while  the  inflammatory  condition,  above 
named,  usually  comes  before  this  period. 

It  does  not  seem  necesisary  at  this  time  to  mention  the 
necessity  of  beginning  an  examination  by  a  thorough  ex- 
posure of  the  entire  field,  including  the  abdomen  and  the 
lower  portion  O'f  the  chest. 

Nature's  method  of  protecting  diseased  areas  are 
simple,  all  her  forces  being  brought  to  attain  physiological 
rest;  this  one  condition  which  is  most  easy  to  appreciate 
is  muscular  rigidity  when  it  is  found,  as  Hilton  says,  "to 
involve  the  muscles  adjacent  to  the  diseased  areas,  par- 
ticularly those  which  have  a  nerve  supply  of  the  same 
origin  as  the  inflamed  organ."  ' 

This  one  feature  will  aid  in  locating  a  stone  in  the 
kidney,  interpreting  a  choliacystitis;  in  short,  it  seems 
more  valuable  in  many  inflammatory  conditions  than  sub- 
jective symptoms,  and  is  present,  although  to  a  less  degree, 
in  neoplastic  development. 

Bimanual  examination  should  not  only  be  vaginal,  but 
rectal,  and  should  be  supplemented  by  distension  of  the 
colon  and  the  stomach  in  doubtful  cases. 

Simple  emptying  of  the  bladder  by  catheterization 
has  been  known  to  clear  up  the  diagnosis  in  an  apparently 
obscure  case  at  the  hands  of  men  of  recognized  ability. 

There  is  a  tendency  to  over-estimate  the  radiograph; 
it  desen'es  a  permanent  place  asi  a  diagnostic  aid.  but  the 
proportion  of  cases  positively  identified  by  this  means  are 
small. 

In  any  case  we  believe  that  a  methodical  examination 
■made  after  a  full  exposure  of  the  field  will  enable  the  phy- 


^30  SURGERY. 

sician  or  surgeon  in  the  greatest  majority  of  cases  to 
eliminate  functional  disturbances,  to  identify  neurotic, 
expressions,  to  interpret  an  acute  inflammatory  disease, 
and  to,  at  least,  suspect  neoplastic  developments  in  a  com- 
paratively early  stage,  and  that  by  so  doing  many  lives 
will  be  saved,  either  by  following  a  systematic  medical 
course  when  applicable,  or  afford  an  opportunity  for  an 
early  surgical  exploration  which  will  generally  be  success- 
ful in  proportion,  other  things  being  equal,  to  the  prompt- 
ness with  which  it  is  applied. — Med.  Brief. 

TRAUMATIC    NEUROSES   FROM   THE    STANDPOINT 
OF  A  SURGEON. 

Bevan  (Jour.  Amer.  Med.  Asso.)  says: 

1.  Real  injuries  of  the  nervous  system  present  positive 
and  immediate  symptoms. 

2.  Those  alleged  injuries  of  the  nervous  system,  with- 
out positive  and  immediate  symptoms  of  gross  lesions,  are 
either  cases  of  malingering  or  abnormal  cerebral  states, 
traumatic  neuroses,  or  a  mixture  of  the  two. 

3.  Traumatic  neuroses  are  the  result  of  two  factors: 
First,  a  brain  readily  affected  by  suggestions;  second, 
suggestions  furnished  by  an  accident  with  or  without  in- 
jury to  the  individual,  suggestions  furnished  by  sympa- 
thetic care  or  craving  for  sympathy,  and  lastly,  and  of 
greatest  importance,  suggestions  furnished  by  medical  at- 
tendants, 

4.  To  establish  a  diagnosis  requires  the  immediate 
and  sometimes  protracted  observation  of  the  patient,  as  in 
the  study  of  any  psychosis.  The  supposed  refined  means 
of  diagnosis,  as  the  dynamometer,  esthesiometer  and  elec- 
tricity, are  seldom,  of  value  and  are  often  of  positive  harm 
as  suggestions  to  the  patient. 

5.  These  cases  recover  rapidly  under  proper  surround- 
ings and  advice  when  the  continuing  causes  are  removed. 
Recovery  may  be  indefinitely  postponed  under  improper 
surroundings  and  advice. 

6.  No  secondary  degenerations  of  the  nervous  system 
follow  traumatic  neuroses.  The  pathologic  conditions  due 
to  an  old-standing  traumatic  neuroses  are  the  degenera- 
tions of  disuse  and  the  general  deterioration  of  the  indi- 
vidual from  confinement,  lack  of  exercise,  dejection,  etc. 

The  subject  of  traumatic  neuroses  will  not  receive  its 
proper  place  until  the  medical  profession  recognizes  their 
responsibility  in  the  development  and  continuance  of  these 
conditions,  and  until  proper  means  are  provided  for  the 
punishment  of  malingerers  and  their  alleged  medical  ex- 
]  erts — Am.  Practitioner. 


THERAPEUTIC  NOTES.  13 1 

BHATSON'S  METHOD  FOR  THE  RELIEF  OF  INOFERABLB 
CANCER  OF  THE  BREAST. 

Some  time  ago  Beatson,  a  Scoth  surgeon,  advocated 
the  idea  that  the  so-called  special  cmcer-cells  would  be 
found  to  be  vacuolated  germinal  cells,  corresponding  with 
those  found  in  the  ovary  alone.  Acting  upon  this  theory, 
Beatson  made  a  number  of  experiments  upon  the  lower  ani- 
mals, and  found  that  after  a  removal  of  the  ovaries  lactation 
was  prolonged  as  long  as  suckling  was  maintained.  Beatson 
then  attempted  to  work  out  his  theory  on  the  human  subject, 
and  his  first  attempt  was  upon  a  young  woman,  whom  he 
subjected  to  o6phorectomy,  and  was  surprised  to  fiad  that 
the  large  recurrent  cancer  that  had  existed  in  this  individual's 
breast  disappeared  entirely  in  the  course  of  a  few  months. 
Since  that  time  a  number  of  English  surgeons  have  followed 
Beatson's  examples,  and  have  had  more  or  less  success. 
From  what  has  already  been  done,  it  would  certainly  seem 
that  this  procedure  might  well  be  adopted  by  all  those  unfor- 
tunate women  who  are  suffering  from  inoperable  cancer  of 
the  breast. — Cyclopcsdia  of  Practical  Medicine. 


Therapeutic  Notes. 


FOni.  BREATH. 

L'Arte  Medica  gives  the  following  : — 
^  Saccharin. 

Bicarbonate  of  sodium,  of  each,  15  grains. 
Salicylic  acid,  60  grains. 
Alcohol,  3,000  grains. 

M,  Sig.:     A  few    drops    in    a   tumblerful    of   water. 
New  York  Medical  JourmL 


Epsom  Salts  Made  Palatable. 

I^  Magnes  Sulphat ^   oz. 

Acid  SulpnDil 2  m 

Syr.  Limonis i^  oz, 

Aq  ad 2  oz. 

Sig  .: —  one  dose. 


i3«  therapeutic  notes. 

Formula  for  Chafing. 

For  chafing  about  the  groins  and  under  the  arms  in 
children,  Dr.  R.  B.  Elderice  recommends  the  following  for- 
mula : — 

Ichthyol I  dr. 

Comp.  tinct.  benzoin i  dr. 

Boric  acid  (finest  power) i   dr. 

Petroleum i}4    to  2  oz. 


Apply  with  each  change  of  napkin. 


Hair  Tonics. 


—Ibid. 


R  Acid  Salicylic I5  g*"- 

Resorcini /^  g*"- 

Tinct.  Cantharadis j^  oz. 

Tinct.  Capsici i  dr. 

Saponin I  dr. 

Lanolin i  oz. 

Aquae  Rosse ad   10  oz. 

Melt  the  lanolin,  dissolve  the  saponin  in  the  same  quantity 
of  water  and  incorporate  the  two.  Dissolve  the  acid  and  re- 
sorcin  in  the  tinctures  and  rose  water  respectively  to  make  up 
the  required  bulk.  More  spirit  may  replace  the  rose  water  if 
required.  Every  night  it  should  be  well  brushed  into  the 
roots  of  the  hair,  which  should  then  be  dried  with  a  soft 
towel. 

This  is  an  effective  substitute  for  the  popular  "  Erasmus 
Wilson's  hair  lotion."  Containing  no  alkali  it  has  no  ten- 
dency to  bleach  the  hair  or  cause  the  affection,  which  it  is 
employed  to  cure.    It  is  both  antiseptic  and  stimulative. 

B  Quinin  Sulphal.' 20gr. 

Acid  Sulph  Dil 15  m 

Tinct.  Cantharadis i  oz. 

Haselin 2  oz. 

Glycerin i  oz. 

Aq  flor  amanti ad  8  oz. 

After  a  vigorous  application  all  excess  should  be 
removed  with  a  towel  in  the  same  way  that  one  would   dry 


JOTTINGS  1  33 

ones   hands   after  an   application    to    them,   for    the   same 
reason. 

B   Hair  Tonic. 

Tinct,  Capsic 3  iv. 

Tinct.  Nux   Vom 3  iss. 

Tinct.  Canth 3  iv. 

01  Rosmarina 3  ii. 

01  Ricini ...  3  iii. 

Eau  de  Cologne g  xii. 

The  above  is  an  excellent  hair  tonic. 

.    LIF. 

Hours  for  Feeding  Young   Infants. 

1  — »<xu  1  to  6  6  weeks  4  to  8  o  .    lo  ..u 

^^^^^  weeks.  1  to  4  months.  months.  8  to  12  months. 

4  a.m.         3  a.m.  3  am.  7  a.m.  7  am. 
7       "            7     "                    7  "                         10  "                      10.30  " 
9       '*          930  "                10  "                        I  P-iO'                      2  p.m. 

II       "  12  n.  I  p.m.  4     "  6  " 

I  p.m.  2.30  p.m.  4     "  7     "  10  " 

3     •<  5     "  7     "  lo    " 

5  "  7.30  "  10  "  ,  • 
7     "  10     " 

9    " 

12 


Jottings, 


HANDY    THERAPEUTIC    HINTS. 

The  little  finger  can  be  used  in  taking  a  delicate  pulse 
when  it  would  be  impossible  to  readily  recognize  it  with 
the  fingers  ordinarily  used. 

Convulsions  may  be  frequently  cut  short  like  magic 
by  turning  the  patient  on  his  left  side.  The  nausea  as  an 
after  effect  of  chloroform  or  ether  narcosis  may  be  gener- 
ally controlled  in  the  same  manner. 

When  chilly  from  exposure  breathe  very,  deeply  and 
rapidly  and  the  increase  in  bodily  warmth  will  be  sur- 
prising. 

Vomiting  after  the  administration  of  chloroform  may 
frequently  be  prevented  by  replacing  the  inhaler  with  a 
linen  cloth  steeped  in  vinegar,  it  to  remain  over  the  face 
for  some  time. 


134  JOTTINGS. 

People  who  have  weak  hearts  should  always  have 
their  principal  meal  Id  the  middle  of  the  day,  and  with  as 
little  water  as  possible. 

Many  a  woman's  ruin  is  due  to  the  old  idea  that  a 
woman  can  safely  leave  her  bed  on  the  tenth  day  after 
confinement. 

Crude  petroleum,  poured  upon  a  burned  surface,  and 
covered  loosely  with  cotton,  will  subdue  the  pain  almost 
at  once. 

Black  pins  in  surgical  dressings  are  preferable,  be- 
cause they  will  not  rust,  and  can  be  more  readily  seen 
when  they  are  to  be  removed. 

Strong  spirits  of  ammonia  applied  to  the  wdunds  of 
snake  bites  or  rabid  animals,  is  better  than  any  caustic. 
It  neutralizes  the  virus. 

In  post  partum  hemorrhage  try  tying  a  piece  of  strong 
webbing  tightly  above  the  knees  of  the  patient. — Mod. 
Medicine. 

TREATMENT   OF  ASTHMA  IN   CHILDREN. 

Kissel  reports  a  number  of  cases  of  bronchial  asthma  in 
children  aged  from  six  to  fifteen  years.  He  obtained  ex- 
cellent results  from  sodium  iodide,  first  recommended  by 
Trousseau.  Not  only  the  individual  symptoms,  but  the  gen- 
eral condition  as  well,  improved  markedly  under  this  treat- 
ment.— Merck's  Archives, 


Widal  recommends,  in  the  Journal^  de  Medecin  de 
Paris,  a  very  simple  method  for  the  removal  of  warts, 
namely,  a  fiannel,  over  which  is  spread  some  green  soap, 
obtained  at  any  druggist's,  placed  over  the  wart  for  a  period 
of  fourteen  days,  by  the  end  of  which  time  the  wart  will 
become  so  soft  as  to  be  easily  shelled  out.  — Medical  Age. 

The  Revista  de  Medicina  y  Cirur'gia  practicas  citing 
the  Bulletin  Medical.,  says  that  the  heats  and  flush- 
ings due  to  the  menopause  are  more  pronounced 
and  vexatious  in  the  premature  and  artificial  meno- 
pause produced  by  double  castration.  Opotherai)eutic 
preparations  are  costly  and  very  often  ineffective.  Dr. 
Gottschalk  recommends  a  more  efficacious  and  simple 
measure,  which  consists  in  taking  every  evening  regularly  a 
full  hot  bath  at    a   temperature   of   104°  F.,  lasting  twenty 


JOTTINGS.  1 35 

minutes.  After  a  few  baths  great  improvement  is  notice- 
able, and  after  some  twenty- six  or  twenty-eight  a  cure  is 
obtainable. — Neiv  York  Medical  Journal. 


For  chilblains  Dr.  Monroe  claims  good  results  from 
one  drachm  of  acetate  of  zinc  to  one  pint  of  water.  Keep 
the  parts  covered  with  absorbent  cotton  and  damp  with  the 
solution.  A  good  idea  is  to  make  a  paste  of  20  grains  to 
half  ounce  of  lard  and  keep  applied  to  parts.  Both  ways 
have  been  tried  and  found  good  practice. 

In  the  dry,  parched,  tickling  sensation  of  an  acute 
laryngitis  or  pharyngitis  yerba  santa  will  frequently  be  found 
of  great  value. 

The  severe  pain  of  gout  has  been  promptly  relieved 
by  the  application  of  lint  saturated  with  alcohol  and  covered 
with  oil  silk. 

When  a  child  complains  of  pain  in  the  knee  for 
any  length  of  time,  without  any  evidence  of  local  disease, 
invariably  be  on  your  guard.  Nine  times  out  often  it  means 
that  the  child  has  hip-joint  disease. 

Milk  is  an  excellent  antidote  to  nitrate  of  silver,  in 
virtue  of  its  large  proportion  of  suspended  albumen. 

In  the  headache  of  migraine  one  grain  of  the 
citrate  of  caffeine  given  every  hour  will  often  produce  most 
marked  relief. 

Strychnia  is  an  excellent  remedy  for  uterine  hemor- 
rhage from  atonicity  or  inertia.  It  may  be  given  in  advance 
if  such  a  condition  is  anticipated. 

The  compound  tincture  of  benzoin  is  an  admirable 
remedy  for  chapped  hands,  lips,  cracked  nipples  and  all 
frosted  conditions,  etc. 

Pure  olive  oil  is  one  of  the  most  easily  digested  and 
palatable  of  any  of  the  fats. 


tthe; 


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Editorial. 


THE  DANGERS  OF  ''ICE  CREAM." 

The  season  is  rapidly  approaching  when  ice  cream 
vendors  will  appear  in  considerable  numbers  in  all  of  our 
cities  and  towns.  From  personal  evidence,  and  that  gathered 
from  reading  our  exchanges,  there  can  be  no  doubt  that  it  is 
time  that  the  manufacture  and  street  sale  of  this  delicacy  was 
controlled  by  law.  Last  summer  two  children,  one  an  infant 
of  less  than  a  year,  the  other  nearly  three  years  old,  were 
brought  into  the  out-door  clinic  of  the  Montreal  General 
Hospital.  Both  exhibited  symptoms  of  irritant  poisoning. 
The  eldest  vomited  freely,  and  made  a  rapid  recovery  being 
practically  quite  well  in  about  an  hour.  The  youngest  one 
was  in  a  state  of  complete  collapse,  pulseless,  blue  rings 
about  both  eyes,  and  a  general  cyanotic  condition.  It  tried 
to  vomit,  but  had  not  sufficient  strength.  Under  treatment 
it  was  sufficiently  well  to  be  sent  home  in  between  two  and 
three  hours.  These  two  children  had  each  partaken  of  an 
egg  cup  of  ice  cream,  purchased  from  a  vendor  at  a  street 
corner,  and  were  within  half  an  hour  seized  with  the 
symptoms  we  have  mentioned.  Not  very  long  ago  an 
inquest  was  held  in  London  on  a  boy  aged  6  years,  and  the 


EDITORIAL.  137 

jury  attributed  its  death  to  unwholesome  ice  cream.  The 
British  Medical  Journal,  writing  about  this  case  says  :  "  It 
appears  that  the  child  and  an  elder  brother  had  eaten  some 
of  this  comestible  obtained  from  an  Italian  who  was  selling 
it  from  a  barrow,  the  subject  of  the  inquest  consuming  a 
double  quantity.  The  next  day  symptoms  of  irritant 
poisoning  set  in  ;  one  child  died  four  days  later,  the  other 
recovered.  The  post-mortem  appearances  were  consistent 
with  death  from  the  effects  of  an  irritant  poison.  Some 
very  wise  and  justifiably  strong  remarks  were  made  by  the 
coroner  as  to  the  risks  run  by  the  consumers  of  these  street 
commodities.  It  will  be  remembered  that  not  long  ago 
Dr.  Klein  made  a  bacteriological  investigation  of  some  ice- 
cream and  of  the  water  in  which  the  glasses  containing  it 
were  rinsed,  with  the  result  that  both  were  found  to  be 
swarming  with  thousands  of  micro-organisms.  Recently, 
also,  some  20  cases  of  poisoning  were  reported  among  the 
customers  at  an  ice  cream  stall  in  Antwerp,  and  no  doubt 
this  delicacy  is  responsible  for  more  illness  than  is  ordinarily 
attributed  to  it.  Nor  is  this  to  be  wondered  at  when  we 
consider  the  sources  of  contamination  arising  from  the  qua- 
lity of  its  constituents  and  the  habitual  filthiness  of  its 
vendors.  It  is  manufactured  from  the  commonest  and 
stalest  materials,  and  stored,  usually,  under  the  bed  of  the 
merchant  in  the  purlieus  of  Saffron  Hill.  The  unsold 
residue  is  hashed  up  again,  however  far  gone  in  decomposi- 
tion it  may  happen  to  be.  As  the  activity  of  pathogenic 
bacteria  is  only  temporarily  inhibited  by  the  process  of 
freezing,  very  little  hindrance  is  opposed  to  their  incubation 
under  the  favourable  conditions  afforded  by  their  nocturnal 
depository.  In  addition  to  these  circumstances,  every  pro- 
vision is  made  for  the  transference  of  communicable  diseases 
from  the  children  themselves,  owing  to  the  Italian  concep- 
tion of  cleanliness  as  applied  to  the  washing  of  the  spoons 
and  glasses  used  by  them." 


It   is  our  custom   to   mention   through  these  columns, 
rom   time  to  time,  new  preparations    that  are   oflfered  the 


138  EDITORIAL. 

profession  by  reliable  manufacturers,  if  they  are  known  to 
possess  real  merit.  A  preparation  that  is  just  now  attract- 
ing much  favourable  comment  from  the  profession  is  the 
new  antiseptic  emulsion,  Firolyptol  with  Eucalyptol  and 
Kreosote,  prepared  by  The  Tilden  Company,  Manufacturing 
Pharmacists,  New  Lebanon,  N.Y. 


MONTREAL  GENERAL  HOSPITAL. 

We  have   been    favoured   with   a  copy   of  the  Seventy- 
ninth   Annual    Report   of    this    most    excellent    institution- 
This  hospital   continues   to  do   a  vast  amount  of  good,  and 
with  its  growing  years  constantly  adds   to    its  supporters  the 
very   best  citizens  of   Montreal.      During  its  hospital  year, 
extending  in  this  report  from  May,  1900,  to  April,  1901,  it 
added  forty-six  names  to  its  list  of  governors,  the  qualifica- 
tions of  this  position  being  a  donation  of  one  hundred  dol- 
lars.    The  attending  staff  of  the  hospital   has   not  had  any 
change    for  several   years.     The    ordinary    income    of    the 
year  was  $75,994. 18   and  "the  ordinary  expenditure  for  the 
same  period  was  $84,280.75,  showing  an   excess  of  expendi- 
ture over  receipts  of   $8,286.57.      Comparing   the  ordinary 
expenditure  of  1899-1900,  $81,570.75,  with  that  of  the  1900- 
1901,  $84,280.75,  the   latter  year   shows    an  increased  ex- 
penditure of  $2,710.     Comparing  the  income  of  1899- 1900, 
$67,421.72  with    that    of   1900-1901,  $75,994. 18,  there   is  an 
increase  in  the  latter  year  of  $8,572.46.     During  the  year 
the  hospital   suffered  a   very   severe  loss  by  the  death  of  its 
President:,  Mr.  Wolferstan  Thomas,  who  during  his  term  of 
office,  assisted  largely,  possibly  mainly,  in   having  the  hos. 
pital     completely    transformed     into    a    properly    equipped 
modern  hospital,  and    the  erection    of   the  Jubilee  Nurses' 
Home.     This  latter  is  one  of  the  cosiest  nurses'  home  to  be 
found  anywhere.     Were   those,   who    as  students,  attended 
this  hospital  forty-five  years  ago,  to  visit  it  now,  they  would 
not    recognize,  in    the  present  modern    structure,  their  old 
medical  home.     Its  nursing  staff  of  the  present  day  is  so 
amazingly  ahead  of  what  it  was  then  that  one  wonders  how 


EDITORIAL  139 

the  work  was  ever  done  successfully  by  the  "  Sara 
Gamps"  who  passed  half  of  their  time  in  knitting  and 
sewing. 

The  total  number  of  in-door  patients  treated  to  a 
conclusion  during  the  year  was  2,823.  There  was  discharged 
2,573  and  there  died  in  hospital  250.  Of  the  250  deaths* 
105  occurred  within  three  days  of  admiss'on.  Excluding 
these  the  death-rate  was  5.13,  or  including  them,  8.85.  In 
the  out-door  department  there  were  during  the  year  41,606 
consultations.  These  figures  show  the  great  work  which 
this  General  Hospital  is  doing.  Its  claim  for  support  is 
strong,  and  the  public  of  Montreal,  whose  generosity  is 
proverbial,  will  see  we  feel  sure  that  it  does  not  suffer  for 
lack  of  funds. 


THE  AUTHOR, 


Miss  Ottilie  A.  Liljencrantz,  the  author  of  "  The  Thrall 
of  Leif  the  Lucky,"  a  Viking  romance  announced  for  early 
publication,  is,  herself,  a  descendant  of  the  find  old  sea  rovers 
she  describes.  She  is  a  resident  of  Chicago,  and,  although 
very  young,  has  spent  many  years  preparing  herself  for  her 
first  book.  Ever  since  bhe  conceived  the  ambition  to  write 
a  great  romance  about  the  Vikings  she  has  made  a  close 
study  of  all  the  available  literature  about  that  period.  Her 
naturalinclinatioh  and  her  enthusiasm  over  the  achievements 
of  her  forefathers  helped  her  into  a  ready  understanding  of 
the  Sagas  and  all  the  wonderful  traditions  of  the  Northland* 
The  exploits  of  Leif  Ericsson  appealed  to  her  particularly 
and  she  decided  to  write  her  story  around  his  voyages  to 
Greenland,  and  his  famous  voyage  of  discovery  to  America. 
After  the  long  time  spent  in  preparation  she  has  put  two 
years  into  the  writing  of  the  book  itself,  and  the  publishers 
say  that  her  perfect  understanding  of  the  Viking  life  will  be 
found  one  of  the  greatest  charms  of  the  story,  that  she  has 
contrived  to  impart  the  atmosphere  of  their  wild  freedom 
into  its  every  page.     Miss  Liljencrantz  would  appear  to  be 


140  BOOK    REVIEWS. 

well  qualified   for  her   work,  and  "  The  Thrall  of  Leif  the 
Lucky  "  will  be  awaited  with  interest. 


DR.  RICHARD  MAURICE  BURKE. 

This  distinguished  medical  man  graduated  at  McGill 
University  in  1862,  and  soon  after  showed  that  the  tend  of 
his  energy  was  in  the  direction  of  mental  diseases.  In  this 
class  of  affections  he  soon  became  an  expert,  and  was  many 
years  ago  appointed  Medical  Superintendent  of  the  Insane 
Asylum  at  London,  Ont.  He  continued  to  fill  this  position 
up  to  his  death,  which  was  sudden,  and  apparently  due  to 
an  accident.  Dr.  Burke  was  a  keen  thinker  and  very  ad- 
vanced in  his  views.  His  nature  was  gentle,  and  he  was  full 
of  sympathy  for  the  unfortunate.  He  died  on  the  19th  of 
February. 


Book   Reviews, 


International  Clinics.— A  quarterly  of  clinical  lectures  and 
especially  prepared  articles  on  all  branches  of  medicine  and 
surgery  and  other  topics  of  interest  to  students  and  practi- 
tioners ;  by  leading  members  of  the  medical  profession  through- 
out the  world,  edited  by  Henry  W.  Cattell,  A.M.,  M.D., 
Philadelphia,  U.  S.  A.,  with  the  collaboration  of  John  JB. 
Murphy,  M.D., Chicago ;  Alex.  D.  Blackader,  M.D.,  Montreal; 
H.  C.  Wood,  M.D.,  Philadelphia;  T.  M.  Rotch,  M.D.,  Bos- 
ton; E.  Landort,  M.D.,  Paris;  Thos.  G.  Marton,  M.D,,  of 
Philadelphia,  and  Chas.  H.  Reed,  M.D.,  J.  B.  Ballantyne, 
M.D.,  of  Edinburgh,  and  John  Harold,  M.D.,  of  London, 
with  regular  correspondents  in  Montreal,  London,  Paris,  Leip- 
sic  and  Vienna.  Volume  III., Eleventh  Series.  J.  B.  Lippin- 
cott  Co.,  Philadelphia,  1901. 

This  volume  has  thirty-one  articles  and  is  very  freely  illus- 
trated with  plates  and  figures.  Some  of  the  papers  are  of  extreme 
interest,  notably  the  one  by  Valdemar  Bic,  M.D.,  Laboratory 
Assistant  in  Finsen's  Institute  at  Copenhagen,  Denmark,  entitled 
"Phototherapy  after  Finsen's  Methods."  This  article  was  pre- 
pared by  request  of  Dr.  Finsen,  who  has  just  received  the  noble 
prize  of  fifty  thousand  dollars  for  his  valuable  services  to  the 
medical  sciences.  The  effect  of  light  as  a  therapeutic  agent, 
according  to  Finsen's  investigation,  are  here  described.     The  re- 


BOOK  REVIEWS.  I4I 

suits  in  smallpox  and  lupus  are  truly  marvellous,  several  photo- 
gravures of  the  latter  affection  showing  the  condition  before  and 
after  treatment  are  very  striking  and  conclusive  as  to  the  value 
of  modified  light  in  the  treatment  of  disease.  Any  one  of  the 
other  papers  can  be  read  with  profit.  Of  special  interest  are 
the  following  :  "Antitoxic  Sera";  their  preparation  and  standardiza- 
tion by  J.  M.  H.Eyre,  M.D.,  F  R.S.,  Edinburgh  ;  "  Clinical  Aspects 
of  Spa  Treatment,"  by  Beverly  Robinson,  M.D.  ;  "Gonorrhoea 
and  Marriage,"  by  Prof.  Louis  Julien ;  ".On  the  Drawbacks  to  the 
Spinal  Use  of  Cocaine  and  th^  Accidents  due  to  it,"  by  Paul 
Reclus,  M.D.  ;  '-The  Prophylaxis  and  Early  Diagnosis  of  Heart 
Disease,  Palpitation  and  Organic  Disease  ;  Tobacco  and  Heart 
Lesions,  Cure  of  Heart  Lesions,"  by  Jas.  J.  Walsh,  M.D  ,  Ph.D.; 
"Clinical  Treatment  of  Inebriety,"  by  T.  D.  Crothers,  M.D.  ; 
*'  The  Localization  of  Nervous  Lesions,  Points  in  the  Diagnosis 
and  Surgery  of  Lesions  of  the  Conus  Terminalis  and  the  Cauda 
Equina,"  by  Prof.  Demetrius  Roncali ;  "  Surgical  Treatment  of 
Appendicitis,"  by  A.  Routhier,  M.D. ;  "The  Clinical  Laboratory 
in  Private  Practice  and  in  the  Physician's  Ofllce,"  by  C.  N.  B. 
Camac,  M.D.,  etc. 

This  valuable  quarterly  more  than  maintains  the  high  standard 
aimed  at  by  its  authors,  and  through  absolute  merit  is  making  itself 
almost  indispensable  to  the  busy  members  of  the  profession  as  a 
means  of  being  kept  thoroughly  posted  in  medical  knowledgo. 

J.  B.  McC. 

An   International   System    of  Electro -Therapeutics 

for  Students,  General  Practitioners  and  Specialists.  By 
numerous  Associated  Authors.  Edited  by  Horatio  R.  Bigelow, 
M.D.,  Permanent  Member  of  the  American  Medical  Associa- 
tion ;  Fellow  of  the  British  Gynaecological  Society  and  of  the 
American  Electro-Therapeutic  As.sociation  ;  Member  of  the 
Philadelphia  Obstetrical  Society,  of  the  Society  Frangaise 
d'Electro-Th^rapie,  and  of  the  Anthropological  and  Biological 
Societies  of  Washington,  D.C.,;  Author  ot  "Gynaecological 
Electro-Therapeuticj,"  and  "  Familiar  Talks  on  Electricity 
and  Batteries."  Second  edition.  Revised  and  brought  up-to- 
date,  with  several  new  departments  embodying  the  most  recent 
developments  of  theScience.  Edited  by'G.Betton  Massey,M.D., 
Ex-President  and  Fellow  of  the  American  Electro-Therapeutic 
Association  ;  Member  of  the  American  Medical  Association  ; 
Author  of  "  Conservative  gynaecology  aud  Electro-Therapeu- 
tics," etc.  Thoroughly  illustrated.  Royal  Octavo.  Pages 
y-1147.  Prices  net,  delivered,  extra  cloth,  $6.00;  sheep,  $7  ; 
half  russia,  $7.50.  1  hiladelphia,  F.  A.  Davis  Company,  pub- 
lishers, 1914-16  Cherry  street. 

Electricity,  as  a  therapeutic  agent,  is  being  employed  by  general 
practitioners  and  specialists  to  an  extent  now  not  dreamed  of  a 
few  years  ago.  Improved  apparatus,  a  growing  knowledge  of  the 
laws  and  action  of  electricity  in  regard  to  the  living  tissues  of  the 
human  body,  the  recorded  experiences  of  those  eminent  in  the 
practical  app  icaiion  of  this    remedy,   have    all  tended  to  increase 


142  BOOK    REVIEWS. 

the  status  of  electricity  as  a  potent  means  of  rectifying  pathological 
conditions  and  commend  it  to  more  general  use.  The  failures  and 
lack  of  benefit  derived  from  its  use  by  those  vrho  employed  it 
empirically  is  in  marked  contrast  to  the  beneficial  results  which 
may  be  obtained  from  its  use  in  a  scientific  manner,  and  in  accord- 
ance with  better  understood  laws.  To  employ  electric  energy  in 
the  treatment  of  diseases  successfully  and  intelligently,  requires  as 
thorough  a  knowledge  of  the  subject  as  possible,  in  regard  to  the 
physics  of  electricity,  its  physiological  action  and  the  technique 
to  be  employed  in  its  application  to  various  forms  of  diseases. 
These  can  only  be  thoroughly  mastered  in  laboratories  and  hos- 
pital wards  under  the  guidance  of  competent  teachers,  but  this 
knowledge  can  be  gained,  to  a  certain  extent,  by  the  possession 
and  study  of  such  a  work  as  the  present  one,  which  contains 
detailed  information  on  all  points  in  this  connection  and  writ- 
ten by  those  specially  trained  and  from  practical  experience,  capable 
of  giving  reliable  information  and  instruction. 

This  second  edition  has  been  thoroughly  revised  and  has 
four  new  articles,  one  relating  to  the  galvanic  current,  one  on 
the  electrical  treatment  of  aneurism,  one  on  Roentgen  rays  and  one 
on  the  treatment  of  cancer  by  the  cataphoresis  of  mercury.  The 
first  section  is  introductory,  and  the  historical  sketch  of  the  rise  of 
electricity,  forms  very  interesting  reading.  In  connection  with  the 
earlier  investigations,  the  work  done  by  Pliny,  Thales,  Gilbert, 
Guericke,  Newton,  Gray,  Dufaye  and  Nolet,  Franklin,  Humboltd, 
Galvani,  Volta,  Ampere,  Devey,  Oersted,  Berzelius,  Faraday,  etc., 
is  described  and  the  earlier  history  of  electro-therapeutics  in 
Europe  and  America  is  given.  Electro-physics  and  electro-physi- 
ology and  kindred  subjects_receive  full  attention  from  nine  diiTerent 
authors. 

Animal  electricity  is  treated  by  Dr.  Wesley  Mills.  The  Galvanic 
current  by  G.  Betton  Massey,  M.D.  Electro-  diagnosis  by  Dr. 
W.  F.  Robinson.  Roentgen  rays  by  Max  J.  Stern,  M.D.  Cata- 
phoresis, anodal  diffusion,  electrical  osmosis  or  voltaic  narcotism, 
by  Frederick  Peterson,  M.D. 

Section  C,  gynaecology  and  obstetrics  has  two  articles  covering 
the  field  of  electro-therapeutics  in  those  branches.  Among  the 
writers  are  Drs.  Grand  and  Famarque,  assistants  at  the  clinic  of 
Dr.  Apostoli,  Paris,  G.Betton  Massey,  M.D.,  Dr.  A.  Tripin,  Paris, 
Dr.  A.  Goelet,  New  York,  J.  M.  Baldy,  M.D.,  F.  H.  Martin, 
Chicago,  J.  H.  Kellogg,  M.D.,  A.  Lapthorn  Smith,  M.D.,  Montreal, 
etc. 

In  diseases  of  the  nervous  system  C.  Eugene  Riggs,  M.D.,  dis- 
cusses diseases  of  the  brain;  VVm.  J.  Marton,  M.D.,  diseases  of  the 
spinal  cord;  Wm.  M.  Leszynsky,  affections  of  the  peripherel  nerves 
and  Morton  Prince,  M.D.,  the  neuroses. 

Disorders  of  the  thoracic  and  abdominal  organs  have  articles  by 
A.  D.  Rockwell,  A.M.,  M.D.,  Dr.  Larat,Paris  and  N.  J.  Davis,  jun., 
Chicago.  Electricity  in  diseases  of  childhood,  is  written  by  May 
Putnam  Jacobi,  M.D.  The  final  section  on  electro-surgery  has 
nine  articles  in  which  the  use  of  electricity  is  discussed  in  the'chief 


BOOK  REVIEWS  143 

specialties  and  in  aneurism,  strictures  and  enlarged  prostate,  can- 
cer, electro-thermal  surgery,  facial  blemishes  and  in  diseases  of  the 
skin. 

In  these  articles  the  results  of  treatment  are  given,  the 
various  forms  of  apparatus  employed  described,  and  the  method  of 
using  them  made  clear  by  lucid  directions  and  wood  cuts.  To  those 
wisliing  to  become  familiar  with  the  use  of  electricity  in  medicine, 
according  to  the  most  recent  authorities,  this  comprehensive  volume 
can  be  most  heartily  commended.  J.    6.   McC. 

Annual  and  Analytical  Cyclopsedia  of  Practical  Med- 
icine by  Charles  E.  dfe  M.  Sajous,  .Vl.  D.,  and  one  hundred 
associate  editors,  assisted  ,  by  corresponding  editors,  colla- 
borators and  correspondents.  Illustrated  with  chromo-litho- 
graphs,  engravings  and  maps.  Volume  II.,  F.  A.  Davis  Co., 
pubhshers,  Philadelphia,  1900. 

Volume  II.,  which  was  sent  in  due  time  by  the  publishers, 
through  some  mishap,  was  not  received,  hence  the  lateness  of  this 
review  R'hich  is  of  a  duplicate  volume.  We  recently  reviewed  volume 
VI.,  the  last  of  the  series.  The  subjects  included  in  this  volume  are 
those  from  Bromide  of  Ethyl  to  Diphtheria  and  include  a  number 
which  are  worthy  of  special  attention  as  they  are  carefully  written, 
and  exhaustive  practical  articles.  The  editor  claims  his  aim  to  be 
"to  facilitate  the  labour  of  the  practicing  physician,  and  to  assist 
the  investigators  and  authors  in  their  researches,  and  to  elucidate 
through  contributions  from  men  possessing  special  knowledge  or 
unusual  experience  on  a  particular  line  of  diseases  which,  owing  to 
their  complexity,  are  not  generally  understood."  That  this 
desirable  result  has  been  obtained  may  be  learned  from  a  perusal 
of  some  of  the  more  prominent  articles,  such  as  those  on 
Diphtheria  by  Drs.  Northrup  and  Bovaird,  Cirrhosis  of  the  Liver 
by  Professor  Adami  ;  Cholera  by  Professor  Rubino  ;  Cerebral 
Hemorrhage  by  Dr.  Wm.  Browning ;  Cholebithiasis  by  Professor 
Graham  ;  Dilatation  of  the  Heart  by  Dr.  Vickery  ;  Deaf  Mutism 
by  Dr.  Holger  Mygind ;  Chloroform  by  Dr.  E.  de  M.  Sajous.  One 
finds  in  these  articles  the  results  of  the  personal  researches  of  the 
authors,  and  a  complete  summing  up  of  the  work  and  results  of  the 
investigation  of  others,  making  them  valuable  sources  of  reference 
to  practitioner,  teacher  or  writer.  A  number  of  excellent  colour 
plates  and  wood  cuts  adorn  the  volume  and  illustrate  the  text. 

J.  B.  McC. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Bar 
Lockwood,  M.D.,  Attending  Physician  to  the  Bellevue 
Hospital,  New  York.  Second  edition  revised,  with  103  illus- 
trations, many  of  them  in  colors.  Price  $4.00.  W.  B. 
Saunders  &  Co.,  Philadelphia.  ;J.  A.  Carveth  &  Co.,  Toronto, 
Canadian  agents. 

This  is  a  volume  of  over  800  pages  written  in  large  type  with 
the  lines  well  separated.  It  is  just  a  step  beyond  a  simple  abridge- 
ment of  the  ordinary  text-book  of  the  practice  of  medicine,  in 
which  the  essential  points  are  given   in  as  few  words  as  possible. 


144  PUBLISHERS'   DEPARTMENT. 

All  such  works  are  useful  to  the  busy  practitioner  who  can  in  a 
few  snatched  moments  refresh  his  memory  and  prepare  himself  to  in- 
telligently cope  with  the  varied  cases  he  is  called  upon  to  diagnose 
and  treat.  In  this  second  edition  the  latest  views  are  incor- 
porated and  it  may  be  regarded  as  a  safe  guide  in  modern  methods 
of  practice.  While  there  are  times  when  such  manuals  may  be 
profitably  consulted,  lack  of  time  can  be  the  only  excuse  which 
should  induce  the  practitioner  to  rely  upon  them  instead  of  consult- 
ing the  detailed  information  of  the  ordinary  text-book,  and  for 
the  student  to  rely  on  such  epitomies,  will  be  disastrous  to  his 
intelligent  conception  of  the  subject  studied. 

Sqme  of  the  subjects  receive  a  more  extended  consideration 
than  one  might  expect  to  see  in  a  book  of  this  character,  and  here 
and  there  points  are  made  which  give  evidence  of  reference 
having  been  made  bv  the  author  io  the  most  recent  literature. 
Hence  the  book  is  all  the  a'ulh.or  claims  for  it,  a  manual  of  the 
essential  facts  and  principles  of  the  Practice  of  Medicine  in  a 
concise  and  available  form.  J.  B.  McC. 


PUBIvISHKRS  DKPARXMKNT, 


SANMETTO  IN  GE '4IT0-URINARY  DISEASES. 

Dr.  B.  G.  Inman,of  Bradford,  Ohio,  writing,  says  :  "  I  have  used  San- 
met  to  and  find  that  it  is  all  that  one  could  desire  in  the  treatment  of  urinary 
diseases.  With  an  experience  of  thirty  ei^ht  years  of  practice  IJknow  of  no  med- 
icine that  is  more  direct  in  its  action  in  all  cases  of  senile  prostatitis  and  other 
genito-urinary  diseases.  I  regard  Sanmetto  as  one  of  our  best  vitalizing  tonics 
to  the  reproductive  organs,  which  gives  it  a  wide  range  of  usefulness  in  the 
treatment  of  any  nervous  troubles." 


THE  VALUE  OF  SANMETTO  I^  SURGICAL  OPERATIONS. 

It  is  with  pleasure  that  I  attest  the  merits  of  Sanmetto,  and  I  think  my 
experience  with  the  drug  justifies  all  the  good  things  I  can  say  of  it  I  have 
used  it  very  extensively,  and  especially  do  I  find  it  valuable  in  allaying  inflam- 
mation in  the  prostatic  urethra,  before  surgical  operati  mis,  and  in  keeping  the 
urine  bland  and  nonirritaling  after  the  operation  is  complete.  It  always  has  a 
soothing  and  sedative  effect  upon  the  kidneys,-  bladder  and  urethra.  I  shall  con- 
tinue its  use  in  all  forms  of  genito-urinary  irritation. 

THOMAS  P.  GRAHAM,  M.D. 
Chicago,  111. 


SANMETTO  IN  GONORRHCEA.  CYSTITIS,  PROSTATlriS,  IRRIT- 
ABLE BLADDER,  INCONTINE.VrE  OF  URINE  AND  IN 
SEXUAL  NEURASTHENIA  AND  PRE-SENILITY. 
I  have  prescribed  Sanmetto  for  the  past  si <   years,  and  find  it  quite   agree 
able   to   the   patients,   being   very   pleasant   to  take  and  of  great  utility   in  the 
treatment   of  a  large  number  of  cases  frequently  met  with  in  general    practice. 
It  has  given  me  imiformally  good  results   in    all  stages   of    gonorrheal,   cystitis, 
prostatitis,  irritable  bladder  and  incontinenc;  of  urine.        I  have  also  found  it  of 
great  value  in  sexual  neurasihenia  and  much  more  satisfactory  as  an  aphrodisiac 
than  any  drug  that  I  have  employed  during  my  twenty  six  y^ars  of  practice. 

WM.  PARSONS,  M.D. 
Chicago,  III. 


CANADA 

MEDICAL  RECORD 


APRIL,    1902. 


Original  Communications, 


RETROSPECT  OF  LARYNGOLOGY  AND  RHINOLOGY. 

UNDER  THE  CHARGE   OF    GEO.    T.    ROSS,  M.D.,  D.C.L. 

Fellow  American   Laryngological,  Rhiuological   and    Otological   Society,  Laryn- 

gologist,  Western  Hospital,  Lecturer  on  Diseases  of  the  Throat  and  Noie, 

University  of  Bishop's  College. 

REMOVAL    OF    INTUBATION    TUBES    BY    THE    ELECTROMAGNET. 

Collet  describes  fliis  process  as  follows: — The  instru- 
ment consists  of  a  long,  thin  coil,  which  may  easily  be 
held  between  the  thumb  and  forefinger.  Two  armatures 
should  accompany  the  instrument,  the  longer  to  be  used 
for  adults.  These  are  curved,  in  order  to  enter  the 
larynx,  and  the  ends  are  blunt,  so  that  they  will  make 
perfect  contact  with  the  upper  extremity  of  the  tube. 
Before  using  the  instrument,  the  circuit  should  be  com- 
pleted and  the  jaws  fixed  open-  The  curved  extremity  of 
the  magnet  is  then  introduced  into  the  pharynx,  and 
passed  behind  the  base  of  the  tongue  towards  the  larynx, 
until  it  is  brought  in  contact  with  the  tube;  it  is  then 
necessary  only  to  withdraw  the  magnet  with  the  tube 
attached.  The  proceeding  is  instantaneous  and  ex- 
tremely easy.  No  special  knowledge  is  required  by  the 
operator.  Collet  describes  it  as  specially  serviceable  in 
case  of  sudden  obstruction  of  the  tube,  when  there  is 
danger  of  death  from  asphyxia.  The  metalic  part  of  the 
instrument  can  be  easily  sterilized;  the  coil  is  protected 
by  a  rubber  covering  which  can  also  be  easily  sterilized. 

TREATMENT    OF   VASOMOTOR   RHINITIS. 

To  reduce  the  swelling,  Lubinski  recommends  the 
submucus  injection  of  6  to  10  drops  of  a  10  per  cent,  solu- 


146  RETROSPECT  OF  LARYNGOLOGY. 

tion  of  zinc  chlorid,  the  mucosa  having  been  first 
anaesthetized  with  a  10  per  cent,  eucain  solution.  The 
canula  of  the  syringe  should  be  twice  the  usual  length, 
and  it  should  be  slowly  withdrawn  while  the  solution  is 
injected  drop  by  drop.  A  wad  of  cotton  which  has  been 
dipped  in  a  10  per  cent,  antipyiine  solution,  is  then 
pressed  against  the  puncture  to  prevent  bleeding.  The 
general  health  must  be  looked  after,  A  generous  diet, 
iron  and  arsenic,  cold  baths  and  exercise,  a  light  massage 
of  the  swollen  tissues,  with  an  application  covered  with 
cotton  that  has  been  moistened  with  menthol  parafine  (1-4 
to  1-2  per  cent.)  for  five  minutes,  twice  or  thrice  weekly,  are 
remedial  aids,  and  often  suffice  in  milder  cases. 

This  method  is  only  another  of  the  many  modes  devised 
for  the  sub-mucus  application  of  a  strong  caustic.  That 
of  Norval  Pierce,  which  he  calls  sub-mucus  linear  cauter- 
ization, is  probably  a  more  exact  means  of  accomplishing 
the  same  object. 

CARBOLIC   ACID   IN  RELAPSING  TONSILLITIS. 

Kramer  recommends  injections  of  carbolic  acid  into 
the  tonsils,  in  cases  where  these  glands  are  the  seat  of 
repeated  attacks  of  infiammation.  This  treatment  pre- 
vents recurrence-  The  tonsil  is  to  be  cocainized,  and  1-2 
cubic  centimetre  (eight  minims)  of  a  3  per  cent,  solution 
of  carbolic  acid,  by  means  of  a  hypodermic  syringe,  the 
needle  of  which  is  thrust  through  the  anterior  pillar  of 
the  fauces  to  the  depth  of  about  one  centimetre.  The  in- 
jections which  are  given  between  the  inflammatory  attacks, 
are  repeated  every  two  or  three  days;  six  injections  are 
sufficient.  Kramer  believes  that  carbolic  acid  acts  by 
destroying  the  latent  foci  of  pure  micro-organisms  that 
remain  in  the  tissue  of  the  tonsil  and  which  cause  fresh 
outbreaks  of  inflammation. 

NASAL  HEADACHES. 

Bronner  thinks  that  if  a  careful  examination  of  the 
nasal  cavities  were  made,  many  of  the  chronic  so-called 
incurable  headaches  would  be  relieved.  Nasal  headache 
is  often  neuralgic  in  character,  and  always  worse  in.  the 
morning,  whereas  headache  due  to  eye   strain    is   always 


RETROSPtCT  OF  LARYNGOLOGY.  1 47 

better  in  the  morning.  Nasal  headache  may  be  chiefly 
supraorbital  or  postorbital,  and  is  sometimes  felt  at  the 
top  or  hack  of  the  head,  being  more  commonly  diffuse  in 
nasal  obstruction.  Dizziness  is  a  frequent  accompani- 
ment. 

HYPERTROPHIC   RHINITIS- 

This  disease  is  growing  quite  common,  and  its  treat- 
ment should  be  looked  after  carefully.  Robertson  con- 
cludes as  follows: — 

1.  The  utter  uselessness  of  treating  a  growth  of 
organized  tissue  in  the  nostril  by  the  application  of 
sprays  and  galvano-cautery. 

2.  Where  such  growths  exist,  treat  as  you  would  an 
orergrowth  elsewhere. 

3.  Save  all  the  venous  sinus  tissue,  possible,  and  still 
secure  breathing  space  enough. 

4.  The  advantage  of  supra-renal  extract  in  nasal  sur- 
gery. 

5-  The  absence  of  danger  of  synechiae  forming,  as 
they  often  do  after  the  use  of  galvano-cautery  or  caustic. 

6.  The  use  of  dry  pledgets  of  cotton  and  the  disuse  of 
all  fluids. 

7.  The  great  advantage  of  greased  gauze  as  a  surgical 
dressing  in  the  nose,  over  old  methods. 

8.  The  danger  in  the  use  of  cocaine  lessened  by  the 
use  of  supra-renal  capsule  extract.       j 

9.  The  disappearance  of  nasopharyngitis  after  the 
nose  becomes  ventilated. 

GriflQn,  of  New  York,  refers  to  the  difficulty  of  getting 
patients  with  hemorrhagic  diathesis,  to  acknowledge  the 
fact,  if  they  think  an  operation  is  going  to  relieve  them 
of  their  sufferings.  One  case  cited,  where  life  was  finally 
saved  after  extreme  efforts,  the  patient  confessed  a 
family  history  of  this  diathesis,  but  was  anxious  for 
operation,  and  took  the  chances. 

DIAGNOSIS  OF  DIPHTHERIA. 

Fussel,  of  Phila.,  constantly  carries  in  his  pocket  a 
tube  of  blood  serum,  and  makes  a  culture  of  every  throat 
in  any  way  suspicious.     His  reasons  for  doing  so  are  the 


148  RETROSPECT  OF  LARYNGOLOGY. 

following: — 1.  True  cases  of  diphtheria  may  have  few  or 
no  clinical  symptoms.  2.  Tonsillitis  or  pharyngitis  may 
have  severe  symptoms  aad  be  serious,  but  not  true 
diphtheria,  and,  consequently,  not  able  to  transmit 
diphtheria.  3.  A  diphtheric  exude  may  be  easily  de^ 
tached  and  leave  no  bleeding  surface.  4.  An  exudate 
from  some  other  organism  may  be  a  true  membrane  im- 
possible to  detach  from  the  mucus  membrane. 

HEMORRHAGE    FOLLOWING   ADBNOTOMY    AND    TONSILLOTOMY. 

Roy,  of  Atlanta,  gives  the  history  of  two  cases  of  this 
character.  The  first  occurring  shortly  after  the  removal 
of  a  small  piece  of  adenoid  tissue.  There  was  no  history 
of  hemophilitic  diathesis,  but  the  menstrual  period  was 
due,  and  it  was  thought  to  be  a  factor  in  producing  the 
bleeding,  for,  after  hemorrhage  stopped,  the  catamenia 
appeared  freely.  The  second  case  was  after  the  removal 
of  one  tonsil  only,  and  bleeding  did  not  appear  until  five 
hours  after  operation-  This  is  very  unusual  at  the  age  of 
the  child  (four  years),  where  no  family  tendency  in  this 
direction  was  ascertainable. 

CORRECTION    OF    SADDLEBACK   NOSE   BY    INJECTION   OF 
PARAFFIN. 

H.  Smith  reported  three  cases  for  the  correction  of 
nasal  deformities,  and  while  not  resulting  in  a  perfect 
nose,  the  results  were  much  better  than  the  usual  methods 
employed.  The  technique  of  the  operation  was  described, 
and  no  inflammatory  reaction  followed. 

TUBERCULAR    RHINITIS    TREATED    BY    RONTGBN    RAYS. 

Case  shown  by  L.  Lawrence.  The  applications  were 
from  seven  to  ten  minutes.  Result,  abatement  of  symp- 
toms, reduction  of  swelling  of  the  nose,  pain  gone  from 
eyes  and  forehead,  and  a  more  comfortable  feeling 
senerallv- 


XOTES  FROM  THE  CASE  BOOK  OF  A  GENERAL 
PRACTITIONER. 

By  FRANCIS  W.  CAMPBELL,  M.D.,  L.R.C.P.  L.,  D.CL. 

Dean  and  Professor  of  Medicine,  Faculty  of  Medicine,  Unirersity  of  Bishop's 

College. 

COUGH. 

It  is  not  always  an  easy  matter  to  decide  upon  the  cause 
of  a  cough,  and,  therefore,  sometimes  a  difficult  matter  to 
relieve  or  cure  it.  Many  patients  go  about  their  work, 
appear  in  excellent  health,  and  yet  suffer  more  or  less  from 
a  persistent  irritating  cough.  Examination  of  the  chest  in 
these  cases  does  not  show  anything  abnormal  in  the  respira- 
tory murmur.  Examination  of  the  throat  often  reveals  an 
elongated  uvula  which  is  frequently  cured  by  a  simple  astrin- 
gent gargle,  and  the  cough  disappears.  Again,  examination 
reveals  congestion  of  the  vocal  cords,  and  a  soothing  inhalation 
of  a  teaspoonful  of  compound  tincture  of  benzoin  in  a  teacup 
of  hot  water,  frequently  causes  the  cough  to  be  relieved  in  a 
short  time.  But  the  general  practitioner,  especially  during 
the  winter  or  spring,  meets  with  a  great  many  cases  of 
cough,  the  cause  of  which  he  cannot  fathom.  He  calls  it  an 
irritating  cough,  but  the  cause  of  the  irritation  is  a  mystery. 
Experience  will  soon  show  that  it  is  irritating  to  both  the 
patient  and  physician.  To  the  latter  because  he  finds  that 
it  continues  in  spite  of  his  best  efforts,  and  at  last  the 
patient  drifts  from  one  physician  to  another  without  getting 
relief.  Eventually  he  takes  his  case  in  his  own  hands,  and 
buys  from  druggists  some  of  the  numerous  cough  remedies 
they  have  for  sale.  Still  no  relief,  and  he  finds  his  stomach 
thoroughly  out  of  order  because  opium  has  been  a  con- 
stituent of  the  quack  mixtures  he  has  taken.  Nature,  the 
vis  medicatrix  naturae,  possibly  comes  to  his  aid,  the  cough 
disappears,  but  no  thanks  to  his  doctor  or  his  own  pre- 
scribing. This  is  a  brief  sketch  of  what  I  know  occurs  to 
hundreds  of  physicians,  as  it  certainly  has  to  me.  Among 
the  late  remedies  for  this  class  of  cases  is  heroin,  and  it  cer- 
tainly has  proved  a  valuable  addition  to  our  materia 
medica.     There    are    many  combinations    in  use    of   which 


150  NOTES  FROM  THE  CASE  BOOK 

heroin  is  the  chief  constituent.  Some,  in  my  opinion,  are  not 
to  be  recommended  for  general  use.  What  is  needed  is  a  safe 
and  efficient  preparation  whose  action  is  positive  and  de- 
finite. Such  a  combination  we  have  in  glyco-heroin,  made 
by  Martin  H.  Smith  Co.,  of  New  York,  to  which  myatten- 
tionwas  drawn  about  a  year  ago.  Each  drachm  of  this  mixture 
contains  heroin,  gr.  1-16;  ammonia  hypophos,  gr.  3; 
hyoscyamus,  gr.  i  ;  white  pine  bark,  gr.  3^  ;  balsam  tolu, 
gr.  ^  ;  glycerine,  ad-  si.  The  astringent  properties  of 
white  pine  bark  are  of  peculiar  service  in  inflammations  of 
the  respiratory  tract.  It  also  is  of  use  in  arresting  the  night 
sweats  of  phthisis.  Balsam  of  tolu  is  an  aromatic  stimulant 
useful  in  chronic  bronchitis  or  in  the  advanced  stage  of 
the  acute  disease.  Altogether,  this  mixture  has,  in  my 
hands,  proved  to  be  of  the  greatest  value,  and  at  least  a 
dozen  of  my  medical  friends  to  whom  I  have  recommended 
it,  are  loud  in  its  praise.  I  give  below  the  report  of  a  few 
out  of  many  cases  in  which  I  have  used  it.  I  niay  state 
that  the  first  case  is  that  of  the  writer. 

Case  I. — F.  W.  C,  aged  62  years,  general  health  good. 
On  the  23rd  of  January,  1901,  about  10  p.m.  visited  one  of 
the  worst  fires  Montreal  has  had  for  y  ears  ;  was  exposed  to 
great  heat  for  about  fifteen  minutes,  when  he  left  to  return 
home.  Had  to  stand  some  minutes  waiting  for  an  electric 
car,  and  found  that  the  body,  which  had  been  perspiring 
freely,  began  to  feel  chilly.  On  reaching  home  lighted  a 
cigar,  but,  before  smoking  half  of  it,  was  seized  with  a  very 
severe  rigor.  Went  to  bed,  and  the  rigor  lasted  at  least 
twenty  minutes  when  it  left — no  perspiration  followed* 
Passed  a  restless  night,  and,  in  the  morning,  feeling  quite  ill> 
sent  for  a  medical  friend,  who  found  my  temperature 
102,  pulse  100,  respiration  28,  and  evidence  of  commencing 
pneumonia  in  the  anterior  part  of  the  right  lung.  It  is  needless 
to  follow  the  case  minutely.  Briefly,  the  whole  anterior  por- 
tion of  the  right  lung  became  involved,  and  the  inflamma- 
tion extended  to  the  hepatic  peritoneum.  It  was  a  serious 
condition   for  a  man   of  62  years,  and  for  several  days  the 


OF  A  PRIVATE  PRACTITIONER.  15I 

outlook  was  ominous.  But  a  good  constitution,  good  treat- 
ment and  splendid  nursing  brought  about  a  favourable 
termination.  There,  however,  remained  an  irritative  spas- 
modic cough  without  expectoration,  which  was  most  annoy- 
ing as  it  disturbed  sleep,  and,  therefore,  retarded  convales- 
cene.  To  relieve  this  condition  a  mixture  containing  a 
couple  of  drops  of  dilute  hydrocyanic  acid  with  half  a  tea- 
spoonful  of  parogoric  was  prescribed  with  but  little  relief. 
I  then  prescribed  for  myself,  changing  the  mixture  several 
times,  getting  some  relief  from  day  attacks,  but  at  night  the 
cough  was  bad  as  ever.  Seeing  in  one  of  my  medical  jour- 
nals an  advertisement  of  glyco-heroin  I  sent  for  a  sample  to 
New  York,  as  it  was  not  to  be  had  in  any  drug  store  in 
Montreal.  I  soon  received  through  the  Post  Office  four 
ounces,  and  within  forty-eight  hours  very  marked  relief 
ensued,  and  by  the  time  I  had  used  the  four  ounces  I  was 
almost  well.  Four  ounces  more  completely  cured  me.  I 
have  kept  a  bottle  of  it  in  my  house  ever  sirrce,  and  two  or 
three  times  during  the  year  a  threatened  return  has  been 
promptly  relieved  by  two  or  three  doses  of  a  teaspoonful, 
which  is  the  proper  quantity  for  an  adult. 

Case  II. — Miss  A.  P.,  about  24  years  of  age,  has  been 
a  patient  of  mine  all  her  life.  For  the  last  four  or  five  years 
has  every  spring  been  attacked  with  a  spasmodic  cough 
which  lasted  from  two  to  three  months  which  I  failed  to  re- 
lieve. Thinking  possibly  tHat  there  might  be  trouble  in  the 
tliroat,  beyond  my  view,  which  might  be  the  cause  of  the 
cough,  I  sent  her  once  to  Dr.  Birkett,  throat  specialist. 
He  reported  that  his  examination  was  negative.  The  cough 
as  usual  continued  till  the  weather  became  very  warm. 
Last  spring  she  consulted  me  for  the  same  cough,  and  told 
me  very  candidly  that  if  I  failed  to  relieve  her  she  would  try 
some  one  else.  I  prescribed  glyco-heroin  four  ounces,  and 
before  she  had  finished  it  she  was  completely  cured.  She, 
so  far  this  spring,  has  had  no  occasion  to  consult  me. 
lif  -  Case  III. — J.  L.  F.,  a  physician  (specialist),  consulted 
me  in  August,  1 891,  for  a  hoarse  spasmodic  cough,  which 


152  NOTES  FROM  THE  CASE  BOOK 

was  most  aggravating  both  by  night  and  day.  He  feared 
whooping  cough,  as  his  sister's  children,  who  resided  in  the 
same  house,  were  all  down  with  the  disease.  I  prescribed 
for  him  four  ounces  of  glyco-heroin.  Within  a  few  days  he 
reported  to  me  that  he  was  fiity  per  cent,  better.  I  think  that 
he  repeated  the  same  quantity  twice,  by  which  time  he  was 
practically  cured. 

Case  IV. — F.  I.  B.,  aged  about  58  years,  an  old  soldier, 
now  employed  as  watchman  in  a  Safe  Deposit  Company. 
Has  been  a  patient  of  mine  for  the  last  18  years.  Is 
asthmatic,  but  the  attacks  are  not  frequent.  Has  had  re- 
peated severe  attacks  of  acute  bronchitis.  In  December, 
190 1,  sent  for  me — diagnosis,  acute  bronchitis.  Bronchial 
rales  all  over  anterior  and  posterior  chest.  Cough  severe, 
expectoration  characteristic.  Ordered  croton  oil  liniment 
to  chest,  front  and  back,  and  gave  a  mixture  of  vin  ipecac, 
vin  antimon,  tinct.  of  aconite  and  syrup  of  squills.  For  five 
days  this  treatment  was  followed  without  the  slightest  im- 
provement to  any  of  the  symptoms.  I  then  prescribed 
glyco-heroin.  The  following  day  when  I  made  my  visit 
the  patient  exclaimed  on  my  entering  the  room,  "  Doctor, 
why  did  you  not  give  me  that  medicine  before  ?  It  has  given 
me  immense  relief."  And  so  it  had  ;  the  cough  was  greatly 
diminished,  the  expectoration  much  less.  Before  he  had 
finished  a  second  four  ounces  I  allowed  him  out  of  bed,  for 
he  was  practically  convalescent. 

Case  V. — W.  McG.,  aged  about  65,  consulted  me  in 
January,  1902,  for  a  persistent  irritative  cough  which  had 
persisted  since  October  last.  He  had  been  under  the  care 
of  his  family  physician  without  relief.  I  placed  him  on 
glyco-heroin — a  four-ounce  mixture  cured  him  perfectly. 

I  have  brief  notes  of  at  least  a  dozen  such  cases  in 
which  marked  relief  followed  the  use  of  glyco-heroin  (Smith), 
but  the  above  will  suffice  to  show  that  in  it  we  have  a  most 
valuable  therapeutic  agent. 

Dr.  George  Hall,  of  Point  St.  Charles,  Montreal,  whose 
attention  I    drew  some  months  ago  to  glyco-heroin,  sends: 


OF  A  PRIVATE  PRACTITIONER.  1 53 

me  the  following  brief  notes  regarding  its  use  in  his  hands: 

1.  In  three  cases  of  tuberculosis,  where  the  cough  was 
very  troublesome,  especially  during  the  night,  ^i  dose  of 
glyco-heroin  (Smith)  was  given  before  retiring.  Not  only 
was  the  sleep  better,  but  the  ''night  sweats"  were  dimin- 
ished in  severity  and  the  sputum  more  easily  expelled  on 
rising. 

2.  L,  L.,  Aet.  17. — Acute  Laryngitis. — Commenced 
coughing  at  1 1.20  p.m.,  coughed  almost  incessantly  until  1.20 
a.m.  (2  hours),  ^i  glyco  heroin  given,  cough  ceased  in  about 
ten  minutes,  and  patient  slept  until  7  a.m.  without  coughing 
once  in  the  interval. 

3.  Two  cases  of  chronic  bronchitis,  treated  with  the 
usual  remedies  for  about  four  weeks,  with  little  benefit. 
Glyco-heroin  given  in  .^i  doses  every  fourth  to  sixth  hour, 
expectoration  was  freely  established  and  cough  subsided. 
At  the  time  of  writing  both  cases  are  apparently  cured  in 
one  case,  one  month  has  elapsed,  in  the  other  two  months. 

4.  J.  F.,  Aet.  6. —  Whooping  Cough. — Five  drops  of 
glyco-heroin  every  third  hour  relieved  the  paroxsyms,  the 
duration  of  the  latter  were  shorter  and  farther  apart. 

Cancer  in  the  Male  Breast. — Cancer  is  a  rare  disease  in 
the  male  breast.  I  have  only  seen,  in  forty-nine  years,  three 
cases,  one  in  the  Montreal  General  Hospital  when  I  was  a 
student,  where  the  breast  secreted  small  quantities  of  milk, 
and  was  removed  by  the  late  Dr.  Crawford.  The  second  I 
saw  in  1861  at  King's  College  Hospital,  London,  the  breast 
being  excised  by  the  late  Sir  William  Ferguson.  The  third 
case  occurred  in  my  own  practice,  and  I  will  briefly  relate 
it.  All  were  cases  of  true  scirrhus.  I  regret  I  was  unable 
to  keep  track  of  any  of  these  cases,  so  cannot  say  whether 
the  disease  returned  : 

H.  G.,  aged  23,  French  Canadian,  and  previously  em- 
ployed as  a  farm  labourer,  was  examined  by  me  in  February, 
1885,  as  a  recruit  for  the  Royal  Canadian  Regiment  (St. 
Johns,  Que.,  Depot)  and  passed.  His  height  was  5  feet 
6  inches  and  his  weight   145  lbs.     In  the  early  summer  of 


154  PROCEDURE  IN  POST  MORTEM 

1887  he  complained  of  the  straps  of  his  knapsack  hurting 
his  chest.  I  examined  him  carefully  and  found  the  left 
breast  somewhat  enlarged  and  tender  to  the  touch.  I  had 
him  exempted  from  any  duty  requiring  his  wearing  the 
pack  and  watched  the  result.  The  tenderness  became  less, 
but,  by  the  autumn,  he  complained  of  sharp  lancinating  pain 
in  a  distinct  hard  nodule  about  the  size  of  a  large  walnut. 
I  decided  to  remove  the  breast,  which  I  did  in  November. 
1  opened  well  into  the  axillae,  but  did  not  find  the  glands 
involved.  The  wound  healed  rapidly,  and  he  was  discharged 
from  the  Regimental  Hospital  the  end  of  November. 
As  his  term  of  enlistment  expired  in  February,  1888,  he  did 
not  re-engage,  and  I  never  saw  or  heard  of  him  afterwards. 

PROCEDURE  IN  POST  MORTEM  MEDICO-LEGAI. 
EXAMINATION. 

By  CHARLllJS  A-  HEBBEET,  M.R.C.P.,  London. 
Professor  of  Anatomy,  Bishop's  College. 

Case  6. 

This  was  a  case  of  a  young  girl  found  in  the  River  Char- 
les, Boston,  with  evident  marks  of  violence  on  the  body. 

The  body  was  that  of  a  young  girl  aged  14  years,  4 
feet  6  in.  high,  well  nourished  and  developed,  black  hair, 
brown  eyes,  pupils  dilated,  tongue  protruding  and  clenched 
between  the  teeth  with  some  frothy  mucus  on  the  lips;  the 
lips  were  swollen  and  discoloured.  In  the  mouth  was  some 
mud  and  sand.  The  right  side  of  the  face  was  much  swollen 
and  discoloured,  the  lower  lid  showed  a  small  lacerated  wound 
and  there  was  an  ecchymosis  on  the  right  cheek  about  3  in. 
in  diameter,  somewhat  irregular  in  outline. 

Both  arms  showed  similar  marks  of  violence.  On  the 
anterior  and  inner  surface  of  each  arm,  ij^  in.  above  the 
elbow,  was  a  round  dark  bruise  and  on  section  showed  ex- 
travasation of  blood  into  the  muscles  beneath.  On  the  ex- 
tensor aspect  of  each  arm  were  four  small  bruises  each  about 
y^  in.  wide  and  ^  in.  long,  and  separated  from  each  other 
by  about  ^4^  in.  Similar  marks  were  found  along  the  outer 
and  posterior  aspects  of  the  thigh  and  a  larger  bruise  on  the 


MEDICO-LEGAL  EXAMINATION.  I  55 

inner  aspect  of  each  thigh  about  2  in.  in  width  and  irre- 
gular in  shape.  The  left  side  of  the  vulva  also  showed 
bruising,  and  the  inner  side  of  the  left  labium  majus  was 
ecchymosed;  the  hymen  was  intact.  It  may  be  stated  here 
that  the  girl  had  worn  drawers  fastened  at  the  side,  but  old 
and  ragged  at  the  lower  part  in  front. 

Decomposition  was  commencing  at  the  upper  part  of 
the  trunk  and  neck.  Hypostasis  was  remarked  on  the  back  of 
trunk  and  limbs. 

The  Internal  Sections. 

Head^  Scalp. — Showed  no  bruising.  The  bonts  were 
of  a  fair  thickness  and  there  was    no  fracture    of  the   skull. 

Brain,  Membranes. — The  sinuses  full  of  dark  fluid  blood. 
The  piamater  congested.  Vessels  normal.  Substance  of  brain 
apparently  normal  and  there  were  a  number  of  puncta  cru- 
enta  noticed  on  section. 

Thorax  and  Neck. — The  larynx  and  osophagus  both 
contained  some  mud  and  sand.  The  mucous  membrane  of 
the  larynx,  trachea  and  bronchi  was  swollen  and  congested, 
and  was  covered  by  bloody  frothy  mucus.  The  lungs  were 
large,  prominent  on  opening  the  cavity  and  were  much 
congested,  and  bloody  frothy  mucus  exuded  on  pressure. 

Heart,  Pericardium. — Contained  a  small  quantity  of  fluid 
(blood  stained.) 

The  cavities  of  the  right  heart  were  distended  by  black 
fluid  blood  and  some  black  clots.  The  left  side  contained 
a  small  quantity  of  blood  clots.  The  muscle  was  of  a  good 
colour  and  consistence.      Valves  normal. 

Abdomen,  Stomach. — Contained  some  partly  digested 
food  of  prunes  and  milk  and  some  dirty  fluid,  about  one 
pint  in  all. 

Intestines. — Normal. 

Liver. — Substance  normal,  some  congestion  of  organ. 

Spleen. — Similar  report. 

Kidneys. — Similar  report,  capsules  were  adherent. 

Pelvis.— Uterus  25^  in.  long,  virginal. 

Ovaries. — Normal,  no  corpus  luteum. 


156  OSERVATIONS  OF  SEVEN  YEARS'  USE 

The  vagina  was  narrow,  rugose  and  showed  no  other 
marks  of  injury  but  that  described  at  the  orifice. 

Comment. — The  two  questions  to  be  answered  in  this 
case  were :  first,  the  cause  of  death,  and  secondly,  what 
were  the  probable  causes  of  the  bruises  and,  how  far  were 
they  to  be  considered  in  the  decision  as  to  the  death. 

It  was  clear  that  the  death  was  due  to  the  suflfocation 
by  drowning.  The  bruises  had  been  inflicted  before  death; 
the  one  on  the  face  having  evidently  been  caused  by  a  very 
heavy  blow  by  some  blunt  instrument  such  as  a  clenched 
fist.  The  marks  on  the  arms  were  such  as  might  have  been 
made  by  the  forcible  grasp  of  the  hands.  The  somewhat 
linear  character  of  those  of  the  extensor  aspect  suggesting 
that  the  fingers  had  partly  slipped  from  the  first  grip. 
The  marks  on  the  thighs  suggested  the  forcible  separation 
of  the  thighs,  the  position  and  size  being  such  as  might  be 
made  by  the  knees.  The  marks  on  the  vulva  and  labium 
majus  were  made  by  a  blunt  instrument,  but  there  was  no 
penetration  of  the  vagina  and  no  rupture  of  the  hymen, 
the  attempt  at  rape  being  evidently  frustrated  in  part  by  the 
closed  drawers.  The  whole  picture  of  the  case  certainly 
seemed  to  suggest  that  the  child  had  been  assaulted  from 
the  front  with  a  view  to  rape  and  in  resistance  had  been 
stunned  by  a  violent  blow  on  the  face  and  then  thrown  into 
the  river  while  alive  and  died  of  drowning. 


Selected  Articles. 


OBSERVATIONS  ON  SEVEN  YEARS'  USE  OF  CREOSOTE 
IN  PNEUMONIA. 

BY  J.  L.  VAN  ZANDT,  M.  D.,  FT.  WORTH,  TEXAS. 

When  I  left  college  in  1856  I  had  been  taught  that  the 
proper  treatment  of  pneumonia  was  by  means  of  blood  let- 
ting and  tartar  emetic  in  the  first  stage,  and,  later,  calomel 
and  blistering.  Nothing  or  but  little  was  said  of  the  vis 
medicatrix  naturae,  and  when  Jim  Miller,  about  four  miles 
north  of  Dallas,  got  well,  I   congratulated  myself  that  I  had 


OF  CREOSOTE  IN  PNEUMONIA.  1$^ 

cured  one  case  of  pneumonia,. 

Within  a  year  or  two  I  read  a  work  on  "  Practice,"  by  J. 
Hughes  Bennett,  of  Edinburgh,  in  which  he  laid  great  stress 
on  feeding  and  gave  but  little  medicine,  but  yet  his  mortality 
was  much  less  than  I  had  seen  elsewhere  reported.  Later, 
I  read  a  little  work,  '*  Nature  and  Art  in  Disease,"  by  Sir 
James  Forbes.  Then  it  dawned  on  me  that  a  large  .per  cent, 
of  cases  would  get  well  with  or  without  medicine  if  he  could 
only  keep  them  alive  long  enough.  In  other  words,  pneu- 
monia was  a  self-limited  disease  and  would  run  its  course  if 
not  interrupted  by  death. 

It  is  true  I  gave  medicine  from  the  beginning  of  the 
attack,  hoping  to  modify  the  disease,  though  I  had  no  hopes 
of  aborting  it  or  materially  shortening  its  course.  For  a 
long  time  I  gave  carbonate  of  ammonia  to  all  cases,  and, 
later,  except  in  asthenic  cases  I  gave  salicylate  of  ammonia. 
I  believe  the  disease  was  distinctly  modified  by  these  reme- 
dies. Not  until  long  after  I  began  the  use  of  salicylates  of 
ammonia  did  I  know  that  the  salicylates  had  been  vaunted 
as  a  specific  in  the  disease.  I  did  not  give  in  sufficient  doses 
for  this  and  so  got  only  a  m5difying  effect.  I  believe  that 
measles  was  about  as  amenable  to  an  abortive  treatment  as 
was  pneumonia. 

So  you  will  see  I  was  not  looking  for  a  curs  for  pneu- 
monia when  I  gave  creosote  to  my  first  case,  one  with  an 
enteric  complication,  and  was  as  much  surprised  as  anyone 
at  the  result. 

A  shrewd  aunt  of  mine  said,  when  I  was  a  small  boy, 
that  I  would  learn  better  from  observation  than  from  books. 
From  books  I  learn  that  pneumonia  is  a  self-limited  disease 
and  must  run  its  course.  From  observation  I  learn  what  is 
"  better,"  that  in  a  large  per  cent,  of  cases  creosote  has  a 
decidedly  curative,  I  might  say,  an  abortive  effect. 

In  a  former  paper  (N.  Y.  Med.  Record,  March  30,  1901), 
I  gave  extracts  from  a  number  of  writers  who  enthusiastically 
claimed  the  curative  effects  of  creosote  in  pneumonia,  also 
reported  sixteen  consecutive  cases  of  my  own,  treated  dur- 
ing the  winter  of  1899  and  1900,  of  which  four  were  dismissed 
on  the  second  day,  five  on  the  third,  and  one  on  the  fourth, 
(10  or  62^  per  cent,  by  the  end  of  three  days),  one  each  on 
the  fifth,  sixth,  seventh  and  eighth,  and  two  on  the  tenth 
days.  Since  that  time  I  have  lost  only  one  case  ;  that  I 
shall  mention  later. 

As  further  evidence  on  the  curative  effects  of  creosote. 
I  will  give  some  extracts  from  personal  letters  received  since 


158  OSERVATIONS  OF  SEVEN  YEARS'  USE 

my  last  paper  was  written.  Prof.  Andrew  H,  Smith,  of 
New  York,  says  :  "  I  have  long  felt  that  in  all  probability, 
the  pneumonia  of  crisis  belonged  to  the  infection  with  pneu- 
mococci,  while  lysis  indicated  a  mixed  infection.  This  ap- 
plies, however,  only  to  cases  not  treated  with  creosotal  or 
other  germicide.  I  believe  such  treatment  is  capable  of 
causing  an  early  lysis,  before  time  for  crisis  arrives,  say  by 
the  second  or  third  day  the  fall  would  begin.  I  have  seen 
many  such  cases,  and  have  rarely  seen  a  crisis  when  the  re- 
medy was  begun  early." 

Dr.  A.  H.  Davidson,  of  Boerne,  Texas,  says :  "  I  saw 
your  first  report  on  creosote  in  pneumonia  1898  and  since 
then  have  used  it  in  all  cases  with  good  results." 

Dr.  Emma  H.  Yates,  of  Ander,  Texas,  says :  "  You 
taught  us  that  creosote  gave  startling  results  in  pneumonia, 
and  I  have  certainly  found  it  so.  I  have  been  agreeably 
surprised  that  my  patients  did  so  well.  I  seldom  needed  to 
make  a  second  visit.  At  first  I  doubted  my  diagnosis  when 
they  recovered  so  speedily,  but  I  could  not  confirm  my 
doubts.  I  was  positive  the  diagnosis  was  correct."  Having 
to  make  long  trips  to  the  country,  she  says  she  left  medicine 
with  instructions  to  send  report  the  next  day,  and  reiterates 
that  she  seldom  had  to  make  a  second  visit.  She  had  been 
practicing  only  two  years  and  had  only  ten  or  a  dozen  cases, 
but  had  been  well  pleased  with  results  in  all. 

May  1 1,  about  six  weeks  after  the  publication  of  my 
last  paper.  Dr.  Geo.  H.  Sanborn,  of  Henniker,  N.  H.,  wrote 
to  "  personally  thank  "  me  for  it.  The  day  after  reading  the 
paper  he  sent  to  Boston  for  the  carbonate  of  creosote,  and  in 
a  few  days  was  called  to  see  a  lady  set.  45,  sick  two  days, 
pulse  120,  respiration  40  and  temperature  105,  with  rusty 
sputum.  He  gave  creosote  carbonate  and  went  back  next 
day  and  dismissed  his  patient,  thinking  he  had  make  a  mis- 
take in  diagnosis.  He  was  called  back  the  same  evening  to 
find  the  symptoms  as  bad  or  worse.  He  resumed  giving  the 
creosote  and  had  a  speedy  recovery.  Further,  he  says  he 
had  treated  three  other  cases,.all  getting  well,  in  a  very  short 
time.  The  last  case  was  a  man  50  years  old,  temperature 
105,  respiration  50  and  pulse  140,  "raising  large  quantity  of 
rusty  sputum."  This  was  the  evening  of  the  first  day's  ill- 
ness. He  gave  creosote,  and  at  his  visit  the  next  morning 
the  wife  met  him  at  the  door  and  said :  "  Well  Doctor,  I 
guess  you  made  a  mistake  about  that  being  pneumonia.  My 
husband    is   all    right  this  morning    and  is  hungry."     The 


OF   CREOSOTE  IN  PNEUMONIA.  1 59 

Doctor,  to  use  his  own  words,  "  did  not  propose  to  run  any 
chances  and  did  not  omit  the  medicine,"  but  continued  it  for 
three  days  at  longer  intervals,  and  the  patient  was  at  work 
in  a  week.  He  then  goes  on  to  contrast  this  with  his  former 
experience  and  with  the  teaching  of  the  books. 

It  will  be  noted  that  my  report  of  cases  shows  an 
unevenness  of  results,  25  per  cent,  of  cases  being  dismissed 
on  the  second  day,  21  per  cent,  on  the  third  day,  and  yet 
123^  per  cent,  went  on  to  the  tenth,  though  in  all  the  pro- 
tracted cases  the  disease  was  distinctly  modified. 

One  writer  says:  "  When  given  early  in  the  attack  the 
results  are  almost  specific."  While  admitting  the  beneficial 
effects  of  early  giving  T  have  seen  as  decided  effects  when 
given  later,  on  all  symptoms  save  the  colour  of  expectoration, 
as  when  given  early.  It  has  occurred  to  me,  from  my  own 
and  the  observation  of  others,  that  the  difference  of  results 
was  due  not  so  much  to  the  time  of  giving  as  to  the  differ- 
ence in  the  infecting  micro-organism.  I  have  been  impresssd 
with  the  idea  that  the  pneumococci  infected  were  the  most 
amenable  to  treatment,  but  a  lack  of  miscroscopical  equipment 
has  prevented  me  from  putting  this  impression  to  the  test. 

Since  I  began  using  the  carbonate  of  creosote,  October 
29,  1899,  I  have  had  but  one  fatal  case  of  pneumonia 
That  was  April  7,  last,  and  to  that  patient  the  carbonate, 
of  creosote  was  given  early  and  freely  and  seemingly  with 
no  effect  whatever.  This  case,  while  in  a  measure  having 
the  appearance  of  an  ordinary  attack  of  lobar  or  croupous 
pneumonia,  had  some  very  peculiar  features.  He  was  taken 
with  a  chill  about  3  a.m.  I  saw  him  six  hours  later.  He 
had  pain  in  the  side  and  cough  and  was  expectorating  a 
rust-coloured  sputum.  I  diagnosed  a  pneumonia,  but  did  not 
at  the  time  locate  the  pulmonary  lesion.  Later,  however,  I 
I  found  the  posterior  part  of  the  left  lung  involved  from  top 
to  bottom,  while  the  anterior  part  and  the  whole  of  the 
right  one  seemed  to  be  entirely  free  from  disease.  These 
conditions  continued  throughout  the  attack,  which  lasted 
almost  twenty-one  days.  All  this  time  could  be  heard  pos- 
teriorly tubular  breathing,  associated  with  fine  and  coarse 
crepitation.     The  expectoration  varied  very  little. 

The  conclusions  I  have  reached  are  these :  A  large  per 
cent,  of  pneumonic  cases  are  cut  short  or  aborted,  almost  all 
the  rest  are  mitigated,  and  the  remainder,  a  very  small  per 
cent.,   are  not  at  all  affected  by  the  remedy. 

I  have  been  thus  particular  to  dwell  on  these  unfavour- 
able cases  for  two  reasons.      Honesty  requires  it,  and  should 


l60  OBSERVATIONS  OF  SEVEN  VEARS'  USE  OF  CREOSOTE. 

one  of  you  who  has  not  already  done  so,  be  disposed  to  try 
the  creosote  and  find  first  one  of  the  non-yielding  cases,  he 
might  be  disposed  to  discredit  the  whole  thing. 

As  illustrated  in  Dr.  Sanborn's  first  case,  it  has  been 
found  that  the  medicine  must  not  be  omittted  so  soon  as 
active  symptoms  have  subsided,  because  there  will  almost 
surely  be  a  recurrence,  as  I  have  known  quite  a  number  of 
times.  The  medicine  should  be  continued  in  less  quantity 
or  greater  intervals  for  at  least  three  days.  In  broncho- 
pneumonia a  longer  time  is  generally  better. 

A  few  words  with  regard  to  the  particular  preparation 
and  dose  :  My  original  formula  was  made  by  adding  one 
drop  of  creosote  to  my  then  common  dose  of  seven  and  a 
half  grains  of  salicylate  of  ammonia.  This  combination  I 
continued  to  use  in  most  cases  till  1899.  In  some  creosote 
was  given  without  the  salicylate,  because  of  great  prostra- 
tion or  gastric  irritability.  I  lost,  as  I  now  remember,  two 
cases  of  my  own,  and  two  turned  over  to  me  "  in  extremis." 
Some  of  these  I  think  might  have  been  saved  by  my  present 
medication. 

In  1899  I  read  an  abstract  of  a  report  of  a  case  treated 
with  carbonate  of  creosote,  by  Cassoute,  of  Marseilles,  France, 
and  as  it  furnished  an  easy  and  pleasant  way  to  increase  my 
dose  of  creosote,  I  at  once  adopted  its  use  and  have  found 
no  difficulty  in  giving  it  in  any  desirable  dose  to  any  patient. 
It  is  almost  devoid  of  taste  and  odour  and  may  be  given  in 
emulsion  or  stirred  in  hot  sweetened  water  to  be  taken  dur- 
ing agitation  as  it  does  not  dissolve.  The  emulsion  is  an 
ideal  way  particularly  for  small  children.  Do  not  mix  with 
alcohol  or  acids,  as  these  will  develop  the  taste  and  odour  of 
creosote. 

It  may  be  asked,  may  not  guaiacol  or  its  carbonate 
be  used  instead  of  carbonate  of  creosote.  I  think  not. 
Thinking  to  test  the  matter  I  gave  thiocol,  a  preparation  of 
guaiacol,  in  one  case,  but  my  patient  grew  steadily  worse  as 
the  disease  advanced,  until,  after  about  three  days,  I  sub- 
stituted carbonate  of  creosote,  and  in  twenty  four  hours  a 
marked  mitigation  of  symptoms  occurred.  I  have  not  half 
the  courage  or  disposition  to  experiment  further. 

Dose  :  To  an  adult  I  have  been  in  the  habit  of  giving  seven 
and  a  half  to  ten  grains  or  minims  every  three  hours,  in 
urgent  cases  giving  the  dose  more  frequently  for  a  few  times. 
Some  have  recommended  one  dram  night  and  morning, 
while  others  have  put  the  daily  amount  at  two  and  a  Half  to 


RELIEF    OF    PAIN    IN    NEURALGIC    CONDITIONS.  l6l 

three  drams.  Dr.  Sanborn,  whose  report  of  cases  I  have  given, 
gave  one  drop  every  hour.  It  may  be  that  some  of  us  are 
giving  more  than  necessary  and  that  better  results  may  be 
had  by  giving  smaller  doses  at  shorter  intervals.  In  some 
cases  I  formerly  got  good  results  from  one  drop  of  creosote 
alone  every  three  hours. 

Ordinarily,  I  use  the  carbonate  of  creosote  without  other 
medication.  I  never  use  expectorants  or  nauseants.  Occasion- 
ally, a  few  doses  of  some  anodyne  are  given  in  the  begin- 
ning of  painful  cases,  and  strychnine  where  indicated. — The 
Medicus,  Feb.,  1902. 

RELIEF    OF    PAIN    IN    NEURALGIC    CONDITIONS. 

By  E.  H.  Sickler,  M.D.,  New  Baltimore,  Mich. 

When  called  to  treat  a  case  of  acute  neuralgia,  whether 
of  purely  nervous  origin,  or  resulting  from  traumatisms,  or  of 
a  malarial  rheumatic,  or  gouty  character,  or  a  manifestation 
of  auto-toxemia,  the  most  important  factor  from  the  patient's 
standpoint  is  the  relief  of  the  pain,  which  is  usually  of  an 
excruciating  character.  In  trigeminal  neuralgia  the  suffering 
produced  is  sometimes  well-nigh  unendurable.  In  sciatica 
it  radiates  from  the  hip  to  the  knee  or  heel  of  the  affected 
limb,  making  either  walking  or  the  sitting  posture  im- 
possible. In  the  intercostal  form  the  pain  will  shoot  from 
one  intercostal  nerve  to  another.  Occasionally,  the  pain  may. 
be  of  a  nagging  kind,  a  twinge  of  pain  in  the  hip  on  moving 
the  limb,  but  this  mild  form  is  quite  unusual. 

To  effect  a  positive  cure  in  cases  of  neuralgia  it  is  nece.*' 
sary  to  submit  the  patient  to  a  thorough  examination,  and 
to  discover  as  far  as  possible  the  real  cause  of  the  pain.  The 
presence  of  a  uric  acid  diathesis,  of  chronic  malaria,  of  kidney 
disease,  of  digestive  disorders,  or  of  a  simple  neurotic  tendency, 
will  all  afford  valuable  clews  as  to  the  method  of  treatment 
to  be  adopted.  For  the  immediate  relief  of  the  pains  mor- 
phine has  been  the  most  extensively  used,  and,  it  may  also 
be  said,  abused  remedy.  While  a  blessing  in  some  cases  it 
has  been  a  distinct  curse  in  others,  by  setting  up  a  habit 
from  which  the  unfortunate  victim  has  found  it  most  diffi- 
cult, if  possible  at  all,  to  extricate  himself.  Local  applica- 
tions, such  as  the  use  of  heat  and  cold,  of  counter-irritants, 
and  electricity,  may  be  resorted  to  with  more  or  less  benefit 
in  connection  with  the  internal  use  of  analgesics. 

Among  these  I  have  recently  found  in  heroin  hydro- 
chloride a  drug  which  surpasses  morphine  in  some  important 


I62  RELIEF    OF    PAIN    IN    NEURALGIC    CONDITIONS. 

respects.  Morphine,  even  when  given  hypodermically,  has 
the  inhibiting  effect  of  opium  on  the  unstriped  muscular 
fibers  of  the  intestines,  restraining  bowel  movements.  This 
we  know  is  contrary  to  what  is  most  desired  in  neuralgias  of 
gouty  or  rheumatic  character — that  is,  the  prompt  elimina- 
tion from  the  blood  of  all  deleterious  substances  which  are 
causative  factors  in  producing  the  conditions  from  which  the 
neuralgia  results.  Heroin  hydrochloride  does  not  have  this 
effect  on  the  intestines,  and  is  not  followed  by  the  headache  or 
nausea  produced  by  morphine.  The  use  of  heroin  is  not 
attended  with  any  cerebral  maViifestations  ;  it  is  simply  anal- 
gesic, and,  to  a  lesser  degree,  hypnotic.  Moreover,  its  con* 
tinued  administration  does  not  give  rise  to  any  craving. 

The  following  cases  will  show  its  mode  of  action  in  pain- 
ful conditions : 

Case    i — E.    J ,  aged   thirty  five    years,    married, 

sailor,  is  not  only  exposed  to  inclement  weather,  but  is  also  a 
moderately  heavy  alcoholic.  He  is  a  heavyweight  (220 
pounds).  He  has  had  attacks  of  sciatica  lasting  from  two  to 
ten  weeks  for  the  past  five  years,  generally  in  winter.  The 
present  attack  began  January  15,  1901,  and  since  then  he 
complained  of  excruciating  pains  in  the  left  leg,  running 
from  the  hip  to  the  heel  along  the  great  sciatic,  lesser  sciatic, 
and  short  saphenous  nerves.  Locomotion  was  impossible. 
Temperature  99^^;  pulse  82  ;  urine  normal,  except  for 
hyperacidity  and  brick-dust  (amorphous  urates)  deposit  on 
standing.  Apparently  he  was  lithemic.  I  placed  htm  on  a 
rigid  vegetable  diet,  forbade  all  liquors,  applied  hot  bran 
bags  along  the  limb,  gave  him  a  diuretic,  a  cathartic,  and 
lithium  citrate  tablets,  grains  5,  every  four  hours.  I  also 
ordered  tr.  aconite,  tr.  iodine,  and  tr.  opii,  to  be  painted 
over  the  affected  area.  Morphine  sulphate,  ^  grain,  was 
administered  subcutaneously,  and  some  j4  grain  tablets  of  the 
drug  left  with  the  patient  to  be  taken  if  necessary  for  the 
pain,  as  he  lived  some  distance  in  the  country.  On  January 
17  I  found  him  in  about  the  same  condition  as  at  the  pre- 
vious visit,  except  that  the  pain  was  less  severe,  which  was 
due  to  the  fact  that  he  had  taken  all  the  morphine  (six  J^ 
grain  tablets).  His  bowels  had  not  moved.  Seeing  that 
something  else  had  to  be  done  I  withdrew  the  morphine,  and 
gave  him  heroin  hydrochloride,  1-12  grain,  for  the  relief  of 
the  pain.  Another  cathartic  was  administered,  and  the  pre- 
vious medication  continued.  On  January  19  he  was  much 
brighter.  Heroin  hydrochloride  had  controlled  the  pain 
very  well ;  the  bowels  had  moved,  and  there  was  very  little 


RELIEF    OF    PAIN    IN    NEURALGIC    CONDITIONS.  163 

sensitiveness  to  pressure  along  the  aflfected  nerves.  He 
could  also  move  the  leg  to  some  extent.  All  previous  medi- 
cation was  continued.  On  January  21  I  found  him  sitting 
in  a  chair,  and  with  the  exception  of  an  occasional  twinge  in- 
the  hip  he  felt  very  well.  The  temperature  and  pulse  were 
normal.  The  lithium  citrate  was  continued,  as  his  urine  was 
still  hyperacid.  He  had  not  been  compelled  to  take  any  of 
the  heroin  hydrochloride  for  the  last  twelve  hours.  In  ten- 
days  he  was  around  again,  and  has  since  had  no  repetition  of 
the  attack. 

Case  2. — T.  N ,  married,  aged  thirty-five,  farmer; 

previous  health  good.  On  February  13,  while  drawing  ice, 
he  exposed  himself  to  great  cold  by  sitting  on  a  block  of  ice 
which  was  covered  with  a  little  straw.  On  February  15  he 
awoke  with  severe  pains,  radiating  from  the  right  hip  to 
the  heel.  On  examination  I  found  the  great  and  small 
sciatic  nerves  painful  from  the  gluteal  region  to  the  knee. 
Temperature  99"  ;  pulse  ^6  ;  urine  normal.  Diagnosis :  Scia- 
tica due  to  excessive  cold.  I  gave  him  a  laxative  ;  applied 
hot  bran  bags  to  the  leg,  and  administered  two  doses  of  1-12 
grain  heroin  hydrochloride  hypodermically,  injecting  at 
different  points  along  the  greater  and  smaller  nerves.  In 
addition  to  this  I  left  a  few  doses  (i-i2  grain)  of  the  drug  in 
solution.  Before  my  departure  he  felt  much  relieved.  On 
the  1 6th  his  wife  came  to  my  office,  telling  me  that  he  was 
greatly  improved,  and  only  had  a  slight  soreness  in  the  hip. 
A  few  days  after  this  the  patient  presented  himself  at  the 
office,  and  expressed  himself  as  cured. 

Case  3. — Emma  G ,  aged  twenty-eight,  has  been  a 

chronic  invalid  for  the  past  ten  years.  I  was  unable  to 
obtain  a  clear  early  history  of  the  case,  but  my  examination 
showed  a  probable  reflex  irritation  of  the  spinal  nerves  due 
to  utero-ovarian  disorders.  One  of  her  first  physicians  put 
her  in  a  plaster-Paris  cast  (jacket)  for  spinal  curvature  (?). 
She  has  become  so  accustomed  to  this  support  that  she  thinks 
she  is  unable  to  walk  without  it.  As  the  results  of  the 
constant  wearing  of  this  hard  plaster  cast  there  has  arisen  an 
irritation  of  the  intercostal  nerves.  This  occasionally  flares 
up  into  a  severe  intercostal  neuralgia.  In  a  patient  of  ner- 
vous temperament,  especially  in  an  invalid,  it  is  obviously 
the  better  way  to  attempt  to  control  the  pain  without  the 
use  of  opiates.  This  has  sometimes  been  impossible,  and 
morphine  has  been  given.  Since  my  success  with  heroin 
hydrochloride  in  sciatica  I  have   used  this    remedy  in  her 


1 64  PROGRESS  FO  MEDICAL  SCIENCE. 

case  with    the  best   results,  and  have  obviated  any  risk  of 
establishing  a  pernicious  drug  habit. 

In  Cases  i  and  3  it  is  conclusively  shown  that  heroin 
hydrochloride  is  much  safer  and  as  efficient  an  analgesic  as 
morphine.  In  Case  i  especially  is  the  result  striking,  for  in 
previous  attacks  the  patient  had  used  a  great  deal  of  mor- 
phine without  permanent  benefit,  and  the  attacks  lasted 
longer.  It  is  well  for  physicians  to  look  forward  to  the 
patient's  future,  especially  so  when  prescribing  morphine  for 
neurotic  persons.  Moreover,  I  can  recall  no  previous  cases 
of  neuralgia,  sciatica  or  otherwise,  treated  with  morphine,  in 
which  the  results  were  as  satisfactory  as  in  these  two  cases. 
— Medical  Age,  January  25,  1902. 


Progress  of  Medical  Science. 


MEDICINK    AND     NEUROLOQY 

"^  IN   CHARGE  OP 

J.  BRADFORD  McCONNBLL,  M.D. 

Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College;  Physician  Western  Hospital. 


HEREDITY  IN  ITS  REIiATION  TO  IMMUNITY  AND 
SELECTIVE     ACTIVITY    IN    TUBERCULOSIS. 

H.  M.  King  {Med.  Record,  vol.  60,  no.  15,  Memphis 
Medical  Monthly),  thus  summarizes  the  result  of  observa- 
tions in  a  series  of  cases: 

(a)  Of  two  hundred  and  forty-two  consecutive  cases  of 
phthisis,  approximately  one  in  every  four  gave  a  history  of 
phthisis  in  the  parents.  (&)  Nearly  one  in  three  gave  a  his- 
tory of  previous  phthisis  in  a  brother,  sister,  or  both,  (c) 
More  than  two-thirds  of  those  giving  a  history  of  previous 
phthisis   in   brother,   sister,    or   both,   had    non-phthisical 


MEDICINE   AND    NEUROLOGY.  165 

parents,  (d)  As  a  rule,  in  the  incidence  of  individuals 
of  phthisical  parentage  afterward  developing  phthisis, 
a  much  longer  period  was  found  to  exist  between  supposed 
exposure  to  infection  and  the  subsequent  appearance 
of  the  disease  than  was  the  case  in  the  incidence  of 
those  giving  a  non-phthisical  heredity.  (e)  Of  one 
hundred  and  three  fatal  cases  of  phthisis,  the  average 
length  of  life  after  development  of  the  disease  of  those 
giving  a  history  of  phthisis  in  the  parents  was  to 
that  of  individuals  of  non-phthisical  parentage  approxi- 
mately as  four  to  three. 

The  following  conclusions  naturally  follow: 
1,  The  percentage  of  consumptives  having  a  tuber- 
culous parentage  is  actually  smaller  than  that  having  a 
non-tuberculous  parentage,  and  much  smaller  than  would 
be  more  than  accounted  for  by  the  additional  risk  of  infec- 
tion to  which  the  former  class  is  subjected- 

2.  Tuberculosis  in  the  parents  renders  to  no  inconsider- 
able extent  an  immunity  to  the  disease  in  the  offspring, 
an  immunity  which,  of  course,  is  but  relative  and  not  suffi- 
ciently protective,  but  still  demonstrable,  asi  is  shown  by 
increased  resistance  to  the  progress  of  the  disease  and  in- 
creased tendency  to  recover  among  this  class. 

SANTONINE. 

This  drug,  which  has  generally  been  looked  upon  only 
as  reliable  anthelmintic  and  very  seldom  thought  of  except 
in  certain  forms  of  verminous  trouble,  is  now  found  to  possess 
a  much  wider  range  of  action  and  to  be  of  special  value  in 
the  treatment  of  epilepsy  and  the  pains  of  locomotor  ataxia. 
The  physiological  action  of  this  drug  is  markedly  upon  the 
nervous  system ;  taken  in  large  doses,  producing  great  weak- 
ness, tremor,  perspiration,  coldness  of  the  extremities,  vomit- 
ing, and  not  infrequently  quick,  sharp  convulsions,  terminat- 
ing in  death  from  paralysis  of  respiration. 

The  effect  upon  the  vision  is  very  marked  ;  at  first, 
everything  appears  blue,  which  speedily  turns  to  a  greenish 
yellow,  which  may  be  followed,  if  large  doses  have  been 
taken,  by  total  blindness,  lasting  a  week  or  more.  The 
physiological  action  of  this  drug  is  so  marked  in  its  effect 
upon  the  nervous  system  that  we  obtain  a  clue  to  a  remedial 
agent  of  great  power  in  influencing  general  changes  of  nervous 
sensibility;  In  its  action  we  have  an  excellent  reproduction 
of  the  symptoms  of  epilepsy  and  the  pains  of  locomotor 
ataxia,  and  Lydstone  claims  that  he  has  obtained  better  re- 


l66  PROGRESS  OF  MEDICAL  SCIENCE. 

suits  from  it  in  epilepsy  than  from  the  bromide  treatment. 
The  dose  recommended  in  these  cases  is  two  grains  three  or 
four  times  a  day,  gradually  increasing  to  fifteen  grains  at  a 
dose,  if  that  amount  is  well  borne.  In  the  lulgurant  pains  of 
locomotor  ataxia  we  have  given  two  grains  three  times  a 
day  with  better  results  than  from  any  other  drug,  the  pain 
almost  entirely  disappearing  while  under  its  influence. 
Studying  the  action  of  drugs,  irom  the  dual  standpoint,  there 
can  be  no  doubt  of  the  wide  range  of  action  of  santonine  on 
the  nervous  system  and  its  great  value  in  many  other  dis- 
eases.— New  York  Med.    Times, 

ARSENIC. 

Dr-  T.  C-  Simpson,  of  Louisville,  contributes  a  practi- 
cal article  in  the  use  of  arsenic  to  the  American  Prac- 
titioner and  Neit:s-  We  take  the  following  extracts  from 
it: 

Arsenic  is  one  of  our  most  valuable  medicines,  and 
one  that  is  not  as  popular  as  it  should  be  among  the  pro- 
fession generally.  Many  ijractitioners'  who  do  not  see 
much  of  skin  diseases  seem  to  have  an  idea  that  arsenic 
is  a  remedy  which  can  be  administered  in  almost  every 
lesion  of  the  skin  with  advantage,  and  fail  to  recognize 
that,  as  a  rule,  it  is  contra-indicated  whenever  the  layers 
of  the  skin  are  inflamed,  being  most  useful  when  the  epi- 
derm  is  dry  and  improperly  nourished,  and  of  very  little 
use  when  the  corium  is  inflamed.  Psoriasis  is  a  typical 
disease  of  the  former  class,  and  in  its  treatment  arsenic  is 
a  standard  remedy.  As  stated  above,  the  medicine  should 
not  be  prescribed  during  the  inflammatory  stage  of  a 
skin  disease.  When  used,  it  should  be  kept  up  for  weeksi, 
even  months.  Dr.  Hare  calls  our  attention  to  the  use  of 
arsenic  as  a  valuable  appetizer  in  doses  of  a  minim  of 
Fowler's  solution  with  ten  grains  of  bicarbonate  soda  and 
a  tablespoonful  of  infusion  of  gentian  before  meals.  I 
have  used  it  this  way  and  certainly  found  it  a  very  valu- 
able tonic.  It  is  also  useful  in  certain  forms  of  morning 
diarrhoea  and  nausea;  also  it  is  valuable  in  the  treatment 
of  various  forms  of  anaemia,  in  which  case  it  must  be 
given  over  long  periods- 
It  is  hardly  necessary  to  remind  you  that  it  is  almost 
a  specific  in  the  treatment  of  chorea,  and  its  value  as  a 
blood  tonip  in  malaria,  and  its  great  value  in  diabetes  and 
asthma.  It  is  held  by  ]\furray  and  other*!  that  it  is  useful 
in  those  asthmatic  cases  which  are  youncc.  and  the  old 
with  marked  emphysema.  It  is  also  valuable  in  cases 
that  have  nasal  disorders  due  to  hyperemia  of  the  respira- 


MEDICINE  AND  NEUROLOGY.  i6 

tory  mucous  membrane.  While  recognizing  the  value  of 
arsenic,  we  must  not  forget  that  it  is  possible  for  it  to 
produce  evil  influence;  that  it  is  capable,  when  adminis- 
tered too  long  a  time  in  large  doses,  of  causing  pigmenta- 
tion of  the  skin,  irritation  of  the  stomach  and  of  the 
respiratory  tract,  and,  more  serious  still,  peripheral 
neuritis. 

In  the  treatment  of  chorea  I  find  it  of  the  greatest 
value.  You  must  use  it  in  increasing  doses,  and  this  is 
one  of  the  few  diseases  in  which  arsenic  is  so  valuable 
that  you  have  to  give  it  in  ascending  doses,  even  to 
tolerance-  I  find  it  of  the  greatest  value  in  anemia;  even 
the  obstinate  and  often  incurable  cases  of  pernicious 
anemia  jdeld  better  to  arsenic  than  to  any  other  known 
remedy;  it  is  to  be  given  in  small  doses  and  kept  up  for 
months.  In  the  small  dose  you  are  not  so  likely  to  pro- 
duce stomach  disturbances.  The  effect  of  the  drug  in 
this  disease  is  not  due  to  its  increasing  the  number  and 
quality  of  the  red  blood  corpuscles,  but  rather  to  its  pre- 
venting or  delaying  their  destruction  in  the  portal  circula- 
tion. By  timely  use  of  laxatives  and  carefully  watching 
the  dosage,  you  may  easily  adjust  the  blood-making  forces. 

TREATMENT  OF  MIGRAINE. 

The  writer  leans  to  the  view  that  migraine  in  the  ma- 
jority of  instances  is  of  toxic  origin.  He  rejects  the  theory 
that  it  is  a  degenerative  neurosis.  The  largest  number  of 
cases  are  among  brain-workers  and  those  following  se- 
dentary occupations.  Sailors,  truckmen,  and  others  who 
lead  an  outdoor  life  associated  with  muscular  exertion,  are 
almost  exempt.  From  this  he  argues  that  in  migraine 
there  is  usually  a  passive  congestion  in  the  portal  circula- 
tion. This  leads  to  fermentation  in  the  intestine  and 
absorption  of  toxic  products,  with  the*  development  of  the 
explosive  headaches.  The  marked  hereditary  element  in 
these  cases  is  explained  by  the  theory  that  all  disorders  of 
the  alimentary  tract  have  a  tendency  to  pass  from  parents 
to  offspring. 

With  these  views  of  the  origin  of  migraine  the  writer 
readily  arrives  at  a  method  of  treatment  which  aims  at 
restoring  the  general  tone  of  the  nervous  system,  develop- 
ing the  muscles,  improving  the  circulation  in  the  abdomen^ 
and  so  far  as  drugs  are  concerned,  administering  intestinal 
antiseptics  with  cathartics.  In  prophylaxis  all  cases 
should  be  regarded,  without  exception,  as  chronic  dys- 
pepsia, one  of  the  commonest  symptoms  of  which  is  con- 
stipation.   The  mercurial  laxative  should  be  given  at  least 


1 68  PROGhhSS  OF  MEDICAL  SCIENCE. 

every  week.  This  should  consist  of  a  five-grain  blue  pill  at 
liight,  followed  by  a  saline  in  the  morning.  In  addition, 
oue  to  two  drachms  of  sulphate  of  soda  with  ten  grains  of 
sodium  salicylate  is  to  be  given  in  a  tumbler  of  hot  water, 
sipped  every  morning  on  arising.  Half  an  hour  before 
each  meal  a  pill  is  taken  containing  one-twentieth  of  a 
grain  of  bichromate  of  potassium,  with  three  grains  of 
bismuth  subcarbonate  half  an  hour  after  meals.  At  night 
a  full  dose  of  an  intestinal  antiseptic,  ten  grains  of  phenol 
bismuth  or  ten  grains  of  ammonium  benzoate  or  sodium 
benzoate,  is  given  in  two  capsules.  Sometimes  when  the 
intestinal  derangement  takes  the  form  of  diarrhoea,  the 
above  prescription  is  quite  as  useful  as  in  those  cases  in 
which  there  is  constipation. — W.  J.  Thomson,  Med.  Rec. 

BRONCHIAX  AFFECTIONS  IN  GOUT  AND  OBESITY. 

By  Dr.  J.  Anders,  of  Philadelphia  {Meil.  tSoc.  State 
of  Pa.,  St.  Louis  Medical  and  Surgical  Journal). 

Although  the  pathogenesis  of  the  abnormal  conditions 
in  the  lungs  in  obesity  is  not  clear,  it  can  be  assumed  that 
the  deposit  of  fat  in  the  body  plays  a  mechanical  part. 
He  describes  the  symptoms  concurrent  with  over-fatness, 
namely,  pain  in  the  subscapular  and  intrascapular  muscles, 
more  marked  when  the  patients  make  an  effort  to  maintain 
the  erect  posture.  The  physical  signs  vary,  but,  as  a  rule, 
tactile  fremitus  and  percussion  notes  are  enfeebled  on 
account  of  the  abnormal  deposition  of  fat.  There  is  a 
weakened  vesicular  murmur,  although  in  rare  instances 
the  murmur  may  be  exaggerated-  Among  the  adventi- 
tious sounds  are  moist  rales,  although  the  author  has  also 
observed  whistling  sounds,  the  presence  of  mucus,  how- 
ever, predominating  on  ausculation.  The  author  discussed 
asthma  in  obese  subjects  and  the  theories  of  its  cardiac 
origin.  Asthma  in  corpulency  is  due  to  the  high  position 
of  the  diaphragm  in  individuals  who  overfeed.  There  is 
good  reason  to  believe  that  hepatic  inadequacy  may  be  a 
cause.  He  believes  that  the  severe  paroxysmal  dyspnoea  in 
asthma  can  be  helped  by  assuming  the  erect  posture,  as 
there  is  no  characteristic  sputum  or  vasomotor  spasm  in 
these  conditions.  The  question  of  the  relation  of  asthma 
to  polysarcia  is  somewhat  obscure,  the  author's  conclu- 
sions being:  (1)  That  asthma  occurs  in  about  five  per 
cent,  of  the  cases  of  obesity;  (2)  that  it  only  occurs  in  ex- 
treme polysarcia;  (3)  that  there  is  present  a  gouty  state  or 
history  in  most  cases  in  which  true  asthma  is  secondary 
to  the  obesity;  and  (4)  that  about  one-half  of  the  cases  are 
curable  by  overcoming  the  causative  condition. — Phil.  Med. 
Jour. 


SURQKRY. 


IN   CHARGE    OP 

ROLLO  CAMPBELL,  M.D., 

LectureronSurgsry,  University,© f  Bishop's  College  ;  Assistant  Surgeon,   Western  Hospital  ; 

AND 

GEORGE  FISK,  M.D., 
Instructor  in  Surgery,  University  of  Bishop's  College  ;  Assistant^Surgeon,  Western  Hospital. 


ON  THE  PASSING  OF  THE  TREPHINE. 

T.  H.  Manley,  New  York,  records  his  objections  to 
the  trephine  and  his  reasons  for  preferring  the  chisel. 
By  using  the  trephine,  sinuses  may  be  opened;  hernia 
cerebri  may  result;  the  serrations  are  cleansed  with  diffi- 
culty, and  the  operator  is  working  in  the  dark. 

In  connection  with  the  subject  of  vault  fractures,  he 
calls  attention  to  a  few  things  in  connection  with  it  of 
practical  importance.  (1).  Make  a  large  incision  to  freely 
expose  the  skull.  (2)-  Leave  all  aseptic  sub-  or  epidural 
coagula,  however  extensive,  undisturbed-  (3)  Let  all 
lacerations  in  the  dura  mater  be  securely  closed  with  fine 
aseptic  gut  suture.  (4)  Reimplantation  of  trephine  buttons 
of  skull-bone  invariably  fails,  and  any  procedure  which 
will  conserve  the  skull  is  of  great  advantage  to  the  adult. 
In  the  child  under  fifteen  years,  as  Oilier  has  correctly 
demonstrated,  the  periosteal  layer  of  the  dura  mater  will 
regenerate  ample  new  osseous  tissue  to  fill  in  a  large 
breach.  (5)  Silkworm  gut,  or  Grin  de  Florence  fishgut, 
answers  best  for  suture  of  the  scalp;  small  wicks  of 
aseptic  gauze  in  the  angles  of  the  wound  provide  for 
ample  drainage.  (6)  For  antiseptic  powder  over  the 
wound  here,  or  indeed  any  scalp  wound,  nothing  surpasses 
finely-ground  fresh  mustard. — Kansas  City  Medical  Rec. 

DIRECT    INTRODUCmON      OF     PURGATIVE      INTO      THE 

liARGE    INTESTINE    IN    CASES    OF    OPERATION 

FOR  SEPTIC   PERITONITIS. 

A.  M.  Sheild  calls  the  attention  of  the  profession  to 
a  method  which  he  believes  is  of  great  utility  in  the 
surgery  of  septic  peritonitis — the  direct  introduction  of 
purgatives  into  the  intestines  at  the  time  of  operation- 
It  is  not  too  much  to  say  that  in  many  of  these  cases  the 
patient's  life  hangs  on  the  possibility  of  overcoming  the 
paralytic  obstruction  and  the  free  evacuation  of  gas  and 
feces.  The  worse  the  case  the  more  difficult  is  this  to 
bring  about,  since  the  patient  vomits  everything  he  takes 
by  the  mouth. 


170  SURGERY. 

He  has  hitherto  only  used  this  method  in  cases  of 
perforative  appendicitis,  and  here  the  performance  of  the 
Injection  is  very  simple.  The  nozzle  of  a  small  syringe — 
the  hydrocele-injecting  syringe  is  a  convenient  form — is 
introduced  into  the  ''stump"  of  the  appendix  and  the  solu- 
tion directly  thrown  into  the  cecum.  Three  drachms  of 
magnesium  sulphate,  with  ten  drops  of  tincture  nux 
vomica,  and  a  drachm  of  glycerin  in  an  ounce  of  water 
is  the  formula  generally  employed.  Two  hours  after- 
wards a  turpentine  enema  is  given,  and  the  result  has 
been  excellent.  He  has  employed  this  method  in  five  bad 
cases  of  septic  peritonitis  associated  with  perforative  ap- 
pendicitis. In  every  case  the  results  were  surprising. 
And  though  the  number  is  too  small  for  a  pronouncement 
as  to  establishing  intra-cecal  purgatives  as  a  definite  line 
of  treatment,  yet  the  cases  are  sufficiently  striking  to 
justify  him  in  urging  a  trial  of  it.  It  is  obvious  that  in 
other  cases  the  solution  could  be  easily  and  safely  thrown 
into  the  colon  by  means  of  a  hypodermic  syringe  obliquely 
introduced.  Further  evidence  may  elicit  better  purga- 
tives than  magnesia. — Brit.  Med.  Jour. 

THE  SURGICAL  TREATMENT  OF  ASCITES  DUE  TO 
CIRRHOSIS  OF  THE  LIVER. 

G.  E.  Brewer,  New  York,  has  collected  from  the 
literature  60  cases  thus  treated.  The  operation  in  most 
cases  was  that  recommended  by  Morison,  as  follows: 
Under  general  anaesthesia  open  the  abdomen  and  evacu- 
ate the  fluid,  then  rub  the  upper  peritoneal  surface  of  the 
liver  and  the  under  surface  of  the  diaphragm  with  gauze 
sponges  until  raw,  freely-bleeding  surfaces  are  produced. 
The  same  procedure  should  be  carried  out  on  the  outer 
surface  of  the  spleen  and  its  adjacent  peritoneal  surface- 
Finally,  stitch  the  great  omentum  to  a  freshened  peri- 
t(meal  surface  on  the  anterior  abdominal  wall.  A  glass 
drain  should  be  introduced  to  the  lower  part  of  the  pelvis 
through  a  separate  supra-pubic  wound.  The  upper  wound 
should  then  be  closed  and  dressings  applied.  The  fluid 
which  collects  in  the  pelvis  should  be  frequently  pumped 
out  through  the  glass  drainage  tube  for  a  week  or  ten 
days  until  the  daily  secretion  is  markedly  diminished. 
The  tube  may  then  be  removed  and  the  wound  allowed  to 
heal.  In  reviewing  the  statistics  furnished  by  this  table, 
it  will  be  seen  that  at  least  six  cases  have  been  cured  of 
ascites  by  this  procedure  and  have  remained  well  for  a 
period  of  two  vears  or  more;  six  others  have  been  relieved 
of  this  symptom  for  from  two   to   six    months,  but   have 


SURGERY.  171 

died,  either  without  a  return  of  the  ascites,  or  have  not 
been  under  observation  long  enough  to  demonstrate  that 
the  cure  is  permanent.  Another  case,  that  of  a  patient 
suffering  from  hemorrhages  from  the  alimentary  canal, 
was  promptly  cured  by  this  operation,  and  a  number  of 
others  have  been  materially  improved-  Thirty-eight  have 
recovered  from  the  operation,  and,  when  we  consider  that 
in  the  great  majority  of  instances  these  patients  were  in 
the  last  stages  of  an  incurable  disease,  and  if  we  are  to 
accept  the  statements  of  White  and  Thompson,  within  a 
few  weeks  of  an  inevitable  death,  this  fact  should,  the 
writer  believes,  encourage  our  medical  friends  to  suggest 
the  operation  at  an  earlier  and  more  favourable  stage  of 
the  disease.  If  this  is  done  the  writer  believed  that  later 
statistics  will  show  a  substantial  improvement  over  those 
able  at  this  time  to  present.— 3/erf.  News,  St.  Louis  Med 
Revietv. 

PERMANEKCY   OF   CURE   IN   OPERATIONS  FOR  HERNIA. 

The  question  of  mortality  in  the  radical  treatment  of 
hernia  has  been  disposed  of  by  the  brilliant  statistics  of 
Coley,  Bull,  and  others.  Permanency  of  the  cure  after 
operation  depends  upon  a  small  number  of  simple  featuresi. 
These  are: 

The  wound  must  heal  primarily.  There  must  be  im- 
mediate union  without  suppuration  scars,  and  the  l&ast 
possible  amount  of  cicatrical  tissue. 

The  stitches  should  not  be  drawn  tightly.  This 
avoids  pressure  necrosis,  which  is  liable  to  occur  from  the 
edema  following  an  operation.  It  is  possible  that  there 
is  always  a  certain  amount  of  pressure  necrosisi  whenever 
a  suture  is  used,  but  it  is  reduced  to  the  smallest  propor- 
tions by  drawing  the  stitches  just  tight  enough  to  place 
the  tissues  in  apposition  without  causing  pressure.  A 
small  amount  of  necrotic  tissue  will  furnish  a  good  cul- 
ture medium  and  thus  prevent  primary  union. 

The  edges  of  the  surface  to  be  united  must  be  free 
from  fat  and  other  unstable  tissues.  No  matter  how 
perfect  a  union  may  be.  if  the  attachment  is  to  a  tissue 
which  has  little  resistance,  the  union  is  of  no  value.  It 
is  necessary  to  carefully  dissect  away  the  soft  muscular 
or  connective  tissue,  as  well  as  masses  of  fat.  For  the 
same  reason,  blood-clots  must  not  be  allowed  to  interpose 
between  the  surfaces  to  be  united. 

The  tissues  should  be  manipulated  with  the  greates.t 
care  during  operation.  The  utmost  care  must  be  exer- 
cised to  avoid  rough  handling.  The  less  the  tissues  are 
disturbed,  the  better  the  primary  union. 


1/2  SURGERY. 

The  wound  should  be  supported  by  broad  rubber  ad- 
hesive plaster  strips.  This  secures  as  perfect  rest  as  is 
possible  for  the  tissues,  and  favours  a  minimum  of  cicatri- 
cal tissue. 

The  patient  should  be  kept  in  bed  for  two  or  three 
weeks.  On  this  point  there  is  a  wide  difference  of  opinion, 
but  it  seems  reasonable  to  suppose  that  if  an  opportunity 
is  given  for  the  wound  to  become  firm,  there  will  be  less 
likelihood  of  its  giving  way. 

Abnormal  intra-abdominal  pressure  should  be  elimin- 
ated. Constipation,  strictures  of  the  urethra,  and  enlarge- 
ment of  the  prostate,  as  well  as  obesity,  all  favour 
increased  abdominal  pressure  and  should  be  eliminated 
by  appropriate  treatment. — A.  J.  Ochsner,  in  Am.  Med. 

NATURAIi   METHOD    OF   DRAINING   THE   PEBITONEIAI. 

CAVITY. 

In  1896  the  writer  suggested  and  began  using  the 
postural  method  of  draining  the  peritoneal  cavity.  This 
consisted  of  introducing  a  liter  of  salt  solution  at  the 
completion  of  an  abdominal  operation,  and  then  elevating 
the  foot  of  the  bed  for  twenty-four  hours.  It  is  no  longer 
thought  necessary  to  elevate  the  feet,  as  absorption  seems 
to  be  quite  as  rapid  in  the  prone  position.  Aside  from 
drainage,  the  introduction  of  normal  salt  solution  into  the 
abdominal  cavity  favours  the  movements  of  the  intestines^ 
and  by  being  floated  upward  they  are  assisted  in  regaining 
their  normal  position.  Since  using  peritoneal  infusions, 
the  writer  has  had  no  case  of  post-operative  obstruction, 
The  routine  use  of  normal  saline  solution  in  the  peritoneal 
cavity  is  free  from  danger,  and  is  of  great  value  in  prevent- 
ing general  or  local  peritonitis.  It  prevents  shock  fpom. 
loss  of  blood,  and  is  one  of  the  best  general  stimulants. 
Frequently  when  the  pulse  is  160  and  weak,  at  the  close  of 
an  operation,  it  will  be  found  that  within  a  few  hours 
afterward  the  pulse  has  fallen  to  120  and  has  become  full 
and  regular.  Another  marked  advantage  is  the  preven- 
tion of  thirst  and  the  stimulation  of  the  urinary  excretion. 
The  effect  upon  the  kidneys  is  the  same,  whether  the  in- 
fusion is  made  directly  into  the  abdomen  or  a  high  saline 
enema  is  given.  The  average  increase  in  the  excretion 
of  the  kidneys  in  twenty-four  hours,  in  those  who  receive 
salt  solution,  amounts  to  about  150  cubic  centimeters. 
This  dilution  of  the  urinary  excretion  lessens  vesical  irrita- 
tion, and  catheterization  after  operation  is  much  less  fre- 
quently needed.  The  increased  elimination  tends  toward 
the  lessening  of    infection.     The    researches    of    Flexner 


SURGERY.  173 

have  shown  that  patients  with  moderate  impairment  of 
kidney  function  succumb  to  infections  that  are  well  borne 
by  others  who  have  a  normal  power  of  elimination.  After 
saline  infusions,  patients  may  complain  of  distress  over 
the  diaphragm.  This  is  obviated  by  the  application  of  a 
two-inch  strip  of  adhesive  plaster  around  the  base  of  the 
chest.  This  pain  is  attributed  to  an  increase  in  the 
functional  activity  of  the  absorbing  areas  of  the  dia- 
phragm; in  no  instance  could  it  be  attributed  to  periton- 
itis or  pleurisy. — John  G.  Clarke,  in  Univ.  of  Penn.  Med. 
Bulletin.  -^  ^ 

SUPPURATING  WOUNDS. 

The  use  of  compresses  of  sodium  bicarbonate  in  the 
treatment  of  suppurating  wounds  is  again  brought  forward 
by  Neic  York  Medical  Journal,  August  31.  It  is  claimed 
that  (especially  in  burns)  these  compresses  rapidly  arrest 
suppuration  and  promote  cicatrization  even  in  cases  re- 
bellious to  all  other  treatment.  Moreover,  the  dressing 
gives  excellent  results  in  wounds  which  heal  rapidly  with- 
out suppuration,  by  causing  the  resulting  scar  to  be  almost 
inappreciable.  In  abscesses  the  results  are  equally  satis- 
factor3^  Compresses  may  be  applied  as  moist  dressings, 
either  renewed  every  day,  or  by  moistening  in  situ  twice  or 
thrice  daily,  or  again  by  placing  between  the  compress 
and  the  outer  covering  a  compress  covered  with  boric 
vaseline  to  prevent  evaporation;  in  this  last  case,  the 
dressing  may  be  left  in  place  for  two  days.  The  principal 
advantages  of  this  dressing  are  its  absolute  inocuousness 
and  its  analgesic  and  antiseptic  action,  which  render  it 
invaluable  in  practice  with  children. — American  Journal  of 
Surgery  and  Gynaecology. 

STIFTENED  JOINTS. 

In  two  cases  of  stiffened  joints  where  the  inability  to 
move  the  limb  has  appeared  to  arise  from  rigidity  of  the 
tendons  and  muscular  sheaths,  I  have  injected,  subcutane- 
ously,  olive  oil  into  the  structures,  and  with  some  success. 
I  find  that  a  fluid  drachm  of  the  oil  can  be  injected  around 
the  knee-joint  without  causing  any  after  inflammation  or 
discomfort.  In  one  instance,  where  the  elbow  was  oper- 
ated on  in  this  way,  the  young  woman  obtained,  for  the 
first  time,  some  degree  of  movement  after  six  months' 
entire  fixation  from  rigidity. — Ward,  in  the  Asclepiad. 

(Sweet  almond  oil  is  preferable  to  olive  oil,  as  the 
latter  is  seldom  had  in  a  pure  state  in  this  country. — Ed. 
Detroit  Medical  Journal. 


Therapeutic  Notes. 


Basham's  Mixture. 

An  old,  time-tried  tonic  in  urinary  afifections,  particu- 
larly in  degenerative  conditions  of  the  kidneys,  is  "Basham's 
Mixture."  The  virtues  of  this  preparation  were  extolled  in 
lecture  rooms  quite  half  a  century  ago,  and  same  is  said  to- 
day. In  its  particular  field  of  usefulness  it  has  well  stood  the 
test'of  time.    Its  composition  is  : — 

^  Tr.  ferri  chlor f.  Siij 

Acid  acet.  dil f.  ^iss 

Syr.  simp f  ^ss 

Liq.  ammon.  acetat.,  q.  s.  ad f.  giv 

M.   Sig.: — One     dessertspoonful   every  two  hours, — 
Clinieal  Review. 

Chilblains. 

I^  Liquoris  plumbi  subacetatis. 
Tinct,  opii,  of  each,    i   ounce. 
Aq.  dest.,  q.  s.  ad  16  ounces. 
M.  Sig.:  Keep  applied  freely  on  well-moistened   soft 
cloth. 

Dr.  J.  H.  Vadikin  recommends  for  chilblains  a  stupe 
consisting  of  one  teaspoonful  of  acetate  of  zinc  to  a  bowl  of 
hot  water.  He  has  tried  it  very  successfully. — New  York 
Medical  Journal. 

Nutrient  Enemata. 

In   many  instances  a  nutrient  enema  composed   only  of 
whiskey  and  peptonized  milk  will  not    be  retained  by  the 
patient.       A    better  combination,    and  one  which  will  give 
more  satisfactory  results,    is  the  following  : — 
B   Beef  peptonoids,  2  drachms. 
Yelk  of  egg,  No.  i. 
Whiskey,  ^  ounce. 
Tinct,  opii,  5 'to  10  minims. 
Salt,  q.  s. 

Peptonized  milk,    q.  s.    ad    6    ounces.  —  Medical 
Fortnightly 


jottings.  175 

Pruritus  Ani. 
The    following    gives    great    service    in    relieving    the 
troublesome  itching  : — 

^  Alumnol,  30  grains. 

Pulv.  camphore,  15^  drachms. 
Lanolini,  q.s.  ad  i  ounce. 
M.  Sig.: — Apply     locally     night     and     morning. — 
Journal  of  the  American  Medical  Associatiofi. 

HEMOPTYSIS. 
B  Acidi  gallici,  2  drachms. 

Acidi  sulph.  aromat.,  i   drachm. 
•  Glycerini,    i   ounce. 
Aq.  destillatae,  q.s.  ad  6  ounces. '5^^'^* 
M.  Sig.: — Teaspoonful  at  dose  ;    repeat  frequently. — 
Pepper. 

To  Prevent  Bed-Sores. 
^  Alumin., 

Sodii  chloridi,  of  each,  yi  ounce. 
Aquae, 

Alcoholis,  of  each,  i  pint. 
M.  Sig.: — Use  twice  a  day   locally. — Forbes   [Mary- 
land Medical  Journal). 

Calomel  in  Hemorrhoids. 

This  drug  is  not  only  curative,  but  also  prevents  the 
phlebitis  which  causes  so  much  pain.  For  external  haemor- 
rhoids give  laxatives,  and  powder  with  calomel  ;  for  in- 
ternal haemorrhoids  use  calomel  suppositories  or  an  oint- 
ment of 

R  Calomel,  30  grains. 
Vaselin, 

Lanolin,  of  each,  ^  ounce. 
Add  belladona  or  opium  if  desired.       Wash  anus  with 
boric-acid  water  after  each  defecation. —  Journal  de  Medecine 
de  Bordeaux, 


Jottings, 

Tincture  of  iodine  locally  will  abort  a  sore  throat. 

Codeine  is  the  only  opiate  that  should  be  given  children. 

To   remove  cerumen  apply  ether  to  the  meatus^with 
a  pipet. 


176  JOTTINGS. 

A  good  topical  application  in  ivy  poisoning  is  chloral 
hydrate. 

In  marked  chlorosis  give  clysters  twice  daily  of  defi- 
brinated  blood. 

For  angina  pectoris  give  ^  to  ^  gtt.  of  tr.  of  lobelia 
every  two  hours, 

Quassin  is  by  all  odds  one  of  our  best  tonics  combined 
with  strychnine,  it's  the  best. 

For  ringworm,  wash  and  apply  pyrogallic  acid  fifteen 
grains  in  collodion,  one  ounce. 

When  a  urinary  antiseptic  is  needed  try  lithium  benzoate. 
It  is  eliminated  through  the  kidneys,  increases  the  flow  of 
urine  and  sedates  the  urinary  tract. 

Always  be  on  the  lookout  for  "  walking  typhoid."  If 
a  man  comes  to  you  "  feeling  sick  "  be  sure  and  take  the 
temperature  and  inspect  the  tongue  and  abdomen. 

•I 
INFANTILE  COLIC. 

A  towel  dipped  in  boiling  water,  wrung  out  rapidly, 
folded  to  proper  size,  and  applied  to  the  abdomen  with  a 
dry  flannel  over  the  hot  towel,  acts  like  magic  in  infantile 
colic.  ' 

OBTHOFORM  IN  TOOTHACHE. 

Hildebrand,  in  Therapeutische  Monatsschrift,  states 
that  orthoform  instantly  and  completely  relieves  severe 
pain  due  to  inflammation  of  the  pulp  in  decayed  teeth.  It 
should  be  applied  in  alcoholic  solution  on  absorbent  cotton. 
— Journal  of  the  American  Medical  Association. 

WRITERS'  CRAMP. 

Several  sufferers  from  writers'  cramp  are  reported  to 
have  obtained  great  relief  by  becoming  enthusiastic 
golfers.  This  game  requires  the  use  of  the  upper  ex- 
tremities just  to  the  degree  adapted  to  people  who  have 
lived  a  sedentary  life.  The  movements  are  necessarily  co- 
ordinate, and  they  are  combined  wdth  proper  exercise  of 
the  lower  extremities,  and  a  large  amount  of  time  is  passed 
in  the  open  air. 

HOT  MILK. 

Hot  milk  is  a  most  nutritious  beverage — a  real  luxury,  the 
value  of  which  but  few  people  know.    Many  who  have  abund- 


JOTTINGS  177 

ance  of  milk  never  think  of  using  it  as  a  drink — or  rather 
as  an  eatable — for  we  should  eat  milk  instead  of  drinking 
it,  that  is,  take  it  in  small  sips.  Why  ?  Because  the 
casein  of  milk  when  it  comes  in  contact  with  the  acid  of  the 
gastric  fluid,  coagulates  and  forms  curd,  and  if  swallowed  in 
large  quantities  at  once,  a  large  curd  is  formed,  which  the 
stomach  handles  with  difficulty.  The  gastric  fluid  can  mingle 
much  more  readily  with  the  small  curds  that  result  from 
sipping  the  milk. 

TETRANITROL. 

Huchard  has  used  tetranitrol  as  a  vasodilator  in  one 
hundred  and  twenty  patients,  and  has  found  it  free  from 
the  unpleasant  effects  of  nitroglycerin,  headache,  throb- 
bing of  temporals,  etc.  He  also  holds  that  it  does  not 
affect  the  haemoglobin  like  other  nitrates.  It  has  the 
great  advantage  of  mild  prolonged  action.  Its  action  is 
manifest  in  from  fifteen  minutes  to  three-quarters  of  an 
hour,  and  if  continued  in  from  1  to  2-grain  doses,  four  or 
live  times  a  day,  it  keeps  the  vessels  in  a  state  of  reduced 
tension-  It  is  indicated  when  there  is  increased  arterial 
tension,  as  in  arteriosclerosis,  in  coronar}'  angina,  in  dilita- 
tion  of  the  heart  from  peripheral  vascular  constriction,  in 
uric-acid  dyscrasia,  in  tabetic  crisis  and  in  interstitial 
neT)hritis. 

LOCOMOTOR  ATAXIA. 

Dr.  S.  Leduc,  Professor  of  Medicine  in  the  School  of 
Medicine  at  Nantes  (Gazette  Medicale  de  Nantes),  basing 
his  practice  on  the  theory  that  the  syphilitic  origin  of 
locomotor  ataxia  is  scarcely  contested  to-day,  for  a  past 
history  of  syphilis  is  found  in  nearly  all  ataxics,  has  in- 
jected daily  into  the  muscles  of  the  patient's  thigh  2  gram- 
mes— rabout  30  minims — of  the  following  solution: — 

R    Corrosive  sublimate, 

Recrystallized  sod.  chlor,,  of  each,  3  grains. 
Aq.  dest.,  300  minims. 

M. — It  is  said  that  amelioration  was  at  once  manifest. 
Treatment  was  continued  for  periods  of  three  weeks, 
followed  by  remissions  of  fifteen  days.  Six  years  from  the 
commencement  of  the  treatment  the  patient  has  lost  the 
knee-jerk,  and,  although  some  lightning  pains  persist,  he 
walks  well,  even  at  night,  and  leads  a  very  active  life. — 
Neic  York  Medical  Journal. 


178 


SOUVENIR  DE  JEUNE  AGE." 


(A  reminisence  of  the  Nurses  Ball  of  the  Graduating  Cla'se  of  1892, 

Montreal  General  Hospital,  held  in  the  Victoria  Armoury  Hall, 

Cathcart  Street). 

T  slept ;  and  as  I  slept  I  dreamed — a  curious  dream  to  nie  it  seemed, 

— (A   scene  from  long-ago  redeemed),  a  spaceous   hall,  where  in  there 

gleamed 
Faces  bright  which  fairly  beamed  with  joy  and  gladness  ;  nor  yet  deemed 
It  wrong,  that  from  their  labours  weaned,  with  light  fantastic  toe  careened 
With  ardent  youth  ;  or  on  them  leaned 

with  tender  glances. 

While  sparkling  eye  and  rosy  cheek,  and  heaving  bosom  all  bespeak 
The  pleasure  they  enjoy  who  seek  the  sensuous  waltz's  measure  sweet 
With  a  congenial  partner — neat,  yet  manly  ;  one  whose  feet 
Scarce  touch  the  floor,  they  are  so  fleet ;  one  who  is  told,   and  withal  1 

meek, 
A  strong  protector  of  the  weak — 

Such  fair  maid  fancies. 


But  while  I  stood  and  pondered  there,  on  scene  so  brilliant,  face  so  fair, 
On  flasLing  teeth  and  wondrous  hair,  I  suddenly  became  aware 
That  I  was  not  alone,  for  there,  beside  me  where  I  stood,  the  air 
Was  redolent  with  perfume  rare. 

Faint  yet  so  sweet 

A  lovely  voice,  surpassing  kind  (like  sighings  of  the  summer  wind. 
Such  voices  may  true  lovers  find,  as  walking  with  their  arms  entwined 
Their  oft  repeated  vows  they  bind—)  '•  Tell  me  "  it  said  "  what  do  you  find 
"In  me  so  strange  you  seem  inclined  to  be  afraid,  are  you  so  blind  ? 
"  You  cannot  see  the  mask  behind  ?  "  I  gave  my  card — ,  as  I  opened 
In  the  blank  space  was  "  Memory  "  signed. 

faithful  but  fleet! 

Then  she  told  in  accents  clear 
How  it  came  that  I  was  here. 


**Thi8  is  the  room  in  the  Armoury  Hall,  where  the  nurses  (bless  'em  one 

and  all) 
**  From  the  General  Hospital,  Montreal,  thought  they'd  like  to  give  a  ball. 
"  (For  eight  of   them  graduate  this  fall).     So  what  did  they  do  but  a 

meeting  call, 
**  At  which  those  nurses  short  and  tall,  decided  they  should  have  a  ball 
"But  alack!  alas!!  the  question  rose  "What  would  Miss  L.  say  d'you 

suppose?" 
"  When  of  our  little  plot  she  knows?  "    "She  seldom  opposition  shews, 
"  Or  counter  to  our  wishes  goes  "  says  one,  whose  face  is  like  a  rose 
With  smiles  alike  for  friends  and  foes — "  I'll  tell  you,  girls,  what  /propose 
*'  Let's  all  draw  lots  to  see  who  goes  to  tell  that  Miss  (of  portly  pose)." 
Then  there  was  excitement  great,  among  that  class  of  nurses  eight 
To  see  on  whose  unlucky  pate  should  fall  the  heavy  hand  of  fate — 
The  papers  torn  in  pieces  straight,  each  took  one  with  a  heart  elate 
Hopng  that  she  at  anyrate,  woulda't  have  to  face  that  maid  sedate, 
Fearing  that  what  she'd  to  relate,  might  make  her  just  a  bit  irate. 


179 

The  ballot  o'er,  she  with  brown  eyes,  declares,  amid  profoun  lent  sighs  I 

"  That  she  alas  !  ha-s  got  the  prize,"  so  straiglitwav  down  the  p^issage  hies- 

In  the  direction  where  there  lies  the  room  which  Miss  L.  occupies — 

The  Matron  listens  with  surprise,  while  nurse  lays  forth  in  tempting  guise 

(In  words  which  we  can  but  surmise)  the  object  of  her  enterprise. 

The  audience  o'er,  her  panction  got,  \n  that  same  meeting  were  a  lot 

Who  (and,  I  think,  quite  rigiitiy)  thought,  a  private  house  too  small  and 

hot 
To  have  a  dance  in, — that  they  ought    to  have  some  place  more  fitting 

sought. 
Says  one  (whose  name  I  have  forgot)  "  The  Armoury  Hall  is  just  the  spot." 
Th'  idea  was  new,  and  so  it  caught,  the  fancy  of  the  girls — they  wrought 
And  baked  and  worked  and  ice-cream  bought,  called  flags  and  flowers  to 

their  support, 
Until  they  very  air  was  frought 

with  an  atmosphere  of  myst'ry. 

At  length  th'  eventful  night  came  round ;  their  guests  made  welcome  to 

the  sound 
Of  sweet  enchanting  music  (found  where' ere  there's  beauty,  I'll  be  bound 
And    dainiy  feet  to  trip  the  ground).     Their  words  of   welcome  almost 

drowned 
In  the  general  buz  of  talk  around. 

Repeated  now  in  History. 


But  while  I  watched  this  fairy  dell,  methought  I  heard  a  tinkling  bell 
Which  somehow  seemed  to  break  the  spell — the  Voice    beside  me  cried 

"  farewell  " 
And   vanished — where  I  cannot  tell,  while  the  tinkle-TiNKLE    seemed  to 

swell. 
Till  it  seemed  to  sound  the  very  knell  of  earthly  things,  and  with  a  yell !  : 

I  woke;  and  thought  I  was  in well, 

A  place  whence  folk  can't  hurry  ! 

— Envoi — 

"  'Twas  nothing  but  an  aching  tooth  which  some  poor  fellow  had,  forsooth 

and  wanted  me  to  quarry  I 
But  it  brought  me  back  from  scenes  of  youth: — I'm  telling  you  the  honest 
truth 

ruage  be  uncouth. 

Hang  it !  I  waf?  sorry  !  ! 

— R.  W., 

'93- 


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A  NE^V  GENERAI/  ANAESTHETIC, 

The  Dublin  Medical  Press,  of  December  11,  1901,  says: 
^'Tliere  are  a  number  of  minor  operations  in  surgery 
that  occupy  from  five  to  twenty  minutes,  a  period  of  time 
too  long  for  completion  under  the  anaesthesia  of  nitrous 
oxide  gas.  To  meet  this  difficulty  the  admixture  of 
oxygen  and  nitrous  oxide  has  been  tried,  but  the  com- 
pound has  not  met  with  general  favour,  and  its  use  has 
never  been  very  general.  Cocainisation  of  the  c'prd  in  the 
hands  of  some  French  surgeons  has  given  good  results, 
but  in  quite  a  number  of  cases  the  results  have  been  dis- 
astrous. Schleich's  infiltration  method  has  gradually 
lost  ground,  if,  indeed,  it  could  ever  be  said  to  have  been 
in  favour  in  this  country.  For  a  time  the  freezing 
methods  by  evaporation  of  ether  and  chloride  of  ethyl 
were  tried,  but  at  best,  they  were  only  suited  for  a  very 
limited  group  of  cases.  It  is,  therefore,  with  pleasure 
that  we  note  the  good  results  that  are  being  obtained  by 
the  use  of  pure  chloride  oi  ethyl  as  a  general  anaesthetic. 
At  the  recent  Congress  of  Surgery,  M.  Malherbe,  who  has 
been  using  the  anaesthetic  since  1898,  when  he  first  used 
it  in  the  clinic  of  Professor  von  Hacker,  speaks  highly   of 


EDITORIAL  l8l 

its  properties  as  an  anaesthetic  and  its  comparative 
freedom  from  toxic  or  other  undesirable  after  effects. 
We  concede  that  the  chorus  of  praise  which  ushers  in  new 
remedies,  should  be  largely  discounted  without  there  are 
good  grounds  for  anticipating  that  the  drug  will  prove  a 
satisfactory  and  safe  general  anaesthetic  for  minor  opera- 
tions generally.  We  will  do  no  more  than  draw  attention 
to  the  fact  that  it  belongs  to  the  ethyl  group,  and  that  its 
percentage  of  chlorine  is  small.  All  the  volatile  ethyl 
compounds  have  anaesthetic  properties,  and,  a«  a  rule,  are 
not  lethal;  indeed,  the  oxide  of  the  radical  principally 
produces  its  injurious  effects  by  producing  inflammation 
of  one  or  more  of  the  tissues  than  by  direct  action  as  an 
anaesthetic.  One  of  the  great  troubles  of  the  use  of  the 
oxide  is  its  irritating  suffocative  effect  on  the  respiratory 
mucous  membrane  which  the  antecedent  use  of  nitrous 
oxide  or  chloroform  does  not  wholly  overcome.  The 
chloride  of  ethyl,  "if  we  are  to  judge  from  the  clinical  re- 
ports, has  no  irritant  action  on  the  respiratory  tract,  and 
it  has  the  further  advantage  of  acting  very  quickly,  and* 
is  not  followed  by  the  headache,  vomiting,  bronchial 
irritation,  and  renal  pains  which  so  often  follow  etheriza- 
tion. The  patient  quickly  recovers  from  the  anaesthetic 
effects  of  the  vapour,  and  the  return  to  consciousness  is 
complete.  M.  Malherbe  (Le  Progres  Medical)  employed  the 
anaesthetic  170  times  without  one  unpleasant  result,  and 
in  each  case,  found  the  effects  of  the  chemical  were  uni- 
form. We  cannot,  however,  judge  from  the  experience 
of  one  surgeon  in  so  small  a  number  of  cases,  but  we 
think  a  good  case  is  made  out  for  its  tentative  use. 


SOME  REMINISCENCES  OF  SYME. 

Dr.  Donald  Maclean,  Professor  of  Surgery  at  Ann 
Arbor  University,  Michigan,  and  an  Ex-President  of  the 
American  Medical  Association,  has  published  some  inter- 
esting personal  reminiscences  of  Syme,  the  celebrated 
Scotch  surgeon,  whose  pupil  he  was  at  Edinburgh,  forty 
vears  ago.  Although  no  man  could  possibly  be  more  ab- 
steminons  in  his  habits  than  Syme,   all   through   his   life,. 


102  .  EDITOKIAL 

nevertheless  he  seems  to  have  had   a   distinct   feeling   of 
dislike  for  teetotallers.     Professor  Maclean  recalls  how  a 
boy  of  not  more  than  twelve  years  of  age  presented  him- 
self, suffering  from  a  peculiarly  loathsome  disease-     Syme, 
with  an  expression   of   disgust   on    his   face,    said   to    the 
youthful  sinner:     "Are  you  a  teetotaller?"  and  when  the 
boy  replied  "Oh  yes,  sir,"  Syme  quietly  said,  with  an  ex- 
pressive twinkle  in  his  eye:  "I  thought  so."     Coming  once 
upon  Dr.  Maclean  while  sitting  on    the   doorstep    of   the 
Royal   Infirmary  playing  with  a   skye  terrier  pup  which 
had  been    given    him    by    a   grateful    patient,  Syme   said, 
with  an  air  of  mock  severity,  "Permit  me  to  inform  you 
that  there  are  just  three  steps  to  ruin  for   a  young   man: 
first,  a   dog,  second,  a  pipe,   and   third,    a  woman."     Dr. 
Maclean  recalls  one  of  the  boldest  operations  which  even 
Syme  ever  performed.     A  shipwrecked  sailor,  in  making  a 
desperate  leap  for    his    life,  ruptured    the    common    iliac 
artry  close  to  its    bifurcation,    with    the    result    that    an 
enormous  aneurysm  developed.     Syme  determined  to  oper- 
ate, and  asked  I'rofessor  (now  Lord)  Lister  to.  be  present. 
The  latter  brought  with  him  an  instrument,  now  known 
as  Lister's  aortic  compressor,  which  he    had    de^^sed  ex- 
pressly for  the  case.     Syme,  who  was  naturally  of  a  con- 
servative disposition,  was  not  particularly  impressed  by 
the  instrument  when  shown    to    him.     He    proceeded    to 
operate,  and    when    he    laid    open    the    aneurysm,  terrific 
haemorrhage  took  place,  which,  but    for    Lister's   instru- 
ment, would,  undoubtedly,  have  proved  fatal.     As  it  was, 
the  aorta  was  controlled,  and  Syme  was    able   to   tie   the 
common  internal,  and  external  iliac  arteries,  and  to  save 
the  patient's  life.     Syme  was  one  of  the  pioneers   in    the 
operative  treatment  of  cancer  of  the  tongue  by  entire  re- 
moval of  the  organ.     His  earliest  cases  were  unsuccessful, 
and,  consequently,  he  was  somewhat  severely  criticized  in 
certain  quarters.     L^ndeterred    by    this,    however,  at    the 
meeting  of  the  British  Medical  Association  at  Edinburgh 
in  1858,  he  performed  the  operation  once   more   before    a 
large  number  of  distinguished  surgeons  from  all  parts   of 
the  kingdom.     After  the  patient  had  been  removed  to  his 
bed,  the  audience    loudly    applauded    the    operator.     Dr. 


EDITORIAL.  183 

Maclean  continues:  "The  professor  calmly  turned  round 
as  he  was  drying  his  hands  and  pointed  to  a  notice  on  the 
wall  requesting  order  and  silence  in  the  amphitheatre. 
This  facetious  act  elicited  a  fresh  burst  of  applause. 
He  then  stepped  forward  with  the  evident  intention  of 
saying  something,  and  instantaneously  every  sound 
ceased,  every  breath  was  held,  every  ear  was  eager  to 
catch  the  slightest  sound  which  dropped  from  his  lips. 
Rumour  has  it  that  the  following  was  what  they  heard: 
"Gentlemen,  permit  me  to  assure  you  that  I  have  reached 
an  age  an  d  a  position  in  the  profession  at  which  I  care 
neither  for  censure  nor  commendation,"  and  he  bowed 
politely  and  walked  out  of  the  amphitheatre.  The  last 
time  Dr.  Maclean  saw  Syme  was  in  1872,  shortly  after  the 
great  surgeon  had  had  an  attack  of  apoplexy.  When  he 
had  shaken  hands  for  the  last  time,  Syme  seized  the  collar 
of  his  coat,  and  with  a  quick,  nervous  movement,  turned 
him  rapidly  round  so  that  he  could  look  into  his  face  and 
said,  "Be  sure  and  keep  your  eye  on  Lister  and  his  anti- 
septic investigations.  I  feel  sure  that  there  is  something 
in  them.  And  remember,  sir,  look  forwards,  do  not  look 
backwards*"  Prophetic  words!  But  even  Syme  could 
hardly  have  foreseen  how  much  there  was  in  these  in- 
vestigations of  his  distinguished  son-in-law. 


THE  STRANGE  ADVENTURES  OF  AN  ANATOMIST'S 

HEAD. 

Xavier  Bichat  passed  a  considerable  part  of  his  short 
life  in  the  dead-house,  but  his  own  mortal  remains  appear 
to  have  had  a  more  singular  fate  than  usually  befalls  the 
fragments  of  humanity  in  which  he  sought  so  eagerly  to 
discover  the  secret  of  life.  Writing  recently  in  the  Temps, 
M.  G.  Claretie  says  it  is  well  known  that  when  Cuvier  was 
put  into  his  coflfin  an  iron  cage  was  placed  over  his  head  so 
that  it  might  not  be  stolen  as  Bichat's  had  been.  A  writer 
in  the  Chronique  Medicale,  commenting  on  this  statement, 
says  that  in  1808  there  came  in  ?.  curious  fashion  of  doing 
honour  to  "  masters  of  medicine  "  by  keeping  their  heads 


184  EDITORIAL. 

in  the  condition  of  anatomical  preparations  for  40  years. 
Bichat  was  buried  in  the  St.  Catherine  Cemetery,  in  a  small 
corner  bought  by  one  of  his  colleagues  at  the  Hotel  Dieu, 
and  might  never  have  been  found  if  the  pious  care  of  friends 
had  not  from  time  to  time  renewed  the  marks  by  which  the 
grave  was  identified.  The  cemetery  having  been  closed, 
Bichat's  remains  were  removed  to  Pere  Lachaise.  On 
November  16,  1845,  the  body  was  exhumed  under  the 
direction  of  Dr.  Denonvilliers,  and  in  the  presence  of  four 
members  of  Bichat's  family,  one  of  whom  was  Dr.  Adet  de 
Roseville,  assistant  physician  of  Saint  Lazare,  husband 
of  Bichat's  niece.  The  report  of  the  exhumation  states 
that,  under  a  gravestone  bearing  the  inscription  "  A  Xavier 
Bichat,  par  les  Membres  de  la  Societe  d'Instruction 
Medicale,"  there  was  discovered,  at  a  depth  of  i  m.  70  cm., 
in  a  soil  of  remarkable  dryness,  an  excellently-preserved 
skeleton.  The  cervical  vertebrae  were  perfect,  but  the  head 
was  missing.  Further  digging  failed  to  bring  the  head  to 
light.  Professor  Roux,  who  was  present,  came  forward  and 
stated  that  the  head  of  Bichat  had  "  come  into  his  hands  " 
three  years  after  the  death  of  the  great  anatomist.  He 
described  the  head,  calling  attention  to  the  following  points  : 
(l)  The  existence  of  a  fracture  of  the  occipital  bone,  which 
he  himself  had  made  at  the  post-mortem  examination  ;  {2) 
the  obliteration  of  the  alveoli  of  the  first  upper  molar  of  the 
left  side  and  of  the  corresponding  one  on  the  right,  which 
Bichat  had  had  extracted  towards  the  end  of  his  life,  after 
having  suffered  much  from  those  teeth,  as  he  says  himself 
in  his  article  on  the  teeth  in  his  Anatomic  General  \  (3)  the 
perfect  correspondence  of  the  articular  surfaces  of  the  atlas 
found  in  the  grave  with  those  on  the  skull.  M.  Malgaigne 
had  previously  arranged  in  an  oak  coffin  all  the  bones  as 
they  were  taken  up,  and  M.  Roux  completed  them  by 
restoring  with  his  own  hands  the  skull  which  had  been  so 
long  separated  from  the  skeleton.  It  may  be  mentioned 
that  the  ceremony  of  the  translation  of  the  relics  to  Pere 
Lachaise  was  attended  by  some  4,000  members  of  the 
medical  profession. 


EDITORAL.  185 

PRESIDENT   McKINLEY'S   CASE. 

The  Cleveland  Medical  Journal  makes  the  following 
remarks  in  a  recent  issue.  We  commend  them  to  our 
readers,  especially  those  resident  in  cities,  because  a  large 
amount  of  truth  is  condensed  into  a  few  lines  : 

"  Under  present  customs  the  surgeon  expects  the 
general  physician  to  call  him  in  consultation  in  every 
surgical  case;  the  surgeon,  when  first  consulted,  usually 
forgets  to  call  a  general  physician.  In  the  first  case  the 
surgeon  assumes  that  the  internist  can  know  nothing  of 
surgery,  while  in  the  second  he  credits  himself  with  a  full 
knowledge  of  internal  medicine  in  addition  to  his  surgical 
skill.  The  surgeon's  experience  does  not  lead  him  to  the 
acquirement  of  facility  in  the  finer  methods  of  physical 
diagnosis,  and  in  what  appears  to  him  a  purely  operative 
case  he  not  infrequently  overlooks  slight  morbid  changes  in 
the  heart,  blood  vessels,  lungs,  kidneys  or  other  organs. 
The  time  has  now  come  when  the  surgeon,  in  asking  the 
consulting  support  of  the  general  physician  on  the  ground 
of  his  especial  surgical  training  and  skill,  must  no  longer 
assume  to  be  a  specialist  in  internal  medicine.  In  addition 
to  being  distinctly  unfair,  this  attitude  is  illogical  in  the 
extreme,  and  is  at  times  productive  of  results  much  less 
happy  than   might   be  obtained  by  the  hearty  co-operation 

of  both   parties The   medical  profession  would  not  now 

feel  under  the  necessity  to  condone  the  want  of  care  in 
prognosis  that  was  shown  by  some  at  least  of  the  President's 
surgeons.  The  thin-walled  heart,  accompanied  by  a  dispro- 
portionately rapid  and  irregular  pulse,^could  not  have  failed 
very  early  in  the  case  to  have  unfavourably  impressed  the 
physician  skilled  in  estimating  the  reserve  power  of  a  cardiac 
muscle." 


A  VERY  TIMELY  TREATISE  ON  SMALL-POX. 

A  very  timely  treatise  on  small-pox,  to  sell  at  $3,  is 
announced  for  publication  early  in  April,  by  J.  B.  Lippin- 
cott  Company.     It  is  written  by  Dr.  George  Henry  Fox, 


1 85  EDITORIAL. 

Professor  of  Dermatology  in  the  College  of  Physicians, 
and  Surgeons,  New  York  City,  with  the  collaboration  of 
Drs.  S.  Dana  Hubbard,  Sigmund  Pollitzer  and  John  H. 
Huddleston,  all  of  whom  are  oflScials  of  the  Health  De- 
partment of  New  York  City,  and  have  had  unusual 
opportunities  for  the  study  and  treatment  of  this  disease 
during  the  present  epidemic. 

The  work  is  to  be  in  atlas  form,  similar  to  Fox's 
Photographic  Atlas  of  Skin  Diseases,  published  by  the 
same  house.  A  strong  feature  of  the  work  will  be  its 
illustrations,  reproduced  from  recent  photographs,  the 
major  portion  of  which  will  be  so  coloured  as  to  give  a 
very  faithful  representation  of  typical  cases  of  variola  in 
the  successive  stages  of  the  disease,  also  unusual  phases 
of  variola,  vaccinia,  varicella,  and  diseases  with  which 
smallpox  is  liable  to  be  confounded.  These  illustrations 
number  thirty-seven,  and  will  be  grouped  intO'  ten 
coloured  plates,  9  1-2  by  10  1-4  inches,  and  six  black  and 
white  photographic  plates. 

The  names  of  Dr.  Fox  and  his  associates  assure  the 
excellence  of  the  work,  in  which  will  be  described  the 
symptoms,  course  of  the  disease,  characteristic  points  of 
diagnosis  and  most  approved  methods  of  treatment. 


AMERICAN    PRECOCITY    IN    FEMALE    PUBERTY. 

Dr.  Geo.  J.  Englemann,  of  Boston,  in  a  report  at  the 
recent  meeting  of  the  American  Gynaecological  Associa- 
tion in  Chicago,  gave  the  results  of  over  10,000  observa- 
tions as  to  the  time  of  first  menstruation  of  American- 
born  women.  As  a  result  of  his  investigation,  he  con- 
cludes that  the  American-born  are  more  precocious  than 
the  women  of  other  countries  in  the  same  zone;  14  is  the 
age  of  puberty  in  the  United  States  and  Canada;  15.5  in 
the  temperate  zone  of  Europe.  But  racial  characteristics 
fade  rapidly  away  in  America,  the  age  of  puberty  in 
Germany  being  15-5  to  16,  in  Ireland,  15.3,  and  for  the  girl 
born  in  America,  of  German  or  Irish  parentage,  14.5. 
The  Canadian  French  alone  of  all  races  are  more  pre- 
cocious than  the  American  of  the  same   class   when  born 


EDITORIAL.  •  187 

ic  this  country,  the  mean  age  being  found  to  be  137 
whereas  the  age  is  between  14  and  15  in  the  native  land. 
Mentality,  surroundings,  education  and  nerve  stimulation 
stand  out  prominently  in  this  country  as  the  factors  which 
determine  our  peculiar  precocity. 

THE  EFFICACY   OF  VACCINATION. 

According  to  Dr.  J-  E.  Laberge,  of  the  Contagious 
Diseases  Hospital,  Montreal,  the  efficacy  of  vaccination  as 
a  preventive  of  smallpox,  has  been  abundantly  proven 
within  the  last  year  in  this  city.  Since  May  last  there 
have  been  in  the  City  of  Montreal  Contagious  Diseases 
Hospital  240  cases  of  smallpox,  and  in  no  instance  had  a 
single  patient  been  vaccinated-  In  addition  to  these, 
there  was  a  staff  of  eighteen  persons,  physicians  and 
nurses,  who,  for  these  months  have  been  in  daily  and 
hourly  contact  with  these  smallpox  patients,  but  not  one 
of  them  has  ever  contracted  the  disease.  The  order  issued 
to  municipalities  throughout  the  province  of  Quebec  has 
been  fairly  well  obeyed,  an'i  three  hundred  and  forty- 
seven  municipalities  have  so  far  adopted  the  prescribed 
by-laws  with  regard  to  general  vaccination  with  its  ac- 
companying fines  for  non-fulfillment  of  same. 


THE  LATE  DR.  W.   S    MUIR,  OF  TRURO,  N.S. 

Many  of  our  readers  will  learn  with  deep  regret  of  the 
death  of  the  above-named  medical  man.  He  died  last 
month  from  appendicitis,  after  two  or  three  days'  illness, 
an  operation  having  been  performed.  Dr.  Muir  was  a 
constant  attendant  at  the  meetings  of  the  Canadian 
Medical  Association,  and  ever  evinced  great  interest  in 
its  welfare.  He  w^as  most  genial  in  his  character,  and 
was  universally  beloved  by  all  who  knew  him.  He  will 
be  greatly  missed.  ^ 


MEDICO-CHIRURGICAL     SOCIETY     OF    MONTREAL. 

This  Society  now  occupies  elegant  quarters  over  the 
West  End  branch  of  the  Bank  of  Montreal,  St.  Catherine 
street-     The  lecture  room  will  seat  a    hundred   and    fifty. 


Io»  .  EDITORIAL. 

Tborc  is  a  well  supplied  reading  room,  the  nucleus  of  a 
good  library  and  a  writing  room-  These  are  practically 
open  day  and  evening,  to  the  members-  The  officers  for 
the  present  year  are:  President,  Dr.  George  E.  Arm- 
strong; Vice-President,  Dr.  H.  S.  Birkett;  Secretary,  Dr. 
Alfred  Bazin;  Treasurer,  Dr.  J.  M.  Jack;  Trustees,  Drs. 
Perrigo,  Dr.  G.  A.  Brown  and  Dr.  F.  J.  Shepherd. 


YOU'LL  HAVE  TO  SHOW  US. 

A  recent  number  of  the  Medical  Fortnightly,  says: — 
"Japanese  dentists,  according  to  a  contemporary,  perform 
their  operations  in  tooth-drawing  with  the  thumb  and 
forefinger  of  one  hand-  The  skill  necessary  to  doi  this  is 
acquired  only  after  long  practice,  but  when  once  it  is  ob- 
tained the  operator  is  able  to  extract  half  a  dozen  teeth 
in  about  thirty  seconds  without  once  removing  his  fingers 
from  the  patient's  mouth.  A  dentist  in  this  country  is 
mentioned  in  the  papers  as  using  this  method  with  suc- 
cess, having  learned  it  from  a  Japanese.  , 


THE   CO\V  PEA. 


The  'Cow  Pea"  is  the  title  of  the  latest  publication 
issued  by  the  Experiment  Farm  of  the  North  Carolina 
State  Horticultural  Society  at  Southern  Pines,  N.C-  This 
book  neatly  bound  and  illustrated,  in  plain  and  concise 
manner,  discusses  the  value  and  uses  of  this  important 
CI  op,  the  "Cow  Pea."  Every  reader  can  get  a  copy  free 
by  writing  to  the  Superintendent  of  Experiment  Farm, 
Southern  Pines,  N.  C- 


CANADIAN    MEDICAL    ASSOCIATION. 

The  annual  meeting  of  the  Canadian  Medical  Associa- 
tion will  be  held  in  Montreal  on  the  i6th,  17th  and  i8th 
days  of  September,  1902.  The  President  is  Dr.  Francis  J. 
Shepherd,  152  Mansfield  St.,  Montreal,  the  Local  Secretary, 
Dr.  C.  F.  Martin,  Durocher   St.,  Montreal,  and   the  General 


PERSONALS.  189 

Secretary,  Dr.  George  Elliott,  129  John  St.,  Toronto. 
Dr.  William  Osier,  Professor  of  Medicine  in  Johns  Hopkins 
University,  will  deliver  the  Address  in  Medicine  and  Dr. 
John  Stewart,  Halifax,  Nova  Scotia,  the  Address  in  Surgery. 
Arrangements  are  already  well  in  hand  for  a  very  large 
meeting. 


Jonathan  Hutchinson,  F.R.S.,  General  Secretary  of  the 
New  Sydenham  Society,  has  requested  Messrs.  P.  Blakiston's, 
Son  &  Co.,  of  Philadelphia,  the  American  agents  of  the 
Society,  to  announce  the  publication  of  "An  Atlas  of 
Clinical  Medicine,  Surgery  and  Pathology,"  selected  and 
arranged  with  the  design  to  afford,  in  as  complete  a  manner 
as  possible,  aids  to  diagnosis  in  all  departments  of  practice. 
It  is  proposed  to  complete  the  work  in  five  years,  in  fasciculi 
form,  eight  to  ten  plates  issued  every  three  months  in  con- 
nection with  the  regular  publications  of  the  Society.  The 
New  Sydenham  Society  was  established  in  1858,  with  the 
object  of  publishing  essays,  monographs  and  translations  of 
works  which  could  not  be  otherwise  issued.  The  list  of 
publications  numbers  upwards  of  170  volumes  of  the  greatest 
scientific  value.  An  effort  is  now  being  made  to  increase 
the  membership  in  order  to  extend  its  work. 


Personals. 


Dr.  Benoit  has  been  appointed  physician  to  the    Mont- 
treal  Goal. 

Dr.  J.  Alex.  Hutchison,  of  Montreal,  has  been  appointed 
surgeon -in -chief  to  the  Central  Vermont  Railroad. 

Dr.  J.  W.  Geoffrien,  of  Chicago,    a   graduate  of   Laval 
University,  has  left  that  city  to  establish  himself  in  Montreal. 

Professor  J.  S.  Donald,  of  the  Medicai  Faculty  of  Bishop's 
College,  has  been  appointed  public  analysist  in  place  of  the 
late  J.  Baker  Edwards. 


190  BOOK  REVIEWS. 

Dr.  A.  G.  McDougall,  late  house  surgeon  to  the  Toronto 
General  Hospital,  has  been. appointed  medical  attache  to  the 
regiment  in  charge  of  the  Boer  prisoners  at  Hamilton,  Jamaica, 

Dr.  Shirres,  of  Montreal,  has  been  appointed  Professor  of 
Nervous  Diseases  in  the  University  of  Vermont,  Burlington. 
Dr.  Shirres  came  to  Canada  with  Lord  Aberdeen  as  physician 
to  the  Vice  Regal  family. 

Dr.  H,  L.  Reddy  has  resigned  his  position  as  one  of  the 
attending  physicians  to  the  Western  General  Hospital,  with 
a  view  of  devoting  more  time  to  the  Women's  Hospital,  of 
which  he  is  chief  physician  and  accoucheur.  Dr.  W.  Grant 
Stewart  was  elected  to  replace  Dr.  Reddy  on  the  staff  of  the 
Western  Hospital. 

Dr.  W.  H.  Drummond,  M.D.,  Bishop's,  1884,  Professor 
of  Medical  Jurisprudence  in  the  Faculty  of  Medicine,  Bishop's 
University,  author  of  "  The  Habitant,"  "Johnny  Courteau" 
and  other  poems,  is  to  have  the  degree  of  LL.D.  conferred 
on  him  by  Toronto  University,  in  June,  Dr.  Drumirond 
was,  on  the  i8th  of  March,  the  recipient  of  a  public  dinner 
from  the  Canadian  Society  of  New  York,  at  which  over  two 
hundred  guests  sat  down,  among  them  being  some  of  the 
most  distinguished  men  of  the  United  States,  Dr.  Wolford 
Nelson,  of  New  York,  and  Dr.  Tetreault,  of  Orange,  N.  J., 
both  graduates  of  Bishop's  College,  attended  to  do  honour 
to   their  fellow  graduate. 


Book   Reviews, 


International  Clinics. — A  quarterly  of  clinical  lectures  and 
especially  prepared  articles  on  all  branches  of  Medicine  and 
Surgery  and  other  topics  of  interest  to  students  and  practi- 
tioners. By  leading  members  of  the  Medical  profession 
throughout  the  world.  Edited  by  Henry  W.  Cattell,  A.M., 
M.D.,  Philadelphia,  U.S.A.,  with  the  collaboration  of  John 
B.  Murphy,  M.D.,  Chicago  ;  Alex.  D.  Blackader,  M.D.,  Mont- 
real;  H.  C.  Wood,  M.D.,  Philadelphia  ;  T.  M.  Rotch,  M.D., 
Boston;  E.  Landort,  M.D,,  Paris;  Thos.  G.  Marton,  M.D., 
of  Philadelphia,  and  Chas.  H.  Reed,  M.D. ;  J.  B.  Ballantyne, 
M.D.,  of  Edinburgh  and  John  Harold,  M.D.,  of  London  ; 
with  regular  correspondents  in  Montreal,  London,  Paris, 
Leipsic  and  Vienna;  volume  IV.;  eleventh  series.  J.  P, 
Lippincott  &  Co.,  Philadelphia,  1902.  Canadian  agent, 
Charles  Roberts,  1524  Ontario  street,  Montreal. 


BOOK  REVIEWS.  igi 

This  the  last  volume  of  the  eleventh  series  is  not  behind  its 
predecessors  in  its  quota  of  interesting  and  instructive  articles. 
There  are  thirty  one  papers  under  the  headings  of  Therapeutics, 
Medicine,  Surgery,  Neurology,  Paediatrics  and  Dermatology,  with 
a  special  article  on  the  Keeping  of  Case  Records  in  Private 
Practice,  by  Frederick  Packard,  M.D.,  Judson  Deland,  M.D., 
John  H.  Musser,  M.D,  J.  P.  Crozier  Griffith,  M.D.,  J.  K.  Mitchell, 
"M.D.,  Alfred  Stengel,  M.D. 

The  first  of  a  serier  of  papers  is  given  by  Dr.  Horatio  C. 
Wood,  jun.,  entitled  a  Description  of  the  Methods  of  Investigating 
the  Action  of  Drugs.  He  points  out  the  fact  that  the  older  prac- 
titioners had  not  the  advantage  of  seeing  at  college  the  methods  of 
investigating  drugs  now  to  be  observed  in  the  modern  pathological 
laboratory,  and,  as  clinical  methods  do  not  give  reliable  results  in 
ascertaining  the  true  value  of  a  drug,  a  description  of  recent 
methods  will  enable  readers  to  interpret  the  results  from  the 
pathological  laboratory.  The  present  article  considers  the  action 
of  drugs  on  the  circulation.  The  methods  are  described  in  detail 
and  illustrated  by  lithographs  of  the  various  forms  of  apparatus 
used. 

Prof.  Albert  Mathieu,  of  Paris,  gives  a  special  article  on  the 
Treatment  of  Muco  Membranous  Colitis,  which  is  replete  with 
practical  suggestions.  The  relation  of  the  local  irritation  and  the 
general  neurotic  condition  is  pointed  out  and  exhaustive  diiection 
given  in  regard  to  diet  and  local  and  general  medication.  The 
application  of  massage,  hydrotherapy  and  moral  hygiene  in  this 
affection  is  fully  described. 

Sir  Dyce  Duckworth,  M.D.,  LL.D.,  contributes  an  article  on 
Clinical  Observation  on  Certain  Diathetic  Conditions.  His  thirty 
years  of  experience  has  enabled  him  to  sift  from  the  old  doctrines 
of  the  diatheses,  (acts  which  are  of  great  importance  in  understand- 
ing two  groups  of  pathological  conuuions — the  strumous  diathesis 
and  the  arthritic  diathesis.  He  proves  conclusively  the  existence 
of  these  two  tendencies,  the  liabilities  associated  with  their 
presence,  their  antagonism  to  each  other,  and  the  important  bear- 
ing of  a  recognition  of  this  state  on  the  diagnosis,  prognosis  and 
treatment  of  these  affections,  and  pays  high  tribute  to  the  skill  and 
acumen  of  our  predecessors  in  the  art  and  science  of  medicine  who 
accomplished  so  much  without  the  mpans  of  investigation  which 
we  now  possess. 

One  of  the  most  interesting  articles  in  this  number  is  that  on 
Prognosis  in  Chronic  Valvular  Disease  of  the  Heart,  by  J.  Mitchell 
Bruce,  M.A.,  M.D.,  LL.D.,  F.R.C  P.,  London. 

Prognosis  should,  he  stated,  not  be  empirical,  but  be  based 
on  the  practical  application  of  scientifically  determined  facts. 
The  facts  are  these  connected  with  the  etiology,  pathological 
anatomy,  clinical  character  and  course  of  the  affection. 

An  old  rheumatic  lesion  is  a  scar,  an  affair  of  the  past  and 
rarely  progressive,  and  a  favourable  prognosis  can  be  made  ;  while 
in  syphilitic  or  atheromatous  changes  we  must  forecast  less 
favourably. 


192  PUBLISHERS'   DEPARTMENT. 

The  unfavourable  local  lesions,  such  as  aortic  incompetence, 
are  so,  because  they  are  so  often  degenerative  or  specific  in  origin. 
Then  the  prognosis  in  any  stated  case  of  valvular  diseases,  he 
points  out,  depends  much  on  the  environments  and  conditions  of 
life  in  each  case,  and  the  forecast  must  carry  with  it  suggestions  of 
measures  for  prevention,  the  avoidance  of  fresh  attacks  of  rheuma- 
tism and  over  exercise  in  youth.  '1  he  work  engaged  in  by  the 
adult,  the  abuse  of  alcohol,  tobacco,  syphilis.  The  child-bearing 
period  in  the  female  and  in  advanced  life  the  influence  of  the 
various  forms  of  degeneration,  some  of  which  are  amenable  to 
treatment ;  all  have  a  distinct  bearing  on  the  prognosis  and  must 
be  carefully  estimated  in  forming  our  conclusions. 

Among  other  interesting  paper«  are:  Winged  Insects  and 
their  Larvae  as  Parasites  of  Men,  by  James  J,  Walsh,  M.D.,  Ph.D.; 
Types  of  Hemiplegia,  by  G.  L.  Walton,  M.D. ;  Moveable  Kidney, 
by  Frank  Lydston,  M.D. ;  The  Operative  Relief  of  some  Forms 
of  Prostatic  Hypertrophy,  by  Charles  H.  Chetwood,  M.D. ; 
Clinical  Lectures,  by  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  and 
John  B.  Deaver,  M.D. 

J.  B.  McC. 


PUBIvISHKRS  DKPARnrMENT, 


SANMEITO    IN    GENITO-URINARY     TROUBLES    AVD    IN    DIS- 
EASES OF  MUCOUS  MKMliRANES  OF  A  CHRONIC 
CHARACTER. 

I  do  not  generally  endorse  proprietary  medicines,  but  Sanmetto  is  such  an 
elegant  combination  that  I  must  make  an  exception  in  its  favour.  I  have  used 
several  bottles  of  it  in  my  practice  witli  the  most  gratifying  and  surprising 
results.  I  used  it  in  a  case  of  inflammation  of  neck  of  bladder.  Have  also 
used  it  in  several  other  cases  and  will  ".ay  that  I  have  never  used  any  prepara- 
tion which  has  given  me  such  satisfactory  results  in  genito  urinary  diseases  as 
does  Sanmetto.  I  am  afraid  that  the  druggist,  in  one  case,  substituted  the 
elixir  of  saw  palmetto,  which  they  have  tried  to  have  me  use  instead  of  San- 
metto, as  it  did  not  taste  as  it  should,  but  I  have  tried  so  many  preparations  of 
saw  palmetto  with  no  beneficial  results  that  I  w^nt  the  genuine  Sanmetto  or 
none. 
Racine,  Wis. 

H.  G.  PECK,  M.  D. 


SANMETTO  IN   CYSTITIS,   HYPERTROPHY   OF    THE   PROSTATE 
AND  IN  PRE-SENILITY. 

I  have  prescribed  Sanmetto  in  my  practice  for  a  period  of  seven  years  with 
the  happiest  results  to  my  patients  and  great  satisfaction  to  myself.  In  cystitis, 
true  hypertrophy  of  the  prostate,  and  where  the  complex  generative  system  has 
lost  its  tone,  vigour,  and  vivacity,  it  is  the  remedy  par  excellence.  Many  imita- 
tions are  on  the  market,  but  the  Od.  Chem.  Co.  of  New  York  makes  the  only 
Sanmetto. 

J.  M.  STUKEY,  M.  D. 
Lancaster,  Ohio. 


CANADA 


MEDICAL  RECORD 


MAY,    I902. 


Original  Communications, 


SOME  MEDICAL  FALLACIES. 

Bead  before  the  Young  Men's  Cliristiaa  Association  of  Green  Bay,  Wisconsin,  U.  S., 

in  March,  1902,  by 

W.  E.  Fairfield,  CM.,  M.D. 

The  Y.M.C.A.  is  a,  semi  religious  body  formed  for 
the  double  purpose  of  receiving  good  itself  and  of  impart- 
ing it  to  others.  It  belongs  to  the  broader  Christianity  of 
the  present  day,  in  that  it  is  non-sectarian.  It  might  be 
likened  to  the  farmer  in  the  religious  field,  who  believes 
in  diversified  agriculture  as  opposed  to  the  one  who  is  a 
specialist  in  some  particular  line.  It  caters  to  man's 
spiritual  welfare,  while  at  the  same  time  it  is  not  neglect- 
ful of  his  material  comforts  and  wants. 

In  what  I  say  this  evening,  I  shall  pay  particular 
attention  to  the  latter  phase  of  its  vocation,  and  at  the 
same  time  shall  claim  the  prerogative  of  him  who  caters 
to  the  former,  in  that  I  ask  your  indulgence  so  far  as 
to  be  allowed  to  wander  from  the  subject  of  my  discourse, 
imitating,  in  so  doing,  many  of  the  popular  divines,  as  you 
will  bear  witness. 

To  deliver  a. popular  address,  it  is  necessary  that  the 
speaker  should  be  satisfied  with  his  effort.  He  should 
feel  that  he  has  handled  his  subject  in  a  masterly  manner, 
and  that  he  has  correspondingly  impressed  his  hearers.  I 
doubt  if  Webster  could  have  delivered  his  address  with 
such  profound  effect,  had  he  not  felt  that  he  was  the 
master  of  Hayne,  not  only  on  the  question  at  issue,  but 
also  in  his  own  personality.  Knowing  his  subject  was  no 
more  essential  than  knowing  his  antagonist  and  his  audi- 
ence. 

In  the  present*  instance,  a  technical  knowledge  of 
medicine  is  not  an  advantage  in  the  strictest  sense,  for  fthe 
speaker  must  be  able  to  so  handle  his  subject  as  to  make 
it  intelligible  to  an  audience,  which,  however  intellectual, 
IS  nevertheless  not  in  possession  of  a  technical  ^iiowledge 
of  medicine. 


194  FAIRFIELD:   SOME   MEDICAL  FALLACIES. 

1  am,  therefore,  reduced  to  the  extremity  of  avoidini^ 
many  things  which  would,  under  some  circumstances, 
prove  not  uninteresting,  and  to  confine  myself  to  homely 
and  common  things,  to  things  of  which  both  you  and  I 
have  some  knowledge,  but  as  to  which  we  may  have  so-ne 
honest  differences  of  opinion. 

Medicine  is  not  as  yet  an  exact  science.  The  most 
eminent  medical  man  cannot,  under  any  circumstances, 
say  positively  that  a  certain  drug,  or  a  certain  combina- 
tion of  drugs  will  cure  a  certain  condition.  True,  it  is 
rapidly  approaching  this  point,  and  the  progress  made  in 
the  past  fifty  years  bids  fair  to  show  us  the  dawn  of  this 
much-desired  era. 

The  exact  nature  of  disease  or  diseased  tissues  is 
being  studied  as  never  before.  The  scientific  physician  is 
no  longer  satisfied  to  know  that  a  certain  drug  has  a  bene- 
ficial ettect  in  a  certain  disease,  but  he  inquires  what  is 
this  disease?  What  structures  are  involved?  How  are 
these  structures  affected?  Why  does  this  drug  become 
btueficial?  and  above  all,  how  can  this  disease  be  pre- 
vented? The  enpyric  has  no  place  in  the  practice  of 
medicine  to-day.  It  is  not  enough  to  know  that  a  certain 
thing  is  good,  but  one  must  know  why  it  is  good.  We  are 
thus  rapidly  approaching  an  age  when  we  will  prescribe 
a  certain  drug  for  a  specific  disease  and  prescribe  it 
intelligently. 

For  years  quinine  has  been  used  as  a  remedy  for 
malaria.  It  was  and  is  a  specific  in  that  it  inhibits  the 
multiplication  in  the  system  of  the  specific  malarial  germ. 
The  germ  itself  is  the  discovery  of  recent  months,  and  it 
has  been  conclusively  proven  that  it  gains  access  to  the 
system,  not  through  the  air  or  water  or  food,  but  through 
the  bites  of  infected  mosquitoes.  The  prevention  of 
malaria,  therefore,  resolves  itself  into  the  annihilation  of 
the  mosquito.  Until  this  is  accomplished,  we  continue  to 
give  quinine,  but  w^e  give  it  with  an  understanding  of  its 
action  and  a  comprehension  of  its  limitations. 

It  is  but  a  few  years  since  the  sore  throat,  which  ac- 
companies scarlet  fever  and  that  of  diphtheria,  were 
believed  to  be  identical.  The  same  remedies  were  applied 
to  both.  Now  we  have  studied  and  know  the  bacillus  of 
diphtheria,  and  that  knowledge  has  already  led  to  the  dis- 
covery of  ail  antitoxin,  which,  injected  into  the  system, 
counteracts  the  poisonous  effects  of  the  bacillus  itself, 
thereby  saving  thousands  of  lives  every  year. 

These  are  but  illustrations  of  the  fact  that  the  scien- 
tific practitioner  looks  for  cause,  and  not  only  wants  to 
remove  it,  but  also  to  know  the  exact  nature  of  the  agent 


FAIRFIELD:   SOME   MEDICAL  FALLACIES.  1 95 

which  he  uses  to  this  end.  The  physician  can  no  longer 
attend  a  meeting  of  scientific  men  and  say  that  a  certain 
drug  will  cure  a  certain  condition;  unless  ne  can  show  the 
cause  of  the  disease  and  the  modus  operandi  of  his  cure, 
he  will  immediately  subject  himself  to  derision. 

Man  has,  for  so  long,  considered  himself  lord  of  crea- 
tion, and  the  bright,  particular  star  of  perfection,  that  it 
is  hard  to  bring  him  to  a  realization  of  the  fact  that  he 
may  be  overestimating  himself.  He  likes  to  be  considered 
master  of  himself  and  of  others,  and  his  arguments  are 
quite  convincing  if  one  but  looks  on  the  surface.  The 
scientific  man  must  look  upon  him,  however,  as  a  more  or 
less  beautiful  machine,  composed  of  many  parts,  and  each 
part  in  turn  composed  of  an  elementary  form  of  substance 
which  we  call  a  cell. 

I  would  have  you  examine  with  me  this  elementary 
body  to  gain  an  understanding  of  many  of  the  phenomena 
connected  with  the  ever-present  processes  of  birth,  growth, 
development,  decline  and  death.  This  cell  is,  to  all  intents 
and  purposes,  a  living  unit.  Its  size  is  so  minute  that 
high  powers  of  the  microscope  are  necessary  to  disclose 
it,  but  when  once  it  is  brought  to  view,  we  have  revealed 
all  the  attributes  of  that  most  lordly  animal,  man  himself, 
excepting  a  love  for  clothes  and  whiskey.  Different  types 
of  structure  have  different  types  of  cells;  those  of  nerve 
tissues  are  not  like  those  of  muscular  tissue,  etc.,  but  they 
are,  notwithstanding,  all  constructed  .on  the  same  plan. 
A  little  atom  bounded  by  a  wall  like  that  of  an  egg,  and 
containing  a  body  or  cell  contents,  with  a  living  center  or 
nucleus.  To  jjrove  the  fact  that  these  cells  are  living  and 
independent  structures,  it  is  only  necessary  to  say  that 
they  possess  the  power  to  defend  themselves  against 
enemies  and  to  propagate  themselves.  Resistance  to  dis- 
ease and  cure  of  diseased  tissues  is  thus  accounted  for. 
This  is  no  theoretical  statement,  but  one  that  can  be 
clearly  and  incontrovertibly  demonstrated. 

In  the  blood  we  have  two  sets  of  cells,  the  white  and 
red  corpuscles.  The  principal  office  of  the  white  is  to 
destroy  poisonous  germs.  Now,  in  blood  poisoning, 
nature  immediately  comes  to  the  rescue  of  the  individual 
by  increasing  its  army  of  white  corpuscles.  Disease 
germs  are  surrounded  arid  destroyed,  surrounded  by  indi- 
vidual corpuscles,  which  absorb  and  destroy  them,  or 
being  unequal  to  the  conquest,  throw  themselves  over  the 
parapet,  holding  the  invader  in  their  grasp,  and  are 
thrown  off  by  the  system  in  the  form  of  pus.  .  A  wonder- 
ful and  interesting  thing  this  process  of  increasing  the 
army  of  defence  at  will;  and  no  more  wonderful  than  the 


196  FAIRFIELD:   SOME   MEDICAL  FALLACIES. 

fact  that  when  once  the  enemy  is  repelled,  the  army  is 
again  reduced  to  a  peace  footing.  No  imperialism  in  this 
living  republic,  no  boasting  after  the  battle,  no  stealing  of 
reputations.  No  co'^i  c  martials  or  appeals  for  vindication 
in  an  army  where  every  duty  is  so  well  performed.  When 
the  strength  of  the  force  of  disease  is  less  than  that  of  the 
defenders,  we  get  well,  when  the  opposite  obtains,  we  die. 
The  great  question  of  cure  rests  with  the  cells  alone. 

Then,  what  is  the  office  of  the  physician?  If  the 
power  to  repel  disease  is  inherent  in  the  cells,  why  take 
medicine,  why  call  upon  the  physician?  Let  me  try  to 
explain. 

In  the  first  place,  these  germs  find  their  way  into  the 
system  from  the  outside;  through  a  wound;  through  the 
digestive  tract,  through  the  respiratory  surfaces,  etc. 
Once  in  the  system,  he  can  do  little  to  combat  them,  but 
he  can  do  much  to  prevent  further  absorptions.  The  in- 
testinal antiseptic  is  no  less  sure  in  preventing  absorption 
of  the  typhoid  bacillus  than  is  the  knife  in  preventing  the 
absorption  of  pus  from  an  abcess  cavity.  When  once 
the  source  of  the  invasion  is  known,  much  can  be  done  to 
prevent  inroads  and  to  sustain  the  powers  of  life,  looking 
to  the  cells  themselves  to  make  the  great  fight.  The  great 
physician  is  simply  the  man  who  best  understands  these 
little  cells,  and  understanding  them,  conserves  their 
powers. 

A  knowledge  of  the  cellular  structure  and  of  the  germ 
theory  of  disease  makes  scientific  reasoning  possible  in 
medicine.  True,  we  have  men  who  do  not  believe  in  the 
germ  origin  of  disease;  we  also  have  men  who  believe  in 
witches,  and  signs  and  wonders.  These  we  will  always 
have  with  us.  Reason  finds  no  place  in  the  space  which 
should  be  occupied  by  brains  in  some  cases.  The  good 
Lord  put  such  people  among  us,  methinks,  to  make  us 
thankful  for  the  faculty  of  reason.  A  little  knowledge  is 
a  dangerous  thing  with  such  people,  as  it  is  with  all 
people.  They  no  sooner  see  a  means  which  is  effective  in 
one  case,  than  they  make  it  applicable  to  all  cases.  A 
narrow  man  is  to  be  avoided  on  general  principles.  He  is 
the  one  vou  will  invariably  find  clinging  to  one  of  the  isms 
of  medicine.  He  will  believe  in  massage  as  a  cure  for 
everything;  or  in  the  waters  of  some  particular  spring, 
or  in  some  patent  medicine,  or  some  diabolical  mixture 
supposed  to  have  been  originated  by  an  Indian  medicine 
man,  or  in  some  form  of  bath;  or  in  suggestion  or  hypnot- 
ism, or  mental  therapeutics  or  Christian  Science.  He  will 
agree  with  the  homoeopath  that  the  part  of  a  thing  is 
greater  than  the  whole;  that  a  drop  of  alcohol  put  into  a 


FAIRFIELD:   SOME   MEDICAL  FALLACIES.  197 

barrel  of  watei-  aiid  well  sliakeii  is  more  powerful  than  a 
whole  barrel  of  alcohol;  that  like  cures  like,  aiid  so  he 
would  cut  oft  the  second  leg  to  remove,  the  inconvenience 
occasioned  by  the  loss  of  the  first.  He  will  carry  a  potato 
in  his  pocket  to  cure  rheumatism,  and  blame  God  Al- 
mighty for  the  loss  of  his  child  from  smallpox,  when  he 
neglected  vaccination. 

lie  careful  of  the  man  who  is  too  narrow  to  accept  the 
good  from  whatever  source  it  may  come;  whether  he  be 
allopath,  homoepath,  eclectic,  Indian  or  just  common 
fool. 

There  is  no  such  thing  as  hydropathic,  allopathic, 
homoepathic  and  eclectic  schools  to  the  scientific  man- 
He  acknowledges  no  man's  right  to  adopt  a  remedy  and 
say  "It  is  mine;  it  belongs  to  my  school."  He  is  eager 
and  ready  to  accept  it  as  soon  as  its  worth  is  proven,  and 
it  is  to  such  a  man  that  you  and  I  must  look  for  advance- 
ments along  the  line  of  scientific  medicine.  A  man  may 
accidentally  discover  a  gold  mine,  but  it  takes  application 
and  knowledge  and  reasoning  and  labour  to  perfect  the 
incandescent  light,  or  harness  the  powers  of  Niagara.  The 
unreasoning  quack  or  empyric  may  light  upon  a  remedy  of 
merit,  but  it  takes  work  and  thought  to  evolve  a  rational 
treatment  for  disease. 

I  am  always  amused  when  I  am  shown  a  prescription 
containing  a  multiplicity  of  remedies.  When  I  see  ten  to 
twenty  drugs  in  a  prescription,  I  know  that  it  was  written 
by  a  man  whose  knowledge  of  the  case  under  observation 
was  limited.  His  is  the  shot  gun  theory,  namely,  in  many 
missiles  one  of  them  may  hit  the  mark.  When  I  see  thirty 
remedies  in  a  mixture  I  can  discover  at  least  twenty-five 
reasons  for  not  giving  it. 

I  want  to  let  you  into  another  professional  secret. 
Those  of  this  audience  who,  before  they  reformed,  attended 
the  theatre,  know  that  when  a  doctor  has  a  part  in  a  play, 
he  is  invariably  accused  of  giving  bread  pills.  If  I  should 
ever  fail  to  hear  this  superannuated  Joke,  I  would  feel 
lonesome  and  robbed  of  my  rights.  Now,  physicians  call 
this  form  of  treatment  the  administration  of  a  "placebo." 
It  is  Christian  Science  treatment  under  another  name,  and 
is  equally  honest  and  efficacious.  If  a  man  can  be  cured 
by  believing  that  there  is  no  such  thing  as  pain,  he  can  be 
cured  by  believing  that  a  bread  pill  is  the  remedy  he 
needs,  and  he  will  have  the  added  advantage  of  not  appear- 
ing inconsistent  when  he  puts  his  thumb  in  his  mouth 
after  he  hits  it  with  the  hammer. 

Now,  the  "placebo"  is  going  out  of  fashion — in  fact  I 
mav  sav  that  it  is  entirelv  so.     Instead  of   it  we  have  re- 


igS  Fairfield:  some  medical  fallacies. 

course  to  suggestive  therapeutics,  which,  in  other  and 
phiiuer  language,  means  simply  that  the  illness  being 
imaginary  and  the  patient  not  possessed  of  sufficient 
reasoning  power  to  see  it,  he  is  simply  told  that  he  will  be 
better  to-morrow  and  to-morrow,  and  the  impression  thus 
made,  removes  the  imaginary  difficulty.  Some  have 
elaborated  this  suggestion  so  nicely  that  they  are  able  to 
impart  its  blessings  through  the  medium  of  scraps  of 
paper  and  cheap  handkerchiefs  sent  through  the  mail.  I 
think  this  could  be  further  elaborated  by  saying  into  a 
phonograph,  "Please  put  |5.00  in  the  slot.  Now  pull  down 
the  lever.  There!  Now  listen  carefully  and  attentively. 
You  are  a  wonderful  creature,  and  a  combination  of 
circumstances  have  conspired  to  keep  you  from  occupying 
that  position  your  merit  deserves.  You  are  not  appreci- 
ated by  your  companions,  and  I  only  can  read  your  soul. 
You  will  be  better  to-morrow,  better  to-morrow,  when  you 
must  come  again,  and  be  sure  to  bring  a  new  $5.00  gold 
piece;  the  one  you  brought  to-day  is  plugged."  A  sug- 
gestive sanitarium  with  phonographic  annex  should  be  a 
squealing  success. 

Just  a  word  in  leaving  the  subject  of  "isms'' — because 
.  a  certain  treatment  will  cure  a  cold,  don't  conclude  also 
that  it  is  good  for  burns.  While  it  reduces  fever,  it  may 
not  necessarily  be  good  for  chills.  While  it  may  cure  bald 
heads,  it  may  not  be  applicable  to  the  removal  of  super- 
fluous hair. 

The  matter  of  diet  is  one  that  is  fraught  with  great 
importance  in  its  relation  to  health.  Here,  I  want  to 
warn  you  against  fads.  If  you  are  well,  you  require  a 
well  regulated,  generous  diet,  both  animal  and  vegetable. 
If  your  digestion  is  at  fault,  correct  the  fault  so  that  you 
can  enjoy  a  mixed  diet.  The  narrow  individual  of  whom 
1  spoke  sometime  ago,  will  cling  to  one  thing,  usually  to  a 
so-called  health  food,  or  at  least  to  a  vegetable  diet  with 
a  glass  of  hot  water  as  a  dissipation.  There  is  need  in 
this  country  of  the  establishment  of  a  "Keely  Cure"  for 
the  hot  water  habit.  Because  some  individual  in  a  com- 
munity was  benefited  by  taking  a  glass  of  hot  water  before 
breakfast,  it  follows  that  the  whole  community  must  use 
it.  The  glass  of  hot  water  before  breakfast  is  followed  by 
a  glass  before  lunch  and  dinner.  Then  a  glass  before 
bedtime,  and  one  of  my  patients  went  so  far  as  to  set  an 
alarm  clock  to  waken  him  at  regular  intervals,  so  that  he 
might  partake  of  this  form  of  hydro-therapy,  arguing  the 
while,  that  because  there  were  hot  springs  in  Arkansas, 
the  Lord  had  intended  that  water  should  be  taken  hot.  I 
can  always  tell  the  hot  water  fiend.  He  reminds  me  so 
much  of  a  boiled  lobster. 


FAIRFIELD:   SOME   MEDICAL  B^ALLACIES.  I99 

111  leaving  this  subject  I  want  to  say  a  few  words  on 
the  use  of  drugs.  Let  me  warn  you  against  taking  a 
medicine  on  the  theory  that  "it  won't  do  any  harm  if  it 
does  no  good."  You  are  living  in  too  intellectual  an  age 
to  submit  to  that  form  of  medication.  First,  be  sure  that 
30U  need  a  remedy,  and  then  be  sure  that  you  are  taking 
(he  one  that  will  beneflt  you.  Be  satisfied  when,  after  an 
examination  by  your  physician,  he  simply  tells  you  to 
correct  your  habits  of  life.  Don't  think  that  because  he 
didn't  give  you  seven  prescriptions,  he  don't  understand 
his  bus.ness.  Conclude  rather  that  he  is  not  financially 
interested  in  a  drug  store.  Again,  when  a  physician  pre- 
scribes a  four  ounce  mixture  for  you,  do  not  have  it  re- 
peated and  repeated  indefinitely.  If  he  had  intended  that 
you  should  take  a  barrel  of  the  stuff  he  would  have  pre- 
scribed it  in  that  quantity  in  the  first  place,  and  you  could 
have  saved  money  by  dealing  with  a  wholesale  store. 
Again,  don't  think  that  a  medicine  must  necessarily  taste 
like  shoe  dressing  to  be  efficacious.  Modern  pharmacy 
has  made  it  possible  to  take  at  least  some  preparations 
without  facial  contortions  or  acrobatic  accompaniment. 

A  word  about  domestic  remedies.  Many  of  them  are 
good.  The  hot  foot  bath,  the  poultice,  the  hot  application, 
the  alcoholic  bath  and  many  other  of  the  simpler  remedies 
have  their  fields  of  usefulness.  I  honour  the  good  old 
mother  who  does  her  best  to  assuage  the  pain  of  suffering 
humanity,  Hhe  knows  nothing  of  psycological  thera- 
peutics or  suggestion,  but  her  tender  touch  and  kindly 
smile  should  bear  a  higher  sounding  name.  She  is  a  close 
observer  of  symptoms,  and  is  a  natural  help  to  the  most 
skilled  physician.  She  is  the  mother  whose  kiss  brought 
back  the  merry  laugh  of  childhood.  She  is  the  mother  of 
thouuhtfulness,  tenderness  and  love — our  own  mother.  I 
speak  of  her  with  reverence,  and  I  think  of  her  with 
gratitude.  While  worshipping  at  the  shrine  of  Aescul- 
apius. I  do  not  forget  her  kindly  voice  and  angelic  touch. 

It  will  not  be  out  of  place  to  touch  briefly  upon  an- 
other subject,  upon  whi<h  many  persons  have  a  false  con- 
ception of  the  duties  of  the  physician.  It  has  always 
seemed  strange  to  me  that  enlightened  and  even  highly 
educated  people  should  believe  that  in  some  special  cases 
the  phvsician  is  not  only  justified  in  taking  life,  but  that 
it  is  his  duty  to  do  so.  Men  have  recently  advocated  a 
return  to  the  old  Greek  custom  of  destroying  all  im- 
perfect infants,  but  no  one  takes  them  seriously.  True, 
the  paramount  idea  in  many  minds  seems  to  be  that  a 
beefv  football  team  is  more  of  a  credit  to  a  university  than 
is  a  development  of  brains,  and  if  we   did   not    possess   a 


200  FAIRFIELD :   SOME   MEDICAL  FALLACIES. 

faith  in  the  good  sense  of  mankind  in  general,  we  might 
fear  that  the  propagation  of  the  human  species  would  be 
reduced  to  the  stockfarm  basis.  This  perfection  of 
system  of  course  would  make  it  easy  for  the  ladies,  for  all 
of  their  gowns  could  be  fitted  to  the  Venus  de  Milo,  but 
like  all  great  schemes  it  would  have  its  drawbacks — Byron 
with  his  deformed  foot,  Milton  with  his  sightless  eyes, 
Kobei't  Louis  Stevenson  with  his  tubercular  lungs,  and  a 
host  of  others  would  have  been  promptly  dispatched  under 
such  a  system,  and  aside  from  the  mere  question  of  brains, 
the  world  would  be  a  heavy  loser  by  the  removal  of  such 
men  as  the  German  Emperor,  who,  though  he  has  a 
palsied  arm,  has  originated  a  style  in  moustaches  that  has 
created  a  greater  sensation  than  did  Kipling's  Recessional. 
The  office  of  the  physician  is  to  conserve  life,  not  to 
destroy  it.  The  most  hideous  monstrosity  is  protected  by 
the  commandment,  "Thou  shalt  not  kill,"  and  the  patient, 
who,  suffering  from  an  incurable  or  painful  malady,  would 
wish  to  end  it  all,  must  adopt  the  method  of  Hamlet  and 
shoulder  his  own  responsibilities. 

Expert  witnesses  have  in  many  cases  been  subject  to 
the  ridicule  of  communities,  and  often  with  a  show  of 
reason,  I  presume  that  you  are  all  more  or  less  con- 
versant with  cases  that  have  been  tried  in  Courts,  in 
which  one  set  of  medical  witnesses  has  been  heard  to 
give  testimony  directly  opposed  to  that  of  another  set. 

Before  concluding  that  some  one  was  lying,  or  at 
least,  before  concluding  that  such  testimony  is  valueless,  I 
ask  you  to  visit  a  so-called  Court  of  justice,  and  watch  the 
revolutions  of  its  ponderous  wheels.  \\'atch  the  antics 
of  lawyers  whose  object  it  is,  not  to  get  the  whole  truth, 
but  only  such  part  of  it  as  may  be  favourable  to  their 
cause.  Listen  well  to  the  rulings  of  the  Court,  for  it  will 
bp  a  revelation  to  you.  If  you  are  a  conscientious  man 
you  will  go  home  each  night  and  pray  earnestly  not  to  be 
allowed  to  fall  into  the  sin  of  misjudging  others^ — for  if 
you  do  not  do  this  you  will  be  sure  to  conclude  that  the 
Court  is  more  concerned  in  having  his  judgment  stand  on 
appeal,  than  he  is  in  meeting  out  justice  to  the  litigants. 

The  medical  man  appears  in  a  murder  trial  to  estab- 
lish the  cause  of  death.  The  victim  was  shot  through  the 
heart.  He  swears  that  the  wound  was  the  cause  of  death. 
The  murdered  man  was  fifty  years  of  age.  His  father 
died  of  cerebral  apoplexy.  The  lawyer  for  the  defence 
asks:  ''Did  you  examine  the  brain  of  the  deceased?" 
Answer:  ''No."  "Can  you  swear  positively  that  he  didn't 
die  of  apoplexy?"  Answer:  "No."  "The  man  is  a  fool," 
say  you.  "Not  at  all."  If  he  said  "Yes,"  he  would  be 
made  out  a  perjurer. 


FAIUFIELD:   some   medical  fallacies.  201 

This  is  an  extreme  case,  but  I  only  give  it  to  illustrate 
the  difficulties  of  the  situation.  If  the  medical  witness 
were  allowed  to  go  on,  and  in  his  own  way  give  an  opinion, 
with  the  reasons  for  such  opinion,  things  would.be  greatly 
simplitied.  It  is  safe  to  say  that  the  great  bulk  of  medical 
expert  testimony  is  honestly  given,  and  is  helpful  to  the 
adjudication  of  controversies.  When  it  is  not  so,  the 
trouble  is  with  the  expert,  and  not  with  the  system.  I 
have  little  sympathy  with  the  so-called  expert  who  gets 
into  hot  water  on  cross  examination.  Let  me  tell  you  how 
to  judge  of  the  value  cf  an  expert's  testimony.  The  advo- 
cate whose  cause  he  is  hurting,  will  treat  him  with  re- 
spect during  the  cross  examination;  but  when  he  comes  to 
the  closing  argument,  he  will  try  to  convince  the  jury  that 
the  expert  was  mistaken,  unless  the  case  should  happen  to 
be  tried  in  Brown  County,  in  which  case  he  will  simply 
€all  him  a  liar  and  a  thief. 

If  I  were  in  search  of  a  strictly  commercial  enterprise, 
I  should  adopt  the  manufacture  and  sale  of  a  so-called 
''health  food."  The  field  has  been  worked  to  a  consider- 
able extent,  but  not  enough  to  prevent  a  successful  ex- 
ploitation. 

Now,  you  know  that  all  the  health  food  people  argue 
from  nature,  that  is,  they  pretend  to  follow  along  lines 
indicated  by  observation  of  the  habits  of  animals.  Food 
should  be  eaten  raw,  and  should  be  such  as  exists  natur- 
ally. Butter  should  be  superceded  by  vegetable  oils. 
Whole  wiieat  flour  should  take  the  place  of  the  patented 
article,  because,  forsooth,  the  whole  wheat  kernel  was 
intended  for  nutriment. 

Now,  I  should  follow  out  a  line  of  argument  that 
would  receive  support  from  all  the  health  food  cranks  in 
the  country.  I  should  not  only  use  the  whole  wheat,  but 
I  should  also  include  the  straw,  and  the  roots,  and  even 
the  thistles,  for  do  they  not  grow  together?  I  should  add 
the  chicken,  feathers  and  all,  for  the  feathers  would  not 
be  there  if  they  were  not  intended  to  be  eaten.  I  would 
add  a  sprinkling  of  gravel,  for  the  ostrich  with  his  perfect 
digestion  demands  it.  Then  a  few  tin  cans,  and  pieces  of 
leather,  because  the  goats  from  the  eighth  ward  thrive 
upon  them.  A  sprinkling  of  grasshoppers  and  a  high- 
sounding  name,  suggestive  of  a  connection  with  a  church 
and  my  fortune  would  be  made. 

Is  this  overdrawn?  Not  a  bit  of  it.  The  appetite  is 
no  longer  a  guide  to  what  we  should  eat.  The  feelings  of 
the  person  are  no  loner  consulted;  reason  itself  has  been 
dethroned  in  thi*;  mad  rush  for  the  elixir  of  eternal  youth. 
The  end  of  the  health  foods  will  come,  but  the  ingenuity 


202  FAIRFIELD:   SOME   MEDICAL  FALLACIES. 

of  the  clever  Cliailatoii  will  last,  and  wheii  he  has  ex- 
hausted this  field  he  will  invade  another  where  suckers 
will  be  equally  plentiful.  Before  leaving  the  subject  of 
foods,  let  me  say  that  the  appetite  was  given  us  to  guide 
in.  the  right  direction.  When  it  leads  us  astray  it  is  be- 
cause we,  by  previous  abuses,  have  led  it  astray.  iSome 
foods  are  best  eaten  raw  and  some  cooked.  Hlome  require 
little  boiling  or  baking,  and  some  a  great  deal.  The  food 
should  be  masticated,  not  bolted.  Articles,  which,  by 
giving  flavour,  add  to  your  enjoyment  of  a  meal,  are  not 
necessarily  injurious.  A  little  pepper,  mustard,  vinegar, 
catsup,  pickel,  etc.,  each  is  good  in  its  place.  They  stimu- 
late the  flow  of  the  digestive  fluids  and  thereby  assist  to 
proper  digestion. 

Home  people  are  continually  crying  out  against  the 
giving  of  drugs,  especially  those  of  the  mineral  group. 
They  do  not  object  to  the  vegetable,  preparations,  for  the 
Good  Lord  intended  them  for  use  as  medicines,  else  he 
would  not  have  created  them.  Minerals  are  for  use  in  the 
arts,  etc.  I  suppose  I  should  bow  down  and  worship 
these  good  people  who  have  such  a  thorough  knowledge 
of  the  Lord's  intentions.  I  should  feel  that  they  must  be 
very  worthy,  else  they  would  not  be  so  entrusted  with  the 
welfare  of  mankind,  but  having  taken  a  few  gallons  of 
decoctions  and  vegetable  pills  in  my  youth,  on  the  ground 
that  they  could  do  no  harm  because  they  were  "vegetable," 
and  having  suft'ered  the  cramps  and  nausea  that  followed 
their  administration,  I  fear  I  have  failed  in  the  develop- 
ment of  my  bump  of  veneration.  As  a  matter  of  fact 
minerals  are  needed  in  the  animal  economy,  and  we  could 
not  live  without  them.  Our  bodies  are  largely  mineral 
and  our  appetites  lead  us  to  supply  ourselves  with  the 
things  that  contain  them.  All  animals  crave  salt,  which 
is  sodium  chloride,  a  mineral.  The  blood  contains  iron 
magnesium,  bone,  lime  and  soda,  nerve  tissue,  i)hosphorus, 
etc.  These  are  only  a  few  of  the  elements  I  might  name. 
Comparativelv  few  'mineral  substances  exist  which  are  not 
found  in  the  animal,  man,  and  science  is  adding  to  their 
number  each  vear.  You  know  that  the  establishment  of 
the  Keelev  cures,  with  their  so-called  chloride  of  gold 
treatment  has  introduced  the  precious  metal  into  the 
bodies  of  nianv  of  our  aristocrats,  and  we  may  expect  to 
hear  in  a  short  time  that  they  are  no  longer  buried  or 
cremated  when  they  die,  but  instead,  are  sent  to  the  mint 

to  be  assayed.  x  •      +i       „.r.c+ 

Vegetables,    on    the    other    hand,    contain    the    most 

dangerous    and     poisonous    alkaloids.     Opium     with    its 

active     principles;      morphine     and     codia;     belladonna, 


FAIRFIELD:   SOME  MEDICAL  FALLACIES.  2O5 

ati'opia,  uiix  vomica,  from  which  strychnia  is  obtained, 
and  hydrocyanic  acid,  which  exists  in  the  almond,  are 
examples  of  what  may  be  secured  from  the  pharmacoepia 
of  safety.  All  of  these  preparations  are  useful  in  the 
treatment  of  disease,  but  they  should  be  handled  by  per- 
sons, who,  being  aware  of  their  dangerous  properties,  will 
efficiently  safeguard  their  administration. 

Upon  the  subject  of  criticism  of  one  physician  by 
another,  I  wish  to  say  a  few  words.  You  know  that  there 
was  a  time  when  it  became  the  duty  of  the  physician  so 
soon  as  he  superceded  another  in  any  case,  to  denounce 
the  first  one  as  a  fool,  and  to  direct  that  all  the  medicines 
left  in  the  house  should  be  promptly  thrown  out  of  the . 
window.  Of  course,  such  things  do  not  occur  now,  or  at 
least  very  rarely.  Knowing  what  I  do,  and  were  I  a  lay- 
man, if  any  man  should  attempt  any  such  action,  I  should 
show  him  the  door.  Such  actions  should  be  an  insult  to 
your  intelligence.  All  physicians  are  bound  by  their 
self-interest  to  do  the  very  best  they  can  for  their  patients. 
They  all  possess  more  or  less  common  sense,  and  they  cer- 
tainly possess  some  technical  knowledge,  else  they  would 
not  be  licensed.  What  would  you  think  of  a  man  in  any 
other  walk  of  life  who  should  act  as  though  he  only  needed 
a  calf  binding  and  plenty  of  shelf  room  to  be  an  improve- 
ment on  the  Encyclopaedia  Brittanica?  They  puff  them- 
selves out,  tell  you  about  the  wonderful  things  they  do, 
incidentally  mentioning  the  fact  that  their  competitors 
are  unfortunately  inferior,  and  if  you  are  at  all  credulous, 
you  thank  the  Almighty  that  the  earth  was  made  round, 
for  if  it  were  flat,  and  a  couple  of  these  heavy  weights 
chanced  to  get  away  from  the  center,  it  would  tip  up  and 
we  would  all  be  thrown  into  space. 

It  is  said  that  the  world  takes  one  at  his  own  esti- 
mate. This  is  not  true.  Our  asylums  are  full  of  people 
who  think  that  they  should  guide  the  destiny  of  nations. 

Don't  appear  to  be  entertained  by  one  of  these  ''know- 
alls."  Don't  allow  them  to  think  that  yours  is  not  a 
higher  order  of  intelligence.  Fortunately,  you  will  meet 
with  fev/  of  these  in  the  present  day.  The  intelligent 
physician  understands  that  he  is  only  lowering  himself 
by  such  streetcomer  methods,  and  if  he  has  no  manhood 
in  him  he  refrains  .from  unjust  criticism  simply  because 
it  doesn't  pay.  He  knows  that  a  man  rarely  attains  emin- 
ence by  pulling  others  down,  and  he  realizes  that  the  in- 
telligence of  the  public  is  not  the  same  in  the  20th 
centui'v  as  it  was  in  the  lOth. 

It  is  desirable  that  the  relations  of  the  physician  and 
the  patient  be  very  close;  that    they    should    trust    each 


204  FAIRFIELD:   SOME   MEDICAL  FALLACIES. 

other,  Lave  faith  in  each  other,  and  be  friends  in  the  best 
sense  of  the  word.  When  you  no  longer  trust  your  phy- 
sician you  do  hiin  an  injury  by  employing  him,  and  when 
you  change  to  another,  don't  imagine  that  he  will  go  over 
the  hill  to  the  poorhouse.  This  is  one  of  the  common 
mistakes  people  make.  Just  remember  that  so  soon  as 
you  discharge  him,  your  enemy  will  become  his  friend. 
If  you  have  two  enemies,  the  doctor  is  the  gainer. 

Does  the  doctor  have  a  deep  interest  in  the  welfare  of 
all  his  patients?  Does  he  not  feel  terribly  hurt  when  one 
of  them  conclude  that  the  man  who  has  taken  care  of  his 
body  for  years  is  no  longer  fit  to  do  so?  Well,  that  de- 
pends upon  circumstances.  There  are  many  men,  and  a 
few  women  whose  loss  from  a  fairly  developed  clientele 
does  not  leave  an  aching  void.  I  have  often  looked  upon 
such  a  change  with  a  feeling  of  profound  thankfulness,  and 
satisfaction,  and  when  I  have  seen  the  other  physician  dis- 
missed, and  myself  substituted,  and  when  I  have  iieard 
the  man  who  has  served  them  well  and  faithfully  vilified 
and  his  ability  questioned,  I  have  immediately  commenced 
plans  to  get  rid  of  this  very  latest  acquisition,  the  easiest 
way  to  do  so  being  to  intimate  that  you  don't  feel  equal  to 
assuming  such  a  grave  responsibility.  Money  is  not  every- 
thing. Self-respect  is  something,  and  a  self-respecting 
medical  man  cannot  undertake  the  case  of  all  people. 
Some  of  them  belong  to  the  veterinary  surgeon  by  rights, 
and  some  to  Dowie. 

I  will  not  apologize  for  anything  I  have  said  to-night. 
I  am  not  entitled  to  any  thanks  for  having  unburdened 
my  mind  to  you.  I  have  carried  many  of  these  ideas  for 
years,  and  in  giving  them  to  you,  I  am  simply  freeing  my 
mind.  By  giving  me  this  opvtortunity,  it  is  I  that  am  in- 
debted to  you. 

One  of  the  most  universal  of  beliefs  is  that  the  phy- 
sician should  do  all  the  charitable  work  of  the  community, 
not  only  freely  but  cheerfully.  The  sick  should  be  at- 
tended without  a  murmur  of  complaint.  Thp  employer 
who  pays  such  wages  as  to  make  the  saving  of  a  dollar  an 
impossibility,  has  no  hesitation,  when  his  servant  falls  ill, 
to  ask  the  physician  to  attend  him  without  charge,  and  he 
feels  verv  much  hurt  if  the  physician  at  the  same  time 
asks  him  to  furnish  the  sick  man's  family  with  necessary 
sustenance  during  the  period  of  his  illness.  The  city  poor 
are  given  over  to  the  tender  mercies,  not  of  the  most  com- 
petent, but  the  cheapest  physician.  The  grocer  gets  full 
pay  for  the  flour  and  potatoes  he  furnishes  the  poor,  the 
coal  dealer  gets  full  price  for  his  coal;  every  one  else  is 
fully  paid  for  his  services  in  their  behalf;  only  the  phy- 


faikfikld:  some  medical  fallacies.  205 

sician  is  underpaid.  I  make  no  complaint  on  this  score, 
for  I  am  not  a  candidate  for  this  office,  but  it  seems  to  me 
that  the  poor  and  the  unfortunate  have  a  right  to  com- 
plain against  a  system  which  is  obviously  vicious.  As 
proof  of  this  assertion  I  have  only  to  state  that  the 
salaries  of  the  County  physician  and  City  physician  com- 
bined, would  not  be  sufficient  to  buy  the  drugs  necessary 
to  the  proper  care  of  the  insane  of  this  County  alone. 
When  we  consider  that  the  salaries  include  the  furnish- 
ing of  all  medicines  and  surgical  appliances,  you  will  not 
fail  to  see  the  justice  of  recognizing  the  self-sacrificing 
devotion  of  these  gentlemen,  for,  of  course,  we  assume  that 
nothing  but  the  best  drugs  are  used  in  this  branch  of  the 
public  service. 

In  closing,  I  wish  to  impress  upon  you  the  fact  that 
physicians  have  some  rights  as  men,  even  as  gentlemen,  in 
the  community  in  which  they  live.  You  and  I  have  no 
inherent  right  to  pass  judgment  upon  their  motives,  their 
manners,  or  their  abilities,  without  something  more  than 
a  speaking  acquaintance  with  them.  The  school  teacher, 
clergyman  and  the  physician  are,  by  common  consent,  the 
objects  of  criticism  at  all  pink  teas.  The  servant  girl 
question  is  always  to  the  front  at  the  assemblages  of  the 
400,  but  among  those  of  the  higher  order  of  intellect,  who 
contribute  to  the  elevation  of  mankind  by  the  formation 
of  a  club  to  which  they  give  the  high  sounding  name  of  the 
"Colonial  Queens"  or  something  equally  euphonious;  to 
these  people  with  their  pink  teas  distinctively  belongs  the 
duty  of  villifying  the  frail  little  lady  who  industriously 
and  conscientiously  trys  to  train  the  young  entrusted  to 
her  care,  to  these  belong  the  privilege  of  lampooning  the 
preacher  who  daily,  on  bended  knees,  implores  a  blessing 
on  them  from  on  high,  and  to  these  is  given  the  task  of 
destroying  the  reputation  of  a  physician  who  is  probably 
labouring  honestly  and  faithfully,  if  not  successfully,  to 
overcome  and  defeat  suffering  and  death. 

Fortunately,  there  is  a  bright  side  to  the  shield.  In 
every  community  there  are  thoughtful,  kind  and  consider- 
ate Christian  men  and  women.  Some  of  them  may  not  be 
regular  church  goers,  but  all  possess  that  wiiich  the 
French  term  "Noblesse  oblige,"  and  which,  for  want  of  a 
better  term,  we  will  call  manhood  and  womanhood.  They 
are  the  bright  stars  which  shineiupon  the  pathway  of  man, 
whether  he  be  physician,  clergyman,  teacher,  merchant  or 
labourer.  In  the  darkest  hours,  their  memory  is  the 
sweetest.  I  have  felt  the  hearty  pressure  of  their  hands 
when  my  life  seemed  a  mistake  and  a  failure.  They  are 
to  me  the  oases  in  the  desert  of  conflict  with  disease.     The 


206  TREATMENT  OP  SCARLET  FEVER. 

influence  of  one  such  individual  is  irresistable.  In  their 
presence  one  feels  safe  and  secure.  Their  afflictions  are 
my  afflictions,  and  my  burdens  are  shared  by  them.  So 
long  as  they  exist,  the  practice  of  medicine  will  not  be 
drudgery,  and  men  will  continue  to  exert  their  best  efforts 
to  the  end  that  sutfering  humanity  shall  find  a  measure  of 
relief. 


Selected  Articles. 


PROPHYLAXIS  AND  TREATMENT  OF  SCARLET  FEVER. 

By  Newton  M.  Otis,  M.  D.,  Fairbury,  III. 

•  Scarlet  fever  is,  with  the  possible  exception  of  small- 
pox, the  most  contagious  of  the  acute  infectious  diseases, 
and  the  physician's  duty  in  regard  to  prophylaxis  is  an 
imperative  one.  The  whole  subject  is  one  of  quarantine  of 
the  patient  and  his  attendants,  and  the  disinfection  of  the, 
patient,  the  room  he  occupies  and  everything  that  was 
brought  in  contact  with  him.  This  must  be  insisted  upon 
in  the  mildest  as  well  as  in  the  most  severe  cases. 

The  patient  should  occupy  a  room  from  which  every- 
thing not  absolutely  essential  to  comfort  has  been  re- 
moved. This  includes  all  curtains,  rugs,  pictures,  hang- 
ings, clothing,  etc.  It  should  be  well  lighted  and  heated, 
and  as  far  removed  and  completely  isolated  from  the  other 
living  rooms  of  the  dwelling  as  possible.  Into  it  only  the 
physician  and  nurses  should  enter.  Whenever  possible  an 
adjoining  room  should  also  be  set  aside  for  the  use  of  the 
nurse  and  immediate  attendants. 

I  do  not  believe  that  the  hanging  of  a  sheet  moistenecB 
with  carbolized  or  other  germicidal  solution,  over  the  dooi^ 
or  in  the  room,  has  any  other  value  than  to  impart  a  false 
sense  of  security.  It  should  be  remembered  that  the  area 
of  contagion  in  scarlet  fever  is  small,  probably  but  a  few 
feet  from  the  patient,  and  the  infection  is  carried  from 
the  sick-room,  either  by  the  attendants,  or  by  the  beding, 
clothing  or  excreta  of  the  patient,  or  by  some  object 
brought  in  close  contact  with  him.  Everything  in  a  room 
occupied  hy  a  scarlet  fever  patient  must  he  looked  upon  as  a 
possible  source  of  infection. 

The  physician  himself  too  often  ignores  the  very  pre- 
cautions he  insists  others  should  observe,  and,  as  an  ex- 
ample, and  for  the  protection  of  his  patients,  before  enter- 
ing the  sick-room  should  don  a  garment  which  completely 


TREATMENT  OF  SCARLET  FEVER.  2O7 

covers  his  clothing,  and  before  visiting  other  patients 
should  wash  his  hands,  face  and  beard  with  a  germicidal 
solution.  The  nurse  is  more  liable  than  the  physician  to 
convey  the  disease,  and  upon  leaving  the  apartments  of 
the  sick  should  make  a  complete  change  of  clothing  and 
use  a  germicidal  solution,  paying  especial  attention  to  her 
hair. 

Quarantine  should  be  maintained  for  a  period  of  six 
to  eight  weeks  from  the  date  of  invasion.  It  must  be 
longer  if  at  the  expiration  of  this  time  desquamation  is 
not  complete,  or  the  case  is  complicated  by  suppurating 
glands  of  the  neck  or  a  purulent  discharge  from  the  ear, 
nose  or  throat.  In  very  mild  cases  four  weeks  is  probably 
a  long  enough  time  for  quarantine. 

For  the  disinfection  of  the  clothing,  bedding,  towels, 
etc.,  a  standard  solution  of  copper  sulphate  1  lb.  and  bi- 
chloride of  mercury,  drachms  4,  to  the  gallon,  of  water, 
and  used  in  the  proportion  of  two  ounces  to  the  gallon,  is 
efficient  and  cheap.  Into  a  boiler  or  tub  containing  this 
solution,  all  bedding  and  clothing  is  placed,  followed  by 
the  usual  process  of  the  laundry.  The  excreta  should 
stand  for  some  hours  in  a  strong  carbolic  or  chlorinated 
lime  solution  before  they  are  disposed  of.  Dishes,  trays, 
napkins,  etc.,  should  first  be  rinsed  in  a  disinfecting  solu- 
tion before  leaving  the  sick-room. 

When  desquamation  begins  the  patient  should  receive 
a  daily  soap  and  water  bath,  and  twice  daily  should  be 
annointed  with  a  five  per  cent,  carbolized  vaseline  or  olive 
oil. 

The  room  occupied  by  the  patient  should  be  disin- 
fected, preferably  with  formaldehyde  gas,  but  if  an  appar- 
atus is  not  at  hand,  fumigation  with  sulphur,  if  properly 
done,  is  efficient.  At  least  4  lbs.  of  sulphur  must  be  used 
for  each  1,000  c.  feet  of  space.  All  doors  and  windows 
must  be  closed  and  their  crevices  stopped.  The  walls 
should  be  moistened,  or  wet  paper  hung  in  the  room,  as 
moisture  is  essential  to  success.  Leave  the  room  closed 
for  twenty-four  hours,  after  which  scrub  the  walls  and 
wood  work  with  a  bichlorid  solution.  All  books,  pictures 
and  playthings,  which  have  been  in  the  hands  of  the 
patient,  should  be  burned. 

Formaldehyde  gas  is,  of  course,  superior  to  sulphu'r 
as  a  disinfectant.  At  least  one  pint  of  fluid  must  be  used 
for  each  1000  cubic  feet  of  space,  and  it  is  to  be  remem- 
bered that  its  action  is  stronger  in  a  warm,  dry  atmos- 
phere. It  has  been  shown  that  sheets  sprinkled  with) 
formaldehyde  and  hung  in  a  room  which  has  been  tightly 
closed  and  previously  warmed,  forms  an  easy  way  of  using 


208  TUEATMEXT  OF  SCARLET  FEVER. 

this  agent.  An  ordinary  sheet  will  absorb  about  150  to 
200  cubic  c.  of  formalin,  and  this  is  sufficient  to  disinfect 
500  cubic  feet  of  space.  Recent  experiments  of  Yehrman, 
of  the  Chicago  Board  of  Health,  have  demonstrated  the 
etlectiveness  of  the  sheet  method  of  using  formalin.  It& 
simplicity,  together  with  the  fact  that  unlike  sulphur,  it 
will  not  fade  or  injure  the  contents  of  the  room,  will  un- 
doubtedly make  this  the  common  method  of  disinfection. 
It  is  recommended  that  after  the  sheets  are  hung  in  the 
room  the  formalin  be  sprinkled  on  them  by  means  of  an 
atomizer. 

The  efforts  of  a  physician  to  prevent  the  spread  of  a 
contagious  disease  is  usually  a  thankless  task,  and  not 
always  can  we  carry  out  in  detail  the  methods  advocated, 
in  this  paper,  but  the  nearer  we  can  approach  it,  the  more 
certain  will  be  our  success. 

Treatment. — In  no  disease  of  childhood  is  it  more  im- 
portant to  treat  the  patient  and  not  the  disease  than  in 
scarlet  fever.  In  a  disease  which  presents  itself  in  such 
varied  types,  and  which  has  so  many  complications  that 
every  case  must  be  a  law  unto  itself.  Since  Sydenham,  in 
the  seventeenth  century,  gave  us  the  first  clear  description 
of  scarlet  fever,  until  the  present  time,  many  drugs  have 
been  offered  as  specifics,  but  all  have  proved  valueless, 
and  a  clearer  conception  of  the  disease  has  taught  us  that 
it  has  a  self-limited  course  which  cannot  be  modified  by 
any  known  treatment.  Our  efforts  are  to  modify  its  symp- 
toms, shorten  its  course  and  prevent  its  complications. 

I  shall  endeavour  not  to  trespass  on  the  subject  which 
is  to  follow,  but  a  discussion  of  scarlet  fever  would  be  in- 
complete without  considering  those  complications  of  the 
throat,  ear  and  kidneys,  which  occur  with  such  frequency 
as  to  become  a  part  of  the  clinical  history  of  most  cases. 

Acknowledging  that  our  treatment  is  purely  sympto- 
matic, I  shall  not  consider  the  disease  in  its  various  stages, 
but  discuss  the  therapeutic  measures  applicable  to  the 
symptoms. 

Fever. — For  the  reduction  of  the  temperature,  the  use 
of  cold  water  supersedes  all  other  measures  in  efficiency. 
Mild  cases  with  a  temperature  below  103.5,  require  no 
treatment,  but  sponging  with  water  at  a  temperature  of 
80  will  do  much  to  allay  restlessness  and  produce  a  feeling 
of  comfort.  A  temperature  of  104  or  over  is  always  an 
indication  of  active  measures  and  either  the  cool  bath, 
or  cold  pack  will  be  found  useful.  I  prefer  the  cold 
pack,  as  it  is  less  troublesome  to  apply  and  more  certain 
in  its  effect.  The  patient  is  wrapped  in  a  sheet  which  has 
been  dipped  in  water  at  a  temperature  of  75  or  80  degrees 


TREATMENT  OF  SCARLET  FEVER.  209 

and  placed  in  bed  with  light  woolen  blankets.  The  nurse 
should  place  a  hot  water  bottle  at  the  patient's  feet,  as  the 
extremities  are  apt  to  become  chilled.  An  ice  bag  or  cold 
cloths  are  applied  to  the  head.  The  patient  should  re- 
main in  the  pack  from  fifteen  to  twenty  minutes,  cold 
water  being  sprinkled  on  the  enveloping  sheet  at  frequent 
intervals,  with  gentle  rubbing  of  the  body  as  long  as  the 
pack  is  continued.  The  pack  not  only  reduces  tempera- 
ture, but  in  cases  characterized  by  the  tardy  appearance 
of  the  eruption,  it  will  be  found  the  quickest  means  of 
developing  the  full  rash.  There  is  one  other  measure  for 
using  cold  water  for  the  reduction  of  temperature  which 
is  not  as  commonly  used  as  its  merits  would  warrant.  I 
refer  to  the  high  colon  injection  of  ice  water.  In  malig- 
nant cases  with  very  high  temperature  this  procedure  will 
be  found  very  efficient.  The  water  must  be  as  cold  as 
would  be  used  for  drinking  purposes,  and  must  be  injected* 
high  into  the  colon  by  means  of  a  long  rubber  tube.  This 
is  one  of  the  quickest  and  surest  ways  of  reducing  tem- 
perature. 

I  do  not  believe  the  cold  tar  derivatives  should  be  used, 
for  their  antipyretic  effect,  but  small  repeated  doses  of 
phenacetine  will  be  found  useful  for  their  sedative  action. 
Where  there  is  great  restlessness,  sodii  bromide,  either 
alone  or  in  combination  with  phenacetine,  has  proved  use- 
ful. Plenty  of  cold  water  should  be  allowed,  and  older 
children  may  hold  pieces  of  cracked  ice  in  the  mouth. 

Vomiting,    so    common  in    the    beginning    of    scarlet 
fever,  seldom  persists  after  the  first  few  hours,  and,  like 
convulsions,  has  a  very  different  interpretation  during  the 
period  of  invasion    than  when  it  occurs   at   a   later   date. 
Bismuth,  or  small  repeated  doses  of  calomel,  about  one- 
tenth    grain,    given    every   hour    until   the   bowels   move 
freely,  is  usually  all  that  is  required.     The  diet  should  be 
curtailed  in  amount,  or  discontinued  altogether,  as  long 
as   this   symptom   lasts.     Convulsions   occurring  at  a  late 
period    of    the    disease  are  usually   uremic.     At  the  be- 
ginning they  are  usually  due  to  the  high  temperature  and 
toxic  action  of  the   scarlatina   infection.     They    are    best 
controlled  by  the  use  of  bromides,  which  must   be    given 
in  comparatively  large  doses,  or  by  chloral  hydrate  which 
is   best   given   per   os,  dissolved   in    milk,   and    by   those 
measures  already  described  for  reducing  the  temperature. 
It  is  well  in  the  beginning  of  every  case  of  scarlet  fever  to 
secure  a  free  evacuation  of  the  bowels  at  once,  and  by  so 
doing  we  remove  a    possible    source   of   irritation,  which 
frequently  acts  as  a  causative  factor  in  producing  convul- 
sions. 


^10  TKEATMENT  OF   SCAULET  FEVER. 

That  the  heart  is  especially  affected  by  the  scarlatina 
infection  is  shown  by  the  fact  that  the  pulse  is  always 
rapid  in  proportion  to  the  temperature,  and  in  all  severe 
cases  measures  to  sustain  it  are  called  for.  This  is  especi- 
ally true  in  cases  complicated  with  suppuration  of  the 
glands  of  the  neck,  otitis  media  and  gangrenous  processes 
of  the  throat. 

An  irregular,  rapid  pulse  with  feeble  first  sound  is 
always  an  indicator  for  stimulation,  no  matter  w^hat  the 
period  of  the  disease.  Alcoholic  stimulants,  digitalis, 
stropthanthus,  ether,  camphor  and  ammonia  are  most  use- 
ful. The  quantity  to  be  given  is  governed  only  by  their 
effect.  Alcohol  is  best  given  in  the  form  of  brandy  or 
whiskey,  diluted  with  hot  or  cold  water.  Digitalis  I  pre- 
fer to  give  as  the  fluid  extract,  in  1  m.  doses  to  a  child  of 
live  years,  repeated  every  three  or  four  hours.  Strychnine 
is  best  given  hypodermically  sin  to  ^h  of  a  grain  and 
camphor,  which  is  one  of  the  best  cardiac  tonics,  is  also 
given  hypodermically  in  doses  of  1-4  to  1-2  gr.  to  a  child  of 
live  years. 

The  throat  in  mild  cases  will  require  little  or  no 
treatment.  Ice  held  in  the  mouth  will  relieve  the  heat 
and  dryness,  while  the  external  application  of  camphor- 
ated oil,  and  warmi  compresses  are  useful.  In  those  cases 
characterized  b}'  an  intense  angina,  pseudo  or  true  diph- 
theria, with  marked  cervical  adenitis,  we  have  one  of  the 
serious  complications  to  deal  with.  Topical  applications 
to  the  throat  are  useful  if  the^'  can  be  used  without  a 
great  resistance  on  the  part  of  the  patient,  but  when  every 
ai>plication  means  a  struggle,  their  frequent  repetition 
should  not  be  practiced.  To  give  a  list  of  drugs  for  local 
treatment  of  the  throat  would  include  nearly  every 
astringent  and  local  sedative  in  the  pharmacopoeia.  Every 
physician  has  his  favourite  remedies,  and  as  cleansing  of 
the  throat  of  its  secretions  is  our  object,  there  is  little 
choice.  Personally  I  have  found  hydrogen  peroxide,  car- 
bolic acid  and  boracic  acid  useful.  The  first  I  use  as  a 
swab  for  the  throat,  and  spray  in  the  nose.  Carbolic  acid 
is  used  as  a  spray  in  combination  with  tannic  acid, 
glycerine  and  water,  and  boracic  acid  as  a  gargle  or  swab. 
The  adenitis  is  best  controlled  by  the  use  of  the  ice 
bag  or  cold  pack.  Suppuration  is  less  likely  to  occur  than 
when  heat  is  used,  while  pain  and  tenderness  is  relieved 
equallv  as  well.  ,        . 

When  suppuration  seems  imminent,  warm  antiseptic 
compresses  should  be  used  and  free  incisions  made,  with 
irrigation  as  soon  as  pus  becomes  localized.  Enlarged 
glands  which  show  little  tendency  to  change  may  often  be 


TREATMENT   OF   SCARLET   FEVEU.  211 

resolved  by  the  use  of  an  ointment  containing  ichthyol, 
mercury  and  belladonna. 

The  diphtheritic  processes  in  the  throat  of  the  scarlet 
fever  patient  calls  for  an  accurate  differential  diagnosis 
before  the  line  of  treatment  to  be  followed  is  decided  upon. 
The  exudate  occurring  during  the  height  of  the  scarlet 
fever  process  is  usually  of  streptococcic  origin,  while  at  a 
later  period  it  is  more  often  true  diphtheria  due  to  Klebs- 
Loetler  bacillus.  In  the  former  instance  those  measures 
already  described  for  the  treatment  of  the  angina  will  be 
found  useful,  while  in  the  latter  antitoxin  is  our  main  reli- 
ance. Without  the  aid  of  the  microscope  the  differential 
diagnosis  is  often  difficult,  sometimes  impossible,  and  the 
old  adage,  "When  in  doubt,  play  trumps,"  is  most  applic- 
able. 

When  the  diphtheritic  membrane  involves  the  larynx 
the  use  of  the  calomel  fumigation  is  often  of  marked  bene- 
fit. Ten  to  fifteen  grains  of  calomel  should  be  burned 
under  an  improvised  tent  or  canopy,  and  repeated  every 
two,  three  or  four  hours,  as  the  condition  may  warrant, 
Intubation  is  of  course  indicated. 

When  stenosis  is  not  relieved  by  these  measures,  after 
a  careful  differential  diagnosis,  and  the  use  of  antitoxin 
early  in  the  case  of  true  diphtheria,  or  the  other  measures, 
if  the  membrane  is  a  pseudo-diphtheria,  are  usually  all 
that  will  be  required. 

Complications  of  the  ear  are  troublesome  and  should 
receive  prompt  attention.  We  seldom  have  a  simple 
catarrhal  inflammation,  but  an  inflection  of  the  tympanic 
cavity  due  to  streptococcus.  As  soon  as  an  otitis  is  sus- 
pected or  complained  of,  a  careful  examination  should  be 
made  The  ear  speculum  with  strong  reflected  light 
should  be  used,  and  if  there  is  no  bulging  of  the  drum,  we 
may  trv  palliative  measures.  A  blister  or  leech  may  be 
applied*^  in  front  of  the  tragus,  or  hot  water  instilled  into 
the  external  meatus  and  hot  dry  external  applications 
used  Warm  oils,  melted  vaseline  or  irritants,  such  as 
chloroform  or  carbolic  acid,  should  not  be  poured  into  the 

ear.  .  +     n-   w 

If  these  measures  are  not  successful  m  controlling 
pain  and  checking  the  inflammation,  there  is  but  oni 
rational  treatment;  that  is,  paracentesis  of  the  tympanuiT/ 
with  drainage.  This  is  a  very  simple  operation,  lli^ 
point  of  incision  should  be  that  portion  of  the  drum  which, 
is  most  bulging,  and  the  opening  must  be  an  incision  not 
a  mere  puncture.  Carrv  the  incision  well  downward  to 
the  floor  of  the  meatus."    A  free  flow  of  pus  follows  with 


212  TREATMENT  OF  SCARLET  FEVER. 

immediate  relief  of  symptoms.  Cleansing  with  a  boracic 
acid  or  biclilorid  solution  is  all  the  after-treatment  re- 
quired in  simi)le  eases. 

Until  recently  I  had  a  dread  of  this  simple  procedure, 
but  after  performing  it  and  noting  its  excellent  results,  I 
should  not  hesitate  to  do  it  in  every  case  not  relieved  by 
more  simijle  measures. 

Treatment  of  the  post-scarlatina  nephritis  is  that  of 
an  acute  nephritis  occurring  independently  of  this  disease, 
and  to  enter  into  a  detailed  treatment  is  to  involve  us  in 
a  discussion  of  acute  nephritis  in  general. 

During  the  height  of  the  scarlet  process,  the  urine  in 
perhaps  the  majority  of  all  but  the  mildest  cases,  will 
show  traces  of  albumen,  blood  corpuscles  and  a  few  casts^ 
but  this  involvement  of  the  kindneys  is  not  productive  of 
special  symptoms,  and  other  than  warning  us  of  the  pres- 
ence of  renal  irritation,  may  be  ignored. 

The  serious  kidney  lesions  occur  after  the  substance 
of  the  active  fever  process.  It  may  follow  the  mildest 
as  well  as  the  more  severe  cases,  and  may  prove  a  more 
serious  condition  than  was  the  primary  disease. 

The  prophylaxis  of  this  complication  should  receive 
careful  attention.  Every  convalescent  case  should  be 
warned  against  exposure  in  cold  and  damp,  and  the  diet 
should  be  light  and  largely  non-nitrogenous.  Water 
should  be  used  freely,  the  bowels  kept  loose  with  frequent 
warm  baths  to  promote  activity  of  the  skin.  These  mear 
sures,  no  matter  how  carefully  adhered  to,  are  often  of  no 
avail,  and  the  frequency  with  which  nephritis  occurs  in 
spite  of  a  most  careful  regime  has  lead  many  observers  to 
place  but  little  confidence  in  preventive  measures. 

With  the  first  svmptoms  of  kidney  involvement  tte 
patient  should  be  confined  to  bed,  an  absolute  milk  diet 
instituted,  with  free  evacuation  of  the  bowels  induced  pre- 
ferably by  a  concentrated  saline. 

The  urine  may  be  increased  and  rendered  less  irritat- 
ing by  the  use  of  the  alkaline,  or  small  doses  of  acetate  or 
citrate  of  potash  may  be  given.  In  mild  cases  this  is  all 
the  treatment  required. 

Cases  characterized  with  marked  dropsy,  seanty  urine 
and  uremic  symptoms  require  more  active  measures. 
Counter  irritation  over  the  kidneys  maintained  by  the  use 
of  mustard  or  dry  cups  followed  by  poultices,  depletion  by 
the  production  of  copious  water  stools  best  induced  by  the 
Rochelle  or  Epsom  salt,  diaphoreses  from  the  use  of  hot 
wet  pack,  and  the  administration  of  the  milder  diuretics 
such  as  acetate  and  citrate  of  potash,  infusion  of  digitalis 
and  especially  diuretin,  will  be  indicated. 


INCUBATION  OF  SCARLET  FEVER.  213 

Pilocarpin  is  lecommended  for  its  diaphoretic  action, 
but  it  is  a  ma  rived  depressant  and  should  not  be  used  as  a 
routine  treatment.  Kecently  its  use  as  an  inunction  into 
the  skin  (5  cent,  grain  pilocarpine  to  100  grain  ol.  olivea) 
has  been  favourably  commended. 

Uremic  convulsions  will  be  best  controlled  by  the 
hypodermic  use  of  morphia  and  the  rectal  administration 
of  chloral  and  bromides  and  in  cases  with  full  bounding 
pulse  venesection  should  be  tried.  From  two  to  six 
ounces  of  blood  may  be  taken,  according  to  the  urgency  of 
the  symptoms  (Holt).  The  rectal  injection  of  normal  salt 
solution  is  also  useful  in  inducing  a  free  flow  of  urine  and 
aiding  the  elimination  of  toxic  substances. 

Convalescence  requires  iron,  bitters  and  above  all  a 
gradual  return  to  the  customary  habits  and  diet  of  the 
patient. — Medical  Fortnightly. 


ETIOLOGY  AND  INCUBATION  OF  SCARLET  FEVER 

By  Chas.  L.  Hamilton,  M.  D.,  Dwight,  III. 

Read  before  the  Livingston  County  Medical  Society. 

According  to  Osier,  "we  owe  the  recognition  of  scarlet 
fever  to  Sydenham,  before  whose  time  it  was  confounded 
with  measles.  It  is  a  wide-spread  affection,  occurring  in 
nearly  all  parts  of  the  globe  and  attacking  all  races." 

Its  causes  are,  of  course,  both  predisposing  and  excit- 
ing- Very  few  in  our  profession  to-day  deny  that  the 
exciting  or  true  cause  of  scarlet  fever  is  a  germ,  and 
whatever  the  contagious  principle,  so  pronounced  is  its 
character,  that  even  a  moment  in  the  presence  of  a  scarlet 
fever  case,  may  be  sufficient  to  reproduce  the  disease  in  a 
susceptible  individual.  Several  claims  have  been  put 
forth  regarding  the  isolation  of  the  scarlet  fever  germ. 
In  1882  Echlund  claimed  to  have  found  its  specific  germ 
in  the  urine  of  scarlet  fever  patients,  and  also  in  certain 
soil  and  surface  waters.  Later,  Klein  claimed  the  cause 
was  a  streptococcus,  which  produces  an  eruption  in  swine 
similar  to  the  scarlet  fever  eruption  in  the  human  being. 
Still  later,  Edington  and  Jamison  isolated  a  germ  which 
they  found  in  the  blood  of  scarlet  fever  patients  on  the 
first,  second  or  third  days  only,  and  w^hich  re-appeared 
again  in  the  epidermis  on  the  twenty-first  day  of  the 
disease.  W-  J.  Class,  of  Chicago,  has  discovered  a  micro- 
organism in  scarlet  fever  cases,  and  claims  it  to  be  the 
specific  scarlet  fever  germ.  This  he  obtained  from  cul- 
tures from  the  epidermic  scales  and  the  throats  of  800 
patients  affected  with  the    disease.     He   claims   its    chief 


214  INCUBATION  OF  SCARLET  FEVER. 

cultural  characteristics  to  be  its  glutinous  character,  and 
that  it  is  well  marked  iui  primary  cultures  of  germs  taken 
from  the  throat,  growing  a  class  of  organism  closely 
resembling  the  gonococcus,  but  larger.  As  described  by 
him,  it,  is  a  diplococcus,  having  almost  the  appearance  of 
a  tetrad,  owing  to  a  pale  streak  running  transversely 
through  each  half  of  the  organism.  It  takes  the  aniline 
dyes  well  and  is  decolourized  by  (Iriun's  method,  but  not 
completely*  The  culture  medium  is  ordinary  glycerine 
agar,  with  5  per  cent,  sterilized  garden  earth,  (irowth 
occurs  at  35  degrees  C.  in  from  two  to  seven  days,  in  the 
form  of  small  whitish  gray,  semi-transparent  colonies. 

He  gives  the  following  reasons  for  believing  this 
diplococcus  scarlatinae  to  be  the  causative  factor  in 
scarlet  fever: 

1.  ''Because  the  germ  is  invariably  present  in  the 
throat  secretions,  blood  and  scales  of  a  patient  having 
scarlatina,  and  because  it  is  a  separate  and  distinct  organ- 
ism, not  heretofore  described* 

2  "Because  it  has  been  proved  to  be  a  pathogenic 
micro-organism,  killing  mice,  when  injected  in  minute 
quantities  in  a  space  of  time  varying  from  less  than  one  to 
twenty-four  hours,  according  to  its  virulence. 

3.  "Because  It  produces'  in  swine,  a  disease  whose 
macroscopical  lesions  closely  resemble  those  seen  in 
scarlet  fever  as  it  occurs  in  the  human  patient. 

4.  "Because  the  presence  of  blood  from  a  patient  who 
has  just  recovered  from  an  attack  of  scarlet  fever  inhibits 
its  growth- 

5.  "Because  the  subcutaneous  injection  of  a  virulent 
culture  into  guinea-pigs  will,  under  certain  conditions, 
produce  a  nephritis. 

0.  "Because  personal  experiment  apparently  shows 
that  the  blood  serum  of  a  person  who  has  passed  through 
scarlet  fever  protects  an  animal  from  invasion  of  the 
germ." 

Gradwahl  in  the  Philadelphia  Medical  Journal  (March 
24,  1900)  confirms  the  finding  of  Class'  diplococci  in  scarlet 
fever  cases*  He  discovered  it  in  each  of  seven  cases  at 
periods  in  the  disease  varying  from  the  first  week  until 
convalescence.  Cultures  from  blood  revealed  the  diplo- 
coccus in  four  cases,  and  in  one  case  pure  cultures  were 
obtained  from  the  urine.  He  reproduced  the  disease  by 
inoculation  into  the  vein  of  the  ear  in  swine  (two  cases),  a 
rash  appearing  eight  or  ten  days  after  inoculation.  One 
animal  recovered,  was  killed  and  autopsy  revealed  acute 
nephritis.  The  diplococcus  scarlatinae  was  found  in  both 
blood  and  kidneys. 


INCUBATION  OF  SCARLET  FEVER.  21$ 

Baginsk}-  and  Sommerfeld  have  also  announced  the 
discovery  of  a  micro-organ  ism,  which  they  claim  is  always 
present  in  throat  secretions  and  the  blood  of  scarlet  fever 
patients* 

Class  in  the  Journal  of  the  American  Medical 
Association  (September  29,  1900)  discusses  their  claims  and 
concludes  that  their  micro-organism  is  identical  with  the 
one  previously  discovered  by  himself. 

SOURCE   OF  THE   CONTAGION. 

The  chief  source  of  infection  is  the  patient  himself, 
although  it  seems  probable  that  the  area  of  contagion  is 
limited  to  a  radius  of  a  few  feet.  Secretions  from  the 
nose  and  throat,  the  epidermic  scales,  the  excretions 
(urine,  faeces  and  perspirati(m),  the  serum  of  vesicles,  as 
well  as  the  purulent  discharges  from  nose,  throat,  ear  and 
su;;purating  glands  may  be  the  source  of  infection  to 
others.  From  whatever  source  the  micro-organism  comes, 
it  may  be  disseminated  by  the  clothing  of  the  patient, 
doctor  or  nurse,  the  bedding,  books,  letters,  merchandise, 
papers,  foods,  dust  and  domestic  animals.  Many  cases  of 
the  disease  have  been  traced  to  cats  or  dogs  that  have 
been  fondled  by  affected  children,  and  then  allowed  to  go 
from  the  sick  room  and  mingle  with  other  children,  who 
have  not  had  the  disease,  and  who  have  not  been  otherwise 
exposed  to  the  infective  principle. 

Letters  have  carried  death  into  distant  families,  and 
Sajous*  Annual  mentions  the  case  of  a  little  boy  2  1-2 
years  of  age,  living  in  a  district  w^hich  had  been  free  from 
scarlet  fever  for  many  years,  in  which  investigation 
showed  the  cause  of  inoculation  to  be  a  letter  received  a 
few  days  before  the  little  ])atient  was  taken  sick,  from  his 
grand]>arents,  stating  that  a  child  living  with  them  was 
just  convalescing  from  an  attack  of  scarlet  fever  and  was 
'•shedding  her  skin,"  a  few  pieces  of  which  were  enclosed- 
The  letter  and  contents  were  used  as  playthings  by  the 
little  boy,  and  in  one  day  he  was  taken  sick.  Infection 
has  beeii  traced  to  bedding  which  was  aired  in  an  open 
window  on  the  side  next  to  another  house  in  very  close 
proximitv.  Simply  washing  infected  clothing,  the  handl- 
ing of  toys  and  books,  dust  on  window  ledges  or  facings,  or 
in  cracks  in  the  walls  or  retained  on  the  wall  paper,  all 
these  in  rooms  infected,  and  where  no  adequate  disinfec- 
tion has  been  practiced,  have  caused  new  cases,  occurring 
weeks  or  months  after  all  thoughts  of  the  disease  had  dis- 
appeared from  the  minds  of  the  family  occupying  the 
house.  Foods  often  disseminate  contagion,  and  milk  has 
been  thought  to  be  a  good  medium. 


2l6  INCUBATION  OF  SCARLET  FEVEK. 

Power  and  Klein,  in  London  in  1885,  traced  an  epi- 
demic to  milk  obtained  from  one  dairy,  the  original  cause 
of  the  milk  infection  not  being  definitely  determined. 

The  scarlet  fever  micro-organism  is  much  more 
tenacious  of  life  than  that  of  any  other  disease,  with  the 
possible  exception  of  small-pox,  and  hence  the  above- 
mentioned  carriers  of  infection  may  continue  the  disease 
and  cause  its  development  after  long  periods  of  time,  and 
cases  are  on  record  where  phiythings  have  caused  an  out- 
break of  this  disease  after  seven  years  from  the  time  of 
known  exposure. 

MODE   OF    ENTUY    INTO   THE    SYSTEM- 

The  most  common  way  seems  through  the  respiratory 
mucous  membrane  proven  by  the  early  involvement  of  the 
pharynx,  and  also  by  the  fact  that  tonsillar  troubles 
markedly  predispose  to  infection. 

That  the  alimentary  tract  may  be  the  route  of  infec- 
tion is  also  proven,  by  cases  resulting  from  ingestion  of 
infected  food,  to  be  referred  to  hereafter. 

PERIOD  OF  INCUBATION. 

Much  difference  of  opinion  exists  as  to  the  incubative 
period  of  this  disease.     TUe  Indiana  State  Board  of  Health 
and  the  Chicago  City  Health  Board  give  it  as  from  one  to 
seven  days;  Ginon,  four  to  five  days,  and    in    the    United 
States  Army  Keport  some  years  ago,  Surg.  (Jen.  Hamilton 
gave  it  as  from  one  to  three  or  four  days*     Williams,  in  a 
collected  report  from  the  London  Clinical  Society  in  1892, 
collated  several  hundred  cases,  and  gave  the  average  time 
as  two  or  three  days,  minimum  time,  twenty-four  hours, 
and    the    maximum,  seven    da.ys.     Clement    Dukes,  after 
twenty-eight  years  of  experience  in  Rugby  School  {London 
Lancet,  April  21),  181)D)  gives  the  shortest  period  as  twenty- 
four  hours,  and  the  longest  nine  days,  stating  that  in  59 
per  cent,  it  was  between  two  and  four  days.     In  almost  90 
per  cent,  of  all  cases  the  incubation  period  is  between)  two 
and  six  days  (Osier).     Many  writers  heretofore  claimed  to 
have  treated  cases  where  the    incubation    period    varied 
from  fifteen  days  to   three   weeks,  but    in    most   of   these 
cases,  doubtless,  careful  investigation  would  have  shown 
that  there  had  been  several  exposures,  some  of  which  were 
much  more  recent  than  those  which  were  thought  to  have 
produced  the  disease.     I  am  inclined  to  think  that  seven 
days  is  the  longest  period  during  which  the  disease  can  be 
developed  from  previous  exposure* 


INCUBATION  OF  SCARLET  FEVER.  21'J 

TIME  OF   GREATEST   DANGER  OF  INFECTION. 

Much  difference  of  opiiiion  exists  as  to  the  time  of 
greatest  infectiveness  in  this  disease.  It  is  probable  that 
during-  the  incubative  period,  it  is  not  infectious,  but  from 
the  moment  that  fever  develops  or  throat  manifestations 
are  found,  the  disease  is  certainly  communicable  to  others, 
and  the  period  of  greatest  intensity  so  far  as  infectiveness 
is  concerned,  is  probably  when  the  disease  is  at  its  height. 
No  one  doubts  that  from  the  development  of  the  first 
symptom  by  which  it  can  be  recognized,  contagium  is 
present,  and  the  disease,  therefore,  communicable  to 
others. 

The  stage  of  exfoliation  certainly  shows  marked 
power  to  infect  others,  .as  does  the  discharge  in  the  ear 
troubles  occurring  as  sequelae  to  scarlet  fever. 

DURATION  OF  CONTAGIOUS  PERIOD. 

Holt  places  the  average  period  at  six  weeks  or  until 
desquamation  is  complete-  Others  discharge  mild  cases 
in  three  weeks,  but  as  early  infection  comes  chiefly  from 
nose,  throat  and  possibly  breath,  and  late  infection  from 

1.  Purulent  otitis; 

2.  Rhinitis; 

3.  Chronic  pharyngitis; 

4.  Suppurating  glands; 

5.  Eczema; 

6.  Empyema  and 

7-  Possibly  urine  in  nephritis; 
no  definite  time  will  answer  in  all  casej.  We  must  not 
err  in  this  matter,  and  as  long  as  any  possibility  of  infec- 
tion from  any  of  the  above  causes  exists,  we  must  insist 
on  the  isolation  of  the  patient,  and  carelessness,  on  the 
part  of  the  physician,  in  such  cases  is  criminal. 

IMMUNITY. 

One  attack  confers  immunity  usually  for  life,  yet 
some  have  had  this  disease  two  and  even  three  times,  if 
we  are  to  believe  some  of  our  best  diagnosticians.  The 
second  attack  usually  proves  very  mild  in  character  and  is 
found  only  in  very  susceptible  persons,  and  this  suscepti- 
bility seems  to  run  in  families. 

PREDISPOSING   CAUSES. 

Scarlet  fever  is  a  disease  of  childhood,  and  while  this 
is  true,  no  age.  strictly  speaking,  is  exempt,  but    a   large 


2l8  INCUBATION  OF  SCARLET  FEVER. 

majority  of  all  cases,  occur  before  the  age  of  eleven  years^ 
and  susceptibility  decreases  rapidly  from  that  age*  The 
period  at  which  the  highest  susceptibility  is  shown  is 
stated  to  be  five  jears.  It  is  very  mild  the  first  year,  but 
this  may  be  due  to  the  fact  that  infants  are  seldom  ex- 
posed to  the  disease  occurring  in  other  families.  The 
susceptibility  then  increases  rapidly  from  the  first  to  the 
fifth  years,  when  it  reaches  the  greatest  degree,  and  a 
marked  decline  increasing  to  the  age  of  twenty-five  years 
is  noted. 

,  SEX. 

Sex  seems  to  exert  very  little  influence,  although  some 
claim  the  female  is  slightly  more  liable  to  the  disease  than 
the  male.  It  does  seem,  however,  that  the  disease  is 
certainly  more  prone  to  fatality  in  the  latter  than  in  the 
forinei'- 

f 

PREVIOUS   CONDITION    OF   HEALTH. 

As  in  all  disease,  poor  health  means  lessened  resist- 
ance, consequently,  children  with  a  low  degree  of  vitality 
are  more  susceptible  to  the  contagium  of  scarlet  fever. 
Beyond  this,  previous  condition  of  health  has  very  little  to 
do  with  susceptibility. 

Poor  sanitary  conditions  which  often  obtain  in 
residences,  such  as  damp  cellars,  bad  ventilaticm,  studied 
exclusion  of  sunlight  (Nature's  germ  destroyer)  with  de- 
fective house  drainage  act  strongly  as  predisposing  causes. 
So  many  houses  have  faulty  plumbing,  that  it  is  worse 
than  no  i)lumbing  at  all.  and  much  of  modern  medical 
literature  tells  of  the  imj)airment  of  the  general  health, 
particularly  in  children,  due  to  inhalation  of  sewer  air. 
Diarrhoea,  sore  throats,  loss  of  appetite  and  anaemiai  are 
all  frequent,  while  Notter  says:  "There  is  undoubtedly  a 
poisonous  agency  at  work  when  se^er  gas  is  inhaled, 
which,  though  it  may  not  directly  act,  yet  so  prepares  the 
soil  that  the  system  is  unable  to  resist  the  invading  organ- 
ism when  it  comes." 

The  time  of  year  has  much  to  do  with  the  spread  of 
this  disease,  the  period  of  its  greatest  prevalence  being 
autumn  and  winter,  largely  on  account  of  chilling  of  sur- 
face of  the  body,  and  resultant  lesions  of  the  respiratory 
membranes,  and  the  collection  of  children  indoors,  particu- 
larly in  our  i)ublic  schools  during  these  seasons  of  the 
year.  Hershy  says  70  per  cent-  of  the  cases  of  scarlet 
fever  come  from  infection  at  school. — Medical  Fortnightly, 


219 
THE   SYMPTOMS  OF   SCARLATINA." 

By  Henry  Garnsey  Ohls,  M.D.,  Odell,  Illinois. 

The  S3'mptoms  of  scarlet  fever  vary  with  the  severity 
of  the  infection  and  also  with  the  age  and  general  con- 
dition of  the  system  of  the  patient.  Thus  some  epidemics 
are  severe,  the  mortality  being  as  high  as  40  per  cent., 
while  the  average  is  only  from  12  to  14  per  cent.  In  two 
recent  epidemics  in  the  New  York  Infant  Asylum  29 
patients  under  1  year  old  had  a  mortality  of  55  per  cent.; 
37  between  1  and  2  years,  22  per  cent.;  28  between  2  and 
3  years,  7  per  cent.;  and  23  over  3  years,  no  deaths.  It 
may  be  safely  assumed  that  the  mortality  varied  in  direct 
proportion  to  the  severity  of  the  symptoms  and  the  com- 
Dli'jaticnj. 

Invasion. — The  attack  is  usually  ushered  in  by  vomit- 
ing, chills,  a,  rapid  rise  of  temperature  and  sore  throat. 
The  vomiting  is  in  some  cases  repeated  several  times,  it 
is  often  projectile  and  without  nausea.  The  temperature 
in  severe  cases  rises  to  101°  or  105°  F.;  in  mild  cases  it 
may  not  rise  above  101°.  The  pulse  is  very  rapid,  even  out 
of  proportion  to  the  fever.  The  face  is  flushed  and  the 
eyes  brilliant.  The  child  may  not  complain  of  sore  throat, 
but  upon  examination  the  fauces  are  generally  found  con- 
gested and  the  hard  palate  is  often  covered  with  small  red 
points.  A  membranous  deposit  is  often  seen  covering  the 
tonsils  and  fauces  more  or  less,  but  it  is  not  usually  seen 
before  the  3rd  or  4th  day  of  the  fever.  The  tongue,  except 
at  the  edges,  is  nearly  covered  with  a  thick  white  or 
yellowish  coat  through  which  the  enlarged  papillae  pro- 
ject, red  and  prominent.  After  a  few  days  the  coating  is 
cast  off  and  the  whole  tongue  becomes  very  red  and  the 
papillae  remain  prominent  for  6  or  8  days.  In  severe 
cases  the  tongue  is  very  dry  and  brown.  Diarrhoea  is 
not  uncommon,  especially  in  summer.  The  nervous  sys- 
tem is  more  or  less  disturbed;  in  young  children  and 
infants  convulsions  may  be  the  first  sign  of  the  infection. 
Later  the  nervous  symptoms,  such  as  delirium  and  general 
prostration,  depend  upon  the  height  of  the  fever  and  com- 
plications, such  as  nephritis.  Blood  count  shows  marked 
leucocytosis  during  the  height  of  the  eruption. 

Eruption. — The  eruption  generally  appears  in  from  12 
to  36  hours  after  the  first  symptoms  of  the  invasion;  ex- 
ceptionallv  as  late  as  the  3rd  or  4th  day.  In  75  per  cent, 
the  rash  lasts  from  3  to  7  days;  in  5  per  cent.,  2  days  or 
less;  in  15  per  cent,  from  8  to  11  days.  In  a  very  small 
number  it  lasts  over  11  days  and  in  exceptional  cases  ther 
rash  disappears  and  recurs.     The  typical    rash    begins   in 


220  THE   SYMPTOMS   OF  SCARLATINA. 

the  form  of  minute  red  points  on  the  upper  part  of  the 
breast  and  neck,  rapidly  spreading  until  the  surface  in- 
volved is  a  bright,  even  red  colour.  The  body,  face  and 
limbs  may  be  entirely  covered  within  a  few  hours,  or  the 
rash  may  extend  slowly,  only  covering  the  surface  after  2 
or  3  days,  or  it  may  be  limited  to  certain  areas  throughout 
its  course.  Variations  in  the  rash  are  frequent  and  puzzl- 
ing. It  may  be  so  faint  as  to  escape  observation  in  mild 
cases;  or  the  rapid  disappearance  of  a  bright  eruption 
may  be  due  to  heart  failure.  It  is  usually  modified  by 
intercurrent  intestinal  disturbances.  In  malignant  cases 
with  severe  throat  symptoms  the  rash  may  be  poorly  de- 
veloped. The  eruption  may  be  in  large  discrete  patches 
or  macular,  as  in  measles.  In  severe  cases  it  may  be  a 
dark  purple  colour.  It  is  rarely  haemorrhagic.  On  the 
neck  or  chest  there  is  occasionally  a  fine  vesicular  erup- 
tion. Accompanying  a  well  marked  eruption  there  is 
usually  burning  and  intense  itching  of  the  surface,  and, 
in  severe  cases,  swelling,  esj^ecially  of  the  face  and  hands. 
The  constitutional  symptoms  increase  with  the  develop- 
ment of  the  rash,  and  usually  diminish  gradually  as  the 
rash  fades. 

Desquamation. — Soon  after  the  rash  fades  desquama- 
tion of  the  ei)idermis  begins  at  the  spot  where  the  rash 
first  appeared.  From  the  face  and  body  the  superficial 
layers  of  epidermis  come  off  in  fine  scales  or  in  small 
patches.  Where  the  skin  is  thick,  as  on  the  palmar  sur- 
face of  the  hands  and  feet,  the  epidermis  often  separates 
in  large  patches  which  in  exceptional  cases  may  even  as- 
sume the  form  of  casts  of  the  fingers  and  toes. 

The  fingers  begin  to  peel  at  the  tips  on  which  the  new 
epidermis  is  pink  and  contrasts  strongly  with  the  opaque 
gray  colour  and  loosened  edges  of  the  remaining  old 
layers.  The  process  is  complete  as  to  the  trunk  in  from 
1  to  3  weeks,  but  exfoliation  from  the  hands  and  feet  may 
continue  from  3  to  6  weeks  or  even  8  weeks,  if  not 
hastened  by  treatment. 

Mild  Cases.—The  symptoms  of  mild  cases  have  per- 
haps been  sufficiently  indicated  above,  but  to  recapitulate: 
The  symptoms  may  be  so  mild  as  to  be  overlooked  until 
desquamation  occurs.  Usually  there  is  an  abrupt  in- 
vasion with  vomiting  and  a  temperature  from  101°  to  103«. 
The  rash  mav  be  slight,  appearing  within  24  hours  and 
fading  within  3  or  4  days.  The  whole  surface  is  usually 
covered,  but  the  face  may  be  oallid,  especially  around  the 
mouth.  The  highest  temperature  coincides  with  the  full 
eruption  and  is  seen  during  the  first  30  hours  of  the  dis- 


\ 

THE   SYMPTOMS   OF  SCARLATINA.  221 

ease.  It  subsides  b}^  lysis  with  evening  remissions  and 
morning  exacerbations,  reaching  normal  between  the  4th 
and  7th  days.  Desquamation  may  be  overlooked  on  the 
face  and  trunk,  but  can  be  found  on  the  palms  and  soles 
at  the  end  of  the  week.  Otitis  and  nephritis  rarely  occur 
in  mild  cases,  but  their  possible  occurrence  should  not  be 
overlooked.  The  throat  and  constitutional  symptoms  are 
mild  in  this  form  of  the  disease. 

Severe  Cases. — Severe  cases  are  characterized  by  at 
rapid  invasion,  by  a  rash  that  covers  the  whole  surface 
within  a  few  hours,  by  a  temperature  of  104*^  or  over.  In 
cases  that  recover  the  fever  may  reach  the  high  point 
several  days  in  succession;  then  it  abates  about  I''  daily 
until  near  normal,  after  which  thero  may  be  a  moderate 
oscillation  for  a  week  or  so  longer.  The  course  of  the 
fever  is  greatly  modified  by  the  complications.  The  mucui- 
ous  membrane  of  the  mouth  and  fauces  is  intensely  con- 
gested, and  on  the  3rd  or  4th  day  false  membranes  form 
on  the  tonsils  and  may  involve  the  soft  palate,  the  naso- 
pharynx, the  nose  and  even  the  Eustachian  tubes  and 
middle  ears. 

In  the  absence  of  diphtheria  the  false  membrane 
rarely  involves  the  larynx.  The  membranes  contain 
streptococci  and  a  diplococcus  called  by  W.  J.  Class,  d. 
scarlatinae.  Gradwohl  and  others  confirm  his  statement 
that  it  is  found  in  all  cases  of  scarlatina.  There  may,  be 
superficial  ulcers  in  the  mouth  or  fauces.  The  tongue  is 
thickly  coated  and  sordes  collect  on  the  teeth.  The  cervi- 
cal glands  swell,  sometimes  to  great  size,  and  the  tonsils 
often,  become  permanently  hypertrophied.  The  catarrhal 
discharge  from  the  nose  and  mouth  is  excessive  and  more 
or  less  offensive.  The  pulse,  at  first  full  and  bounding, 
later  becomes  weak  and  irregular.  There  is  delirium 
during  the  height  of  the  fever  or  coma  develops  later. 
Sometimes  the  apathetic  condition  resembles  typhoid. 
Desquamation  after  severe  cases  is  occasionally  accom- 
panied or  followed  by  loss  of  the  hair  and  nails.  As  the 
complications  are  the  subject  of  another  paper,  I  will  only 
mention  the  common  occurrence  of  albuminaria,  dropsy, 
and  the  signs  of  sepsis  associated  with  exceptionally 
severe  throat  symptoms,  such  as  gangrenous  sloughing  of 
the  mucous  membrane  and  connective  tissue.  Another 
form  of  sepsis  is  the  so-called  malignant  or  cerebral  case. 
In  this  the  onset  is  sudden  and  violent  with  intense  head- 
ache, the  rash  irregular  or  absent,  the  fever  rising  to  104° 
or  over  within  a  few  hours,  and  higher  daily  till  death, 
which  may  occur  at  any  time  after  the  second  day.     Scar- 


2  22  THE   SYMPTOMS   OF   SCARLATINA. 

iatina  is  liable  to  be  very  severe  or  fatal  in  children  who 
undergo  surgical  operations,  however  slight,  shortly  be- 
fore infection  or  during  the  period  of  invasion.  The 
surgical  wound  is  prone  to  become  gangrenous  under  these 
circumstances. 

Diagnosis. — When  cases  are  seen  in  the  midst  of  an 
ordinary  epidemic,  the  diagnosis  usually  offers  no  diffi- 
culty. Before  the  eruption  appears,  the  attack  cannot  al- 
ways be  distinguished  from  tonsillitis,  though  the  straw- 
berry tongue  points  to  scarlatina. 

This  fact  was  brought  forcibly  to  my  mind  in  one  of 
my  earliest  cases.  The  patient  was  a  young  daughter  of 
Ham,  with  a  complexion  like  good  stove  polish.  The  con- 
dition of  the  skin  certainly  did  not  throw  any  light  on  the 
diagnosis.  But  the  temperature,  and  especially  the  bright 
red  papillae  of  the  tongue  projecting  through  the  coating, 
,was  to  my  mind  the  very  picture  of  scarlatina,  which  was 
proven  to  be  authentic  by  subsequent  developments!. 
Cases  that  are  very  mild  throughout  are  not  easy  to  diag- 
nose, but  desquamation  or  the  development  of  other 
typical  cases  by  infection,  may  throw  a  sinister  light  on 
an  apparently  trivial  illness.  Rapidly  fatal  cases  without 
eruption  may  seem  like  special  dispensations  of  Pro- 
vidence till  perchance  other  cases  with  the  usual  eruption 
clear  up  the  diagnosis.  Diphtheria  cannot  always  be  dis^- 
tinguished  from  scarlatina  at  the  outset.  But  the  tem- 
perature is  lower  in  diphtheria,  and  the  membrane  is 
tougher  and  more  adherent,  leaving  a  bleeding  surface 
when  detached.  The  bacteriologic  examination  of  the 
false  membrane  and  secretions  from  the  fauces  will  assist 
in  the  diagnosis  of  doubtful  cases,  and  should  always  be 
used  when  available.  Erythema  and  roseola  occurring  in 
numerous  small  circular  spots  on  the  trunk  or  extremities 
may  be  caused  by  dental  of  gastrointestinal  irritation. 
Such  spots  and  erythematous  syphilides  also  bear  some 
resemblance  to  the  scarlatinal  rash,  but  the  history  of  the 
case  and  the  absence  of  fever,  or  the  comparatively  low 
temperature  will  not  permit  an  error  in  diagnosis.  A  red 
rash  like  that  of  scarlatina  may  precede  the  papular  erup- 
tion of  variola.  It  may  be  noticed  on  the  pubic,  the  in- 
guinal and  lateral  thoracic  regions.  The  intense  head- 
ache of  variola  and  the  "shotty"  feel  of  the  papular  erup- 
tion ought  to  clear  up  the  diagnosis  within  twenty-four 
hours.  An  erythematous  rash  may  precede  the  character- 
istic rose  spots  of  typhoid  fever,  and  it  has  been  observed 
in  influenza  also. 

A  similar  rash  in  blotches  everywhere  except  on  the 
face    has    been    noted  after  tracheotomy  performed   for 


REMARKS   OX   HEROIX    HYDROCHLORATE.  223 

laryugeal  diphtheria.  But  it  runs  a  rapid  course  and  is 
not  followed  by  desquamation,  a  statement  that  applies 
as  well  to  all  the  rashes  that  stimulate  scarlatina,  except 
possibly  that  of  erysipelas.  The  latter  can  be  dis- 
tinguished by  its  limited  extent,  by  the  connective  tissue 
edema  and  the  fact  that  desquamation  is  limited  to  the 
surface  involved.  Belladona,  quinine  and  other  drugs 
sometimes  cause  a  scarlatinoid  rash,  but  they  should  offer 
no  difliculty  in  diagnosis. — Medical  Fortnightly. 


A  FEW  REMARKS  ON  HEROIN  HYDROCHLORATE. 

By  E.  Y.  Johxson,  M.D. 

Every  physician  has  daily  need  of  an  analgesic,  and 
many  have  been  the  combinations  made  up  for  the  purpose 
with  morphia  or  its  salts  as  a  last  resort.  The  train  of 
evils  following  the  use  of  the  latter  drug  are  only  too 
familiar  to  all  of  us.  I  speak  of  the  vicious  habit  which 
once  formed  is  rarely  broken,  and  which  has  wrecked 
thousands  of  lives.  Aside  from  this,  the  immediate  bad 
results  from  the  use  of  morphia,  such  as  constipation, 
diminished  kidney  action  and  sick  stomach,  are  very 
serious  objections  and  preclude  its  use  in  many  instances. 
Codeia,  vaunted  as  its  substitute,  is  of  little  value  as  an 
analgesic.  Having  a  special  action  upon  the  respiratory 
tract  and  pelvic  organs,  it  has  a  field  of  usefulness,  but  as 
a  p^in  reliever  it  is  not  what  was  hoped  and  looked  for. 
Lately  the  new  drug  "heroin"  has  attracted  attention,  and 
I  have  tried  it  in  many  conditions  where  there  was  pain 
of  the  most  intense  type,  and  this  paper  is  the  result  of 
my  experiences.  I  shall  not  give  you  clinical  reports,  but 
will  give  you  in  a  general  way  the  applications  thera- 
peutically of  the  remedy.  Heroin  is  a  chemical  produced 
from  morphine,  but  greatly  different  in  effects.  It  has  all 
or  even  more  of  the  pain-relieving  qualities  of  morphine, 
but  none  of  its  bad  effects.  Except  in  rare  cases  of 
idiosyncrasy  it  does  not  constipate,  does  not  diminish  the 
urinary  secretion,  does  not  cause  sick  stomach,  and  last 
and  most  important  of  all.  does  not  cause  a  habit  of  using 
it.  It  w^as  first  introduced  as  a  remedy  for  congh,  especi- 
ally the  harassing  cough  of  advanced  phthisis,  and  gave 
excellent  results.  From  that  its  use  has  gradually  spread, 
nntil  now  it  is  used  largely  as  a  pain-reliever. 

Heroin  comes  in  two  forms,  the  alkaloid  and  the 
hydrochlorate.  The  alkaloid  is  insoluble  in  w\ater,  and, 
therefore,  not  as  rapid  in  its  effects  as  the  salt.  This 
fact  accounts  for  the  failure  of  many   physicians   to   get 


224        REMARKS  ON  HEROIN  HYDROCHLORATE. 

good  results  from  the  drug.  My  experience  has  been  con- 
fined to  the  hydrochlorate,  so  in  spealving  of  it  the  hydro- 
chlorate  is  meant.  It  is  a  white  crystalline  powder,  very 
freely  soluble  in  water — simple  elixir,  tinctures,  etc.  It 
has  a  bitter  taste.  By  reason  of  its  solubility  it  may  be 
prescribed  in  combination  with  almost  any  liquid  drug. 
In  coughs  it  will  control  the  paroxysms  better  than  any 
agent,  1  know  of.  In,  bronchitis  I  have  found  it  to  give 
great  relief  when  combined  with  expectorants,  as  it  not 
only  lessens  the  violence  of  the  cough,  but  seems  to  have 
.a  specially  soothing,  quieting  influence  on  the  inflamed 
mucous  membrane.  In  the  cough  of  phthisis  nothing  I 
ever  used  has  given  so  much  relief.  For  this  I  give  in  it 
powders  1-8  gr.  each,  combined  with  grs.  v  of  sacch.  alba., 
one  to  be  taken  at  bed-time,  to  be  repeated  in  two  hours  if 
necessary,  and  I  rarely  find  it  necessary  to  repeat  it.  It 
always  checks  the  cough  and  allows  the  patient  the  sleep 
he  so  much  needs.  In  the  dyspnoea  of  asthma  it  soon  re- 
lieves the  paroxysm,  allays  the  nervousness,  and  promotes 
sleep.  For  this  purpose  it  may  be  given  hypodermatically 
or  combined  in  solution  with  the  various  asthmatic 
remedies,  such  as  nitroglycerine,  atropia  and  grindelia. 

As  a  pain-reliever  I  have  found  it  of  the  greatest 
value  in  acute  articular  rheumatism,  migraine,  neuralgias, 
sciatica  and  nervous  headache.  For  this  purpose  I  em- 
ploy it  hypodermatically,  giving  from  one-eighth  to  one- 
sixth  grain  at  each  dose.  I  have  given  it  continuously  in 
one  case  of  chronic  Bright's  disease  for  over  six  months 
to  relieve  the  headache,  and  with  great  success.  The 
patient,  a  fenmle  about  thirty  years  old,  could  not  take 
medicine  internally.  I  began  on  one-sixth  grain  hypo- 
dermatically, and  now  only  use  one-twelfth  grain.  The 
headaches  only  come  now  at  long  intervals,  and  there  is 
no  desire  for  the  drug.  Six  months  ago  the  urine  con- 
tained quite  a  large  amount  of  albumen  and  casts.  To- 
day there  is  barely  a  trace  of  albumen,  not  constant,  and 
no  casts.  I  can  not  say  the  heroin  has  cured  the  case, 
but  I  do  know  the  patient  has  vastly  improved  and  is  very 
grateful.  I  have  used  heroin  in  cholera  morbus  and  in- 
testinal colic  with  quick  results.  In  every  case  relief  is 
quick.  In  these  cases  I  use  it  hypodermatically.  The 
relief  from  pain  following  its  use  by  hypodermic  is  as- 
tonishingly quick — in  some  instances  within  a  minute.  In 
more  thaii  one  instance  relief  was  had  so  quickly  that 
patients  expressed  alarm. 

Given  to  a  morphine  habitue  in  place  of  the  usual 
drug,  it  satisfies  the  craving  and  seems  to  destroy  it  finally 
without  any  longing  for  the  new  drug;  and  in   this   field 


MEDICINE  AND  NEUROLOGY.  225 

aloue  it  should  prove  very  useful.  I  do  not  hesitate  to 
use  it  lor  any  pain  demanding  immediate  relief.  One 
patient  describing  its  effects  compared  to  morphine,  said: 
"Morphine  seems  like  a  great  big  man  seizing  hold  of  you 
and  forcibly  dragging  you  off,  while  heroin  takes  you*^  by 
the  hand  and  gently  leads  you." 

t^leep  is  produced  by  heroin  usually  in  from  eight  to 
lifteen  minutes  if  given  hypodermatically,  and  usually  lasts 
from  eight  to  twelve  hours.  The  patient  awakens  re- 
freshed. There  is  no  special  thirst  afterward;  no  dryness 
of  skin  or  fauces;  no  itching.  The  first  effect  is  to  stimu- 
late the  heart  with  accelerated  pulse,  followed  by  a  slower 
pulse,  but  full  and  regular.  The  resi)irations  are  reduced 
in  number.  I  have  used  it  in  both  strong  and  weak  with 
good  and  bad,  hearts,  with  uniformly  good  results.  The 
hypodermic  tablets  are  not  as  effective  as  when  the 
powder  is  dissolved  and  used  hypodermatically,  so  that  now 
I  carry  one-twelfth  grain  powders  in  my  case,  using  one  or 
two  as  occasion  demands.  I  have  not  tried  it  on  children 
under  ten  years  of  age,  but  would  feel  perfectly  safe  in 
doing  so.  The  dose  for  an  adult  is  from  one-twenty-fourth 
to  one-sixth  grain,  according  to  the  effect  desired.  It  can 
be  repeated  every  hour  or  two. — American  Practitioner  and 
News.Dec,  1901.' 


Progress  of  Medical  Science. 

MKDICINK    AND     NEUROIvOQY 


IN   CHARGE   OF 

J.  BRADFORD  McCONNELL.  M.D. 


Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College  ;  Physician  Western  Hospital. 


RESUI.TS  IN   ONE   THOUSAND  CASES  OF  NITROUS 
OXIDE   AND   ETHER   NARCOSES. 

Nitrous  oxide  is  the  safest  general  anaesthetic.  Its 
only  danger  is  from  asphyxia,  and  this  can  be  avoided  by 
mixing  the  gas  with  atmospheric  air  and  with  oxygen. 
The  tirst  sign  of  impending  suffocation  should  be  a  warn- 
ing for  the  admission  of  more  air,  and  it  is  surprising  how 
easily  some  patients  can  be  anaesthetized,  even  when  it  is 
very  much  diluted.  The  main  advantages  of  nitrous  oxide 
as  a  preliminary  to  ether  are  its  safety  and  its  rapid  and 
pleasant  action!    The  principal  disadvantages  with  ether 


226  PROGRESS  OF  MEDICAL  SCIENCE. 

are  its  disagreeable,  pungent  odour  and  its  irritating 
euect  upon  tlie  respiratory  mucous  membrane,  as  well  as 
the  slowness  with  which  anaesthesia  supervenes.  In 
using  the  two  in  combination  or  succession,  the  pleasant 
anu  rapid  action  of  the  nitrous  oxide  replaces  the  un- 
pleasant sensation  of  the  first  stage  of  ether  inhalation, 
i'ull  surgical  narcosis  is  reached  with  small  quantities  of 
the  two  agents,  and  the  saturation  of  the  blood  and  tissues 
is  avoided. 

Chloroform  is  admittedly  more  dangerous  than  ether, 
but  it  has  been  administered  in  cases  where  there  ai'e 
renal  and  pulmonary  complications,  as  it  is  believed  to  be 
less  irritating  to  these  structures.  It  is,  however,  largely 
a  question  of  quantity.  If  the  ether  can  be  kept  some- 
where near  the  amount  of  chloroform  necessary  for  such 
anaesthesia,  it  is  less  irritating  than  the  latter,  and  this 
can  be  accomplished  by  the  simultaneous  administration 
of  nitrous  oxide.  The  number  of  patients  who  cannot 
take  nitrous  oxide  gas  and  ether  is  very  small.  Even 
those  addicted  to  alcoholics  and  narcotics,  who  are  diffi- 
cult to  anaesthetize,  are  readily  brought  under  the 
influence  of  the  mixture.  In  some  cases  where  chloroform 
is  indicated,  it  may  be  well  to  begin  the  anaesthesia  with 
a  mixture  of  nitrous  oxide  and  ether,  and  then  maintain 
the  anaesthetic  with  chloroform.  In  such  a  method  the 
initial  stimulating  effect  of  the  ether  enables  the  chloro- 
form narcosis  to  proceed  with  greater  safety. — H.  W. 
Carter,  in  Med.  Rec. 

INFLUENCE    OF    THE    COLORADO    CLIMATE    UPON    PUL. 
MONARY   HEMORRHAGE. 

S.  G.  Bonney  {Med.  Neics,  vol-  79,  No.  15,  Memphis 
Medical  Monthly),  arrives  at  these  conclusions: 

1.  That  hemorrhage  by  itself,  save  with  few  exceptions, 
furnishes  no  criterion  upon  which  to  base  a  choice  of  clim- 
ate, the  indications  for  high  altitude  in  uncomplicated  and 
in  not  too-far-advanced  cases  being  highly  imi)erative,  in- 
dependent of  this  single  manifestation. 

2.  That  an  exceedingly  small  proportion  of  recurrences 
may  be  expected  in  Colorado,  although  not  necessarily 
reflecting  accurately  the  degree  of  ultimate  improvement 
secured. 

3.  That  recurrences  are  more  likely  to  result,  and  that 
quickly,  in  those  cases  with  hemorrhage  immediately  pre- 
ceding arrival,  and  hence  the  wisdom  of  a  short  delay 
following  the  hemorrhage  before  leaving  home  and  unusual 
precautions  as  regards  rest  upon  arrival. 


MEDICINE   AND   NEUROLOGY.  22/ 

4.  That  primary  hemorrhages  are  comparatively  rare  in 
Colorado  and  usually  take  place  incident  to  a  rapid  pro- 
gressive destructive  change  in  cases  already  with  hopeless 
prognosis,  or  as  a  natural  result  of  some  external  assign- 
able cause,  which,  under  proper  regime,  could  be  avoided. 

5.  That  hemorrhage,  while  less  likely  to  occur  in  Colorado 
than  at  sea  level,  is,  nevertheless,  as  a  general  rule,  more 
severe  and  associated  with  greater  shock. 

(>•  That  the  avoidance  of  hemorrhage,  particularly  in  the 
early  months  of  Colorado  life,  demands  a  most  rigid  com- 
pliance with  detailed  instructions. 

PROPHYLAXIS  OF  TUBERCULOSIS  DURING  CHILDHOOD. 

S.  A.  Knopf  (Johns  Hopkins  Hospital  BuUetui,  iiepteinher, 
1901,  Memphis  Medical  Monthly)  discusses  direct  transmis- 
sion from  parent  to  child — from  the  father  to  child  at  the 
time  of  conception,  from  mother  at  any  time  during  fetal 
life,  and  concludes  that  either  one  is  so  extremely  rare  that 
it  may  wholly  be  left  out  of  our  plans  for  the  prophylaxis 
of  tuberculosis.  Tuberculosis  infection  during  infancy 
comes  from  without  and  not  from  within. 

As  to  the  frequency  of  tuberculosis  in  childhood,  Bol- 
linger in  500  autopsies  of  children  of  all  ages  found  lesions 
of  tuberculosis  in  218  cases. 

As  to  age,  tuberculosis  develops  most  frequently  in  child- 
ren at  about  one  year.  The  maximum  death  rate  is  reached 
between  second  and  fourth  years.  As  to  method  of  infec- 
tion, undoubtedly  many  children  are  made  tuberculous  by 
an  infected  milk  supply.  But  a  large  jjercentago  contract 
the  disease  by  inhalation,  as  autopsies  show  that  the  bron- 
chial glands  harbour  the  oldest  foci.  Tuberculosis  of  the 
intestinal  tract  in  children  is  often  secondary  to  the  pul- 
monary disease,  as  children,  when  quite  young,  do  not  ex- 
pectorate. 

Sputum  from  a  tuberculous  mother,  father,  relative  or 
friend  is  a  very  frequent  source  of  infection  of  little  infants, 
by  the  act  of  kissing.  A  midwife  in  theh  village  of  New  berg 
infected  ten  children,  in  a  short  time,  by  sucking  the  mucus 
from  the  mouth  of  the  new-born,  and  blowing  into  the 
mouths  of  the  asphyxiated.  Inoculation  of  the  infant  is 
rare  except  through  the  rite  of  circumcision. 

After  a  child  is  old  enough  to  creep  it  is  still  more  expos 
ed  to  all  three  methods  of  infection.  It  may  inhale  the 
bacilli  laden  dust  of  the  air  near  the  floor.  It  is  con- 
tinually putting  things  in  its  mouth,  and  may  ingest  the 
bacilli  in  this  manner.  .  It  may  inoculate  itself  by  scratch- 
ing, after  gathering  bacilli  on  its  finger  nails.     This  mav 


228  PROGhESS  OF  MEDICAL  SCIENCE. 

happen  especially  to  children  with  eczema  or  other  slcin 
trouble.  Lupus  is  started  by  the  child  putting  its  lingers 
in  its  nose  or  picking  its  nose. 

How  may  we  counteract  or  avoid  these  dangers  to  which 
children  are  exposed  from  the  ever-i)resent  tubercle  bacilli? 
Boards  of  health  should  issue  pamphlets  containing  in 
plain  language  directions  regarding  the  prophylaxis  of 
tuberculosis.  These  instructions  should  be  placed  in  the 
hands  of  every  mother,  nurse,  kindergartner  and  teacher 
in  the  country. 

The  tuberculous  mother  should  not  nurse  her  child,  nor 
should  she  sleep  with  it.  All  tuberculous  people  around 
children  should  be  rigidly  careful  of  the  disposal  of  sputa, 
and  of  the  "'drop  ejecta"  during  coughing  and  sneezing. 

A  child  should  never  be  kissed  on  the  mouth.  Con- 
sumptives should  not  kiss  at  all. 

The  orthodox  rite  of  circumcision  should  be  done  only  by 
one  shown  by  careful  examination  to  be  free  from  con- 
tagious diseases. 

The  sale  of  ^tuberculous  milk  should  be  made  impossible 
by  necessary  sanitary  laws. 

The  tioor  of  the  rooms  in  which  a  child  lives,  and  on 
which  it  plays  should  not  be  carpeted.  It  should  be  kept 
scrupulously  clean.  The  ordinar}'  broom  should  never  be 
used  in  cleaning  the  children's  rooms;  if  wiping  the  floor 
is  not  practicable  it  should  be  swept  with  moist  sawdust. 

The  visits  of  children  to  menageries,  and  especially  to  the 
cages  of  monkeys  and  apes,  is  a  source  of  danger.  Monkeys 
and  apes  are  especially  liable  to  tuberculosis-  All  animals 
should  be  frequently  examined  and  tuberculous  animals 
destroyed.  No  man  with  tuberculosis  should  be  allowed 
to  remain  as  keeper. 

Thorough  hygiene  should  be  enforced  in  kindergartens 
and  schools,  and  carefully  taught  in  every  school.  Lady 
teachers  and  grown-up  girl  pupils  should  not,  under 
penalty  of  dismissal,  be  allowed  to  wear  trailing  skirts. 

The  proper  use  of  cuspidors,  spit-flasks  and  handkerchiefs 
should  be  enforced  in  every  school  room. 

Obligatory  periodical  disinfection  of  every  school  room 
should  be  instituted.  ; 

Under  a  second  head  he  discusses  prophylaxis  of  pre- 
disposition. 

What  is  predisposition?  As  clinicians  we  answer,  a 
physiological  poverty  whereby  the  system  is  minus 
phagocytic  and  bactericidal  powers.  As  bacteriologists 
we  would  say,  a  predisposition  is  that  peculiar  condition 
whereby  the  various  organs  offer  a  favou'^able  soil  for  the 
ievelopment  of  bacilli. 


MEDICINE   AND   NEUROLOGY,  229 

Inherited  predisposition  is  avoided  as  far  as  possible 
by  careful  hygienic,  dietetic,  athletic,  hydro-therapeutic, 
aero-therapeutic  and  medicinal  measures  directed  to  the 
upbuilding  of  the  tuberculous  or  predisposed  parents. 
Especially  should  the  pregnant  mother  be  careful  as  to 
dress,  food  and  general  hygiene. 

Tuberculous  people  should  avoid  having  children. 

All  measures  calculated  to  strengthen  and  upbuild 
should  be  instituted  for  the  predisposed  children.  Hy- 
gienic clothing,  good  food,  pure  air  and  plenty  of  sunshine. 
Plenty  of  parks  and  playgrounds  in  the  cities  are  of  im- 
portance. The  use  of  alcohol  predisposes  to  tuberculosis. 
The  mouth  should  not  be  neglected.  Teeth  should  be  kept 
clean  and  cavities  promptly  filled.  Enlarged  tonsils 
should  be  removed. 

BASHAM  S  MIXTURE. 

An  old  time-tried  tonic  in  urinary  affections,  particu- 
larly in  degenerative  conditions  of  the  kidneys,  is  "Bas- 
ham's  Mixture.*'  The  virtues  of  this  preparation  were 
extolled  in  lecture  rooms  quite  half  a  century  ago,  and  the 
same  is  said  to-day.  In  its  particular  field  of  usefulness  it 
has  well  stood  the  test  of  time.     Its  composition  is: 

I^  Tr.  ferri  chlor f- .'5iij 

Acid   acet.  dil f.  3iss 

Syr.  sim f.  .^ss 

Liq.  ammon.  acetat.,  q.  s.  ad f.  .^iv 

M.  Sig.     One  dessertspoonful    every    two   hours — 
Clinical  Ncrkic. 

A  PASTE  THAT  W^ILL  ADHERE  TO  ANYTHING. 

Prof.  Alex.  Winchell  is  credited  with  the  invention  of 
a  cement  that  will  stick  to  anything.  Take  two  ounces  of 
clear  gum  arabic,  one  and  one-half  ounces  of  fine  starch, 
and  one-half  ounce  of  white  sugar.  Pulvenze  the  gum 
arabic,  dissolve  it  in  as  much  water  as-  the  laundress  would 
use  for  the  quantity  of  starch  indicated-  Dissolve  the 
Btarch  and  sugar  in  the  gum  solution.  Then  cook  the 
mixture  in  a  vessel  suspended  in  boiling  water  until  the 
starch  becomes  clear.  The  cement  should  be  as  thick  as 
tar,  and  kept  so.  It  can  be  kept  from  spoiling  by  dropping 
in  a  lump  of  gum  camphor,  or  a  little  oil  of  cloves  or 
sassafras.  This  cement  is  very  atrong  indeed,  and  will 
stick  perfectly  to  glazed  surfaces,  and  is  good  to  repair 
broken  rocks,  minerals,  or  fossils.  The  addition  of  a  small 
amount  of  suljihate  of  aluminum  will  increase  the  effec- 
tiveness of  the  paste,  besides  helping  to  prevent  decomposi- 
tion.— Amer.  Jour,  of  Surgery  and  Gynaecology. 


SURGERY. 


IN   CHARGE    OF 

ROLL.O  CAMPBELL,",M.D., 

Lecturer  on  Surgery,  Ur.iversity  of  Bishop's  College  ;  Assistant  Surgeon,  VVestern  Hospital  ; 

AND 

GEORG53  FISK,  M.D. 

Instructorjia  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeoa, "Western  Hospital. 


ADRENALIN. 


Dr.  Winfield  Ayres,  of  Eellevue  Hospital,  New  York, 
has  found  a  mild  solution  of  adrenalin  extremely  useful  in 
certain  kinds  of  genito-urinary  work.  In  examining  the 
urethra  an  irritable  stricture  is  frequently  discovered,  the  first 
evidence  of  the  fact  being  generally  a  severe  haemorrhage, 
which  there  is  sometimes  diffiulty  in  stopping.  It  occurred 
to  Dr.  Ayres  to  use  adrenalin,  and  he  finds  it  answers  the 
purpose  well,  a  solution  of  i  to  100,000  being  sufficient  for 
the  purpose. 

ACROSTIC  ON  FRACTURES  AND  DISIiOCATIONS. 

S.  C.  Mish  gives  the  following  as  an  aid  to  the  memory: 

FRACTURES. 

False  points  of  movements. 

Rotary  displacement. 

Angular  deviation  from  normal  angle. 

Crepitus. 

Tenderness  on  point  of  pressure. 

Unnatural  mobility. 

Eetraction  of  limb  by  muscular  contraction- 

Ecchymosis. 

Shortening,  swelling,  pain. 

DISLOCATION. 

Disturbance  in  function  of  joint. 
Immobility, 
Swelling- 
Loss  of  natural  contour. 
Only  forced  mobility. 
Crepitations,  no  crepitus. 
Angular  deformity. 
Tenderness  and  pain. 
Interference  with  function. 
Old  landmarks  of  joint  destroyed. 
No  shortening  in  shaft  of  bone. — Cal-  Med.  Jour. 


SURGERY  231 

INDICATIONS  FOR  OPERATION  IN  GASTRIC  ULCER. 

The  latest  surgical  thought  as  regards  the  operative 
treatment  of  gastric  ulcer  is  well  expressed  in  the  article 
in  question.  It  has  been  the  custom  to  so  postpone  surgical 
procedure  on  stomach  ulcers  that  when  finally  the  surgeon 
was  called  in  the  patient's  condition  was  desperate  and 
operation  availed  but  little.  Since,  however,  the  inefficiency 
of  drugs  is  now  so  evident  and  surgical  technique  so  im- 
proved, the  surgeon  can  operate  on  gastri'c  ulcers  confident 
that,  if  called  in  time,  he  can  alleviate  if  not  cure  the  dis- 
order. 

There  are  several  operations  which  are  in  use  in  dif- 
ferent phases  of  this  disease,  viz.: 

1.  Gastronomy,  including  the  excision  of  ulcers. 

2.  Gastroplication,  or  turning  in  of  the  stomach  wall, 
to  close  an  ulcer  that  has  perforated,  or  to  strengthen  the 
wall  at  a  point  where  perforation  is  threatened. 

3.  Pylorectomy  for  the  removal  of  an  ulcerating 
pylorus. 

4.  Pyloroplasty  for  the  widening  of  a  pylorus  con- 
tracted by  ulceration. 

5.  Gastro-enterostomy  to  provide  a  short  cut  into  the 
intestine  from  a  stomach  whose  motility  is  interfered  with 
by  ulceration. 

Gastro-enterostomy  is  decidedly  useful  in  relieving 
pyloric  spasm,  decreasing  the  production  of  hydrochloric 
acid,  checking  gastric  hemorrhage  and  promoting  the 
healing  of  ulcers. 

When  such  cases  come  under  the  surgeon's  care  he 
must  know  the  indications  for  operation  and  the  relative 
value  of  the  various  procedures.  Immediate  operation  is 
demanded  where  symptoms  of  perforation  appear.  In  these 
cases  operation  in  the  first  twelve  hours  gives  twice  as 
many  recoveries  as  those  performed  twenty-four  or  forty- 
eight  hours  after  perforation.  Hemorrhage,  alarming  or 
persistent,  also  demands  operation.  After  perforation  re- 
covery without  operation  is  impossible,  while  some  hemor- 
rhages will  yield  to  medical  treatment.  So  the  surgeon 
must  balance  the  probabilities  of  recovery  in  these  cases. 
Roughly  speaking,  hemorrhages  in  gastric  ulcers  may  be 
divided  into  two  classes,  viz. :  those  that  occur  in  the  first 
thirty  years  of  life  and  those  occuring  after  that  time.  A 
study  of  various  hospital  reports,  notably  Guy's  Hospital 
and  the  Massachusetts  General,  shows  that  in  the  first 
period  the  hemorrhages  are  due  to  the  small  round  ulcer, 


232  SURGERY. 

and  seldom  fatal.  In  later  life  hemorrhages  are  generally 
the  result  of  chronic  ulcers,  which  open  the  large  vessels 
under  the  serous  coat,  or  may  even  perforate  adjacent 
organs,  adhesions  being  present.  These,  therefore,  are 
more  dangerous,  and  slight  recurring  hemorrhages  from 
a  patient  over  thirty  should  be  accounted  serious,  and 
operation  should  be  considered.  Gastroenterostomy 
usually,  but  not  always,  relieves  the  hemorrhage,  perhaps 
by  giving  rest  and  free  drainage  to  the  stomach.  It  stops 
the  anaemia  consecjuent  upon  continued  bleeding,  and  so 
favours  the  healing  of  the  ulcer. 

Surgery,  apart  from  its  application  to  hemorrhage  and 
perforation  (the  complications  of  gastric  ulcer),  is  also 
applicable  to  the  treatment  of  the  ulcer  itself.  It  is  well 
to  compare  the  mortality  of  gastric  ulcer  with  the  mortal- 
ity of  the  operations  for  its  relief.  As  in  all  statistical 
reports,  it  is  hard  to  make  a  fair  average  of  the  mortality 
rate  on  account  of  the  difficulty  of  tracing  patients  to  the 
end.  However,  it  would  seem  that  the  average  mortality 
for  all  operative  interference  in  this  disease  is  about  IB.l 
per  cent.,  whereas  the  mortality  of  the  disease  itself  is 
from  25  to  30  per  cent.  This  is  not  absolutely  conclusive, 
for  recurrence  may  take  place  after  the  operation,  thotigh 
how  frequently  is  unknown,  (xastro-enterosotomy  to-day 
has  a  mortality  of  10  per  cent.,  and  Mr.  Mayo  Robson  has 
practically  reduced  his  mortality  to  5  per  cent.  Balancing 
these  facts,  it  would  appear  that  after  a  chronic  ulcer  has 
long  resisted  medical  treatment,  and  the  patient  is  daily 
losing  strength  and  hope,  then  it  is  proper  to  have  recourse 
to  i^u?gery.  To  resume,  it  would  seem  that  these  are  the 
chief  indications  for  surgical  treatment  in  relation  to  gas- 
tric ulcer,  viz.: 

1.  Acute  hemorrhage  should  rarely  be  treated  b;y 
operation.  The  results  of  interference  have  not  been 
good,  wiiile  the.  results  of  medical  treatment  have  been 
satisfactory.  When,  however,  a  hemorrhage  frequently 
repeats  itself,  even  though  not  severe  in  amount,  it  will 
demand  operative  treatment  as  soon  as  its  recurrent  char- 
acter is  plain. 

2.  Small  frequent  hemorrhajres,  threatening  anemia, 
give  a.  clear  indication  for  operation. 

3.  Perforation  of  the  stomach,  either  acute  with  gen- 
eral ppiitonitis,  or  chronic  with  surrounding  adhesion^ 
and  perigastritis,  demands  instant  operation. 

4.  When  an  ulcer  runs  a  chronic  course  with  a  strong 
tendency  to    recurrence,    and    gradually    diminishes    the 


SURGERY.  233 

patient's  capacity  for  work  and  the  enjoyment  of  life,  an 
opeiation  is  indicated,  especially  when  the  patient  is  so 
situated  as  to  be  dependent  on  his  daily  work  for  support, 
and  unable  to  closely  re<;ulate  his  diet. — A.  1'.  Chabot, 
M.D.     Transactions,  Mass.  Med.  Soc. 

QUICK  CONTROL  OF  NOSEBLEED. 

J,  H.  Herring  (St.  Louis  Med.  Review)  says  that  by 
placing  the  index  finger  upon  the  lateral  cartilage  imme- 
diately below  its  juncture  with  the  nasal  bone,  and  making 
steady,  firm  pressure  upward,  inward  and  backward,  ninety 
per  cent,  of  all  cases  of  epistaxis  may  be  effectually  controlled 
in  three  minutes.  The  blood  vessel  from  which  the  bleeding 
takes  place,  in  the  vast  majority  of  cases,  is  located  in  the 
anterior  nasal  chamber  in  the  mucous  membrane  lining  the 
nasal  septum. 

SUPRAPUBIC    OPERATION   FOR   VARICOCELE. 

A.  E.  Bradley,  in  the  Journal  of  the  Associution  of 
Military  Surgeons  for  Auj^ust,  I'JOl,  says  that  so  far  as  he 
is  aware  incision  of  the  scrotal  wall  has  been  the  only 
method  of  operating  upon  the  scrotal  contents.  The 
suprapubic  method,  while  new,  possesses  uncpiestioned 
advantages  over  incision  of  the  scrotum.  The  operi^tion 
begins  with  the  usual  method  of  sterilizing-  the  skin,  which 
is  then  incised  for  a  distance  of  two  and  one-half  inches 
parallel  with  l*oupart's  ligament.  The  underlying  fascia 
is  grasped  by  forceps,  and  with  a  blunt  dissector  torn 
through  until  the  external  abdominal  ring  is  exposed. 
When  the  cord  is  exposed  the  fascia  is  divided  longitudin- 
ally, thus  bringing  the  spermatic  vein  into  view.  Slight 
traction  upon  the  veins  serves  to  pull  them  upward, 
emptying  the  scrotum  of  the  enlarged  and  tortuous  vessels. 
A  ligature  is  then  placed  on  the  upper  and  lower  portions 
of  the  vein,  the  portion  included  between  the  two  being 
removed.  The  uncut  ends  of  the  ligatures  are  now  tied, 
thus  drawing  together  the  severed  ends  of  the  veins  foi^ 
the  support  of  the  testicle.  The  wound  is  then  closed  in 
the  usual  manner.  A  scrotal  supporter  is  used  for  some 
time  after  the  operation. 

It  is  claimed  for  this  high  operation  that  it  secures 
perfect  asepsis,  owing  to  the  locality  of  the  wound,  and  a 
support  for  the  testicle  is  assured  that  would  otherwise  be 
wanting,  and  without  which  atrophy  might  result.  The 
operation  is  practically  devoid  of  mortality,  and  is  one  of 
the  most  succesful  of  surgical  procedures. 


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TYPHUS  FEVER. 

Since  the  year  1847,  when  Montreal  was  visited  by  a 
severe  epidemic  cf  typhus  fever,  but  few  cases  of  the  dis- 
ease have  been  seen  in  this  city.  As  this  outbreak 
occurred  among  emigrants  arnving  from  Ireland  it  was 
known  as  ship  fever.  Emigrants  in  those  days  came  out 
in  small  sailing  vessels  to  Quebec,  the  voyage  occupying 
from  six  to  seven  weeks,  and  there  was  much  overcrowding. 
Moreover,  in  that  year  there  was  an  almost  total  failure  of 
the  potato  crop  in  Ireland,  so  that  those  leaving  that  island 
were  in  a  condition  to  favour  the  development  of  the  dis- 
ease. Forty  years  ago  typhus  was  always  present  in  a  more 
or  less  degree  in  all  the  large  cities  of  Great  Britain,  but 
particularly  in  Ireland.  It  has  since  then  been  gradually 
disappearing,  and  this  disappearance  is  one  of  the  great 
triumphs  of  modern  medicine.  So  far  as  we  can  learn  and 
know  from  personal  observation,  not  over  fifteen  cases  have 
appeared  in  Montreal  since  the  great  epidemic  of  1847, 
One  occurred  in  1868  in  the  practice  of  the  writer,  clearly 
traceable  to  the  opening  of  a  typhus  coffin   of  a  victim  of 


BOOK  REVIEWS.  235 

the  '47  scourge,  proving  the  truth  of  the  observation  by 
Osier  that  the  poison  "retains  its  activity  for  a  remarkably 
long  time."  In  1877  a  local  outbreak  occurred  in  the  House 
of  Refuge  in  this  city,  when  eleven  inmates  were  attacked. 
No  positive  source  of  infection  could  be  traced,  but  at  night 
the  overcrowding  was  so  great  that  there  was  only  about 
88  cubic  feet  of  space  to  each  person.  Five  or  six  years  ago 
two  cases  were  discovered  and  removed  to  the  Civic  Hospital, 
and  recovered.  Early  in  April  of  this  year  two  cases  were 
admitted  into  the  Montreal  General  Hospital  where  they 
were  completely  isolated,  and  both  recovered.  We  were 
asked  to  see  these  cases,  and  there  was  no  question  as  to  the 
disease  being  typhus.  So  far  as  we  can  ascertain  the  source 
of  infection  in  all  these  cases  could  only  be  traced  in  the 
case  which  occurred  in  the  practice  of  the  writer.  The 
others,  we  believe,  were  due  largely,  if  not  entirely,  to  filth 
and  overcrowding.  Typhus  has  not  yet  been  embraced  in 
the  microbic  theory,  so  that  its  cause  remains  to-day  what 
it  was  fifty  years  ago.  Then  it  developed  wherever  un- 
sanitary conditions  prevailed.  Its  practical  disappearance 
in  Great  Britain  has  been  entirely  due  to  improved  sanita- 
tion, and  on  this  line  lies  ihe  safeguard  against  its  appear- 
ance in  the  cities  of  Canada. 


Book   Reviews, 


The  Practical  Medicine  Series  of  Year-Books  com- 
prising ten  volumes  on  the  year's  progress  in  Medicine  and 
Surgery  issued  monthly,  under  the  general  editorial  charge  of 
Gustavus  P.  Head,  M.D.,  Professor  ot  Laryngology  and  Rhino- 
logy,  Chicago  Post-Graduale  Medical  School,  volume  III., 
the  Eye,  Ear,  Xose  and  Throat,  edited  by  Casey  A.  Wood, 
CM.,  M.D.,  Albert  H.  Andrews,  M.D.,  T.  Melville  Hardie, 
A.M.,  M.D.,  December,  igof.  Chicago.  The  Year  Book 
publishers,  40  Dearborn  street. 

The  idea  of  publishing  a  medical  year-book  in  parts  is  a  very 
good  one,  for  we  thus  gel  a  series  of  volumes  of  convenient  size 
instead  of  one  huge  book  which  it  is  a  labour  to  handle. 


2^6  "  BOOK  REVIEWS. 

Then,  too,  we  receive  our  information  in  moderate  doses  and 
at  stated  intervals  which  permits  of  better  assimilation. 

The  volume  under  consideration  gives  a  succinct  account  of 
all  that  has  been  published  in  the  past  year  that  is  of  special  in- 
terest to  those  engaged  in  the  practice  of  ophthalmology,  otology, 
laryngology  and  rhinology,  and  is  a  welcome  addition  to  the  library 
of  the  general  practitioner  as  well 

G.  W.  M. 

Manual  of  Childbed  Nursing  with  Notes  on  Infant  Feed- 
ing, by  Charles  Jeweit,  A.M.,  M.D.,  Sc.D.,  Professor  of  Ob- 
stetrics and  Diseases  of  Women  in  the  Long  Island  College 
Hospital.  Fifth  Edition.  E.  B.  Treat  &  Co.,  241  and  243 
West  23rd  street,  New  York,  1902. 

This  short  and  up-to-date  Manual,  as  the  preface  to  the  5th 
.edition  states,  was  originally  prepared  for  the  'I'raining  School 
for  nurses  at  the  Long  Island  College  Hospital.  In  spite  of  the 
modesty  of  the  writer,  the  number  of  editions  show  it  proved  of 
such  value  that  it  has  now  been  revised  and  enlarged,  and,  we 
have  no  doubt,  will  prove  of  the  very  greatest  service  to  both 
nurses  ar.d  the  well  educated  woman  of  the  day  who  is  about  to 
become  a  mother.  It  is  short,  about  80  pages  ;  every  word  is 
explained,  either  at  once  or  in  the  glossary  at  the  end.  The  nurse 
and  patient  who  folio tv  the  rules  and  regulations,  not  only  for 
themselves,  but  also  as  regards  the  child,  cannot  fail  to  benefit 
proportionately  and  we  cari  heartily  advise  every  nurse  and  pro- 
spective mother  to  possess  a  copy.  H.  L.  R. 

The  Practical  Medical  Series  of  Year  Books,  com- 
pnsmg  ten  volumes  on  the  yt-ar's  progress  in  Medicme  and 
Suigery,  issued  monthly  under  the  general  editorial  charge  of 
Gusiavus  P.  Head,  M.D.,  Professor  of  Laryngology  and 
Rhinology,  Chicago;  Post  Graduate  Medical  School.  Volume 
IV.  Gynaecology,  edited  by  Emilius  C.  Dudley,  A.M.,  M.D., 
Professor  of  Gynaecology,  Northwestern  Uriversity  Medical 
School,  Gynaecologist  to  the  St.  Luke'':  and  Weslev  Hospitals,, 
Chicago,  with  the  collaboration  of  William  Healy.  Chicago. 
The  Year  Book  publishers,  40  Dearborn  street. 

The  object  or  this  book  is  to  give  a  summary  of  the  most 
noteworthy  contributions  to  gynaecology  made  during  the  past  year 
and  a  half.  This  has  accomplished  as  far  as  a  two  hundred  page 
book  will  peimit,  and  it  is  remarkable  how  many  articles  have  been 
included.  The  editor  says  that  recent  literature  stiows  definite 
progress  in  the  following  subjects  : — ist.  The  application  of 
scientific  gynaecology  10  sociologic  problems.  2nd.  The  differentia- 
tion of  pelvic  injections  with  reference  to  etiology,  symptomato- 
logy, diagnosis,  prognosis  and  treatment.  3rd.  The  critical  study 
of  statistics  especially  as  they  relate  to  infections,    neoplasms   and 


BOOK  REVIEWS  237 

displacements.  4th.  Careful  balancing  of  the  relative  indications 
for  gynaecologic  operations.  He  also  finds  that  much  less  attention 
is  being  paid  to  i)lastic  work,  which  formerly  held  the  first  place  in 
gyneacology,  and  a  very  great  deal  more  to  abdominal  surgery  Of 
tills  the  reader  can  judge  for  himself.  His  ttxi  is  made  still  more 
interesting  by  the  introduction  of  a  large  number  of  illustrations. 
There  is  also  an  exceedingly  well  arranged  index,  enabling  us  to 
find  the  opinions  of  leading  writers  on  the  various  subjects. 

A.L.S. 
Essai  de  Semiologie  Urinaire.  Methode  d'interpretation 
de  I'analyse  urologique.  L'urine  dans  les  divers  etats  mor- 
bides,  par  Camille  Vieillard,  Pharmacien-Chimiste,  Laureat 
du  Concours  Brassac,  Membre  de  la  Societe  Chimique  de 
Paris,  Eleve  de  I'lnstitut  Pasteur  (1898).  Preface  par  Albert 
Robin,  de  I'Academiede  Medecine.  Paris,  Sociec^  d'Editions 
ScientifiqueSj  4  Rue  Antoine  Dubois,   1902. 

The  author  points  out  that  a  thorough  knowledge  of  the  urine 
is  becoming  every  year  more  important,  and  at  the  same  time  so 
easily  obtained  that  the  practitioner  is  no  longer  satisfied  with  know- 
ing the  density,  quantity  of  urea,  uric  acid,  chlorides,  phosphoric 
acid  and  the  presence  of  albumen  and  sugar.  The  difficulty  now 
is  to  master  the  interpretation  of  the  analysis.  So  far  the  books 
have  been  chemical  rather  than  clinical.  What  we  want  to  know  is 
the  significance  of  a  few  more  grains  or  less  of  urea ;  that  the  amount 
of  it  represents  the  quantity  of  alburnenoids  which  have  accomplished 
the  complete  cycle  of  vital  changes  and  their  maximum  of  utiliza- 
tion ;  that  the  relation  of  sulphur  incompletely  oxidized  to  the 
total  amount  of  sulphuric  acid,  is  an  indication  of  the  activity  of  the 
liver.  It  increases  or  diminishes  with  hepatic  efficiency  or  deficiency. 
The  symptoms  derivable  from  the  urine  are  so  important  that  the 
diagnosis  in  many  cases  can  only  be  ma-ie  after  the  urine  has  been 
scientifically  anyaiyzed.  Those  who  can  read  French  will  derive 
a  vast  amount  of  information  which  we  have  not  hitherto  seen  in 
any  text  book.  A.L.S. 

Dr.  T.  Buret,  Secretaire  General  de  la  Societe  de 
Medecine  de  Paris.  Traitement  des  maladies  conta^ieu- 
ses  de  I'appareil  generateur,  Guide  Pratique.  Bases  fondamen- 
tales  du  traitement,  examen  critique  des  formules  les  plus 
usuelles  ;  injection  massive  de  sels  hydrogeniques  insolubles, 
simplifiesjet  rendue  pratique  ;  manuel  operatoire  trds  detaill6 
de  ces  injections  ;  grands  lavages  au  permanganate  de  potasse  ; 
nombreuses  observations  et  anecdotes  medicales.  Paris, 
Societe  d'Editions  Scientifiques,  4  Rue  Antoine  Dubois,  1902. 

Paris  being  probably  the  centre  of  the  universe,  as  far  as  the 
treatment  of  syphilis  is  concerned,  this  work,  which  is  fully  up-to- 
date,  contains  many  valuable  points  in  the  management  of  venereal 
and  syphilitic  diseases.  The  chapter   on  gonorrhoea  and  syphilis 


238  ,    BOOK   REVIEWS. 

in  women  is  very  well  written,  and  is  especially  interesting.  We 
may  safely  say  that  this  work  is  a  very  complete  treatise  on  syphilis 
and  venereal  diseases  as  we  understand  them  to-day,  and  being 
written  in  elegant  French,  furnishes  enjoyable  reading  to  those  who 
even  partly  understand  the  language,  A.L.S, 

Studies  in  Psycology  of  Sex.     Sexual  inversion,  by  Have- 
lock  Ellis.     Philadelphia,  F.  A.  Davis  Company,  1901. 

This  work  was  originally  issued  in  England  about  four  years 
ago.     It  was,  I  believe,  favourably  received  by  the  Medical  Press, 
and  its  circulation    was    confined  to   the   scientific   and   medical 
world.       The  London  police,  however,  instituted  a   prosecution 
against  a   bookseller,   who  sold   the   book,  and  the   Recorder  of 
London,  sitting  as  Judge,  decided  that  it  was  not  a  scientific  work, 
and  ordered  it  to  be  destroyed.      It  is  now  republished  in  the 
United  States  and  its  author  has  decided  that  the  various  volumes 
required  to  complete  the  series,  shall  be  issued  from  this  side  of 
the  Atlantic.     I  have  read  the  major  part  of  the  work,  and  believe 
that  the  entire  subject  has  been  treated  from  a  thoroughly  scientific 
stand  point.  There  is,  I  know,  some  who,  never  having  met  with  a 
case  of  sexual  inversion,  will  not  admit   its  existence.     It  exists, 
nevertheless,  and  possibly  more  frequently  than   is  imagined.     1 
have,  during  an  experience  of  nearly  forty  years,  met  with  several 
cases.     One  does  not,  as  a  rule,  publish  them  and  those  recorded 
previous  to  the   issue  of  this   volume,   were  in   connection   with 
asylum  or  prison  reports.     In  the  preface  to  the  first  edition  of  this 
book,  the  author  says  :  "  very  few  indeed,  would  not  be  surprised 
if  it  was  possible  to  publish  a  list  of  the  names  of  sexual  inverted 
men  and  women,  who  at  the  present  time  are  honourably  known 
in  church,   state,    society,  art  or  letters.     This  is  a  startling  state- 
ment, but  I  beheve  it  is  true.  I  have  known  of  sexual  inversion  more 
than  once    in  persons  occupying   prominent   positions.     The  out- 
come of  such  a  book  would,  of  course,  be  shorn  of  much  of  its  value, 
did  not  all  the  startling  facts  it  contains  form  a   basis  upon  which 
to  found  a  rational  method  of  treatment.     The  author  has  made 
this  effort,  and  although  it  is  as  yet  in  the  purely  theoretical  stage, 
nevertheless  it  suggests  much  food  for  thought  in  this  direction. 

F.  W.  C. 

Transactions  of  the  College  of  Physicians  of  Phila- 
delphia. Third  series.  Volume  twenty-third,  Philadelpia. 
Printed  for  the  College,  1891.     Edited  by  William  Zentmayer, 

Although  the  title  page  bears  the  imprint  1891,  it  has  only 
just  been  published.  This  will  be  understood  when  I  mention 
the  fact  that  it  contains  all  the  contributions  read  before  the  So- 
ciety, from  January  to  December,  1891  inclusive.  The  initial  paper 
is  written  by  the  late  Dr.  DaCosta,  and  is  a  short  but  pleasant 
rtsutnt  of  the  life  of  Sir  William  Paget.      Then  follows  a  memoir 


BOOK  REVIEWS.  239 

of  Dr.  William  Pepper,  from  the  pen  of  Dr.  Tyson.  Dr.  Pepper 
had  many  friends  in  the  larger  cities  of  Canada,  To  them,  if  they 
can  get  this  volume,  it  will  recall  one  who  was  their  friend  and  who 
during  his  life  did  much  for  the  profession  of  medicine.  An 
analysis  of  the  character  of  Dr.  Physick,  by  Dr.  George  McClel- 
lan,  is  the  next  paper.  Dr.  Physick,  after  studying  at  the  Uni- 
versity of  Philadelphia,  from  which,  it  is  slated,  he  did  not  wish  to 
graduate^  went  to  London  and  took,  in  1 791,  the  diploma  of  the 
R.C.P.  and  S.  He  visited  Edinburgh  the  following  year  and  re- 
ceived the  degree  of  M.D.  from  its  University.  While  in  London 
he  became  associated  with  John  Hunter,  and  in  the  Hunterian 
Museum,  are  to-day,  some  valuable  preparations,  the  handwork  of 
Dr.  Physick,  made  under  the  direction  of  Hunter.  During  this 
tour  he  was  an  interne  at  the'  St.  George's  Hospital.  He  returned 
to  Philadelphia  in  1793  and  from  that  till  1796  did  not  earn  enough 
money  from  his  profession  "  to  pay  for  the  soles  of  his  shoes." 
Subsequently  he  became  identified  with  surgery  in  the  University 
of  Pennsylvania,  and  afterward  with  Anatomy,  from  which  he  retired 
in  1827  from  failing  health.  The  date  of  his  death  is  not  given. 
This  sketch  is  accompanied  with  a  portrait  in  steel  of  Dr.  Phy- 
sick and  contains  much  of  interest  regarding  the  early  teaching  of 
medicine  in  Philadelphia.  The  rest  of  the  volume  consists  of 
professional  papers,  all  valuable  and  interesting. 

F,  W.  C. 

The  International  Medical  Annual.  A  year  book  of 
treatment  and  Practitioner's  Index,  1902.  Twentieth  year. 
E.  B.  Treat  &  Co.,  2141-2143  West  23rd  Street,  New  York. 
Price  $3.00. 

Within  the  pages  of  this  Annual  are  contained  and  easily 
found,  a  very  excellent  resume  oi  the  Medical  and  Surgical  litera- 
ture of  the  past  year.  The  bulk  of  the  contributions  are  from  the 
pen  of  well-known  British  physicians  and  surgeons.  Those  from 
American  authors  are  equally  as  valuable  as  those  contributed  by 
their  English  confreres.  The  bulk  of  the  volume  is  increasing — 
in  fact  is  nearly  double  in  pages — to  that  in  the  first  years  of  its 
publication.  This  is  due  to  the  increased  demand  of  its  subscribers 
for  more  detailed  information,  especially  in  the  surgical  depart- 
ment. It  is  published  in  a  convenient  size,  and  any  physician  or 
surgeon  who  purchases  it,  will  soon  find  that  its  value  is  far  beyond 
its  cost. 

F.  W.  C. 

Genito-Urinary  Disease^  and  Syphilis,  for  Students  and 
Practitioners.  By  Henry  H.  Morton,  M.D.,  Clinical  Pro- 
fessor of  Genito-Urinary  Diseases  in  the  Long  Island  College 
Hospital;  Genito-Urinary  Surgeon  to  the  Long  Island  Col- 
lege and  Kings  County  Hospitals  and  the  Polhemus  Memo- 
morial  Clinic,  etc.     Illustrated  with  half-tones   and  full   page 


240  BOOK   REVIEWS. 

colour  plates.  Pages  xii-372.  Size  g}4 'x.  7  inches.  Price, 
extra  cloth  $3.00  net,  delivered.  Philadelphia,  F.  A.  Davis 
Company,  publishers,  1914-16  Cherry  Street. 

In  reviewing  this  work,  it  is  at  once  apparent  that  the  author  is 
very  much  at  home  with  the  practical  chnical  aspect  of  the  subject, 
for  the  text  abounds  with  most  apt  and  useful  descriptions  of 
clinical  methods  and  technique,  which  in  so  many  works  is  un- 
fortunately omitted  to  give  room  for  some  transient  theory,  or 
obsolete  method.  The  illustrations  are  good  and  the  arrange- 
ment and  division  of  each  subject  is  excellent.  In  reviewing  the 
treatment,  it  is  refreshing  to  note  the  concist  yet  minute  directions 
for  the  adoption  and  execution  of  any  line  of  treatment  and  the 
various  reasons  for  selecting  the  same.  Some  very  novel  and 
instructive  diagrams  are  introduced  to  explain  the  treatment  of 
chronic  urethritis  by  the  use  of  the  endoscope.  They  cannot 
fail  to  aid  the  beginner  in  this  puzzling  work. 

We  are  pleased  to  recommend  this  work  as  a  most  useful  one 
to  practitioners  and  students  alike.  It  is  clear,  up-to-date  and 
not  too  exhaustive. 

G.  F. 

Syphilis,  A  Symposium.— A  small  volume,  published  by  E. 
B.  Treat  &  Co.,  New  York,  is  made  up  with  contributions  by 
seventeen  recognized  authorities.     Price,  $r.oo. 

Many  of  these  contributions  are  well  worthy  of  careful  perusal. 
While  syphilis  is  undoubtedly  a  subject  which  has  always  received 
most  exhaustive  attention  in  literature,  yet  it  is  a  disease  of  such 
varying  characteristics  that  the  more  unusual  forms  as  noted  by 
specialists  are  always  interesting  and  instructive.  The  chapter  on 
"  Unrecognized  Syphilis  in  General  Practice,"  by  L.  Duncan  Buck- 
ley, is  worthy  of  all  attention.  There  is  illustrated  most  clearly 
the  great  danger  to  the  innocent  occasioned  by  persons  who  are 
suffering  from  unrecognized  syphilis,  and  one,  therefore,  ignorant  of 
the  necessary  precautioi^to  prevent  contagion.  That  syphilis  is 
not  necessarily  a  venereal  disease  is  to-day  most  generally  accepted 
and  this  fact  has  contributed  largely  towards  the  efforts  to  prevent 
its  spread. 

In  the  last  few  pages  are  given  the  answers  to  numerous 
pertinent  questions  on  syphilis  by  the  various  syphilographers. 
They  are  well  worthy  of  careful  consideration. 

G.  F 


CANADA 

MEDICAL  RECORD 


JUNE.     I902. 


Original  Communications. 

A  HAXF  CENTURY  OF  PRACTICE. 

On  the  7th  of  May  the  Medical  Profession  of  Mont- 
real honoured  three  of  its  members,  who  had  completed 
fifty  years  of  active  practice,  by  a  Dinner  at  the  Place  Viger 
Hotel.  These  gentlemen  were  Dr.  J.  P.  Rottot,  Dean  of 
the  Faculty  of  Medicine,  in  Montreal,  of  I.aval  University, 
Dr.  D.  C.  McCallum,  Emeritus  Professor  of  Obstetrics  in 
McGill  University,  and  Sir  William  H.  Kingston,  Professor 
of  Clinical  Surgery  in  the  Medical  Faculty  (Montreal)  of 
Laval  University.  One  hundred  and  fifty  sat  down  to  the 
best  dinner  the  celebrated  Place  Viger  could  produce. 
The  tables  were  beautifully  decorated  with  flowers,  plants, 
etc.  The  Chair  was  occupied  by  Dr.  Francis  W.  Campbell, 
the  Dean  of  the  Medical  Faculty  of  Bishop's  University,  and 
he  was  supported  on  either  side  by  the  guests  of  the  evening. 
The  memt  card  was  made  an  appropriate  memento  of  the 
occasion,  the  front  of  the  card  having  the  photos  of  the 
three  gentlemen  in  whose  honour  the  dinner  was  given.  A 
fine  orchestra  discoursed  beautiful  music  during  the  entire 
evening,  and  Mr.  Labelle,  a  magnificent  tenor  engaged  for 
the  occasion,  sang  several  solos.  After  dinner  the  chairman 
proposed  "The  King,"  which  was  enthusiastically  received, 
and  the  national  anthem  was  sung.  The  chairman  then  rose' 
and  proposed  the  toast  of  the  evening.     He  said ; 

"Gentlemen, — In  proposing  the  health  of  Our  Guests' 
permit  me  to   express   my  personal  gratification   at  being 


242  A  HALF  CENTURY  OF  rRACTICE. 

present  upon  an  occasion  which  will  ever  be  memorable  in 
the  medical  history  of  our  city.  This  gratification  is,  I  am 
sure,  felt  by  every  one  who  now  surrounds  this  festive  board. 
An  event  like  the  present  does  not  often  occur,  for  the  op- 
portunity is  somewhat  rare.  So  far  as  my  memory  serves 
me,  only  twice  in  this  city  within  a  period  of  fifty  years 
hsve  similar  banquets  been  held,  the  recipients  being  the  late 
Dr.  George  W.  Campbell  and  the  late  Dr.  D'Orsonnens.  Our 
profession  does  not  seem  to  tend  toward  longevity,  and 
green  old  age  is  somewhat  rare.  But  to-night,  gentlemen, 
we  have  met  to  do  honour  to  three  of  our  confreres,  Dr. 
Rottot,  Dr.  McCallum  and  Sir  William  Kingston,  who,  in 
the  Providence  of  God,  have  been  permitted  to  see  this 
green  old  age — have  been  permitted  to  see  the  turning 
point  of  fifty  years  of  active  medical  work.  What  is  even  still 
more  to  be  thankful  for  is  the  fact  that  their  hands  are  still  on 
the  plough,  the  furrows  are  still  well  made.  The  hands  that 
direct  seem  to-day  as  steady  as  when,  in  the  first  gush  ,of 
youthful  enthusiasm,  they  won  their  first  innings  in  the  race 
for  professional  position.  Long,  I  say,  may  this  green  old 
age  continue. 

"  Gentlemen,  our  guests  have  contributed  much  to  the  medi- 
cal history  of  Montreal.  Each  has  done  his  part  to  make 
this  city  the  centre  for  medical  education  in  the  Dominion. 
Dr.  Rottot  graduated  in  1847  from  the  Montreal  School  of 
Medicine,  which  after  a  time  became  the  medical  depart- 
ment of  Victoria  College,  and  now  is  a  branch  of  Laval 
University.  He,  early  in  his  career,  became  a  teacher  in 
this  Faculty,  and  for  years  has  been  its  Dean.  Dr.  Mc  Gal- 
ium graduated  from  McGill  in  1850,  and  in  a  few  years,  after 
serving  an  apprenticeship  in  several  minor  chairs,  took  charge 
of  the  important  chair  of  obstetrics,  which  he  held  for  many 
years.  Sir  William  Kingston  took  his  degree  from  McGill  in 
.1851.  H  is  career  as  a  med  ical  man— of  late  years  in  the  surgical 
line  and  as  professor  of  clinical  surgery  in  Laval — is  well 
known.  Unlike  his  brother  guests,  who  have  held  strictly 
to  professional  work.  Sir  William  Kingston  entered  the  arena 
of  public  life.     Many  of  us  can  remember  when  he  occupied 


A  HALF  CENTURY  OF  PRACTICE.  243 

the  position  of  Mayor  of  this  city,  and  the  sanitation  he 
then  commenced.  To-day  he  is  a  grave  and  reverent 
'  Senator,'  doing  good  work,  let  us  hope,  by  arresting,  as 
occasion  demands,  the  impulsive  and  sometimes  ill-matured 
work  of  the  democratic  *  Commons.' 

"  Gentlemen,  I  have  occupied  perhaps  too  much  time  in 
introducing  this  toast.  If  so,  forgive  me  ;  for  out  of  the  full- 
ness of  the  heart  the  mouth  speaketh.  1  have  known  our 
guests  during  all  my  professional  life — my  term  is  only  a  few 
years  beyond  theirs  ;  and  I  close  by  saying  the  city  of  Mon- 
treal is  proud  of  our  guests,  the  medical  profession  of  Mon- 
treal is  proud  of  our  guests.  Long  may  they  be  spared  to  us. 
I  give  you  Dr.  Rottot,  Dr.  McCallum  and  Sir  William 
Kingston — Our  Guests." 

Dr.  E.  P.  Lachapelle  then  rose  and  spoke  in  French  as 
follows  : — "  It  is  with  pleasure,  gentlemen,  that  I  rise  on  behalf 
of  my  French-speaking  brethren,  to  add  a  few  words  only  to 
the  health  which  has  just  been  so  eloquently  proposed  by 
the  worthy  president  of  the  banquet. 

"  The  occasion  which  has  brought  us  together  this  even- 
ing is  not  one  which  happens  every  day.  We  entertain  to- 
day the  three  oldest  doctors  in  active  practice  ;  we  celebrate 
their  medical  golden  wedding.  And  in  order  to  give  to 
this  feast  the  character  which  it  deserves  and  to  make  it  in 
every  way  worthy  of  those  whom  we  wish  to  honour,  we 
have  called  together  to  the  one  banquet  the  representatives 
of  the  various  nationalities  who,  in  Montreal,  divide  the 
field  of  professional  work. 

"  We  forget  our  rivalries  of  every  day  in  order  for  a 
moment  to  join  together  in  making  this  unique  offering 
of  sympathy  and  admiration. 

"  Our  rivalries !  Is  that  the  proper  word  to  use }  Are  we 

not  all  fellow-workers  in  the  same  work,  directing  our  efforts 

day  by  day  towards  the  same  end  ?     And  do    we  any  the 

less  practice   the   same  profession  because  we  speak  a  dif- 

erent  language  .-*     Is  our  profession  for  that  reason  any  the 

ess  enlightened  or  the  less  humane  ? 


244  ^   HALF  CENTURY  OF  PRACTICE, 

"  Let  me  tell  you,  gentlemen,  that  I,  for  one,  do  not  think 
so.  Indeed,  the  occasion  which  brings  us  together  to-night 
is  one  that  does  not  occur  often  enough,  for  it  serves 
to  show  better  than  words  that  we  are  not  actuated  by  a 
spirit  of  rivalry,  but  rather  by  emulation,  and  that  we  are 
brothers  who,  in  spite  of  all  that  may  be  said,  belong  to  one 
family — -the  family  of  medical  men.  Is  it  not,  moreover, 
this  brotherly  spirit  which  makes  every  one  of  us  so  happy 
to-night  in  joining  together  to  do  honour  to  our  distinguished 
guests.  Doctors  Rottot  and  McCallum  and  Doctor  Sir 
William  Hingston  ?  The  lives  themselves  of  our  honourable 
brothers,  are  they  not  beautiful  examples  of  brotherly  love  ? 
Have  they  not,  side  by  side  for  fifty  years  and  more,  exer- 
cised their  art  with  the  same  assiduity  and  the  same  de- 
votion, all  three  of  them  consecrating  their  talents  and  their 
strength  to  the  same  purpose ;  to  teach  the  principles  of 
an  art,  to  relieve  suffering,  to  heal  disease  and  to  help  the 
poor.  And  think  you  that  when  they  thus  contributed  all 
that  was  best  in  them,  of  both  heart  and  health,  they  were 
acting  as  Canadians,  Englishmen  or  Irishmen  ? 

"  No !  gentlemen,  they  acted  so  because  they  were  men  of 
learning,  because  they  were  charitable,  indeed,  because  they 
are  medical  men.  It  is  for  this  reason  that  we  are  so 
proud  of  them  ;  this  is  why  we  honour  them  to-night,  this 
is  why  they  will  always  remain  for  us — models  to  imitate 
and  masters  in  whose  footsteps  we  must  follow. 

"  Is  it  not  that  which  has  filled  their  lives  with  which 
we  should  fill  our  own?  The  mission  which  they  laid  out 
for  themselves,  and  which  they  have  so  well  fulfilled  and 
the  duties  of  which  they  are  still  performing — should  we  not 
endeavour  to  accomplish  in  our  turn,  each  in  the  feeble 
measure  of  his  capacity,  if  we  wish  to  attain  to  the  full 
height  of  our  vocation  .■*  What  better  or  more  recent 
proof  could  be  given  to  all  of  the  identity  of  our  lives,  or 
to  the  unitedness  of  the  medical  family. 

"  Yes !  gentlemen,  the  reason  for  coming  together  is  a 
beautiful  one.  Members  of  the  same  family  and  fellow 
abourers  in  the  same  field,  we  have  for  a  moment  laid  ou 


A  HALF  CENTURY  OF  PRACTICE.  345 

work  aside  and,  moved  by  the  same  spirit  of  sympathy 
and  admiration,  come  to  salute  our  leaders  and  elder  brethren 
in  the  profession,  and  to  proclaim  what  all  the  world  al- 
ready knows,  that  they  have  deserved  well  of  our  profes- 
sion and  of  our  country. 

"  We  raisfe  our  glasses  with  emotion,  for  we  are  honour- 
ing fifty  years  of  study,  of  hard  work  and  devotion  to  duty, 
when  we  drink  to  the  health  of  Doctors  Rottot,  McCal- 
lum  and  Sir  William  Kingston.  Yes  !  let  us  drink  to  their 
health,  that  for  many  long  years  to  come  they  may  remain 
among  us  the  personification  of  professional  success  ob- 
tained by  their  application  to  duty,  perseverance  in  devo- 
tion and  integrity  of  character. 

"  Rise  !  gentlemen,  and  drink  the  health  of  our  honoured 
guests." 

The  toast  was  received  with  great  enthusiasm. 

Dr.  Rottot  was  first  called  upon  to  reply,  which  he  did 
in  the  following  terms  : 

"  Mr.  Chairman  and  Gentlemen : — 

"  With  my  thanks  deign  to  accept  also  my  most  hearty 
congratulations  for  the  complete  success  of  this  magnificent 
banquet  to  which  you  have  summoned  the  three  oldest  phy- 
sicians of  Montreal,  in  order  to  do  them  honour  and  to  reward 
them  for,  in  the  words  of  a  dear  Jesuit  friend,  having  triumphed 
over  death  for  more  than  seventy  years.  It  is  both  discreet 
and  prudent  for  me  not  to  give  the  exact  age  of  my  com- 
rades, as  they  might  not  be  pleased  if  I  did.  We  doctors 
so  seldom  triumph  over  our  old  enemy.  Death,  that  we  may 
feel  tempted  to  accept  these  congratulations  and  to  glorify 
ourselves  for  having  so  long  succeeded  in  escaping  death. 
But  no!  Let  us  rather  bow  down  before  the  only  Giver  of 
all  good  and  thank  Him  for  the  victory  which  is  His  alone 
and  Who  alone  can  make  it  last, 

"  This  is,  indeed,  a  rare  sight — to  see  the  professors  and 
graduates  of  three  different  Universities  assembled  together 
on  the  same  day  and  around  the  same  table,  in  order  to 
celebrate  the  golden  wedding  of  three  of  their  brethren, — a 
unique  celebration  in  the  history  of  our  country.  The  twen- 
tieth century  had  reserved  for  us  this  surprise  and  this  re- 


246  A  HALF  CENTURY  OF  TRACTICE. 

joicing.  But,  if  the  habit  of  diagnosing  has  given  me  any 
certainty,  I  feel  sure,  after  casting  my  eyes  about  me,  that  I 
am  not  mistaken  in  predicting  that  there  will  be  many  others 
to  imitate  us. 

"  We  appreciate  very  highly  the  delicacy  of  your  proceed- 
ings and  your  efforts  to  procure  for  us  a  moment  of  hap- 
piness ;  you  wished  to  make  us  forget  the  worries  and  cares 
of  life  ;  have  you  attained  your  object  ?  You  would  have 
attained  it  perfectly,  I  might  say,  you  would  have  suc- 
ceeded in  bestowing  upon  us  more  than  the  mere  illusion  of 
happiness  ;  yes,  you  would  have  rendered  us  perfectly  happy 
if,  by  a  good  nature  beyond  measure,  you  had  undertaken 
to  prepare  for  us  the  speeches  that  we  were  to  make  to-night. 
In  this,  however,  I  am  only  speaking  for  myself;  for  what 
would  have  been  kindness  to  me  would  have  been  cruelty  to 
others,  to  deprive  them  of  the  pleasure  of  charming  us  by 
their  eloquence.  But,  though  T  would  have  preferred  to 
have  spoken  through  you  and  would  have  heartily  thanked 
you,  still,  since  you  wish  it,  I  will  sacrifice  myself  and  con- 
form to  the  established  practice.  I  had,  for  the  occasion,  pre- 
pared two  pieces  of  eloquence :  one  very  long  and  the  other 
very  short ;  in  the  first  I  would  have  interested  you  in  giv- 
ing an  account  of  the  changes  and  the  progress  of  medical 
science  which  have  taken  place  in  Montreal  during  fifty  years; 
in  describing  the  modest  beginning  of  our  first  medical 
school,  its  struggles  and  the  obstacles  which  it  had  to  van- 
quish before  it  became  the  Faculty  of  Medicine  of  Laval 
University  ;  or  in  describing  the  student  life  of  those  days, 
so  different  from  that  of  the  present  time.  But  at  a  banquet 
of  this  kind  should  we  not  have  a  pleasant  time?  My  long 
and  accurate  discourse  would  have  tired  you,  if  it  did  not 
indeed,  send  you  to  sleep;  so  I  suppressed  it.  As  for  the' 
other  and  shorter  one,  I  suppressed  it  too,  and  I  am  glad  to 
see  what  pleasure  this  announcement  seems  to  give  you. 
You  feel  relieved  to  hear  that  those  two  speeches  have  been 
suppressed,  but  believe  me,  you  are  not  more  relieved  than 
I  am. 


A  HALF  CENTURY  OF  PRACTICE.  247 

"  Now,  Doctors  Kingston  and  McCallum  must  allow  me 
to  speak  to  them  freely,  and  you,  gentlemen,  allow  me  to 
detach  myself  for  the  moment  from  my  venerable  brothers, 
so  that  I  may  speak  to  them  as  though  I  were  one  of  you.  I  also 
wish  to  express  to  them  my  esteem  and  sympathy  Besides,  if 
I  accepted  your  invitation  it  was  with  this  object  in  view:  I 
did  not  wish  to  share  with  these  gentlemen,  in  silence,  the 
praises  which  they  deserve  for  so  many  reasons;  for  their 
labours,  their  science,  their  so  varied  and  numerous  successes, 
as  well  as  for  their  venerable  age.  I  feel  that  I  am  too  young 
to  be  placed  on  an  equal  footing  with  them. 

"  In  saying  this  I  am  only  proclaiming  a  truth  which  is 
evident  to  the  eyes  of  all — you  have  only  to  glance  even 
discreetly  at  us  three  to  see  that  the  hair  of  my  friends  is  as 
white  as  snow  and  that  there  is  very  little  at  that.  Compare 
those  two  with  the  third  !  It  is  all  very  well  for  Sir  William 
to  say  that  he  is  the  youngest  and  that  he  can  prove  it  by 
his  certificate  of  baptism  ;  but  he  will  not  tell  you  that  he 
was  three  years  old  when  he  was  baptised. 

"Since  I  have  suppressed  my  speeches  I  will  replace  them 
by  an  enigma  like  in  the  time  of  Esop,  with  this  difference, 
however,  that  Esop,  in  making  his  enigma,  had  an  object  in  view 
which  I  have  not^-he  wished  for  fame  and  glory.  His  great 
reputation,  as  you  know,  is  due  to  the  fact  that  no  one  could 
explain  his  enigmas,  which  proved  that  he  was  more  clever 
than  any  of  his  comtemporaries.  Unfortunately  I  am  not 
in  the  presence  of  his  contemporaries,  otherwise  I  might 
have  attempted  his  experience,  but  I  have  to  address  my  own 
and  this  makes  me  more  circumspect.  This  is  my  enigma  ; 
What  is  at  once  the  most  beautiful  and  the  most  rare  thing 
on  the  earth  .''  You  see  this  enigma  is  very  easy.  If  you  can- 
not solve  it  at  a  single  glance  let  me  come  to  your  aid ;  don't 
let  your  imagination  run  wild  ;  you  need  not  even  go  outside 
of  this  room;  be  satisfied  to  run  your  eyes  around  this  table 
and  you  will  soon  discover  that  of  all  the  things  that  you 
have  ever  seen  worthy  of  your  admiration  there  is  nothing 
more  beautiful  or  at  the  same  time  more  rare  than  old  age. 


248  A  HALF  CENTURY  OF  PRACTICE. 

Not  the  old  age  which  appears  stooped  and  decrepit  in  a 
body  bent  towards  the  earth,  with  faltering  gait,  with  a  dim- 
med intelligence,  but  the  old  age  we  admire  in  an  active  and 
vigorous  frame,  with  a  forehead  free  from  wrinkles ;  with 
the  strength  and  vivacity  of  a  mind  in  full  activity  ; — in 
short,  that  beautiful  and  noble  old  age  which  shines  with 
such  rare  and  incomparable  brightness  in  our  two  Doctors, 
Sir  William  Kingston  and  Dr.  McCallum." 

Dr.  D.  C.  McCallum  then  rose  and  replied  to  the  toast 
as  follows : — 

''  Mr.  Chairman  and  Gentlemen, — I  thank  you  sincerely 
for  your  kindness  in  associating  me  with  my  friends, 
Dr.  Rottot  and  Sir  William  Hingston,  in  the  reception  of 
the  great  honour  which  you  have  conferred  upon  us  by  this 
fine  banquet,  on  the  attainment  of  our  Jubilee  year  in  the 
practice  of  medicine.  For  the  cordial  manner  in  which  you 
have  responded  to  the  toast  to  my  health,  I  return  you  my 
heartfelt  thanks. 

"  Fifty  years  is  a  long  time  to  look  forward  to,  but  how 
short  it  appears  when  we  take  a  retrospective  view  of  the 
same  period  of  time.  At  the  beginning  how  slowly  the 
years  pass  and  we  then  look  hopefully  forward  to  being  able 
to  make  good  use  of  our  opportunities  and  to  accomplish 
much  important  work  in  the  world.  The  backward  look, 
however,  reveals  to  us  that  although  we  have  personally 
done  but  little  to  advance  our  own  interests  or  those  of  our 
fellow-men  the  world  moves  on,  and  that  during  the  progress 
of  the  fifty  years  great  and  important  changes  have  taken 
place  in  our  country  and  in  the  profession  to  which  we 
belong. 

"What  was  the  condition  of  Canada  in  the  year  1850? 
and  how  does  it  compare  with  the  condition  of  the  country 
fifty  years  after  ? 

"  In  1850  it  consisted  of  two  provinces,  Upper  and  Lower 
Canada,  with  an  area  of  about  550,000  square  miles;  having 
a  single  Parliament,  migrating  at  stated  periods  from  one 
province  to  the  other  ;  with  separate  and  often  conflicting 
provincial  interests,  becoming  rapidly  more  acute  and 
threatening  seriously  the  peace  and  prosperity  of  the  country. 


A  HALF  CENTURY  OF  PRACTICE.  249 

^-„  "  In  1900  instead  of  two  provinces  it  was,  by  the  Act  of 
Confederation  passed  in  the  year  1867,  made  to  include  the 
provinces  of  Ontario,  Quebec,  Nova  Scotia  and  New  Bruns- 
wick. To  which  were  subsequently  added  Manitoba  in  the 
year  1870,  British  Columbia  in  1871,  Prince  Edward  Island 
in  1873;  and  in  1880  all  British  possessions  on  the  North 
American  Continent  "(excepting  Newfoundland)  were 
annexed  to  Canada  by  Imperial  order  in  Council.  So  that 
Canada  now  extends  from  the  Atlantic  to  the  Pacific  Ocean, 
3,500  miles  from  East  to  West  and  1,400  miles  from  North 
to  South,  and  embraces  an  area  of  nearly  4,000,000  square 
miles. 

"  In  place  of  one  migrating  Parliament,  as  in  1850,  Con- 
federated Canada  has  now  an  established  Federal  system  of 
government  consisting  of  a  central  or  Federal  Parliament 
which  is  invested  with  the  authority  to  originate  all  measures 
and  to  establish  all  regulations  and  laws  for  the  development, 
stability  and  interests  generally  of  the  Dominion  ;  and  each 
separate  province  has  its  own  legislature  to  which  is  con- 
fided the  management  of  its  own  local  aflfairs,  thus  minimiz- 
ing, if  not  entirely  removing,  the  danger  arising  from  a 
clashing  of  provincial  interests.  If  any  province  considers 
that  it  has  a  grievance  it  can  invoke  the  British  America  Act 
and  lay  the  grievance  before  the  Federal  Parliament  or 
carry  it  to  the  Privy  Council  of  England. 

"  In  1850  trade  relations  between  the  two  provinces  and 
between  Canada  and  foreign  countries  were  very  limited. 
In  addition  to  coasting  craft  only  a  few  sea-going  sailing 
vessels  visited  Canadian  ports  during  the  summer  months. 
In  1900  sea- going  shipping — British,  Canadian  and  foreign 
— entered  and  cleared  from  Dominion  ports,  numbered  28,- 
546,  with  a  registered  tonnage  of  22,800,000  tons. 

"  In  the  beginning  of  the  half  century  scarcely  any 
attempt  had  been  made  to  develop  the  mineral  wealth  of 
the  country.  Iron  and  copper  were  the  only  metals  that 
attracted  attention,  and  operations  for  their  development 
were  established  at  Lake  Superior,  in  the  Eastern  Town- 
ships, at  St.  Maurice  and  the  Moisie.     At  the  end  of  the 


250  A  HALF  CENTURY  OF  PRACTICE. 

half  century  the  mines  of  non-metallic  and  metallic  minerals 
had  been  developed  to  such  an  extent  that  the  value  of  the 
minerals  extracted  in  one  year  amounted  to  the  large  sum 
of  $63,775,000. 

"  In  1850  communication  between  widely  separated  parts 
of  the  country  was  maintained  by  means  of  stage  coaches 
and  steamboats.  There  was  not  a  single  mile  of  railway  in 
Upper  Canada,  and  in  Lower  Canada  there  was  but  one 
short  line  between  Laprairie  and  St.  Johns,  Que.,  and,  it  is 
said,  the  first  rails  laid  were  made  of  wood.  Fifty  years  after 
there  were  196  railways  in  Canada,  their  lines  intersecting 
the  country  in  every  direction.  These  railways  being 
furnished  with  luxurious  palace,  sleeping  anJ  buffet  cars, 
and  supplied  with  every  convenience  to  render  travelling 
easy  and  enjoyable.  Besides  these  steam  railways  there 
were  twelve  lines  operated  by  electricity. 

"In  1850  there  were  no  telegraph  nor  telephone  lines. 
To-day  we  can  be  placed,  by  means  of  the  telegraph,  rapidly 
in  communication  with  the  most  distant  parts  of  the 
Dominion,  and  we  can  converse  with  our  neighbours  and 
transact  business  verbally  at  a  distance  of  hundreds  of  miles 
through  the  telephone. 

"These  few  instances  which  might,  did  time  permit,  be 
greatly  increased  in  number,  suffice  to  shew  the  more  than 
satisfactory  progress  that  our  countt'y  has  made  during  the 
last  fifty  years.  This  progress  has  attracted  the  attention 
of  business  men  and  capitalists  the  world  over,  and  the  future 
of  Canada  may  be  considered  as  now  secure  and  p«'omises 
to  be  even  more  brilliant  and  successful  than  the  most  de- 
voted and  optimistic  of  her  citizens  anticipate. 

"  While  we  must  admit  that  the  respect  and  approval 
with  which  we  are  now  regarded  by  the  mother  country  and 
by  foreign  communities  are  due,  in  a  great  measure,  to  the 
energy  and  wisdom  displayed  in  the  development  of  our 
material  resources,  I  do  not  hesitate  to  say  that  the  main 
cause  of  Canada's  popularity  at  the  present  day  and  the 
favour  with  which  Canadians  are  everywhere  regarded,  is  to 
be  found  in  the  exhibition  of  Canadian  prowess  in  the  war 


A  HALF  CENTURY  OF  PRACTICE.  2$  I 

now  being  waged  between  Great  Britain  and  the  Boers  in 
South  Africa.  Man  is  by  nature  combative,  and  few  things 
attract  his  attention  and  evoke  his  enthusiasm  more  than 
courageous  deeds. 

"  Our  young  men  who  have  taken  part  in  this  warhave» 
by  their  resourcefulness,  endurance  and  great  courage,  made 
for  themselves  a  name  that  will  always  occupy  an  honourable 
place  in  the  annals  of  Britain's  wars.  Paardeburg  and 
Kleinhart's  River  will  not  be  readily  forgotten,  and  the  dar- 
ing, unflinching  advance  of  the  men  in  the  fighting  line  of 
Canadians,  on  Cronje's  position,  in  the  former,  and  the 
magnificent  courage  and  "  no  surrender"  in  the  face  of  great 
odds,  of  the  men  with  Bruce  Carruthers  in  the  latter,  stamp 
them  with  the  hall  mark  of  heroism.  Heroes  all  of  the 
purest  metal.  Heroes  sans  petir  et  sans  reproche.  All 
honour,  then,  to  our  brave  lads  who  have  so  nobly  done  their 
duty  to  the  Empire,  and  who  have  by  gallant  deeds  im- 
parted so  brilliant  a  lustre  to  the  renown  of  their  country. 

"  The  profession  of  medicine  in  Canada  has  advanced 
during  the  last  fifty  years  pari  passu  with  the  profession  in 
Europe  and  America  in  the  great  progress  and  development 
that  have  taken  place  during  that  time  in  the  science  and  art  of 
healing. 

"Previously  to  the  year  1847  the  profession  in  this 
province  was  imperfectly  organized.  There  were  then 
three  examining  boards — one  for  the  district  of  Quebec,  a 
second  for  the  district  of  Montreal  and  a  third  for  the  dis- 
trict of  Three  Rivers.  An  Act  was  passed  by  the  Parlia- 
ment of  Canada  in  1847  incorporating  the  profession  under 
the  name  of  "the  College  of  Physicians  and  Surgeons  of 
Lower  Canada."  All  the  members  of  the  profession  living 
at  that  time,  French  and  English,  united  their  efforts  to  secure 
that  great  and  desirable  measure.  The  provisions  of  this 
Act,  wisely  conceived  and  judiciously  carried  out,  have  for 
the  last  fifty-five  years  regulated  the  examination  of  can- 
didates and  their  admission  to  the  ranks  of  the  profession, 
and  have  secured  the  registration  of  all  persons  legally  en- 
titled to  practice  medicine,  surgery  and  midwifery  in  the 
province. 


252  A  HALF  CENTURY  OF  PRACTICE. 

"  The  same  Act,  revised  as  occasion  demanded,  is  in 
force  at  the  present  day.  The  license  it  issues,  however, 
authorizes  the  recipient  to  practice  his  profession  merely 
v^rithin  the  limits  of  the  Province  of  Quebec.  He  cannot 
pass  into  another  province  of  the  Dominion  and  there  estab- 
lish himself  in  practice.  He  cannot  even  pass  over  the  line 
separating  Quebec  from  Ontario  and  prescribe  for  a  suffering 
patient  without  exposing  himself  to  arrest  or  to  the  inflic- 
tion of  a  fine.  This  applies  equally  to  the  licentiates  of 
different  provinces  of  the  Dominion.  The  license  issued  in 
one  province  does  not  confer  ad  practicandum  rights  in 
another  province,  nor  are  such  rights  recognized  in  Great 
Britain.  If  the  licentiate  desires  to  practice  in  another 
province  than  that  in  which  he  has  already  qualified,  he  is 
obliged  to  submit  to  an  examination  as  to  his  qualifications. 

"  An  effort  is  now  being  made  by  our  esteemed  friend, 
Dr.  Roddick,  Dean  of  the  Faculty  of  Medicine  of  McGill 
University,  which  has  received  the  warm  approval  and  sup- 
port of  a  latge  majority  of  the  profession,  to  have  this  em- 
barrassing limitation  to  the  work  of  the  medical  licentiates  of 
the  provinces  of  the  Dominion  removed,  and  to  secure  for 
them  the  right  to  practise  their  profession  in  any  part  of  the 
Dominion  or  in  any  part  of  the  World  where  the  British 
flag  flies. 

"  The  measure  he  ha.<;  proposed  to  secure  this  inestimable 
privilege  to  the  profession  of  Canada  is  to  establish  a 
Dominion  Medical  Council  for  the  examination  of  candidates 
and  their  admission  to  the  profession,  whose  diploma  or 
license  would  entitle  the  holder  to  practice  in  any  part  of 
the  Dominion,  and  lead  to  his  recognition  and  enregistra- 
tion  by  the  British  Medical  Council,  which  enregistration 
would  secure  for  him  the  right  to  practise  his  profession  in 
any  part  of  the  British  Empire. 

"  The  Act  which  he  has  drawn  up  and  laid  before  the 
Federal  Parliament,  and  now  awaits  its  decision  before  it, 
can  be  submitted  to  the  Local  Legislature,  provides  that 
the  existing  Provincial  Examining  Boards  shall  retain  their 


A  HALF  CENTURY  OF  PRACTICE.  253 

integrity,   and    preserves    all  the   rights   and    privileges    to 
which  they  have  heretofore  been  entitled. 

"The  autonomy  of  the  provinces  in  the  matter  of 
medical  education  is  not  to  be  interfered  with. 

"  If  this  movement  can  be  conducted  to  a  successful 
issue  it  will  increase  materially  the  sphere  of  action  and  field 
for  practice  of  the  Canadian  licentiate;  place  him  in  a  more 
commanding  and  satisfactory  position,  and  open  up  to  him 
the  possibility  of  obtaining  professional  appointments  in  the 
civil  and  military  services  of  the  Empire. 

"  Gentlemen, — As  a  Canadian  and  as  a  lover  of  my 
country  it  has  afforded  me  great  and  unmixed  pleasure  to 
see  members  of  the  two  great  races  in  whose  hands  rest  the 
destinies  of  Quebec  meeting  together  on  an  occasion  of  this 
kind  in  friendly  and  sociable  intercourse.  • 

"It  is  a  striking  and  soul-comforting  evidence  of  the  re- 
spect, esteem  and  good  feeling  which  these  races  entertain 
for  each  other,  and  which  every  patriotic  Canadian  ought, 
to  the  best  of  his  ability,  to  endeavour  to  perpetuate. 

"  Let  us,  gentlemen,  cultivate  in  ourselves  and  take  every 
favourable  opportunity  to  kindle  in  others  a  spirit  of 
patriotism.  Canada  is  a  country  of  which  her  sons  may  well 
be  proud.  A  not-unimportant  part  of  the  greatest  and  most 
liberal  Empire  of  the  world,  with  self-government  secured  to 
her  and  with  no  old-world  class  distinctions  among  her  peo- 
ple, she  is  at  present  the  freest,  happiest  and  most  desirable 
place  on  the  surface"  of  the  globe  in  which  to  dwell.  And  if 
that  government  be  considered  the  nearest  to  perfection 
which  confers  the  greatest  personal  freedom  on  the  individual 
consistent  with  perfect  security  to  life  and  property  then 
have  we  in  Canada  a  government  as  near  perfection  as  any 
government  in  the  world." 

Sir  William  Kingston  replied  as  follows  : — 

"Gentlemen, — I  have  had  many  marks  of  sympathy  and 

kindness  from  various  sources.     I  had  a  marked  evidence 

of  your  kindness  a  few  years  ago,  when  Her  Gracious  Majesty 

honoured  the  members  of  the  Medical  Profession  in  Canada 


2  54  ^  HALF  CENTURY  OF,  PRACTICE. 

in  my  humble    person— and  when  you  noticed  the  circum- 
stance by  a  banquet. 

"You  were  good  enough,  on  that  occasion,  to  endorse  ag 
it  were,  Her  Majesty's  action;  not  that  it  required  endorsa- 
tion,  for  the  Queen  can  do  no  wrong,  as  Blackstone  puts  it  ; 
still  it  was  to  me  a  matter  of  great  gratification  to  hear  from 
the  lips  of  your  distinguished  Chairman  on  that  occasion, 
and  from  the  lips  of  many  around  the  festive  board,  so  many 
tokens  of  good  will. 

"  This  evening  it  is  somewhat  different.  My  colleagues  and 
myself  are  feted  and  toasted  ; — and  what  for  }  Because  we 
have  not  seen  fit  to  allow  ourselves  to  be  buried  or  cremated 
within  fifty  years  of  our  graduation  in  medicine. 

"And  here  I  should  wish  to  disabuse  your  minds  of  the 
possible  thought  that  fifty  years  in  medicine  are,  with  the  addi- 
tion of  the  minimum  of  to-day — the  necessary  21  indicates 
a  certain  age.  My  colleagues  graduated  in  the  forties  ; — 
way  back  in  the  forties—  I  somewhere  in  the  fifties.  You 
see  what  possibilities  that  circumstance  opens  to  our  contem- 
plation. Then  there  is  another  circumstance  to  which  I 
wish  to  direct  your  attention  :  My  Alma  Mater  was  model- 
led, in  part,  on  the  Universities  of  Edinburgh  and  Dublin 
and  Glasgow.  Now,  in  the  first  of  these,  it  is  related  by 
Graham,  in  "  Social  Life  in  Scotland,"  in  the  i8th  century 
that  it  was  not  unusual  for  bright  youths — bright  youths,  mind 
you — to  enter  the  University  at  a  very  tender  age  and  to 
graduate  long  before  the  age  demanded  in  this  country.  He 
mentions  the  name  of  Colin  McLaurin,  who  afterwards  became 
the  celebrated  mathematician,  famous  throughout  the  world. 
He  entered  at  eleven  and  graduated  at  fifteen.  The  same  is 
said  of  Hume  and  Robertson  and  Hill,  afterwards  Principal 
of  the  University.  Now,  if  these  bright  youths  could  enter 
the  University  under  the  shadow  of  Arthur's  Seat,  and 
graduate  at  so  tender  an  age,  why  could  not  the  same  privil- 
eges have  been  extended  to  another  youth  by  the  University 
here, — modelled  after  that  of  Edinburgh — to  which  we  point 
with  pride,  under  the  shadow  of  Mount  Royal?'' 


VALEDICTORY   ADDRESS.  255 

During  the  evening  Drs.  Desrosiers,  Cra'g,  Guerin  and 
others  enlivened  the  banquet  with  songs.   . 

Dn  Gird  wood  in  a  neat  speech  proposed  the  health  of 
the  Chairman,  which  was  most  enthusiastically  received. 
Dr.  F,  W.  Campbell  replied  briefly,  giving  some  interesting 
incidents  of  medical  students'  life  in  Montreal  almost  fifty 
years  ago ;  after  which  God  Save  the  King  was  sung,  and 
a  very  pleasant  and  memorable  banquet  was  closed. 


VALEDICTORY  ADDRESS  TO  THE  GRADUATING  CLASS 
AT  THE  3 1ST  ANNUAL  CONVOCATION  OF  THE 
MEDICAL  FACULTY  OF  THE  UNIVERSITY  OF 
BISHOPS  COLLEGE,  APRIL  23,  1902,  BY  WILLIAM 
E.  DEEKS,  M.D.,  LECTURER  IN  MEDICINE. 

The  members  of  the  Faculty  of  Bishop's  College 
unite  in  extending  to  you  their  heartiest  congratulations 
on  the  completion  of  j'our  college  curriculum  course,  which 
you  have  so  diligently  pursued  during  the  past  four  years. 

It  requires  no  small  amount  of  courage  to  initiate  a 
course  of  study  fraught  with  so  much  laborious  work;  and 
extending  over  such  a  long  period  of  time;  and  he  who 
has  successfully  accomplished  what  he  began,  deserves  not 
alone  the  formal  congratulations  of  his  friends,  but  more, 
he  deserves  that  degree  of  success  in  life  which  falls  to  the 
lot  of  the  talented,  ambitious  student.  For  who  knows 
better  than  he,  ''Over  rough  roads  indeed,  lies  the  way  to 
medical  glory." 

You  have  reviewed  to-day,  in  your  valedictory  address, 
your  college  career,  have  shown  grateful  appreciation  to 
those  who  have  so  strenuously  laboured  in  your  behalf, 
have  said  farewell  officially  to  the  old  halls  which  you 
have  learned  to  love  so  well,  and  which  have  so  oft  re- 
echoed with  your  college  songs,  have  closed,  so  to  speak, 
one  epoch  of  your  existence,  and  completed  the  prelimin- 
ary training,  preparatory  to  launching  forth  your  boat  on 
the  great  sea  of  practical  life,  in  the  "struggle  for  exist- 
ence," which  must  terminate  in  success  or  failure.  We 
sincerely  trust  and  hope  the  former.  With  that  end  in 
view  we  cannot  do  better  now  than  offer  you  a  few   sug- 


256  VALEDICTORY   ADDRESS. 

gestions  which,  we  trust,  may  be  of  service  to  you  in   the 
practice  of  your  profession. 

It  appears  to  me  that  the  first  question  each  one  of 
you  should  ask  yourself  is: — "Am  I  in  the  right  profes- 
best  exemplify  my  talents;  where  I  can  be  happy  and  con- 
best  exemplify  my  talents  where  I  can  be  happy?  You  may 
have  been  impelled  thereto,  through  the  pet  whim  of  some* 
doting  parent,  or  misguided,  wealthy  aunt,  or  because  the 
respectable  calling  of  the  profession  induced  you  to  enter 
in  view  of  imaginary,  pecuniary  advantages;  or  not  knowing 
what  else  to  do,  and  morbidly  curious,  you  entered  its  ranks 
Gentlemen,  let  me  tell  you,  now^,  that  unless  your  motive 
for  entering  the  profession  of  medicine  is  ulterior  to  these, 
unless  you  have  an  enthusiastic  love  for  the  work,  a  burn- 
ing scientific  desire  to  do  good  to  your  fellownien,  unless 
the  vocation  be  congenial  in  every  respect,  stop  right  here, 
correct  your  mistake,  disregard  the  adverse  criticism  of 
idle  gossip-mongers,  and  enter  that  business  or  profession 
where  your  talents  lie,  where  you  can  be  enthusiastic  in 
your  work,  happy  and  contented.  "Be  sure  you  are  right 
and  then  go  ahead."  Even  should  you  enter  another 
profession,  your  time  has  not  been  wasted  ;  you  have 
gleaned  a  scientific  knowledge  over  a  large  range  of 
subjects,  have  been  taught  unselfishness,  true  manliness 
and  to  sympathize  with  the  sufferings  of  others.  Better  far 
to  have  erred  for  four  years  and  been  corrected  than  to 
live  a  life  of  one  constant  grand  mistake. 

You  must  next  consider  whether  you  will  begin  now 
actively  your  practice,  or  first  enter  a  hospital  for  an  in- 
definite period.  Those  of  you  who  can  afford  it  cannot  do 
better  than  spend  some  time  in  a  hospital  (if  a  position  be 
obtainable),  as  you  will  then  be  able  to  digest  and  as- 
similate the  knowledge  you  have  been  persistently  cram- 
ming. It  begets  confidence  in  yourself  which  is  so  essen- 
tial. If  you  have  no  confidence  in  yourself,  how  can  you 
expect  others  to  confide  their  lives  in  your  hands?  Hos- 
pital training  does  that,  and  helps  to  fix  in  your  mind  a 
large  number  of  practical  little  things  which  the  ordinary 
student  has  no  opportunity  of  obtaining. 


VALEDICTORY   ADDRESS.  257 

Our  methods  of  training  the  student,  clinically,  are  in 
some  respects  grievously  at  fault. 

The  clinical  material  in  the  out-door  departments  is 
not  utilized  as  it  should  be.  It  is  this  class  of  cases  that 
you  will  meet  with  in  your  every -day  practice;  you  are 
sent  into  the  wards  to  study  pneumonia,  typhoid,  pleurisy, 
tabes  dorsalisj  and  a  variety  of  rare  conditions  gathered 
from  the  four  corners  of  the  earth,  and  know  nothing  about 
the  treatment  of  a  common  cold  or  colic  or  the  applica- 
tion of  a  mustard  plaster.  This  you  must  acquire  from 
your  own  experience,  or  humiliatingly  accept  your  lessons 
from  an  old  housewife  or  nurse,  who  usually  will  com- 
municate your  inexperience  and  ignorance  to  the  neigh- 
bours, and  this  will  not  redound  to  your  advantage. 

If  this  be  true  of  the  medical  department,  how  in- 
finitely worse  is  the  surgical.  You  are  expected,  yea,  are 
compelled  to  sit  on  the  benches  for  hours  at  a  stretch, 
watching  the  skilful  manipulations  of  surgeons,  day  after 
day,  on  operations  which  you  would  never  pretend  to  at- 
tempt without  a  special  training,  instead  of  hearing  surgi- 
cal clinics  on  differential  diagnosis.  When  you  have  once 
learned  the  technique  of  an  operation,  which  is  readily 
acquired,  you  will  only  profit  by  remaining  through  it  if 
you  are  taking  a  practical  part.  Otherwise,  your  time  is 
better  employed  in  assisting  in  the  simpler  things  one 
sees  in  the  out-door  departments. 

In  this  way,  then,  you  would  be  the  better  of  a  hos- 
pital training  by  seeing  the  practical  little  things,  oft  the 
forerunners  of  great  ones,  and  dealing  with  them. 

The  next  point  you  have  to  decide  is  location.  Will 
you  undertake  a  country  practice  with  its  arduous,  though 
healthy  life  and  promise  of  quick  returns,  or  will  you  go 
to  the  city,  where  the  profession  is  now  overcrowded  The 
guiding  principle  it  appears  to  me  is,  to  seek  that  life, 
country,  town,  or  city,  most  congenial  to  your  nature,  that 
place  you  would  best  like  to  live  in  and  go  to  work.,  You 
cannot  be  happy  and  successful  living  any  place  if  your 
mind  is  constantly  reverting  to  some  other  locality. 

Having  decided  those  points,  your  attitude  towards 
your  fellow  practitioners,  members  of  irregular  schools, 
and  your  patients  must  be  your  next  consideration. 


258       ,  VALEDICTORY   ADDRESS. 

Do  not  delude  yourself  into  thinking  that  you  will  be 
a  welcome  visitor  in  any  community  by  your  fellow  prac- 
titioners. You  will  engender  a  certain  amount  of 
jealousy  and  animosity.  They  will  resent  your  entrance 
into  a  field  considered  peculiarly  their  own.  They  know 
that  by  your  coming  their  incomes  will  be  curtailed  and 
their  bread-winning  powers  interfered  with. 

Let  your  manner,  however,  toward  your  seniors  be 
dignified,  courteous  and  respectful,  and  know  well  that 
though  you,  fresh  from  the  college  halls  and  pathological 
laboratories,  may  know  more  about  the  microscopical 
aspects  of  pathogenic  bacteria,  liver  cirrhosis,  or  com- 
pounded-mono-syllabic  tumours,  still,  he  may,  "with  a  face 
like  a  benediction,"  carry  in  his  head  experiences  which 
years  only  can  acquire,  a  sympathy  and  wisdom  which 
ripens  as  did  McClure's,  a  dignity  and  self-possession 
which  will  put  crude  foppishness,  snobbish  dilettanteism 
and  blind  egotism  to  shame,  though  you  may  seem  from 
your  pedantic,  linguistic  expressions  as  though  you  had 
been  at  *'a  great  feast  of  languages  and  stolen  all  the 
scraps." 

Your  instincts,  coupled  with  the  training  you  have  had 
of  human  nature,  will  soon  enable  you  to  know  where 
merit  lies,  where  science  ends  and  charlatanism  begins, 
whom  to  select  as  your  professional  companions,  in  whom 
you  can  confide  and  trust,  who  will  prove  helpful  to  you 
and  whom  you  can  reciprocally  help. 

''Be  to  their  faults  a  little  blind  and  to  their  virtues 
wondrous  kind,"  and  you  will  find  in  the  end  that  it  pays. 

Of  irregular  schools  of  treatment  what  shall  I  say? 
Is  their  very  existence  not  an  unfavourable  comment  on 
our  own  narrow-mindedness? 

We  should  remember  that  the  medicine  of  to-day  is  a 
developing,  not  a  developed  science,  that  as  marvellous 
things  have  been  from  time  to  time  revealed,  stupendous 
in  their  far-reaching  effects  upon  disease,  so  just;  as 
marvellous  will  yet  be  discovered,  that  there  may  be  and 
undoubtedly  is  a  grain  of  truth  in  every  system  that  pre- 
vails irrespective  of  its  nomenclature.  Had  we  not 
physicked  and  bled  our  patients  a  few  years  ago  almost  to 
death's   door,   homoepathy   with   its   infinitesimal   dosage 


l^  ■  VALEDICTORY    ADDKESS.  259 

would  never  have  sprung  into  existence,  had  we  realized 
a  little  more  the  advantages  of  massage  in  this  modern 
fortune-making,  indolent-living  age,  osteopathy  would 
never  have  been  heard  of;  had  we  appreciated  fully  and 
been  able  to  find  the  proper  sphere  for  suggestibility  in 
those  cases,  particularly  where  idleness  in  a  restive  dispo- 
sition begets  the  habit  of  introspectiveness  and  leads  to  all 
sorts  of  functional  neuroses,  then  Mrs.  Eddy  with  her 
Christian  science  would  have  been  unknown,  and  another 
human  flower,  now  notorious,  ''born  to  blush  unknown." 

Let  us,  gentlemen,  be  tolerant,  broad-minded,  recep- 
tive, acknowledging  merit  wherever  found,  and  endeavour 
to  separate  the  germs  of  truth  from  the  mountain  of  chafe, 
no  matter  how  colossal  the  disproportions.  Nothing  will 
help  to  spread  a  false  science  more  than  to  decry  it,  especi- 
ally if  that  science  can  show  results.  These  schools  do 
show  results  for  each  and  all  of  them,  are  the  handmaidens 
and  recognized  methods  of  treatment  of  th^e  regular 
schools,  under  different  names,  but  not  utilized  or  apr 
preciated  as  they  should  be.  No  amount  of  ranting  and 
talking  will  convince  a  man  that  he  was  wrong  to  be  cured 
of  rheumatism  by  an  osteopath,  when  you,  by  all  your 
nostrums,  failed  to  do  so.  Novelty  attracts  credulous  hu- 
manity, and  osteopathy  may  do  more  to  restore  an  individal 
than  massage,  though  the  methods  are  almost  the  same  and 
the  latter  infinitely  cheaper. 

Now,  what  attitude  must  you  adopt  towards  your 
patients?  You  will  not  long  be  settled  in  a  community 
before  the  public  will  begin  to  feel  your  pulse  even  before 
you  feel  theirs;  they  will  want  to  know  your  politics,  your 
religion,  and  whether  you  are  sporty.  Give  certain  classes 
of  individuals  a  little  latitude,  and  they  will  want  to  con- 
taminate your  oflflce  with  smoking,  gossip,  and  perchance 
a  friendly  game  of  cards;  but  be  warned  that  just  as  soon 
as  you  permit  your  office  to  be  the  resort  of  idlers, 
loungers,  gossip-mongers,  jockey  and  baseball  enthusiasts, 
just  so  soon  have  you  driven  the  first  nail  in  your  profes- 
sional coffin. 

Never  allow  that  class  of  man  to  become  familiar; 
"familiarity  breeds  contempt."     He  will   not  only  waste 


'?^0  ¥ALEDieTORY    ADDRESS. 

• 

^Qur  time,  but  superciliously  look  askance  when  you  seek 
reward  for  your  servicevS.  He  will  soon  call  you 
^'Doc./'  and  disgrace  you.  The  man  who  dubs  you  that 
insults  you,  and  if  it  calls  forth  your  imm-ediate  resent- 
ment, you  will  keep  yourself  free  from  the  meanest,  most 
contemptible  stigma  that  attaches  to  a  professional  man, 
detracting  from  his  .dignity  and  degrading  to  his  moral 
tone  and  self-respect.  If  your,  aim  be  to  attract  the  best 
class  of  practice,  do  not  Tim,  John,  Jessie,  Kate  anybody. 
Such  is  justifiable  only  on  terms  of  the  greatest  intimacy, 
or  to  your  servant  or  lackey. 

If  you  would  be  respected,  preserve  your  self-respect. 
"Never  seem  a  saint  and  play  the  devil,"  be  straightfor- 
fward,  honest  and  honourable,  and  don't  forget  that  you 
are  gentlemen  by  profession  as  by  training."  "The  success- 
ful man  knowsi  nature  as  well  as  his  profession."  If  you 
would  succeed,  you  must  be  able  to  do  more  than  diagnose 
a  case  and  prescribe  some  nauseating  dose,  you  must  study 
your  case  on  its  own  merits,  and  realize  that  you  are  treat- 
ing a  human  being  with  intelligence,  and  not  an  animal. 
No  two  natures  are  alike.  "What's  one  man's  meat  is 
another  man's  poison."  Be  tactful  as  well  as  skillful, 
never  jump  at  conclusions  or  make  snap  diagnoses.  If 
not  certain,  keep  your  mouth  shut  till  your  judgment  is 
formed,  remembering  that  "the  silent  man  has  much  in  his 
favour."  Never  exaggerate  the  gravity  of  a  case.  Some 
physicians  make  themselves  ridiculous  and  think  they 
magnify  their  own  importance  by  doing  so.  That  may  be 
swallowed  by  men  gullibly  ignorant,  but  not  by  men  of 
common  sense  who  can  see  through  deceit  so  obviously 
and  odiously  transparent. 

Be  frank  and  take  the  patient  or  the  patient's  most 
intimate  friend  into  your  confidence.  If  the  case  be 
serious,  never  be  ashamed  to  acknowledge  it;  if  un- 
certainty exists,  then  seek  a  consultation.  It  will  beget 
confidence  in  them  for  you,  and  they  will  be  more  reliant 
on  you  and  your  judgment  in  future. 

Never  gloat  over  big  operations  as  though  you 
revelled  in  blood  and  cutting,  and  were  devoid  of  feeling, 
the  butcher  element  predominating. 


VALEDICTORr  ADDRESS:  26l 

Man  is  an  animal,  but  one  of  the   highest    onier,  en- 
dowed with  a  delicate,  nervous  organism,  acutely  sensitive 
to  pain,  and  external  impressions.     His  whole  nattire  re*- 
sents  and  revolts  against  a  cruel  action  or  an  unkind'  word, 
particularly  if  laid  on  a  bed  of  sickness,  but  appreciates 
sympathy,  kindness  and  consideration;  -,  Never  forget,  also, 
that  wealth  or  position  in  life  never  makes  us  more  sensip 
tive  to  pain  or  suffering.     The  squalid  hut  of  poverty  may 
be  the  home  of  the  most  delicate  and  timid  creature..  -Be 
kind,  considerate  and. tender  in,  your, manipulations  where 
suffering   is,  and    you    will    receive  gratitude   in    return. 
Particularly  is  this  applicable  to  the  fair  sex.     "Woman, 
fairest  of  creatures,  God's  last  and  best  gift  to  man."     Sen- 
sitive, modest,  retiring,  acutely   intuitive,  craving  for   sym- 
pathy and  hope  in  suffering,  for  consideration  and  respect 
in  health.     In  your  relations  with  them  never  forget  that 
"immodest  words  admit  of  no  defence,  for  want  of  decency 
is  want  of  sense."     The  medical  profession  is  undoubtedly 
a  grand  profession,  carrying  with  it    enonndils     responsi- 
bilities, not  alone  of  life,  but  of  the  happiness  and  charac- 
ters of  individuals  which  it  is  your  duty  to  safeguard  and 
protect.     You    are    the    guardian    of    inviolable    secrets 
sacred  as  God's  laws.     Be  not  their  betrayer.     A  word,  a 
thought,  an  action  from  you  may  be  the  ruination   or  the 
salvation  of  a  life.     Yours   it   is   to    relieve   pain,  restore 
health,  bring  comfort,  console  and  cheer,  and  though  your 
remuneration  be  but  the  look  of  gratitude,  yoiir  duty  must 
never  be  slighted;  never  shirked.     You  need  never  expect 
to  amass  wealth  from  your  profession.     Many  and  many- 
physicians  are  spending' their  lives  "Dropping  buckets  into 
empty  wells,  and  ■  growing  old   in   drawing   nothing   out," 
Instead  of  that,  however,  you  inay  confidently  expect,  and 
will  assuredly  receive  from  many  what  to  some  natures  is 
infinitely   sweeter  far,   absolute   COTifidence,  implicit  trust, 
grateful  appreciation  and  undying  love.     And  when  your 
faculties  begin  to  dim,  and  the  suiiset  of  life  with  evan- 
escent ray  lights  up  the  gray  hairs  of  declining  years,  and 
hoary  age,  ripened  with  deeds  of  love*  and  charity,  beckons 
you  to  your  last  resting  place,  you  will  have  the  keen  satis- 
faction of  being  surrounded  by  those  whose  lives  you  have 


262  THREE  CA»ES  OF  VAGINAL  HYSTERECTOMY. 

gladdened  and  perchance  have  saved,  whose  hearts  com- 
forted, and  sorrows  soothed,  pouring  benedictions  on  your 
head,  and  then  you  will  feel  that  you  have  not  lived  in 
vain,  and  will  welcome  the  "Eternal  hope  which,  like  a 
rainbow  of  summer,  gives  a  promise  of  Lethe,  at  last." 

The  Faculty  unite  in  wishing  you  fatewell  and  God- 
speed. 


THREE  CASES  OF  VAGINAL  HYSTERECTOMY,  WITH 

REMARKS  ON  THE  FUTURE  OF  HYSTERECTOMY 

FOR  CANCER.* 

BY  A.  LAPTHORN  SMITH,  B.A.,  M.D.,  M.R.C.S.,  EXG.,  MONTREAL,  P.Q. 

Fellow  of  the  American  and  British    Gyiijecological   Societi'-s  ;    Professor  of  Gynse- 
cology  in  the  University  of  Vermont,  Burlington  ;  Professor  of  Clinical 
Gynsecolofry  in  Bishop's  University,  Montreal ;   Surgeon-in-Chief  of 
the  Samaritan  Free  Hospital  lor  Women  ;  Gynecologist  to  the 
Western  General  Hospital;  Gynsec  'loglst  to  the  Montreal 
Dispensary,  and  Consulting  G\na»cologist  to  the 
VVoman's  Hospital,  Montreal. 

As  my  mental  attitude  towards  cancer  of  the  uterus 
has  undergone  a  great  change  during  the  past  year,  and  as 
my  present  method  of  treating  it  promises  a  certain  cure 
in  every  early  case  in  which  it  is  employed,  it  may  be  of 
interest  to  briefly  outline  my  experience  during  the  last  ten 
years,  which  will  at  the  same  time   explain   how    I   have 
come  to  accept  my  present  course  of  action.     In  the  early 
days  of  my  work  hardly  a  week   used   to  pass  without  a 
patient  coming  to  me  with  the  cervix   a  mass   of  cancer, 
and  with  the  broad  ligaments  full   of   the   same   disease^ 
so  that  it  was  impossible  to  draw  the  uterus  down,  even 
as  much  as  a  quarter  of  an   inch.     Too   often   the   whole 
vagina  was  infected,  and  in  two  or  three  cases  there  was 
a  large  opening  into  the  bladder  or  rectum  which  rendered) 
the  poor  creature's  life  a  living  death.     At  that  time  no- 
thing was  attempted  for  the  relief  of  these  patients  excepl^ 
to  keep  them  as  free  from  pain  as   possible  by  means  of 
opium  or  morphine  suppositories.     The  smell  was  so  hor- 
rible that  their  friends  and  relatives  might   well    be   for- 
given for  praying  for  their  death.     And    when    death   at 
last  came,  either  from   sepsis   or   hemorrhage,  every   one, 
including  the  patient  and  doctor,  was    very    glad.     Now, 

*This  article  appeared  in  "American  and   Gynaecol.   Surgery"  for 
April. 


THREE  CASES  OF  VAGINAL  HYSTERECTOMY.       263 

until  the  happy  release,  even  in  these  hopeless  cases,  we 
can  do  much  for  the  comfort  of  all  concerned.  By  curet- 
ting away  all  the  necrosed  tissue  with  a  sharp  curette,  and 
cauterizing  the  remaining  tissues  with  the  thermo-cautery, 
it  is  possible  for  a  patient  who  is  in  a  hopeless  condition 
as  far  as  any  curative  operation  is  concerned,  to  live  for 
several  years  almost  without  knowing  that  she.  has  the 
disease,  and  for  her  eventually  to  die  a  painless  death  from 
cancer  of  the  liver  or  other  internal  organs.  Indeed,  I  feel 
sure  that  the  heat  of  the  actual  cautery  is  the  most 
powerful  means  we  possess  of  arresting  the  disease.  This 
is  proven  by  the  much  better  ultimate  results  obtained  by 
Dr.  Byrne,  of  Brooklyn,  than  by  any  one  else.  He  ampu- 
tates the  cancerous  cervix  with  the  galvano-cautery  knife, 
and  he  has  many  cases  living  after  from  five  to  ten  years. 
Many  of  my  own  cases  have  been  curetted  two  and  three 
times  at  intervals  of  from  three  to  six  months,  so  that  I 
know  of  several  who  were  still  alive  nearly  two  years  after 
the  disease  had  reached  the  hopeless  stage.  So  much  for 
the  cases  which  are  too  far  advanced  for  hysterectomy. 

Now  the  question  comes  up:  "Which  cases  are  to  be 
classed  as  hopeless,  and  which  are  we  justified  in  perform- 
ing hysterectomy  on?"  It  is  precisely  on  this  point  that 
my  opinion  has  undergone  a  decided  change.  Up  till  my, 
visit  to  Brussels  four  years  ago,  I  w^as  doing  vaginal 
hysterectomy  for  all  those  cases  in  which  the  uterus  was 
at  all  movable  even  if  the  broad  ligament  on  one  or  both 
sides  was  rather  thicker  than  usual.  But  I  had  noticed 
that  while  the  death  rate  of  the  operation  was  slight,  the 
disease  advanced  much  more  rapidly  than  it  did  in  the 
much  worse  cases  which  were  only  curetted  from  time  to 
time.  So  that  at  the  end  of  two  years  from  the  operation 
there  was  not  one  woman  living,  and  most  of  them  died 
within  a  year.  On  discussing  this  point  with  Jacobs,  of 
Brussels,  he  told  me  that  his  experience,  which  was  far  more 
extensive  than  mine,  was  exactly  similar.  So  much  so, 
indeed,  was  he  impressed  with  this  common  observation 
that  he  told  me  he  had  given  up  removing  the  uterua 
for  cancer  altogether!  When  I  returned  home  I  adopted 
a  new  course;  I  ceased  removing  the  uterus  whenever  the 
broad  ligaments  were  infiltrated,  even  if  the  uterus  were 


264  THREE  eAaea  of  vaginal  hysterectomy. 

fairly  movable,  and  contented  myself  with  the  palliative 
treatment  already  described.  In  other  words,  I  placed  all 
these  cases  in  the  hopeless  class,  but  assured  them  nearly 
two  years  of  comfort  for  themselves  and  their  friends, 
instead  of  giving  them  only  three  to  six  months,  during 
most  of  which  they  suffered.  But  to  make  up  for  this  I 
devoted  all  my  energies  to  discovering  as  many  cases  as 
possible  while  the  disease  was  strictly  limited  to  the  uter- 
ine tissue  and  before  it  had  spread  to  the  cellular  tissue 
in  the  broad  ligaments.  I  made  a  vigorous  campaign  in 
the  medical  journals,  calling  upon  the  general  prac^ 
titioners  to  spread  information  among  their  patients  as  to 
the  danger  of  irregular  uterine  hemorrhages  in  women 
over  forty-five,  especially  if  they  had  had  the  menopause, 
and  their  periods  had  left  them  for  several  years.  This 
was  very  important,  as  it  had  been  the  general  opinion 
among  women  that  this  return  of  bleeding  from  the  uterus 
was  a  subject  for  self-congratulation  as  indicating  a  re- 
newal of  the  vigour  of  youth.  Another  fallacy  which  I 
asked  them  to  correct  was  that  as  long  as  there  was  no 
bad  odour  from  the  vaginal  discharge,  there  was  no  need 
to  suspect  cancer.  On  the  contrary,  when  the  bad  odour 
makes  its  appearance  the  time  for  vaginal  hysterectomy, 
has  passed,  so  that  it  is  Of  the  greatest  importance  to  dis- 
cover it  before  it  has  reached  the  bad  smelling  stage.  My 
crusade  has  been  successful;  thanks  to  the  general  prac- 
titioners who  have  com^  "within  my  influence.  I  no  longer 
see  these  terribly  neglected  and  terribly  smelling  cases 
which  I  used  to  see  so  often  ten  years  ago.  Although  in 
many  of  them  still  the  disease  is  perilously  near  the  hope- 
less condition  above  mentioned,  this  is  not  the  fault  of  the 
family  doctors  who,  as  a  rule,  send  me  the  case  within  a 
few  days  of  its  discovery,  instead  of  losing  six  precious 
\nonths  cauterizing  the  cervix  before  sending  them  to  me,, 
as  they  formerly-  used  to  do.  Since  the  women  themselves 
seldom  consulted  their  family  doctor  until  the  disease  was 
considerably  advajiced,  the  next  duty  which  I  felt  that  we 
owed  these  women  was  to  look  for  cancer  before  the 
women  complained,  and  to  urge^  an  examination,  especi- 
ally in  all  cases  where  there  was  bleeding  on  intercourse, 
or  where  the  menstrual  flow  was  becoming  more  profuse 


THREE  CASES  OF  VAGINAL  HYSTERECTOMY.       265 

at  forty-five  instead  of  getting  less.  The  result  has  been 
that  gradually,  year  by  year,  I  have  been  getting  these 
cases  earlier,  until  now  it  is  the  exception,  rather  than  the 
pule,  to  find,  on  removing  the  uterus,  that  the  disease  had 
not  yet  entered  beyond  the  uterine  tissue,  and  consequently 
these  women  have  all  been  saved  from  a  horrible  death-. 
In  these  cases,  of  course,  most  rigourous  precautions  have 
been  taken  to  avoid  infecting  the  healthy  cut  surfaces;  first 
the  vagina  and  external  genitals  are  thoroughly  disin- 
fected with  soap  and  water  and  bichloride;  then  the  cauli- 
flower growth  is  cut  off,  and  the  uterus  curetted  and  disin- 
fected with  carbolic  acid,  and  then  cauterized  with  the 
Paquelin  cautery,  until  dry;  the  cervix  then  being  packed 
with  sterilized  cotton  and  then  tightly  sewed  up.  Many 
such  cases  which  would  have  been  ultimately  saved  have 
died  through  reinfection  during  the  operation. 

And  now  I  come  to  the  last  advance;  one  which,  as  I 
have  stated,  will"  save  every  woman  so  treated  from  death 
from  cancer.  Several  times  during  the  last  ten  years  I 
have  had  occasion  to  perform  Behroeder's  amputation  of  a 
badly  lacerated  cervix  of  long  standing,  in  women  over 
forty-five  years  of  age;  and  during  the  operation  I  |jave 
found  the  tissues  friable  and  brittle;  so  that  the  ligatures 
would  sometimes  cut  out.  Much  to  my  disappointment 
some  of  these  women  afterwards  died  of  cancer.  I  there- 
fore came  to  the  conclusion  that  in  all  women-  over  forty- 
five  who  were  bleeding  profusely  or  irregularly  I  would 
take  no  chances,  but  head  off  the  fell  disease  by  removing 
the  whole  of  the  uterus!  I  felt  the  more  justified  in  doing 
this  because  of  the  number  6t  cases  Ihave  seen  in- which 
the  cervix  was  apparently  all  right,  but,  on  opening  th(? 
uterus  after  removal,  undoubted  cancer  of  the  fundus  was 
discovered.  In  Cullen's  work  on  cancer  of.  the  uterus  there 
are  many  engravings  which  illustrate  my  point,  which  he 
evidently  believes  in  very  thoroughly.  I  have  already 
said  in  several  df  lay  papers  on  cancer  of'  the  cervix,  that 
if  every  woman  with  a  lacerated  cervix  had^  it  repaired, 
within  a  year  sitter  its  occuiTence,  death  from  ■  cancer  of 
the  cervix  would  be  unknown.  (It  is  not  -safe,  I  might 
mention  here,  to  let  these  women  go  around-  with  a-  bad 
laceration  until  they  are  nearly  forty-five;  for  sometimes 


266 


THREE  CASES  OF  VAGINAL  HYSTERECTOMY. 


1  have  seen  women  of  thirty  or  thirty-three  have  cancer 
develop  on  a  tear).  I  will  now  say  that  if  every  woman 
with  menorrhagia  at  forty-five  had  her  uterus  removed  by 
vaginal  hysterectomy,  death  from  cancer  of  the  fundus 
would  also  be  unknown!  With  such  an  object  in  view,  I 
am  sure  I  will  not  appeal  in  vain  to  the  hundreds  of 
general  practitioners  who  read  these  lines,  and  in  whose 
hands  alone  rests  the  fate  of  the  thousands  of  women  who, 
as  above  shown,  are  likely  candidates  for  death  from 
cancer. 

The  following  three  cases,  briefly  stated,  were  treated 
on  these  lines: 

Montreal;  widow;  first  menstruated  at  12,  being  painful 
Montreal;  widow;  first  menstruated  at  12,  being  painful 
and  coming  on  every  three  weeks;  mother  of  eight 
children,  two  of  them  twins,  born  at  7  months;  never  de- 
livered with  instruments;  one  confinement  18  years  ago 
was  severe,  and  she  was  never  as  well  since,  always  being 
nervous.  Her  periods  left  her  at  45,  and  she  saw  nothing 
till  47,  when  she  began  to  have  irregular  hemorrhages. 
She  had  a  great  deal  of  pain  with  her  womb,  very  little 
'Vhites,"  and  there  was  no  bad  smell,  but  Dr.  Wilson  in- 
forms me  that  the  discharge  was  watery  and  very  acrid,  as 
it  excoriated  the  skin  around  the  vulva.  Moreover,  her 
mind  was  seriously  affected,  and  it  was  a  question  whether 
she  would  not  have  to  go  to  the  asylum.  Vaginal  hyster- 
ectomy was  performed  on  the  6th  of  February  with  no 
trouble  whatever;  the  operation  only  requiring  eleven 
minutes  from  first  incision  until  the  uterus  was  out.  The 
latter  was  double  the  normal  size,  and  retroverted,  and 
on  cutting  it  open  a  hemorrhagic  area,  the  size  of  half  a 
cherry,  was  found  near  the  fundus.  She  made  a  rapid 
recovery  and  went  home  in  three  weeks. 

Case  2.  Mrs.  M.,  widow,  49  years  of  age,  sent  to  me  by 
Dr.  Maas  for  profuse  and  too-frequent  menstruation.  Her 
periods  first  began  at  the  age  of  14,  and  were  always 
abundant.  She  was  married  at  19,  and  in  the  next  eighteen 
years  she  had  fourteen  children,  the  last  one  11  years  ago. 
Menstruation  now  comes  on  every  three  weeks,  and  is  very 
profuse,  large  clots  coming  away,  and  between  the 
periods  she  has  a  profuse  yellow  discharge.     On  examina- 


THREE  CASES  OF  VAGINAL  HYSTERECTOMY.       267 

tion  the  uterus  was  found  retroverted  and  there  was  a 
deep  laceration  extending  up  to  the  internal  os.  The 
everted  lips  cannot  be  brought  together  owing  to  the 
amount  of .  hypertrophy  and  cystic  growth.  On  introduc- 
ing the  sound  very  gently  profuse  bleeding  began.  Going 
on  the  principle  that  if  she  did  not  already  have  cancer 
she  was  on  the  verge  of  having  it,  I  had  no  hesitation  in 
advising  the  removal  of  the  uterus,  in  which  she  and  her 
doctor  heartily  concurred.  This  was  done  two  weeks  ago, 
and  she  is  now  going  around  looking  very  much  better,  and 
will  go  home  in  another  week. 

Case  3.  Mrs.  B.,  sent  to  me  by  Dr.  Smythe.     She  gave 
me  the  following  history:  She  is  now  38  years  of  age;  her 
menstruation  began  at  12;  this  was   normal,  except   that 
she  was  very  ill  for   a   year,  when   she  was  18;  she  was 
.married  at  23,  and  has  had  three  children,  the  last  one  10 
years  ago;  instruments  were  used  (by  a  doctor  whose  name 
I  will  not  mention)  after  being  in  labour   only   about  two 
hours.     This  "finished  her,"  for  she  had  no  children  after 
that;  in  fact,  she  was  in  bed   for   the   next   five  months. 
Her  menstruation  left  her  at  thirty-five,  but   after  three 
years  it  began  again  very  profusely  and  irregularly,  and 
she  also  bleeds  freely    on   coitus  or   digital    examination. 
Since  two  months  she  has  had  a  profuse  watery  discharge. 
On  examination,  I  found  a  cauliflower  growth  pretty  well 
filling  the  pelvis.     Vaginal  hysterectomy  was  performed 
a  week  ago  with  the  precautions  above  mentioned;  the 
uterus  was  retroverted  and  densely  adherent;  so  that  the 
thickening  of  the  broad  ligaments  may  have  been  partly 
due  to  this  cause.     In  this  as  in  the  other  three  cases,  the 
clamp  method  was  employed,  the  clamps  being  removed  at 
the  end  of  forty-eight  hours.     She  is  feeling  and  looking 
much  better  already,  and  will  be  able  to  go  home  in  two 
weeks. 

My  only  regret  is  that  this  case  was  not  discovered 
before  the  disease  was  so  plainly  evident.  Her  chances 
are  surely  much  less  than  those  of  cases  one  and  two — 
from  whom  the  uterus  was  removed  while  it  was  still  quite 
certain  that  the  disease  was  limited  to  the  uterine  tissue. 
248  Bishop  street,  Montreal. 


Progress  of  Medical  Science. 


MBDICINB    AND     NEUROI^OGY 

IN   CHARGB   OP 

J.  BRADFORD  McCONNELL.  M.D. 

Associate  Professor  of  Medicine  and  Nevirology,  and  Prbfessorof  Clinical  Medicine 
Univei-sity  of  BisUop's  Uollege;  f  Uysician  Western  Hospital. 


TEMPERATURE,  PULSE    AND  RESPIRATION  IN  THE 
DIAGNOSIS  OF  DISEASES  OF  THE  BRAIN. 

J.  T.  Eskridge  concludes  a  lengthy  articlie  in  the  Isiew 
York  Medical  Journal  of  September  28,  1901,  by  the  state- 
ment that  the  temperature,  pulse  and  respiration  offer 
valuable  information  in  the  diagnosis  and  prognosis  of 
certain  diseases  of  1;he  jbrain,  A  change  in  the  character 
of  the  respiration,  rather  than  in  its  frequency,  is  some- 
times one  of  the  first  positive  symptoms  of  organic  intra- 
cranial disease,  especially  of  tubercular  meningitis.  A 
respiration' that  is' more'  frequent^  while  the  patient  is 
asleep  or  unconscious  .  than  it  is  during  the  waking  or 
conscious  moments  is  very  strong  evidence  of  organic  dis- 
ease of  the  brain  so  situated  as  to  interfere  with  the 
respiratory  center. 

Apoplexy  due  to  hemotl*hage  is  attended  with  greater 
disturbances  of  the  temperature  of  the  body  soon  after  the 
occurrence  of  the  sti'oke  than  is  the  case  when  apoplexy 
is  due  to  thrombosis  or  embolism.  .  The  cerebral  hemor- 
rhage attended  by  hemiplegia  is  usually  accompanied  by 
a  slow  fall  in  the  axillary  temperature,  occurring  Within 
an  hour  or  less,  and  the  fall  is  most  marked  on  the 
paralyzed  side:  After  reaction  has  occurred,  which 
commonly  takes  place  in  from  eight  to  twelve  hours,,  ther^ 
is  a  rising  temperature,  which,  is  A  Jittle  greater  on  the 
paralyzed  side, 

In  cerebral  thrombosis  there  is  little  disturbance  of 
temperature  before  the  end  of  thfe  second  day,  except  in 
the  severest  cases.  An  elevation  beginning  with  the 
second  day,  extending, to  the  fourth  day  after  the  stroke, 
is  significant  of.  thrombosis  and  shows  that  secondary 
softening  has  taken  place,  which,  if  extensive,  makes  re- 
covery doubtful.    '  '         '     ' 

If  the  teiiiperatiire  on' the' paralyzed' side  remains  per- 
sistently elevated  some  weeks  after  a- stroke^  it  shows  that 
the  softening  and  inflammation  are  going  on,  and  the 
prognosis  is  correspondingly  grave. 


MEDICU^ti   A'iJC  NEOkOLOGY.  i6g 

The  writer  saj's  that'll'  is  premature  to  formulate 
definite  conclusions  on  the  temperature,  pulse  and  respira- 
tion in  injui'ies  to  the  b'rairi:  It  is  possible  that  if  these 
cases  received  more  'detailed  study,  useful  deductions 
might  be  made  froni  a  considerablei  number  of  them.  The 
following  tentative  conclusions  are  justifiable: 

(a)  In  in'juries  to  the  head  where  the  temperature 
doe^  not  reach  norma:r  or  slightly  above  after  a  few  hours 
after  receipt  of  the  injury,  the  prognosis  is  very  grave. 
The  higher  the  temperature,  the  greater  the  possibility  of 
contusion  and  laceration  of  the  brain  and  its  membranes. 
The  greater  the  variation  of  the  temperature  from  normal, 
either  above  or  below,  the  worse  the  prognosis. 

(b)  A  rapid,  weak,  intermittent  or  irregular  pulse 
denotes  danger.  The  pulse  that  is  at  first  slow,  but  soon 
after  becomes  rapid,  indicates  a  progressive  intracranial 
lesion  and  justifies  a  bad  prognosis. 

(c)  An  exceedingly  slow  and  intermittent  respiration 
indicates  a  lesion  at  the  base  and  posterior  fossa.  A 
respiration  at  first  nearly  normal  in  frequency,  but  which 
later  becomes  quite  rapid,  indicates  a  rapidly  fatal  case. — 
MediGine. 

HYSTERIA. 

As  a  lack  of  proper  controlling  psychic  influence  occa- 
sions this  unbalanced  action  of  the  nervous  system,  psychic 
influence  brought  to  bear  by  the  medical  attendant  may 
exert  great  power  in  controlling  the  disorder.  Let  your 
will  power  stand  in  the  place  of  the  patient's  for  the  time 
being. 

Xext,  the  nei'vous  centers  can  be  brought  to  their  senses 
through  the  sensory  nerves.  Hence,  the  value  of  inhala- 
tions of  nitrate  of  amyl  or  of  carbonate  of  ammonia  in 
hysteric  spasms,  or  feigned  catalepsy;  or,  of  a  deluge  of 
cold  water  in  hysterical  convulsions.  Sumbul  has  a  re- 
markably soothing  effect  in  some  cases.  The  therapeutic 
.  measures,  where  the  patient  is  of  high  nervous  develop- 
ment, and  there  is  emotional  disturbance  simply,  are 
camphor,  valerian  and  soothing  neurotics. 

If  the  hysteria  proceeds  from  disturbances  of  the  repro- 
ductive organs,  fhe  bromides  are  indicated.  Bromidia  I 
find  one  of  the  best  remedies  where  there  are  convulsive 
paroxysms.  I  have  used  comp.  spirits  lavender  with  good 
effect;  also  valerianate  of  ammonium.  In  persistent  cases 
valerianate  of  morphia. 

States  of  malnutrition  call  for  ferruginous  treatment. 
There  is  now  such  a  long  list  of  reliable  preparations  of 
iron  we  have  large  liberty  in  choosing.     I  am  in  the  habit 


270  PROGRESS  OF  MEDICAL  SCIENCE. 

of  using  bark,  iron  and  strychnine.  Also,  when  there  is 
a  strumous  habit,  iodide  of  iron,  valerianate  of  iron,  vale- 
rianate of  zinc,  and  valerianate  of  quinine,  each  one 
grain,  pill  form,  is  a  favourite  formula  with  me.  It  has 
real  value  in  giving  tone  to  the  nervous  system. 

I  have  used  chloride  of  gold  and  sodium  to  advantage 
in  some  cases  where  there  was  evidence  of  spinal  irritation 
and  strumous  diathesis.  Oil  of  sassafras,  one  ounce,  to 
alcohol,  one  pint,  is  a  good  application  for  the  spine  where 
there  is  evidence  of  spinal  irritation. 

Massage  and  electricity  are  auxiliaries  to  improve  the 
circulation  and  stimulate  nervous  and  muscular  action. 
— Dr.  George  Covert,  in  Chicago  Medical  Times. 

BAD  COLDS. 

For  the  benefit  of  those  members  of  the  profession 
who  are  on  the  outlook  for  improvements  on  the 
methods  of  by-gone  days,  I  venture  to  offer  a  single  remedy 
for  the  treatment  of  a  "bad  cold."  Gelsemium  is  not  only 
useful  in  those  cases  which  would  recover  without  medica- 
tion, but  is  also  efficient  where  formidable  symptoms  are 
present,  and,  judiciously  employed,  may  be  the  means  of 
averting  an  attack  of  pneumonia,  pleuro-pneumonia, 
pleurisy  or  other  serious  disease  beginning  in  the  form  of 
a  bad  cold.  Gelsemium  arrests  profuse  nasal  secretions, 
quiets  headaches  and  neuralgia,  subdues  cough  and  pain, 
favors  a  re-establishment  of  the  secretions,  through  its 
influence  upon  the  skin,  kidneys  and  gastrointestinal 
tract. — Chicago  Med.  Times. 

TREATMENT  OF  BRONCHO-PNEUMONIA. 

Caille  (Post-Graduate)  says  that  the  great  danger  in 
this  disease  is  suffocation,  through  filling  up  of  the  air  cells 
with  secretion  and  from  heart  failure  and  pulmonary 
edema.  Here  heart  tonics  and  expectorants  are  indicated. 
In  desperate  cases  raise  the  foot  end  of  the  bed  four  inches, 
and  so  get  gravitation  of  secretions  toward  the  mouth  or  • 
make  use  of  artificial  respiration.  Good  results  from  vene- 
section are  hardly  to  be  expected  in  young  children.  As  a 
stimulant  and  heart  tonic  he  uses  camphor,  strychnine  or 
nitroglycerin,  and  occasionally  digitalis  or  ammonium 
carbonate-  You  may  give  half  a  grain  of  camphor  in  five 
grains  of  sugar  or 

Camphor  gr.  15. 

01.  amyg.  dulc  dr.  11. 

Sig.     Five  minims  hypodermically. 

Or  you  may  give  champhor  (Vz  gr.)  digitalis  (1  gr.)  and 
benzoic  acid  (3  gr-)    combined.     Caffein    and    sodium    ben- 


MEDICINE  AND   NEUROLOGY.  2/1 

zoate  (1  to  2  gr.)  may  be  given  hypodermically.  Whisky 
and  water  may  be  given  if  nefcessary.  If  the  fever  is  from 
105°  to  106°  F.  and  there  is  such  twitching  that  convulsions 
are  feared,  antipyrine  (3  to  5  gr.)  may  be  given  in  water 
per  rectum.  This  will  reduce  the  fever  two  or-  three 
degrees  for  several  hours.  When  the  acute  attack  is  over 
and  resolution  is  delayed,  potassium  iodide  should  be  given 
by  mouth  or  by  rectum.  In  delayed  resolution,  with  or 
without  fever,  think  of  serous  or  purulent  effusion,  and  use 
the  aspirating  needle  to  detect  it. — Med-  Standard. 

THE    MEANS    OF   ARRESTING   ACUTE    ENDOCARDITIS. 

I  wish  to  point  out  the  great  advantage  to  be  derived 
from  the  combined  use  of  blisters  and  poultices  in  the  eajlier 
stages  of  acute  endocarditis,  pneumonia,  pleurisy,  etc.,  where 
pain  is  a  marked  and  troublesome  symptom. 

A  blister  of  the  requisite  size  is  first  placed  over  the 
point  where  pain  is  most  acute,  and  is  firmly  fixed  with  ad- 
hesive plaster.  A  large  linseed  meal  poultice,  as  hot  as  it 
can  possibly  be  borne,  is  at  once  applied  above  the  blister 
and  changed  as  often  as  is  necessary  until  the  latter  has 
fully  risen.  The  blister  is  then  punctured  and  drei^sed  in 
the  usual  way.  When  this  has  been  done  a  thick  layer  of 
cotton  wool  or  spongiopiline  should  be  placed  over  the  en- 
tire surface  lately  covered  by  the  poultices,  to  prevent  any 
possibility  of  chill,  and  allowed  to  remain  vi  situ  as  long  as 
may  be  considered  desirable. 

In  recent  years  poultices  have,  no  doubt,  fallen  into 
more  or  less  disuse,  but  no  one  who  has  had  personal  ex- 
perience of  the  immense  relief  which  they  give  in  painful 
inflammatory  disease  will  fail  to  use  them  in  suitable  cases. 

They  should,  however,  be  applied  at  the  very  com- 
mencement of  the  disease,  and  be  discontinued  as  soon  as 
the  pain  has  been  relieved.  Their  beneficial  action  is,  no 
doubt,  due  to  the  fact  that  they  produce  a  very  decided  de- 
termination of  blood  to  the  surface,  thereby  increasing  the 
exudation  of  serum  and  lessening  nerve  sensibility. — Dr. 
G.  H.  Young,  in  N.  Y,  Lancet. 

GASTRIC  PAIN. 

For  many  years  Prof.  Whitford  has  taught  his  classes 
to  prescribe  the  bicarbonate  of  soda  freely  where  there  is 
f)ersistent  pain  in  the  stomach,  often  depending  upon  gastric 
ulcer.  Sir  Lauder  Brunton  has  recently  advised  that  a 
teaspoonful  of  the  bicarbonate  of  soda  in  a  little  lime  water, 


2/2  SURGJiRY., 

to  which  the  essence  of  peppermint  has  been  added,  gives  a 
more  speedy  relief  from  pain  from  gastric  ulcer  thap  mor- 
phine ;  in  many  cases,  by  the  neutralization  of  acid  fluids 
present,  do  produce  reliet  where  morphine  will.  not. —  Chicago 
Med.  limes,  ,    . 


SURGKRY. 


IN  CHARGE    OF 

,   ,  flOliI^O  C4MPBEIiL,.M.D., 

Lecturer  oa  Surgery,  University^of  Bishop's  College  ;  Assistant  Surgeon,   Western  Hospital; 

ANU 

GEORGE  FJSK,  M.D. 
Instructor jin  Surgery,  University  of  Bisnop's  College  ;   Assistant  Surgeon, JVVestern  Hospital. 


SURGERY  OF  THE  BILIARY  PASSAGES. 

John  B.  Deaver,  iu  the  International  Journal  of 
Surgery  for  October,  1901,  presents  an  excellent  resume  of 
the  surgery  of  the  biliary  passages.  There  is  no  depart- 
ment of  surgery  in  which  skill  in  diagnosis  is  more  essen- 
tial than  in  dealing  with  the  gall-ducts  and  their  diseases. 
^^'hile  gall-stones  are  found  with  great  frequency  post 
mortem,  it  is  to  be  remembered  that  in  95  per  cent,  of  the 
cases  there  are  no  clinical  symptoms.  Cases  of  latent 
stone  are  liable  to  sudden  attacks  of  inflammation  which 
rapidly  jeopardize  the  life  of  the  patient,  unless  surgical 
relief  is  given.  The  two  conditions  caused  by  gall-stone 
are  mechanical  obstruction  and  inflammation,  the  latter 
being  by  far  the  most  important.  In  all  diseases  of  the 
upper  portions  of  the  abdomen,  the  gall-bladder  should  be 
carefully  considered  as  a  factor  in  its  production.  If  this 
structure  can  be  felt  enlarged  as  a  rounded,  tender  mass, 
it  forms  an  easy  clue  to  the  trouble.  Unfortunately,  in 
most  cases  of  gall-bladder  disease  it  is  reduced'  rather  than 
enlarged,  owing  to  the  repeated  attacks  of  inflammation. 
Gall-stones  without  inflammation  of  the  gall-bladder  or 
duct  only  exceptionally  cause  trouble.  They  are  not  given 
to  wandering  along  the  ducts  and  thus  causing  obstruc- 
tion, but  they  do  excite  inflammation  which  prevents 
drainage  of  the  biliary  passages. 

In  a  large  proportion  of  cases  the  gall-stones  cause  no 
trouble,  but  when  they  have  excited  an  inflammatory 
process  the  period  for  conservatism  is  past,  and  the  sooner 
operation  is  undertaken  the  better.  Nature  may  success- 
fully deal  with  this  inflammatory  reaction,  but  usually  it 
recurs  again  and  again,  the  larger  stones  remaining  in  the 
gall-bladder. 


SURGERY.  '  273 

A  dilHculty  in  the  diagnosis  of  these  cases  lies  in  a 
belief  on  the  part  of  the  profession  and  laity  that  gall- 
bladder disease  is  always  accompanied  by  jaundice;  this 
symptom  is  jiearly  always  lacking  or  transitory. 

tSimple  catarrhal  inflammation,  unaccompanied  by 
gall-stones,  need  excite  little  apprehension.  If  stones  are 
present,  operation  should  be  undertaken,  as  dangerous 
complications  may  develop  rapidly.  Where  there  have 
been  repeated  attacks  of  biliary  calculi,  it  is  useless  to 
rely  upon  medical  treatment,  as  the  stones  may  cause 
pressure  necrosis,  empyema,  or  perforation. 

Another  form  of  catarrh  of  the  gall-bladder  without 
gall-stones  occurs  in  the  course  of  the  infectious  fevers. 
The  only  symptoms  are  a  slight  tenderness  over  the  gall- 
bladder, an  increase  in  its  size,  and  slight  elevation  of  the 
temperature,  and  if  the  process  is  severe,  a  leucocytosis. 
This  is  a  form  of  cholecystitis  due  to  infection  of  the 
gall-bladder  with  obstruction  of  the  cystic  duct.  It  sub- 
sides spontaneously  as  a  rule,  but  should  be  watched 
closely,  as  there  may  be  a  rapid  development  of  grave 
complications. 

In  inflammatory  cholelithiasis,  two  different  sets  of 
symptoms  are  found,  according  as  the  stones  are  found  in 
the  cystic  duct  or  in  the  hepatic  or  common  duct.  When 
in  the  gall-bladder  or  cystic  duct,  they  give  rise  to  enlarge- 
ment and  colic.  The  gall-bladder  in  time  becomes  chronic- 
ally thickened  and  often  ulcerated,  and  finally  contracted. 
Such  a  gall-bladder  is  always  infected.  Jaundice,  if 
present,  is  due  to  a  secondary  inflammation  of  the  common 
duct.  When  the  stones  are  in  the  common  duct,  im- 
portant functions  of  the  liver  are  threatened  and  the 
symptoms  are  very  serious.  In  these  cases  the  flow  of  bile 
is  obstructed  and  jaundice  is  always  present.  This  latter 
class  of  cases  is  sometimes  accompanied  by  an  infection, 
with  general  septic  intoxication  or  abscess  of  the  liver. 
As  a  rule,  jaundice  which  accompanies  gall-stone  disease 
is  intermittent. 

When  jaundice  has  existed  for  a  long  time  there  is  a 
tendency  to  hemorrhage,  which  adds  to  the  diflflculty  of 
operation.  As  a  rule  the  diagnosis  must  be  made  after 
the  abdomen  is  opened,  and  it  is  only  then  that  the  neces- 
sary surgical  procedures  are  indicated.  In  a  general  way 
all  stones  must  be  removed,  so  far  as  possible  without 
injury  to  the  ducts,  together  with  the  establishment  odf 
free  drainage.  How  these  indications  are  to  be  met  must 
be  decided  by  the  circumstances  of  the  individual  case. 
Exceptionally  can  all  stones  be  removed  and  a  bladder 
closed  without  drainage,  and  only  in  recent  cases-    Where 


274  SURGERY. 

there  is  any  question,  it  is  better  to  drain  the  gall-bladder. 
Drainage  into  the  duodenum  is  preferred.  The  operation 
for  connecting  the  gall-bladder  with  the  duodenum  is  one 
of  considerable  delicacy,  and  if  the  surgeon  feels  any, 
doubt  as  to  his  capacity  for  dealing  with  this  operation,  it 
is  better  to  drain  externally.  In  cases  where  the  gall- 
bladder is  gangrenous,  excision  is  advisable,  and  this  adds 
little  to  the  gravity  of  the  operation.  If  there  is  doubt  of 
the  integrity  of  the  gall-bladder,  it  is  wiser  to  remove  it. 
It  should  never  be  forgotten  that  in  gall-bladder  surgery 
the  bile  is  always  infected,  and  it  must  be  prevented  from 
coming  in  contact  with  the  peritoneum. 

Early  operation  is  urged  in  extensive  disease  of  the 
gall-bladder  and  its  ducts,  as  in  this  way  the  fatal  liver 
and  kidney  complications  do  not  develop.  It  is  a  good 
working  rule  to  operate  early  in  the  disease  rather  than 
early  in  an  attack,  but  operate  early  in  an  attack  rather 
than  not  operate  at  all. — Aled. 

FISTULA  IN  ANO  AND  ITS  RELATION  TO  PHTHISIS. 

Fistula  is  a  very  common  rectal  ailment.  Out  of  16,- 
060  rectal  cases  treated  at  the  St.  Mark's  Hospital,  Lon- 
don, over  50  per  cent,  were  fistula,  of  which  a  little  more 
than  one-half  were  men.  Again,  fistula  and  phthisis  very 
frequently  go  together,  as  evidenced  by  Allingham's  stat- 
istics, who  reports  1,682  cases  of  fistula,  234  of  which  had 
tuberculosis.  The  author  estimates  that  4-6  per  cent,  of 
all  tubercular  patients  suffer  from  fistula,  while  a  much 
larger  percentage  of  fistula  patients  have  tuberculosis. 

Fistulae,  as  found  in  tubercular  subjects,  are  of  two 
kinds : 

1.  True  tubercular  fistula,  the  result  of  localized 
deposits. 

2.  Fistulae,  induced  or  made  difficult  to  cure,  by  per- 
sistent cough  and  lowered  vitality — the  result  of  phthisis. 

1.  True  tubercular  fistula,  caused  by  swallowing 
tubercular  sputum  or  by  ingestion  of  food  infected  with 
the  bacilli. 

2.  Non-tubercular  fistula  are  frequent  in  phthisical 
subjects.  Very  troublesome  of  treatment,  because  (a) 
these  subjects  are  prone  to  suppuration  from  slight  causes; 
(6)  the  abso^rption  of  fat  of  the  ischio-rectal  fossa  deprives 
the  larger  blood  vessels  of  their  natural  support,  resulting 
in  congestion  and  dilation;  and  (c)  the  persistent  coughing 
of  these  phthisical  patients  causes  a  bruising  of  the  parts 
about  the  anus  which  is  an  important  etiological  factor  in 
the  production  of  abscess  and  fistula. 


SURGERY.  275 

DIFFERENTIAL  DIAGNOSIS. 

The  principal  points  to  be  borne  in  mind  in  diagnosti- 
cating the  tubercular  from  the  non-tubercular  fistula  are: 
In  the  non-tubercular  the  internal  and  external  openings 
are  small  and  round,  the  edges  red,  situated  in  the  center 
of  an  elevation.  In  the  tubercular,  on  the  other  hand,  the 
internal  and  external  openings  are  large,  triangular  in 
shape,  the  edges  bluish  and  drooping  into  the  opening; 
the  non-tubercular  discharges  but  little,  and  the  material 
is  3^ellow  in  colour.  The  tubercular  is  characterized  by  a 
profuse,  whitish,  watery  discharge.  Again,  the  non- 
tubercular  is  sensitive  to  the  probe,  the  tubercular  much 
less  so,  while  the  tight  sphincter,  normal  development  of 
hair  about  the  buttocks  in  the  non-tubercular  fistula  con- 
trasts strikingly  with  the  patulous  anus,  and  long,  silky 
hair  about  the  parts,  and  which  are  always  present  in  the 
tubercular  cases.  Naturally,  it  must  not  be  forgotten 
that  the  finding  of  the  bacilli  in  the  discharge  is  proof 
positive  of  the  origin  of  the  trouble,  though  their  absence 
does  not  indicate  absence  of  tuberculosis. 

TREATMENT. 

Palliative. — Consists  principally  in  taking  proper 
measures  to  drain  thoroughly,  assist  healing  by  the  ap- 
plication of  stimulating  astringent  and  antiseptic  sub- 
stances, and  for  the  rest  to  insist  upon  good  food,  regular 
habits,  proper  hygienic  surroundings;  in  short,  such 
measures  as  would  tend  to  better  the  patient's  general 
condition. 

However,  the  author  operates  upon  all  fistulas, 
tubercular  or  non-tubercular,  when  the  general  conditions 
of  the  patient  permit,  and  then  advises  change  of  climate 
and  anti-tubercular  treatment  if  it  is  a  case  of  phthisis. 

Anaesthesia. — When  a  local  anaesthetic  is  indicated, 
cocain  or  beta-eucain.  As  a  general  anaesthetic  chloro- 
form is  preferred,  as  the  recovery  from  it  is  quicker, 
vomiting  less,  and  it  has  the  further  advantage  of  not 
irritating  the  lungs  or  kidneys. 

Operation. — 1.     Ligation.     2.     Division.     3.     Excision. 

Ligation  consists  in  passing  silk,  wire,  or  elastic 
ligature  through  sinus  and  anus.  The  special  advantages 
claimed  are,  that  it  requires  no  anaesthesia,  causes 
neither  pain  nor  bleeding,  and  does  not  confine  the  patient 
to  bed,  on  the  other  hand,  it  takes  longer  to  cure  and  does 
not  divide  branch  sinuses. 

Division  consists  in  passing  a  grooved  director  through 
the  sinus  until  its  end  is  felt  by  the  finger,  previously  in- 


2'j6  SURGERY. 

troduced  into  the  rectum,  when  it  is  withdrawn  and  rests 
upon  the  anus.  The  bridge  of  tissue  is  then  divided,  the 
sinus  thoroughly  curetted;  if  tubercular,  cauterized;  then 
packed.  It  is  important  to  find  and  treat  similarly  all 
branch  sinuses. 

Excision  consists  in  dissecting  out  the  whole  sinus, 
suturing  and  healing  by  primary  intention. 

The  conclusions  the  author  wishes  to  impress  are: 

1.  Tubercular  fistula  is  secondary  to  tuberculosis  of 
the  lungs. 

2.  Pulmonary  tuberculosis  is  rarely,  if  ever,  secondary 
to  fistula  in  ano,  either  before  or  after  the  operation. 

3.  Tuberculosis  of  the  anal  region  requires  the  same 
radical  treatment  that  is  recommended  for  tuberculosis  of 
other  parts  of  the  body. 

4.  When  general  conditions  are  favourable,  operate 
on  al]  fistulas  irrespective  of  the  kind. 

5.  No  evidence  that  the  cure  of  fistula  will  induce 
phthisis. — Dr.  G.  S.  Gant,  in  Med.  Rec. 

CORNS. 

Dr.  E.  L.  Wood,  of  Danville,  N.Y.,  writes ;  "  A  radical 
cure  for  corns  consists  in  paring  the  callosity  as  closely  as 
possible  without  causing  any  hemorrhage,  then  placing  in 
the  center  of  the  corn  a  very  small  drop  of  croton  oil,  and 
bandaging  for  twelve  hours.  Then  remove  the  bandage 
and  paint  the  corn  with  reliable  cantharidal  collodion ;  a 
pustular  bleb  will  result,  in  the  formation  of  which  the  entire 
callosity,  nucleus  and  all,  will  be  raised  without  very  much 
pain  from  the  tissues  beneath,  and  can  be  easily  removed. 
The  process  should  be  conducted  under  the  care  of  a  surgeon 
to  insure  prompt  sterilization  of  the  part  after  the  callus  is 
removed.  Healing  has  always  been  rapid,  not  requiring 
more  than  three  or  four  days,  with  no  liability  to  recurrenc 
unless  the  foot  is  afterward  abused.  I  have  treated  activ 
working  patients  without  a  loss  to  them  of  more  than 
half-day's  XXme."  —  Courier  Record  of  Medicine. 


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Editorial. 


DR    RODDICK  S  MEDICAL  COUNCII.  BILL- 

As  our  readers  are  aware,  Dr.  Roddick,  M.P.,  who 
represents  the  St.  Antoine  Division  of  the  city  of  Montreal, 
has,  for  the  last  three  years,  at  each  Parliament,  intro- 
duced a  Bill,  having  for  its  object  the  formation  of  a 
Dominion  Medical  Council.  There  are  very  special 
reasons  why  such  a  Bill  should  be  put  in  force  at  as  early 
a  date  as  possible.  When  first  introduced,  this  Bill  met 
with  considerable  opposition,  chiefly  in  Ontario  and  Quebec 
and  British  Columbia.  Dr.  Roddick  spent  much  time  in 
visiting  the  centres  of  Medical  education  in  various  pro- 
vinces and  fully  explaining  its  details.  Friendly  sugges- 
tions were  received  and  the  Bill  amended,  accordingly. 
The  result  of  these  interviews  was  that  a  Bill,  satisfactory 
we  think  to  the  great  bulk  of  the  profession  in  the  Do- 
minion, was  introduced  into  the  present  Parliament.  It 
was  felt,  however,  after  its  first  reading,  that  the  small 
professional  minority  opposed  to  it,  even  in  the  forms  it 
then  possessed,  had  developed  considerable  strength  in  the 
house,  and  that  further  amendments  to  it  would  be  neces- 
sary. The  question  as  to  the  power  of  the  Federal  Parlia- 
ment to  pass  such  an  act  was  fully  admitted  by  both  the 
first  Minister  of  the  Crown  and  the  Leader  of  the  Opposi- 


278  DR.    RODDICKS    MEDICAL    COUNCIL    BILL. 

tion,  and  when  it  came  up  for  its  third  and  final  reading,  it 
consequently  received  the  support  of  both.  Previous,  how- 
ever, to  its  adoption,  an  amendment  was  made  and  ac- 
cepted by  Dr.  Roddick  to  the  effect  that  before  it  can  come 
into  force  it  must  receive  the  support  by  legislative  enact- 
ment of  all  the  Provinces  in  the  Dominion.  In  this  form 
it  passed  the  House  of  Commons,  and  was,  with  trifling 
amendments,  then  passed  by  the  Senate.  The  position, 
now,  as  we  take  it,  is,  that  the  Federal  authorities  have 
provided  the  machinery  by  which  a  great  and  most  im- 
portant measure  can  be  put  into  operation.  In  moving  its 
second  reading.  Dr.  Roddick  entered  into  a  full  and  lucid 
explanation  of  the  entire  Bill,  and  we  think  the  subject  of 
such  vital  importance  that  we  give  it  almost  as  verbatim, 
copied  from  Hansard. 

Dr.  Roddick  said: — 

Mr.  Speaker,  in  moving  the  second  reading  of  the  Bill 
for  the  establishment  of  a  medical  council  in  Canada,  it  is 
my  desire  to  be  brief.  My  main  object  for  framing  this  Bill 
for  the  establishment  of  a  medical  council  in  Canada  is  for 
the  purpose  of  establishing  a  qualification  for  medical  men 
which  would  be  acknowledged  and  accepted  in  all  parts  of 
the  Dominion  of  Canada.  As  you  are  doubtless  aware,  we 
have  at  present  eight  examining  and  licensing  medical 
bodies  in  this  country.  Some  of  these  are  doubtless  doing 
good  work  and  keeping  up,  or  at  any  rate  assisting  in 
keeping  up,  the  standard  of  medical  education,  but  their 
usefulness  is  limited  to  the  territories  over  which  they 
have  special  control.  Barriers  have  been  erected,  as  you 
are  doubtless  also  aware,  around  these  eight  territories,  so 
that  it  is  practically  impossible  for  a  medical  man  to  re- 
ceive a  qualification  to  practice  in  more  than  one  of  the 
provinces.  The  barriers  are  so  marked,  so  strong  and  so 
high,  that  very  few  indeed  have  the  opportunity  of  repre- 
senting the  profession  of  medicine  in  more  than  one  pro- 
vince. The  frontiers  are  so  closely  watched  that  we  con- 
stantly hear  of  medical  men  being  fined,  and  in  cases 
where  this  fine  has  not  been  paid,  imprisonment  has  been 
threatened  for  crossing  a  boundary  river,  or  an  imaginary 
line  between  two  provinces,  in  order  to  serve  and  probably 
to  save  the  lives  of  citizens  of  Canada.  Therefore,  I  con- 
tend that  there  is  reason  for  interference  on  the  part  of 
this  parliament.  I  believe  that  section  91  of  the  British 
North  America  Act  can  well  be  evoked  by  this  parliament 
in  meeting  cases  such  as  I  have   mentioned.     Section  91, 


DR.    RODDICKS    MEDICAL    COUNCIL    BILL.  2/9 

which  refers  to  the  peace,  order  and  good  government  of 
Canada,  I  contend,  might  well  be  brought  into  operation 
by  this  parliament  in  cases  such  as  those  I  have  cited. 
Such  a  state  of  affairs  exists  in  no  other  country  probably 
in  the  world.  Even  between  the  countries  of  France  and 
(j  ermany,  I  am  credibly  informed,  a  neutral,  territory  of  15 
miles  has  been  marked  out  over  which  medical  men  may 
travel  in  the  discharge  of  their  professional  duties  so  as 
to  be  able  to  assist  the  sick  of  either  nationality.  There- 
fore, I  think  it  is  time  something  was  done  in  Canada  in 
order  to  remedy  so  serious  an  evil.  It  may  be  asked  w^hy 
these  unfortunate  men  who  have  been  fined  do  not  take 
steps  to  procure  licenses  in  the  neighbouring  provinces  to 
which  they  are  obliged  constantly  to  travel.  The  reason 
is  that  it  ma}'  be  absolutely  impossible  for  a  man  to  receive 
a  license  in  more  than  one  province.  If  he  has  begun  the 
study  of  medicine  in  one  province  and  if  he  matriculates 
in  that  province,  he  never  can  receive  a  license  to  practice 
in  any  of  the  other  provinces.  For  instance,  if  an  Ontario 
graduate  having  changed  his  mind  as  to  his  domicile,  hav- 
ing passed  his  examinations,  wishes  to  practice  in  the  pro- 
vince of  Quebec,  he  cannot  do  so  for  the  reason  that  the 
medical  board  of  the  province  of  Quebec  insist  that  he 
shall  begin  by  passing  the  matriculation  examination  of 
that  Board.  Some  of  the  ablest  men  in  our  profession  to- 
day have  been  shut  out  from  practicing  in  Quebec  and  in 
Ontario  where  they  might  be  very  useful  in  hospital  and 
professorial  work. 

Another  object  which  I  had  in  framing  this  Bill  and 
in  bringing  it  before  the  House  was  to  obtain  reciprocity 
with  Great  Britain.  That,  Sir,  can  be  done  so  soon  as  we 
have  a  central  examining  board  for  the  Dominion.  In 
1886  the  British  Medical  Council  enacted  that:— 

On  and  after  the  prescribed  day  where  a  person  shows 
to  the  satisfaction  of  the  registrar  of  the  general  council 
that  he  holds  some  recognized  colonial  medical  diploma  or 
diplomas  (as  hereinafter  defined),  granted  to  him  in  a 
British  possession  to  which  this  Act  applies,  and  that  he 
is  of  good  character,  and  that  he  is  by  law  entitled  to 
-practice  medicine,  surgery  and  midwifery  in  such  British 
possession,  he  shall,  on  application  to  the  said  registrar, 
and  on  payment  of  such  fee  (not  exceeding  five  pounds),  as 
the  general  council  may  from  time  to  time  determine,  be 
entitled,  without  examination  in  the  United  Kingdom,  to 
be  registered  as  a  colonial  practitioner  in  the  medical 
register. 


280  DR.    RODDICKS    MEDICAL    COUNCIL    BILL. 

The  definition  states: — 

The  expression  "British  possession"  means  any  part 
of  His  Majesty's  dominions  exclusive  of  the  United  King- 
.  dom,  but  inclusive  of  the  Isle  of  Man  and  the  Channel 
Islands;  and  vk^here  parts  of  such  dominions  are  under 
both  a  central  and  local  legislature,  all  parts  under  one 
central  legislature  are  for  the  purposes  of  this  definition 
deemed  to  be  one  British  possession. 

That  means  that  so  long  as  the  provinces  are  separate 
parts  of  the  confederation,  we  cannot  register  in  Great 
Britain  as  provinces.  The  British  Medical  Council  will 
not  undertake  to  look  after  the  education  of  the  various 
provinces,  but  I  do  state  positively  that  so  soon  as  we  have 
a  central  examining  board  in  the  Dominion  of  Canada,  the 
British  Medical  Council  will  at  once  accept  the  licenses 
from  that  Board  and  allow  our  men  to  register  immedi- 
ately in  Great  Britain,  or  in  any  part  of  the  empire  over 
which  the  British  Medical  Council  has  control.  That  is 
a  very  important  matter.  It  means  that  we  would  have 
open  to  our  young  Canadian  medical  men,  the  army  and 
navy  of  Great  Britain,  as  well  as  colonial  appointments, 
many  of  which  are  very  lucrative,  especially  in  the  East 
and  West  Indies.  It  will  also  open  to  Canadian  medical 
men  appointments  under  the  British  Board  of  Trade,  so 
that  ships'  surgeons  may  be  appointed  directly  from  this 
side,  whereas  now  our  young  men  have  to  go  to  England  to 
first  receive  a  license  in  one  of  the  colleges  of  Great  Britain 
before  they  can  take  a  steamer  across  the  Atlantic. 

This    indicates    how    unfairly    our    medical    men    are 
treated,  but  we  have  the  remedy  in    our   own   hands,  and 
that  remedy  is  simply  the  establishment    of    a  Dominion 
medical  council  and  a  central  examining  Board,  in  order 
to  meet  the  requirements  of  the   British    Medical    Act   of 
1886.     We  have  had  numerous  opportunities  of  testing  the 
disabilities   under   which    Canadian   medical    men    labour 
during  this  present  South  African  war,  and  we  have  con- 
stantly heard  of  how  medical  men  attached  to  Canadian 
battalions  were  not  allowed  to  attend  Tommy  Atkins.     It 
was  in  fact  thought  that  they  were  good  enough  to  attend 
Canadian  soldiers,  but  not  good  enough  to  look  after  Eng- 
lish soldiers.     That  is  a  positive   fact.     Several   of  those 
gentlemen  who  have    returned    from    South    Africa    have 
cited  instances  to  me,  and  I  have  correspondence  bearing 
on  it  which  I  could  produce  if  time  would  permit,  showing 
that  a   great   injustice  had  been   done  to   our  Canadian 
medical     men,    and    done    probably    to    force    our    hand. 
Knowing  as  I  do  several  members  of  the  British  Medical 
Council,   I   am    satisfied   that   nothing    would    give  them 


DR.    RODDICKS    MEDICAL    COUNCIL    BILL.  28 1 

greater  pleasure  than  that  we  should  arrange  in  Canada 
here  a  scheme  which  would  meet  them  half  way. 

Now,  Mr.  Speaker,  in  arranging  a  scheme  of  this  kind, 
there  is  no  intention,  nor  is  there  anj'  necessity  for  any 
interference,  with  the  autonomy  of  the  provinces.  I  am 
aware  that  the  fear  of  such  interference  is  the  great  objec- 
tion which  has  been  offered  to  thisi  measure.  It  is  not 
intended  to  do  away  with  the  provincial  boards  in  any 
way.  They  will  still  continue  to  exist  as  they  have  existed 
hitherto.  They  must  exist  for  certain  purposes.  They 
must  exist  for  the  purpose  of  taxation  and  discipline. 
With  the  provincial  boards  will  be  left  the  question  of 
taxation  and  all  matters  relating  to  the  discipline  of  the 
profession.  They  will  not  be  disturbed.  Their  autonomy 
will  not  be  interfered  with  in  the  least  degree.  I  believe 
that  any  interference  with  the  autonomy  of  the  provinces 
is  unnecessary  and  uncalled  for  in  any  way.  Where  the 
provinces  wish  to  continue  an  examining  board,  as  now, 
they  can  do  so.  I  have  no  doubt  at  all  that  the  larger 
provinces,  that  is  Ontario,  Quebec,  Nova  Scotia  and  Mani- 
toba at  any  rate,  will  each  continue  to  have  an  examining 
board  for  the  purpose  of  examining  and  licensing  men  who 
wish  to  practice  in  a  particular  province  only.  For 
instance,  a  man  who  goes  up  before  the  Ontario  Medical 
Council,  when  this  Act  comes  into  force,  as  I  hope  it  will, 
may  be  examined  by  them  as  he  is  now.  They  will  under- 
take to  examine  him  and  give  him  a  license  to  practice  in 
the  province  of  Ontario  only,  and  he  cannot  go  outside  of 
the  limits  of  that  province  on  that  certificate.  It  will  be 
the  same  in  the  province  of  Quebec.  I  think  that  for  a 
great  many  years  to  come  the  system  in  Quebec  will  con- 
tinue as  it  is  now,  but  I  have  it  on  good  authority  that  the 
smaller  provinces  will  probably  discontinue  the  examining 
of  candidates  who  come  before  them.  I  state  without 
hesitation,  and  without  any  detriment  to  the  smaller  pro- 
vinces, that  in  the  light  of  the  present  progress  in  medicine 
— ^judging  from  the  rapidity  with  which  some  of  the  su"b- 
jects  at  any  rate  are  progressing — it  is  impossible  for  a 
man,  who  is  not  a  teacher  connected  with  a  university,  to 
keep  up  sufficiently  well  to  be  able  to  examine  in  these 
subjects.  Among  the  provinces  there  are  four  which  have 
no  university — British  Columbia,  New  Brunswick,  Prince 
Edward  Island,  and  the  North-west  Territories;  as  they 
have  as  yet  no  teaching  body,  their  men  are  not  able  to 
keep  up  sufficiently  well  to  examine.  On  that  account 
and  for  the  reason  I  have  given,  there  is  no  necessity,  I 
repeat  again,  for  disturbing  the  provincial  board  and  its 
present  methods;  so  it  will  continue  as  before. 


282  DR.    RODDICKS    MEDICAL    COUNCIL    BILL. 

This  Bill,  then,  is  a  purely  permissive  Bill.  It  is 
necessary,  in  order  that  it  may  come  into  operation,  to 
have  the  consent  and  co-operation  of  all  the  provinces.  It 
is  necessary  for  the  medical  board  in  each  province  to  go 
before  the  local  legislature  and  ask  for  a  short  clause  to  be 
tacked  on  to  the  present  Act.  Every  province  has  its 
medical  Act,  and  it  will  be  simply  necessary  to  add  to  that 
Act  something  like  the  following — though  it  need  not  be 
in  exactly  the  same  words: — 

When  there  shall  have  been  established,  under  the 
authority  of  the  parliament  of  Canada,  a  medical  register 
for  Canada,  under  the  control  of  a  medical  council  for 
Canada,  then,  notwithstanding  anything  contained  in  any 
of  the  Acts  hereby  amended,  any  person  duly  registered  in 
the  said  register  as  a  medical  and  surgical  practitioner,  or 
as  a  student  of  medicine  and  surgery,  shall,  without  any 
further  or  other  evidence  of  qualification,  be  entitled  to  be 
registered  in  the  medical  register  of  this  province  as  a  duly 
qualified  medical  and  surgical  practitioner,  or  as  a  duly 
qualified  student  of  medicine  and  surgery,  as  the  case  may 
be,  upon  production  of  a  certificate  under  the  hand  of  the 
registrar  of  the  said  medical  council  for  Canada,  certifying 
that  such  person  is  so  duly  registered  ui)on  satisfactory 
proof  of  the  identity  of  such  person,'  and  upon  payment  of 
such  fee  as  may  be  prescribed  by  the  medical  council  of 
the  province  in  that  behalf. 

A  short  amendment  of  that  kind,  tacked  on  to  the 
medical  Act  of  each  province,  is  all  that  is  required  to 
bring  into  effect  the  measure  I  am  advocating. 

Now,  as  to  the  scheme  itself.  How  is  this  Act  to  be 
put  into  operation?  It  is  necessary,  first,  to  have  a 
medical  council,  which  may  be  called  the  Dominion  Medical 
Council  or  the  Medical  Council  of  Canada,  which  I  think 
would  probably  be  a  better  term.  The  composition  of  this 
council  has  been  a  great  puzzle  to  those  of  us  who  have 
had  to  do  with  the  framing  of  this  Bill.  It  has  occasioned 
me,  personally,  a  great  deal  of  thought  and  consideration. 
We  have  tried  two  or  three  schemes,  which  have  all  given 
more  or  less  satisfaction,  but  which  have  not  quite  met  the 
requirements.  When  I  addressed  this  House  a  year  ago, 
I  stated  that  the  plan  which  seemed  to  satisfy  all  the  pro- 
vinces was  that  three  members  of  the  council  should  be 
taken  from  each  province — one  appointed  by  the  Governor- 
General  in  Council,  one  elected  by  each  provincial  medical 
council,  and,  the  president  of  each  provincial  medical 
council.  That,  we  found,  gave  dissatisfaction  in  the  larger 
provinces.  The  province  of  Ontario,  with  its  2,300  odd 
doctors,   said,    ^'It  is   unfair  to  us  to   give  us  the   same 


N 


DR.    RODDICKS    MEDICAL    COUNCIL    BILL.  283 

number  only  as  the  little  province  of  Prince  Edward  Island 
with  something  like  96  doctors."  Pressure  was  brought 
to  bear  so  strongly  that  I  looked  for  another  scheme,  and 
1  think  I  have  found  one  which  will  give  general  satisfac- 
tion. It  is,  that  for  the  first  100  or  fraction  of  100  practi- 
tioners in  each  province,  there  shall  be  one  member.  That 
will  let  in  Prince  Edward  Island,  and  will  also  let  in  the 
Yukon  when  it  has  a  central  board  established.  For  the 
second  100  or  fraction  thereof  over  50,  there  will  be  one 
member;  and  for  every  600  above  that,  one  member. 
That  principle  can  be  continued  ad  infinitum.  Then  there 
will  be  appointed  members — one'  appointed  by  the  Gover- 
nor-in-Council  from  each  province.  There  will  also  be 
university-  representatives,  each  university  having  a  teach- 
ing medical  faculty  being  entitled  to  send  one,  and  there 
will  be  three  homeopathic  representatives  from  the  entire 
Dominion. 

Now,  it  may  be  asked:  Why  ask  the  government  to 
appoint  one  from  each  province?  I  have  been  constantly 
met  with  the  objection  that  this  would  bring  politics  into 
the  organization.  I  do  not  think  so.  I  think  the  ablest 
men  in  our  country  will  be  selected,  very  often  at  any  rate, 
by  wise  governments  for  a  purpose  of  this  kind.  But, 
Sir,  there  are  two  other  reasons,  cogent  reasons,  why  the 
government  of  the  counti\v  should  have  a  voice  in  the  com- 
position of  this  council.  Doubtless  some  day,  when  it  gets 
thoroughly  into  operation,  this  body  will  be  used  by  the 
Dominion  government  as  an  advisory  body,  having,  as  it 
will  undoubtedly  have,  the  best  men  in  our  countiT  upon 
it,  on  great  questions  of  quarantine,  Or  concerning  epi- 
demics or  pestilences  that  may  reach  our  shores,  in  order 
that  it  may  back  up  the  authorities  who  are  dealing  with 
such  matters  in  the  Dominion  and  in  the  various  provinces. 
This  use  is  made  to-day  of  the  British  Medical  Council  by 
the  government  of  Great  Britain,  and  its  meetings  and 
investigations  have  been  exceedingly  useful  and  practical. 
Another  reason — it  is  a  sordid  one,  perhaps,  but  one  of  con- 
siderable practical  interest — is  that  having  eight  repre- 
sentatives of  the  government  of  the  day  upon  it,  this  coun- 
cil may  well  come  to  the  government  and  ask  for  some 
assistance,  in  the  form  of  a  grant  for  a  certain  number  of 
years,  which  I  feel  satisfied  my  hon.  friend  the  Minister  of 
Finance  (Hon.  Mr.  Fielding)  will  be  able  to  arrange  for  us, 
because  he  has  been  in  the  past — I  take  this  opportunity 
of  saying — exceedingly  kind  to  the  medical  profession.  In 
1897,  when  the  British  Association  visited  this  country,  he 
presented  the  profession  in  Canada  the  sum  of  |5,000  for 
the  purpose    of  entertaining  their  distinguished  visitors. 


2i^4  DR-    RODDICKS    MEDICAL    COUNCIL    BILL. 

Each  university  in  Canada  which  has  a  teaching  medi- 
cal faculty  will  be  represented  by  one  member.  There 
are  nine  such  universities  in  Canada  to-day.  There  are  ten 
active  teaching  medical  faculties,  but  one  of  these,  the 
Trinity  school,  is  not  attached  strictly  to  any  university. 
We  hope,  however,  that  arrangements  may  be  made  to  take 
tnat  body  into  the  composition  of  the  council.  It  is  pos- 
sible that  owing  to  the  fact  that  the  universities  of  Quebec 
and  Montreal  are  practically  separate  and  distinct,  Laval 
might  claim  another  representative.  That  will  give  to  the 
province  of  Ontario  a  total  of  nine  ;  to  the  province  of 
Quebec  eight,  to  Nova  S*cotia  four,  to  Manitoba  four,  to 
New  Brunswick  three,  to  British  Columbia  three,  to  the 
North-west  Territories  three,  and  to  Prince  Edward  Island 
two,  making  altogether  thirty-six,  besides  three  homeo- 
pathic representatives,  which  brings  the  number  to  thirty- 
nine.  It  may  be  thought  that  this  council  is  too  large,  but 
we  must  not  forget  that  it  represents  the  whole  Dominion. 
In  the  province  of  Quebec  alone  there  are  forty  members 
on  the  local  board,  and  in  Toronto  thirty  members,  so  that 
there  will  be  fewer  in  reality  on  this  committee  for  the 
whole  Dominion  than  there  now  is  on  the  board  of  one 
single  province.  These  figures  of  course  will  have  to  be 
constantly  altered.  A  year  ago,  on  the  very  day  I  ad- 
dressed the  House,  I  received  a  telegram  from  the  North- 
west Territories,  stating  that  there  were  110  medical  men 
there.  Yesterday,  I  received  another  telegram,  stating 
that  the  number  had  increased  to  211,  which,  doubtless,  is 
an  evidence  of  the  increase  of  population  in  the  Territories. 

The  homeopathic  representatives,  three  will  be  elected 
by  the  homeopathists  themselves,  from  ocean  to  ocean,  by 
ballot.     That  is  their  own  proposition. 

These  gentlemen  will  serve  a  certain  number  of  years. 
The  appointees  of  the  Governor-General  will  be  named  for 
four  years.  Those  who  are  elected  from  the  profession  or 
by  the  various  councils  will  serve  during  the  life  of  the 
council.  The  university  representatives  and  the  homeo- 
pathists will  be  retained  for  four  years.  The  whole 
scheme  will,  at  the  start,  be  under  the  supervision  of  the 
Minister  of  Agriculture,  who  will  call  the  first  meeting, 
preside  at  it,  and  arrange  to  have  the  council  put  into  busi- 
ness shape.  The  first  meeting  will  be  held  in  Ottawa,  and 
it  is  possible  that  all  the  meetings  will  be  held  there. 

This  council  will  elect,  from  time  to  time,  an  examining 
board,  to  be  composed  of  English  and  French  examiners, 
and  every  candidate  may  elect  to  be  examined  in  either  the 
English  or  French  language.  Examinations  will  be  held 
in  the  centres  where  hospital  facilities  are  the  greatest  and 


DR.    RODDICKS    MEDICAL    COUNCIL    BILL.  285 

the  Students  most  numerous,  so  that  it  will  not  be  neces- 
sary to  disturb  the  students.  As  a  rule  the  students  in 
this  country  are  to  be  found  in  live  difterent  places — Hali- 
fax, Quebec,  Montreal,  Toronto  and  Winnipeg,  and  in  these 
centres  the  examinations  will  be  held. 

It  will  be  necessary  to  exact  a  five  years'  course  of  all 
students  in  the  various  universities  in  Canada,  because 
that  is  now  exacted  by  the  Ontario  Medical  Council  and 
also  b}'  the  British  Medical  Council.  The  final  year  of  the 
course  will  be  purely  a  practical  one,  having  to  do  with  the 
practical  subjects  which  the  practitioner  really  deals  with 
in  his  daily  life. 

There  is  in  the  Bill  a  retrospective  or  retroactive 
clause  intended  to  admit  those  members  of  the  profession 
who  have  been  a  number  of  years  in  practice.  It  is 
thought  that  every  medical  man  who  has  been  five  or  seven 
years  in  practice — the  time  has  not  been  decided  upon,  but 
will  be  in  the  committee  when  we  meet  the  delegates  of  the 
various  provinces — should  have  the  privilege  of  taking  ad- 
vantage of  this  Act.  These  practitioners  will  be  regis- 
tered and  allowed  to  move  from  one  province  to  another  or 
change  their  domicile  for  the  purpose  of  practicing,  but 
the  chances  are  that  when  a  man  has  been  anchored  five 
or  seven  years  in  the  one  place  he  is  likely  to  remain  there, 
so  that  there  will  be  no  stampede  of  these  gentlemen 
towa;rds  any  of  the  newer  provinces.  By  making  the  limit 
five  or  seven  years,  any  danger  of  such  a  stampede  will  be 
avoided. 

There  will  also  be  a  board  of  arbitration  in  order  to 
meet  difficulties  which  may  arise  in  the  early  meetings  of 
the  council.  It  might  occur  that  a  representative  of  a  pro- 
vince might  indicate  that  the  standard  was  not  kept  up, 
as  promisied  originally,  and  that  standard  must  of  course 
be  at  least  as  high  as  anything  in  existence  at  present. 
In  this  event,  the  board  of  arbitration  will  meet  and  be 
composed  of  three  members — one  to  be  appointed  by  the 
Governor-General  from  the  Supreme  Court  of  Canada,  the 
second  will  be  appointed  by  the  Council;  and  the  third 
will  be  a  member  of  the  council  from  the  aggrieved  pro- 
vince. These  three  will  sit  upon  the  case,  as  it  were,  and 
find  out  exactly  where  the  grievance  is,  whether  it  should 
be  considered,  and  what  remedy  should  be  applied.  It  is 
a  very  important  part  of  the  machinery,  and,  while  I  hope 
it  will  never  need  to  be  brought  into  operation,  I  think 
that,  if  it  becomes  necessary,  it  will  be  found  useful.  It 
was  thought  that  a  judge  of  the  Supreme  Court  would  not 
be  influenced  by  any  prejudices  of  a  local  character. 


286  DR.    RODDICKS    MEDICAL    COUNCIL    BILL. 

Now,  the  advantages  in  connection  with  this  Bill  are 
that  we  shall  have  a  more  uniform  standard  of  education 
and  examination  in  this  country;  we  shall  have  the 
barriers  broken  down  which  at  present  exist  on  the 
frontiers  of  provinces,  and  medical  men  will  be  able  to  get 
a  license  to  practice  on  both  sides  of  the  Ottawa  river,  on 
both  sides  of  the  imaginary  line  between  any  two  pro- 
vinces. I  believe  that  it  will  lead  to  removing,  or,  at  any 
rate,  lessening  the  congestion  which  at  present  exists  in 
the  medical  profession  in  some  of  the  provinces.  Medical 
practitioners  will  be  more  generally  distributed,  and  it  will 
allow  a  number  of  our  young  men  to  roam,  as  it  were,,  in 
any  part  of  the  empire.  By  registering  in  Great  Britain, 
as  I  said  before,  they  will  be  able  to  practice  in  aYiy  place 
where  the  British  flag  flies. 

•  We  do  not  see  the  necessity  of  adding  much  to.  what 
Dr.  Roddick  said.  If  the  Medical  profession  of  Canada 
desires  to  have  the  right  to  practice  in  any  part  of  the 
Dominion,  they  should  render  support  to  passing  the  neces- 
sary local  enactment  required  to  put  the  Bill  into  opera- 
tion. If  the  new  members  of  the  profession,  the  new 
graduates,  desire  to  be  qualified  to  practice  in  any  part  of 
the  British  Empire,  or,  in  fact,  almost  the  wide  world,  let 
them  do  likewise.  The  important  point  to  remember  is 
that  the  British  Medical  Act  enables  men  qualified  to 
practice  in  any  country,  to  be  registered  on  the  British 
Medical  Register,  provided  that  country  will  do  the  same 
for  those  whose  names  are  on  the  British  Register.  This 
is  a  boon,  indeed,  especially  when  it  is  remembered  that 
most  of  the  countries  or  nations  of  the  world  have  already 
reciprocated  with  Great  Britain.  It  has  been  asked  why 
Britain  does  not  reciprocate  with  the  various  Provinces. 
The  answer  is  clear  and  explicit.  The  British  Medical  Act 
only  deals  with  countries.  The  provinces  are  only  portions 
of  a  country,  which  country  is  Canada.  In  his  effort  to 
bring  about  a  result  so  desirable,  Dr.  Roddick  deserves  and 
should  receive  not  only  the  thanks,  but  the  earnest  support 
of  the  entire  medical  profession  in  the  Dominion. 


Book   Reviews, 


Abbott's  Bacteriology. — A  Practical  Manual  of  Bacteriology 
for  Students  and  Physicians,  By  A.  C.  Abbott,  M.D.,  Pro- 
fessor of  Hygiene,  University  of  Pennsylvania.  New  (6th)  edi- 
tion, revised  and  enlarged.  In  one  i2mo  volume  of  636  pages 
within  illustrations,  of  which  26  are  colored.  Cloth,  $2.75, 
net.  Just  ready.  Lea  Brothers  &  Co.,  Publishers,  Philadel, 
phia  and  New  York. 

The  past  three  years  have  been  productive  of  rich  results  in 
bacteriological  study,  and  the  new  edition  of  Dr.  Abbott's  excellent 
manual  appears  opportunely. 

Among  other  matters  of  great  and  practical  interest  which  the 
volume  includes  are  the  recent  findings  regarding  the  causation 
of  cerebro-spinal  meningitis  and  dysentery  ;  the  lately  revived  in- 
vestigations in  tuberculosis,  and  the  discovery  of  the  new  group  of 
micro-organisms,  which  appear  to  be  so  closely  allied  to  the  bac- 
illus tuberculosis  ;  the  very  considerable  additions  that  have  been 
made  to  our  knowledge  of  the  mechanism  of  infection  and  immu- 
nity, etc. 

Dr.  Abbott's  work  has  had  a  very  successful  life.  Six  edi- 
tions, each  larger  than  its  predecessor,  in  ten  years,  is  a  record 
reached  by  few  medical  books.  This  rapid  and  increasing  demand 
offers  frequent  opportunities  for  revision,  and  each  of  these  six  dic- 
tions presents  not  only  a  complete  renewal,  but  a  considerable 
enlargement,  so  that  the  volume  now  is  nearly  three  times  its 
original  size. 

That  Abbott's  Bacteriology  is  an  accepted  authority  and  a 
strong  favorite  with  both  student  and  instructor  is  not  at  all  sur- 
prising. 


PUBIvISHKRS  DKPARTMENT^ 


SANMETTO  IN  PROSTATITIS,  ENURESIS,  CATARRH   OF 
BLADDER. 

In  prostatitis,. enuresis,  catarrh   of  bladder   and  all   diseases  of  the  genito- 
urinary system,  Sanmetto  has  been  indispensable  to  me. 

J.  T.  W.  KERNS,  M.D. 
Bellaire,  Ohio. 


SANMETTO  IN  URINARY  TROUBLES  IN   OLD  MEN   AND   CHIL- 

DRE^f. 

So  far  as  my  experience  has  been  with  Sanmetto,  in   urinary  troubles   it  is 
one  of  the  very  best  remedies  we  have  at  present.    I  recommend  Sanmetto  in 


288  publisher's  department. 

Hrinary  troubles  in  old  men  ;  also  for  children  when  subjects  of  that  trouble- 
some complaint,  wetting  the  bed.  I  have  practised  medicine  over  forty-five 
years, 

A.  D.  H.  KEMPER,  M.D. 
Sedgwick,  Kans. 


SANMETTO  IN  ENURESIS,  CATARRHAL  TROUBLE  AND  ATONIC 
CONDITIONS  OF  THE  GENITO-URINARY  ORGANS. 

This  is  to  certify  that  I  have  used  Sanmetto  for  the  past  eight  years,  and  I 
can  truthfully  say  that  it  has  come  to  my  aid  in  my  practice,  in  such  cases  that 
I  deemed  was  necessary,  such  as  enuresis,  catarrhal  trouble  and  atonic  condi- 
tions of  the  genito-urinary  organs.  In  eveiy  case  where  I  have  used  it  faithfully  it 
has  proved  to  be  all  claimed  for  it — a  potential  remedy.  I  have  taken  it  myself. 
As  I  am  over  seventy  years  of  age,  it  has  come  to  my  rescue,  and  the  relief  is 
phenomenal.     I  have  practised  medicine  over  thirty  years  in  Cincinnati. 

WESLEY  H.  WATSON,  M.D. 
Cincinnati,  O. 


CANADA 

MEDICAL  RECORD 


JULY.     1902. 


Original  Communications. 


THE   OBSTETRICAL  FORCEPS. 

BY  A.  LAPTHOKN  SMll  H,  B.A.,  M.D.,  M.U.C.S.,  EXG. 

Professor  of  Clinical  Gyna-colopry  in  Bishop's   Universitjs  IMontreal ;  Professor  of 
Surgical  Diseases  (jit  Women  in  the  University  of   A  ernioiit,  Burlington. 

When  first  requested  by  the  editor  to  contribute  an 
article  on  the  obstetrical  forceps,  the  writer  was  about  to 
reply  that  he  was  not  a  teacher  of  obstetrics  and  that  he 
had  only  used  the  forceps  about  two  hundred  times,  includ- 
ing consultation  cases,  and,  consequently,  that  there  were 
many  others  who  were  much  more  able  to  write  on  this 
subject  than  he;  but  on  thinking  over  his  own  experience, 
especially  as  a  gynecologist  who  has  taken  the  histories 
of  a  great  many  women  who  have  been  injured  by  the  for- 
ceps and  who  has  repaired  these  injuries,  he  came  to  the 
conclusion  that  he  might  do  some  good  by  giving  his  ex- 
perience of  the  abuse  of  the  forceps  as  well  as  by  expres- 
sing his  views  as  to  when  and  how  they  should  be  used. 
No  attempt,  therefore,  will  be  made  to  write  a  classical 
or  library-  article,  and  no  books  will  be  referred  to  or 
quoted;  the  opinions  he  will  express  are  based  on  about 
twelve  hundred  and  fifty  obstetrical  and  seven  thousand 
gynecological  cases,  which,  of  course,  is  a  very  small  num- 
ber when  compared  with  the  vast  aggregate  of  cases  which 
might  be  drawn  upon  for  information.  And  yet  the  care- 
ful consideration  of  even  these  few  cases  may  be  of  value 
to  the  younger  and  less  experienced  of  our  readers  to  whom 
it  is  especially  addressed,  while  the  older  ones  may  take 
some  interest  in  approving  or  condemning  it  in  the  light 
of  their  much  greater  knowledge  of  the  subject. 


290  THE    OBSTETRICAL   FORCEPS. 

The  Use  of  the  Forceps.  If  any  general  practitioner  of 
mature  years  were  asked  which  of  the  many  instruments 
in  his  possession  he  could  least  afford  to  do  without,  he 
would,  on  looking  around  his  various  shelves  and  bags, 
finally  rest  his  eyes  on  his  long  black  bag  and,  almost 
affectionately  reply,  the  forceps,  as  he  thinks  of  the  many 
lives  and  the  amount  of  suffering  it  has  enabled  him  to 
save.  But  it  cannot  be  denied  that  the  forceps  is  an  agent 
which  is  as  potent  for  evil  as  for  good,  according  to  the 
motives  which  prompt  its  employment  and  the  skill  with 
which  it  is  employed.  The  forceps  has  saved  the  lives 
of  hundreds  of  mothers,  but  it  has  shipwrecked  the  lives 
of  thousands.  And  while  it  has  saved  the  lives  of  thou- 
sands of  children  who  would  have  perished  from  prolonged 
compression  in  a  narrow  pelvis,  it  has  killed  a  great  many 
who  would  have  passed  safely  through  if  they  had  been 
allowed  a  little  more  time.  The  object  of  this  paper  will 
be  to  point  out  how  the  forceps  may  be  made  to  accomplish 
the  maximum  of  good  with  the  minimum  of  harm.  There 
are  a  few  simple  rules  which  the  writer  has  laid  down  for 
his  own  guidance,  and  which  he  has  often  pointed  out  to 
his  students  at  his  gynecological  clinics  when  examining 
severe  lacerations  of  the  cervix,  vagina  and  perineum. 

1.  Never  use  the  forceps  until  the  woman  has  been 
twenty-four  hours  in  labour  if  a  first  confinement,  or  twelve 

.  hours  if  a  second  or  subsequent  one,  unless  there  is  some 
urgent  indication  to  do  so. 

2.  Never  use  the  forceps  to  save  one's  own  time. 

If  these  two  rules  were  invariably  followed  there 
would  be  a  tremendous  falling  off  in  the  number  of  women 
with  lacerated  cervices  and  perineums,  and  consequent 
puerperal  infections  and  uterine  displacements.  In 
taking  the  histories  of  nearly  four  thousand  cases  at  the 
Montreal  Dispensary  I  have  learned  that  a  great  many 
women,  who  stated  that  they  had  never  been  well  since 
their  first  confinement,  were  delivered  with  the  forceps  in 
from  one  to  six  hours  after  the  first  pain  of  their  first 
labour.  The  following  extreme  cases  appears  among  the 
histories:  A  woman  who  came  with  a  laceration  through 
the  perineum  and  sphincter  ani  and  about  two  inches  up 


THE    OBSTETRICAL   FORCEPS.  29 1 

the  bowel,  as  well  as  having  a  star-shaped  laceration  of 
the  cervix  and  bands  of  scar  tissue  running  across  the 
vagina  in  every  direction,  stated  that  she  had  the  first 
pain  of  her  first  confinement  at  eleven  p.m.,  while  spend- 
ing the  evening  at  her  father's  house,  which  necessitated 
her  going  home.  She  walked  thither  a  distance  of  half  a 
mile  and  as  she  and  her  husband  had  to  pass  the  door  of 
the  physician  who  was  to  attend  her,  the  unlucky  idea 
occurred  to  them  to  stop  at  the  doctor's  and  let  him  know 
that  labour  had  begun.  Instead  of  telling  them  to  go  home 
and  go  to  bed,  and  that  he  would  call  around  in  the  morn- 
ing, he  unfortunately  got  up  and  dressed  and  arrived  at 
her  house  before  twelve.  By  midnight  he  had  put  her  to 
bed,  examined  her  and  decided  to  apply  the  forceps  forth- 
with. During  the  next  four  hours,  she  said,  he  applied 
the  forceps  thirty  times,  although,  as  he  did  not  use  any 
anesthetics,  she  was  unconscious  most  of  the  time  from 
fainting,  but  her  husband  told  her  that  several  times  the 
doctor  fell  on  his  back  on  the  floor  owing  to  the  instru- 
ment slipping  off  the  child's  head.  At  last  at  four  o'clock 
in  the  morning  he  told  the  husband  that  he  could  do  no 
more  as  he  was  exhausted,  and  that  he  had  better  get  an- 
other doctor.  Dr.  Gaherty,  who  sent  the  patient  to  me 
afterwards,  then  took  charge  of  the  case  and  found  her 
in  a  very  dangerous  condition.  By  eight  o'clock  he  had 
revived  her  enough  to  give  her  an  anesthetic  and  terminate 
the  delivery  with  instruments.  This,  of  course,  was  an 
extreme  case,  but  there  were  many  other  women  who 
stated  that  the  instrument  "was  applied  in  two  or  three 
hours  after  the  first  pain.  The  majority  had  been  attended 
by  a  physician  whose  fee  was  cut  down  so  low  that  it  was 
impossible  for  him  to  devote  the  necessary  time  to  the  case 
and  yet  make  an  honourable  living. 

I  am  almost  ashamed  to  mention  such  a  thing  in  a 
paper  on  the  abuse  of  the  forceps,  but  it  must  be  truthful 
in  order  to  be  of  any  use,  and  so  I  must  say  that  there  are 
many  women  and  still  more  children  lying  dead  and  buried 
to-day  who  would  have  been  alive  and  well  if  the  physician 
had  demanded  and  been  paid  a  sufficient  sum  to  remune- 
rate  him  for  the  time    which  should    have  been    spent  in 


292  THE    OBSTETRICAL   FORCEPS. 

order  to  do  good  work.     Kather  than  reduce  our  service 
to  the  level  of  an  absurdly  small  fee,  would  it  not  be  better 
to  educate  our  patients  up  to  the  level  of  paying  a  reason- 
able fee,  if  they  can  afford  it,  or  attend  them  for  nothing 
at  a  maternity  hospital,  if  they  are  poor  ?    The  forceps, 
of  course,  will  not  be  employed  too  soon  in  such  a  place, 
either  to  save  the  medical  director's  time  or  to  give  prac- 
tice to  the  medical  student.     I  have  made  it  a  rule  not  to 
attend  a  woman  in  her  confinement  unless  she  has  engaged 
me  several  months  beforehand,  among  the  many  reasons 
for  this  being  the  importance  of  seeing  her  a  few  times  in 
order  to  instruct  her  on  the  time  required  for  a  safe  deli- 
very.    The  writer  has  saved  himself  much  annoyance  and 
his    patients    much  danger  by  the    following    method  of 
avoiding  the  use  of  the  forceps  too  soon.     Each  primipara 
is  given  three  one-grain  opium  powders,  one  to  be  taken 
every  hour  as  soon  as  the  pains  begin,  and    if   the  pains 
begin  in  the  night  she  is  told  not  to  awake  her  husband 
until  the  usual  hour  in  the  morning,  nor  let  the  doctor 
know  until  9  a.m.,  as  it  is  most  important  that  her  first 
confinement    should    take    at    least    twenty-four  hours  if 
possible.     Then  she  is  told  the  reason  why;  that  if  she 
has  a  natural  confinement  she  will  have  better  health  than 
ever,  while  if  it  is  hurried  artificially  she  may  become  a 
chronic  invalid  for  life.     The  result  is  that,  supposing  she 
is  taken  with  her  first  pain  at  11  p.m.,  she  takes  her  pow- 
der and  perhaps  goes  off  to  sleep  only  waking  for  a  minute 
at  long  intervals;  she  may  not  even  have  to  take  the  three 
powders.     In  the  morning  she  takes  an  enema  and  a  bath, 
puts  on  clean  clothes,  has  her  breakfast  and  then  sends 
me  word.     I  make  my  first  visit  about  10  a.m.  and  after 
sterilizing  my  hands    I  make    the  first    examination    and 
find  perhaps  that  the  os  is  opened  to  the  size  of  a  ,quar- 
ter-dollar.    I  tell  her  that  everything  is  going  on  well  and 
that  the  baby  will  probably  be  born  before  midnight.     She 
is  told  to  busy  herself  with  her  household  duties  between 
her  pains,  and  that  I  will  return  again  in  the  afternoon. 
On  no  account  should  the  doctor  remain  in  the  house  all 
day,  for  if  he  does  he  will  almost  surely  be  urged  to  do 
something  which  his  judgment  tells  him  would  be  detri- 


THE    OBSTETRICAL    FORCEPS.  293 

mental  to  the  patient's  welfare.  At  the  afternoon  exam- 
ination the  OS  will  perhaps  be  dilated  as  large  as  the  palm, 
and  at  the  evening  visit  the  head  will  probably  be  entering 
the  pelvis  and  I  then  remain  if  I  have  no  other  visits  to 
make.  But  even  then  I  do  not  remain  all  the  time  in  the 
sick  room,  nor  do  I  make  any  more  examinations,  but  I 
order  the  nurse  to  call  me  only  when  she  sees  the  head 
showing  a  little  at  the  vulva.  A  little  bottle  with  a 
sprinkler  on  it,  filled  with  a.  c.  e.  mixture  (alcohol  one, 
chloroform  two,  and  ether  three  parts)  may  safely  be 
handed  to  the  patient,  with  a  cone  made  with  brown  paper 
and  a  towel,  and  she  may  take  a  whiff  of  this  whenever 
a  pain  comes  on  if  it  is  strong;  just  before  the  head  comes 
through  the  vulva  I  take  the  cone  and  bottle  from  her 
and  put  her  quite  asleep  for  a  few  minutes.  When  the 
confinement  is  managed  in  this  way  the  forceps  will  be 
used  very  rarely.  It  has  been  mentioned  above  that  three 
examinations  should  be  made;  but  if  the  physician  sees 
any  way  in  which  one  or  two  of  them  can  be  avoided,  let 
him  do  so,  for  the  n'omari'S  safety  increases  icith  the  fewness 
of  the  digital  examinations.  If  none  at  all  were  made, 
puerperal  sepsis  would  be  almost  unknown.  So  much 
importance  should  be  attached  to  this  that  the  writer  tells 
the  woman  when  she  engages  him  not  to  allow  any  one 
but  him  to  examine  her,  and  not  even  him  more  than  two 
or  three  times. 

It  is  well  also  to  warn  the  patient  that  we  are  going 
to  make  as  few  examinations  as  possible  for  her  sake,  in 
order  to  circumvent  the  machinations  of  the  old  women 
who  call  us  in  to  make  an  examination  every  time  the 
patient  has  a  pain.  After  the  lapse  of  so  many  years  it 
is  amusing  to  look  back  upon  the  scenes  of  one's  early 
confinements,  although  at  the  time  they  were  tragic 
enough ;  as  one  entered  the  darkened  and  ill-smelling  rooms 
one  felt  like  an  innocent  man  on  trial  for  his  life  by  a  jury 
which  has  already  made  up  its  mind  to  convict  him,  when 
through  the  gloom  we  saw  the  pessimistic  faces  of  the  six 
old  women  with  tea-tanned  faces  who  were  there  for  no 
other  purpose  than  to  sit  in  judgment  on  the  young  doc- 
tor.    What  a  howl  of  condemnation  they  set  up  when  after 


294  THE    OBSTETRICAL   FORCEPS. 

an  examination  he  announces  that  he  is  going  home,  as 
the  labour  has  just  begun.  More  than  once  the  writer  has 
weakly  stayed  only  to  be  harassed  and  tormented  for 
twelve  weary  hours  by  the  disparaging  remarks  of  the 
jury,  such  as,  "Can  you  do  nothing  for  her?"  or,  "Hadn't 
you  better  call  a  more  experienced  doctor  ?"  until  weary 
and  goaded  to  desperation  he  has  committed  the  almost 
unpardonable  crime  of  applying  the  forceps  in  the  very 
middle  of  a  normal  labour.  Many  a  time  the  blame  for 
using  the  forceps  too  early  and  thereby  wrecking  the 
woman's  life  should  be  laid  at  the  door  of  these  old  women, 
rather  than  at  that  of  the  young  physician. 

Are  the  injuries  to  the  mother  due  to  the  use  of  the  forceps, 
or  to  the  abuse  of  it?  The  fact  that,  in  my  own  experience 
at  least,  I  caused  more  damage  with  the  forceps  in  my 
earlier  years  than  I  do  now,  would  make  me  believe  that 
much  of  the  terrible  injury  which  the' forceps  inflicts  is  due 
to  the  too  early  and  too  violent  use  of  it.  I  once  saw  a 
practitioner  apply  the  forceps  early  in  labour,  and,  bracing 
his  two  feet  against  the  woman's  buttocks,  he  extracted 
the  child  by  sheer  force.  During  the  last  ten  years  I  have 
caused  very  little  damage  with  the  forceps.  In  fact,  when 
properly  used,  the  forceps  not  only  does  not  cause  lacer- 
ations of  the  perineum,  but  actually  saves  the  perineum 
by  taking  the  weight  of  the  head  off  it  as  the  handles  are 
raised,  and  guiding  the  head  forwards  and  upwards  instead 
of  leaving  it  to  obey  the  forces  which  are  driving  it  down 
upon  the  perineum. 

When  to  remove  the  forceps?  As  the  forceps,  no  matter 
how  delicate  in  structure  it  may  be,  must  take  up  some 
room,  I  think  it  is  best  to  remove  it  before  the  longest 
diameter  of  the  head  comes  through  the  vulva.  As  soon, 
therefore,  as  I  am  sure  that  the  upper  jaw  of  the  child 
can  be  reached  by  the  right  finger  in  the  rectum,  the 
screw  holding  the  blades  together  is  unloosened  wit^  the 
left  hand,  and  first  the  female  and  then  the  male  blade 
is  removed,  the  right  finger  in  the  rectum  all  the  time 
keeping  the  head  down  on  the  perineum.  When  the  next 
pain  comes,  the  head  is  pushed  forward  under  the  arch 
of  the  pubis    and  it  is  thus    born  without    the    perineum 


THE  OBSTETRICAL  FORCEPS.  295 

being  torn.  When  the  rectum  has  been  washed  out  by  a 
soap  and  water  enema  there  is  nothing  unpleasant  about 
putting  the  fingers  in  it;  but  the  enema  is  of  advantage 
for  another  reason,  namely,  the  saving  both  patient  and 
attendant  the  mortification  of  having  the  bowels  moved 
in  the  bed  as  the  head  comes  down. 

No  force  should  he  employed  in  applying  the  forceps. 
While  studying  in  London  twenty-five  years  ago,  the  writer 
received  a  lasting  impression  by  reading  the  report  of  the 
trial  of  a  doctor  for  malpractice,  who,  while  partially 
intoxicated,  forced  a  blade  of  the  instrument  through  the 
vagina  into  the  peritoneal  cavity,  and  then,  when  several 
feet  of  small  intestine  prolapsed,  he  cut  the  latter  off 
thinking  that  it  was  the  cord.  Whenever  I  am  introduc- 
ing the  forceps  this  case  comes  to  mj-  mind  and  I  am  ex- 
tremely careful  not  to  use  any  force;  if  I  cannot  get  it  on 
without  force  I  will  not  use  the  instrument  at  all.  In  fact, 
in  most  of  the  eases  the  blades  drop  in  by  their  own  weight. 

How  to  apply  the  forceps.  Although  I  have  often  seen 
them  applied,  while  I  was  in  England,  while  the  patient 
was  in  the  left  lateral  position,  I  think  there  is  no  com- 
parison between  that  and  the  dorsal  or  lithotomy  position, 
with  the  hips  well  over  the  edge  of  the  bed  and  the  feet 
on  two  chairs,  or,  better  still,  held  by  a  leg  holder,  or 
failing  that,  by  two  women.  I  never  attempt  to  apply 
the  forceps  while  the  woman  is  in  the  bed  and  lying  on 
her  back.  The  male  blade  is  taken  between  the  thumb 
and  finger  of  the  left  hand  and  allowed  to  hang  vertical, 
while  two  fingers  of  the  right  hand  guide  it  between  the 
head  and  cervix,  when  the  handle  is  allowed  to  fall  a  half 
a  circle,  and  the  blade  will  be  above  the  brain.  The  hands 
are  again  quickly  washed  and  the  same  thing  done  with 
the  female  blade,  only  in  different  hands.  When  the 
two  handles  have  fallen  or  are  depressed  a  good  half  circle 
the  locks  will  come  together  and  the  screw  is  tightened. 
The  blades  are  then  applied  transversely  to  the  mother's 
pelvis  where  there  is  most  room,  but  as  the  child's  head 
has  to  rotate  forwards  in  the  pelvis  I  sometimes  take  the 
forceps  off  when  I  get  the  head  in  the  pelvis  and  re-apply 
them  to  the  sides  of  the  child's  head  before  beginning  to 
raise  the  handles. 


2g6  THE    OBSTETRICAL    FORCEPS. 

Choice  of  instruments.  Having  in  my  earlier  years  of 
practice  called  several  senior  practitioners  to  my  assis- 
tance in  diflficult  cases,  and  having  in  turn  been  called  by 
a  great  many  younger  men  since,  I  have  had  opportunities 
of  comparing  the  various  makes  of  forceps,  and  so  far  as 
I  am  personally  concerned,  if  I  had  to  buy  a  new  pair  now 
I  would  choose  the  same  pattern  as  those  I  bought  a 
quarter  of  a  century  ago  and  have  used  constantly  ever 
since,  namely  the  Baudeloque.  (I  have  several  other  kinds, 
but  keep  them  merely  as  curiosities.)  This  instrument  is 
a  foot  and  a  half  long  and  a  pound  and  a  half  in  weight. 
The  handles  are  roughened  and  each  has  a  hook  on  it, 
which,  with  the  rough  handles,  is  a  great  help  when  trac- 
tion is  required,  although  I  seldom  use  the  forceps  in  this 
way.  preferring  as  much  as  possible  to  employ  it  as  a 
lever,  with  the  arch  of  the  pubis  as  the  fulcrum;  the  long 
handles  enabling  one  to  exert  sufficient  force  in  this  way 
with  only  one  or  two  fingers  of  one  hand  on  the  instrument. 
One  might  fear  that  this  would  injure  the  soft  parts  cover- 
ing the  pubic  bones,  but  such  has  never  happened  in  my 
hands.  In  many  cases,  when  the  head  was  arrested  in  the 
pelvis,  I  have  been  able  to  deliver  without  applying  a  sin^ 
gle  ounce  of  traction.  Laying  the  handles  on  the  open 
palm  of  my  hand,  I  have  raised  them  until  they  touched 
the  woman's  abdomen,  describing  exactly  half  a  circle, 
by  which  time  the  head  had  passed  the  vulva.  But  it  is  in 
cases  where  there  is  a  narrow  pelvis,  with  the  head  arrest- 
ed at  the  brim,  and  the  uterus  is  lashed  into  an  ineffectual 
fury  by  the  pains,  threatening  every  moment  to  rupture 
itself,  that  I  have  found  these  forceps  so  useful.  When 
they  are  applied  in  these  cases,  we  must  pull  downwards 
until  the  head  enters  the  pelvis,  and  after  every  pull  wait 
a  moment  to  see  in  what  direction  the  handles  point  before 
making  the  next  pull,  when  they  will  be  found  each  tirao 
to  point  a  few  degrees  of  a  circle  higher  up.  These  for- 
ceps have  this  great  advantage,  that  they  will  do  equally 
well  in  the  most  difficult  and  in  the  easiest  cases.  One 
woman  I  remember,  who  had  had  two  confinements,  each 
time  requiring  the  assistance  of  three  doctors  and  the 
child  having  to  be  killed  both  times.     She  came  to  me 


THE    OBSTETRICAL    FORCEPS,  2()J 

for  her  third  delivery,  and  as  she  was  anxious  to  have  a 
living  child,  I  advised  symphysiotomy,  to  which  she  con- 
sented. As  soon  as  labour  set  in  she  entered  my  private 
hospital  and  all  preparations  were  made  to  operate,  but 
before  cutting  the  pubic  arch  I  made  one  attempt  to 
deliver  by  applying  the  forceps  high  up.  This  was  easily 
done,  the  male  blade  catching  the  child's  forehead  and 
the  other  the  occiput.  It  was  the  projecting  promontory 
of  the  sacrum  which  held  the  head  back,  but  on  applying 
some  considerable  traction  downwards  I  felt  a  clicking 
sound  as  though  the  right  parietal  bone  had  bent  or 
cracked,  and  the  head  came  down.  On  raising  the  handles 
delivery  was  easily  effected  without  any  injurj'  to  the 
mother  and  with  a  living  child  which  the  parents  so  much 
desired.  I  looked  for  a  fracture  of  the  parietal  bone,  but 
there  was  no  sign  of  it;  it  may  have  been  elastic  enough 
to  bend  without  breaking.  I  attribute  my  success  in  this 
case  entirely  to  the  long  forceps. 

Care  of  the  forceps.  This  same  pair  of  forceps  has  been 
in  use  for  nearly  a  quarter  of  a  century,  but  it  has  been 
well  taken  care  of.  I  have  never  once  entrusted  it  to  any 
one  else  to  clean  for  -me,  but  immediately  the  child  has 
been  born  I  have  returned  it  to  the  jug  of  hot  water  from 
which  I  had  taken  it,  and  as  soon  as  the  mother  and  child 
had  been  cared  for  I  have  washed  and  dried  the  forceps 
myself,  finishing  the  drying  by  sterilizing  it  on  the  hot 
stove.  Every  few  years  they  are  re-silver-plated,  and  now 
they  are  as  good  as  the  day  they  were  bought. 

Danger  of  using  tJie  forceps  when  there  are  no  uterine 
contractions.  I  have  already  mentioned  the  danger  of 
using  the  forceps  to  terminate  labour  when  labour  has  either 
not  begun  or  is  only  half  over,  from  the  point  of  view  of 
lacerations  of  the  cervix,  vagina  and  perineum,  but  I  wish 
to  say  a  few  words  about  inversion  of  the  uterus  from 
this  cause.  I  have  noticed  that  this  terrible  accident  is 
more  common  in  the  practice  of  those  energetic  but  mis- 
guided gentlemen  who  convert  their  normal  labours  into 
accouchements  forces  in  most  of  the  cases  in  which  the  child 
is  not  borne  before  they  reach  the  house.  Either  there 
is  uterine  inertia,  and  they  have  to  apply  the  forceps  for 


298  THE 'OBSTETRICAL    FORCEPS. 

this  reason,  or  else  there  is  retained  placenta,  and  they 
hare  to  introduce  their  hand  and  arm  as  far  as  the  elbow 
to  remove  it.  Now  it  is  absolutely  and  mechanically 
impossible  for  the  uterus  to  contract  itself  inside  out.  If 
it  is  inverted,  it  is  because  it  has  been  pulled  inside  out 
by  some  one,-  and  the  only  two  people  who  can  do  that  are 
the  baby  and  the  accoucheur;  neither  of  them  can  do  it 
except  in  one  way,  and  that  is  through  the  cord.  And 
not  even  then,  unless  while  the  uterus  is  relaxed  between 
the  pains.  Sometimes  it  is  unavoidable  because  the  cord 
is  abnormally  short,  or  it  is  twisted  around  the  child's 
neck  several  times  so  that  it  becomes  abnormally  short, 
and  as  the  child  drops  out  of  the  vulva  the  fundus  is  pulled 
down  with  the  placenta  as  soon  as  the  uterus  relaxes. 
Or  the  fundus  is  pulled  down  during  an  interval  between 
pains  by  tractions  on  the  cord  while  delivering  the  pla- 
centa. But  when  the  forceps  is  used  in  the  total  absence 
of  contractions  there  is  absolutely  no  reason  why  the 
uterus  should  not  invert  every  time.  I  was  telegraphed 
for  to  come  to  the  country  to  help  a  medical  friend,  where, 
the  forceps  having  been  applied  in  the  absence  of  pains, 
the  child  was  immediately  followed  by  the  placenta  still 
attached  to  the  fundus.  Before  I  could  get  there  the 
woman  was  dead  from  hemorrhage  and  shock.  In  this 
case  the  cord  was  wound  three  times  around  the  child's 
neck,  and  before  it  could  be  undone  the  uterus  was  in- 
verted. 

Injury  to  the  child- s  head.  There  is  no  doubt  that  many 
children  have  been  killed  and  many  others  maimed  for 
life  from  injuries  to  the  head  caused  by  using  undue  force 
with  the  forceps.  But  all  these  deaths  must  not  be 
charged  to  the  forceps  alone;  many  of  these  children 
would  have  perished  as  well  as  their  mothers  had  delivery 
not  been  terminated  by  their  aid.  In  the  writer's  own 
hands,  out  of  over  twelve  hundred  deliveries,  about  twelve 
children,  or  one  per  cent.,  have  died  from  instrumental 
deliveries,  but  he  has  only  seen  one  case  of  severe  injury 
to  the  brain  among  those  who  survived.  This  was  a  large 
boy,  whose  mother  had  a  generally  small  pelvis,  and  after 
waiting  twenty-four  hours  the  forceps  was  applied  at  the 


SHEPARD  :     DISEASES     OF     THE     FEMALE.  299 

superior  strait  and  the  child  delivered  with  great  diflS- 
culty.  Just  over  the  right  parietal  bone  a  hole. was  found 
through  which  about  a  teaspoonful  of  brain  substance 
exuded.  The  wound  was  carefully  treated  and,  instead 
of  the  child  dying  as  was  expected,  it  made  a  good  recov- 
ery. This  case  was  followed  up  with  interest  until  the 
child  was  five  years  old,  when  he  disappeared  from  view, 
but  when  last  seen  he  had  a  small  pulsating  tumour  at  the 
spot  referred  to  as  large  as  a  quarter  of  a  dollar,  but  he 
was  not  paralyzed  in  any  way.  I  have  heard  of  several 
cases  in  Montreal  where  idiocy,  imbecility,  paralysis  and 
convulsions  have  resulted  from  forceps  injuries  to  the 
brain. 

There  are  many  other  things  about  this  instrument 
which  I  would  like  to  say,  but  the  space  at  my  disposal 
is  limited  and  I  must  bring  my  paper  to  a  close,  with  the 
hope  that  what  I  have  said  may  induce  many  young  prac- 
titioners to  give  nature  a  fair  chance  before  resorting  to 
the  forceps. — Philadelphia  Medical  Journal. 


:   :iGOAPIOL    (SMITH),    IN   DISEASES   OF  THE  FEMAI^E. 

BY    CHARLES    H.    SHEPARD,    M.D., 
Physician  to  Lincoln  Hospital,  Durham,  N.C. 

A  deep  and  general  interest  is  attached  to  all  know- 
ledge pertaining  to  the  treatment  of  common  diseases  of  the 
uterus,  to  which  women  are  subject,  and  a  vast  literature  is 
the  outcome  of  this  profound  and  focussed  interest.  We  live 
to-day  in  an  age  of  transition — a  period  of  change.  A  great 
many  of  the  former  theories  in  medicine  are  fast  passing 
away.  New  medicines  are  made,  achieve  a  short-lived 
success,  and  then  pass  on  to  obscurity.  This  is  true  most 
especially  in  medicines  for  gynaecological  diseases.  Of  the 
newer  remedies  it  is  hard  indeed  to  get  one  that  may  be 
depended  upon  for  long.  They  soon  lose  their  reputation 
and  potency  and  are  relegated  to  the  past. 

We  know  that  all  diseases  of  the  womb  have  not  the 
same  etiology  nor  the  same  pathology,  therefore  they  should 
not  all  have  the  same  treatment.      Far  too  often  the  general 


300  SHEPARD  :     DISEASES     OF     THE     FEMALE. 

practitioner  groups  all  these  diseases  together  as  one  and 
gives  the  routine  treatment.  It  is  not  enough  to  give  ano- 
dyne medicines  for  dysmenorrhea  no  m  ire  than  it  is  suffi- 
cient to  treat  alike  all  forms  of  dysmenorrhea. 

,  The  operation  of  curettement  has  a  most  important 
place  in  these  conditions,  but  like  other  remedial  agencies 
it  has  its  limitation.  When  we  curette  the  uterus  we  rid  it 
of  a  pathologically  obnoxious  lining  membrane,  and  afford 
a  normal  membrane  the  opportunity  to  be  formed. 

The  healthy  woman  v/ith  normal  genitalia  menstruates 
regularly  and  painlessly  once  a  month  from  puberty  to  the 
"  turn"  of  life,  except  that  this  regularity  is  interrupted  by 
pregnancy  and  afterwards  by  lictation.  Any  departure  from 
this  rule  constitutes  an  abnormality.  Amenorrhea  is  less 
frequently  met  with  than  dysmenorrhea  and  irregular  men- 
struation. The  present  age  of  transition  has  brought  forth 
what  is  popularly  known  as  the  "  new  woman,"  and  she  has 
brought  with  her  new  ideas  and  practices  which  in  very  many 
cases  retard  growth  and  the  natural  process  necessary  for  per- 
fect health.  For  leaving  the  old  landmarks,  she  has  to 
suffer. 

The  most  generally  useful  medicine  in  the  conditions  of 
amenorrhea,  dysmenorrhea,  irregular,  scanty  and  fetid  men- 
struation in  my  judgment,  is  a  preparation  of  the  Martin  H_ 
Smith  Company,  of  New  York,  known  as  Ergoapiol  (Smith). 
In  the  female  ward  of  the  Lincoln  Hospital,  Durham,  N.C., 
I  have  used  this  medicine  very  extensively,  and  it  has  not 
only  never  failed  to  benefit  and  cure,  but  I  know  no  remedy 
with  which  I  could  replace  it  were  I  deprived  of  it.  Its  efficacy 
may  be  tested  by  any  physician  who  properly  tries  it.  I 
mention  a  few  cases  with  short  description  of  each,  in  which 
it  has  given  the  most  signal  benefit  in  my  hands. 

Ergoapiol  (Smith)  is  put  up  as  a  small  capsule,  and  is  made 
up  of  a  special  form  of  apiol,  which  is  of  the  the  very  highest 
quality.  Combined  with  this  are  some  other  most  valuable 
hemagogues,  and  they  all  go  to  make  a  fine  preparation.  It 
seems  to  be  a    scientific    pharmaceutical  preparation,  non- 


SHEPARD  :     DISEASES     OF     THE     FEMALE.  301 

toxic,  tonic,  as  well  as  emmenagogue.  What  I  have  to  say 
of  this  preparation  is  based  entirely  on  clinical  experience» 
and  I  feel  safe  in  saying  that  it  will  bear  a  clinical  test  when- 
ever properly  administered. 

REPORT  OF  CASES. 

No.  I.     Mrs.  F.  was  admitted  to  hospital  September  15, 
190 1  ;  married ;  no  children,  though  she  had  been  married 
four  years.     Had  not  menstruated  for  seven  years.     Womb 
had  been  curretted  several  times  ;  suffered  from  leucorrhea ; 
pains  in  right  and  left  iliac  regions  continuous.    Examination 
showed  a  very  small  os,  but  generative  organs  were  other- 
wise found   to  be   normal.     Another   curettement   failed  to 
bring  on  the  menses.     I  then  prescribed  Ergoapiol  (Smith) 
to  be  taken  one   capsule  three   times  a   day,  and  afterwards 
increased  to  one  capsule  four  times  a  day.     After  seven  days 
of    this  treatment  she   complained   of  a  general   feeling   of 
stiffness  in  her  limbs,  gaping  and  a  feeling  of  malaise.     The 
following  morning  she  found,  to  her  delightful  surprise,  that 
she  was  menstruating  for  the  first  time  in  seven  years.     At 
that  time  the  flow  was  somewhat  scanty,  but  the  treatment 
was    continued    through    three    periods.       Each    succeeding 
period  was  more  nearly  normal  than  the  one  that  preceeded 
it.     Now  her  functions  are   regular,  and  I  know  no  reason 
why  she  may  not  become  pregnant. 

Case  No.  2.  Mrs.  S.  complained  of  a  continuous,  dull, 
dragging  pain,  situated  in  the  region  of  the  iliac  fossa  of  the 
right  side.  Menstruation  irregular,  scanty,  fetid.  Married 
six  years ;  had  never  been  pregnant.  Excessive  leucorrhea 
though  otherwise  she  was  perfectly  normal.  Her  weight  was 
140  pounds.  Her  condition  and  the  suffering,  both  physical 
and  mental,  which  it  occasioned  her,  was  rapidly  undermining 
her  health.  She  was  becoming  emaciated,  appetite  of  no 
consequence,  general  weakness.  She  considered  her  con- 
dition "  hopeless."  Cardiac  weakness,  of  which  she  was  a 
victim,  contra-indicated  curettement — which  usually  cures 
"  whites,"  and  allows  the  formation  of  a  healthy  lining 
membrane,      Ergoapiol  (Smith)   was  prescribed   for  her,  one 


302  SHEPARD  :     DISEASES     OF     THE     FEMALE. 

capsule  three  times  a  day.  In  conjunction  with  this  I  gave 
tonic  medicines.  After  six  weeks'  use  of  this  remedy  the 
woman  said  she  was  "  feeling  so  good  "  that  she  did  not  need 
any  further  treatment.  She  had  increased  in  weight,  and 
her  appetite  had  become  all  she  could  wish.  The  menstrual 
flow  was  increased,  and  now,  five  periods  having  elapsed 
from  the  time  treatment  was  instituted,  her  monthly  flow 
has  failed  to  appear.  She  does  not  expect  its  return  for 
some  time — supposing  herself  pregnant. 

No.  3.  Miss  S.  suffered  severe  pain  each  month, 
beginning  a  day  before  the  flow  came  on.  The  flow  was  a 
thick,  clotted  mass,  consisting  of  membrane  and  the  men- 
strual blood  matted  together.  She  had  suffered  from 
puberty,  and  the  suffering  became  more  intense  as  the  years 
passed  on.  She  was  19  years  of  age,  stout,  of  healthy 
parentage.  Admitted  to  Lincoln  Hospital,  January  15, 
1902.  She  declined  an  operation.  I  afterwards  prescribed 
Ergoapiol  (Smith),  and  have  continued  it  for  one  month. 
Her  next  menstruation  was  free  and  easy;  painless  and 
regular.  I  doubt  not  that  keeping  up  this  treatment 
to  another  period  she  will  be  entirely  rid  of  the  hitherto 
troublesome  condition. 

No.  4.  Miss  W,,  tubercular  history.  Menstruation 
very  irregular,  sometimes  three,  sometimes  five  weeks  be- 
tween periods  ;  very  painful ;  scanty.  I  prescribed  Ergo- 
apiol (Smith),  one  capsule  four  times  a  day  beginning  one 
week  before  the  menstrual  period  and  continued  a  week 
after  the  period.  As  a  result  of  this  treatment  the  patient 
feels  a  great  deal  better  in  her  general  health ;  her  monthly 
flow  has  been  rendered  painless  and  increased  in  quantity. 
Ergoapiol  has  a  tonic  action  upon  the  muscular  fibres  of  the 
womb.  Its  effect  is  not  transitory  but  lasting.  This 
superior  preparation  is  decidedly  tonic. 

No.  5.  Mrs.  D.,  a  victim  of  endometritis.  Pain  con- 
tinues between  periods  and  is  aggravated  at  periods.  Leu- 
chorrea  was  very  pronounced;  pains  in  the  back;  "hot 
flushes  "  ;  vertigo,  headache.     Patient   would   not  allow  an 


MALIGNANT  DISEASE  OF  TESTICLE.  303 

operation;  highly  sensitive.  Several  preparations  were 
tried,  but  none  gave  relief  until  Ergoapiol  (Smith;  was  used. 
It  has  entirely  relieved  the  patient,  and  she  is  now  loudly 
singing  its  praises.  In  this  case  treatment  was  kept  up  for 
ten  weeks. 

Case  No.  6.  Mrs.  D.,  widow,  aged  33,  had  three 
children;  youngest  10  years  of  age.  She  had  suffered  all 
her  menstrual  life  severe  pains  in  the  pelvis  at  each  period  ; 
had  to  keep  in  bed  a  week  or  more  each  mouth ;  paroxysms 
of  pain  were  followed  by  a  flow  of  the  **  whites " ;  no 
anaemia ;  womb  found  to  be  flabby  and  relaxed  ;  pains  ex- 
tended down  thighs  posteriorly.  Had  been  treated  for  many 
years  by  various  physicians  of  note,  but  had  received  only 
temporary  benefit. 

Ergoapiol  (Smith)  was  given  her,  one  capsule  three 
times  day,  and  increased  at  the  time  of  the  flow  to  four  a 
day.  After  three  months  of  this  treatment  her  menstrual 
function  became  regular,  and,  being  entirely  well  now,  she 
feels  that  life,  after  all,  is  worth  living. 

Ergoapiol  has  never  failed  in  my  hands.  It  is  not  pos- 
sible that  it  can  cure  obstructive  dysmenorrhea,  but  with 
that  exception  it  is  indicated  in  all  the  other  diseases  of  the  - 
womb  where  a  tonic  and  seditive  action  is  the  requirement. 
I  could  prolong  this  list  indefinitely  with  records  of 
cases  that  have  been  entirely  relieved  of  these  conditions, 
and  I  shall  be  pleased  to  furnish  any  information  desired  as 
to  Ergoapiol  (Smith)  and  its  use. 
Durham,  N.C. 


Selected  Articles. 


RECURRENT  MALIGNANT  DISEASE   OF   TESTICLE. 

BY  A.  CARTER  WEBBER,  M.D.,  CAMBRIDGE^  MASS. 

Mr,  D.,  an  active,  energetic  business  man,  married, 
robust  and  florid,  had  been  in  good  health,  except  for  an 
eczema  on  the  hands  and  legs,  previous  to  the  summer  of 
1894.     At  that  time  he  noticed  an  enlargement  of  the  left 


3O4  MALIGNANT  DISEASE  OF  TESTICLE. 

testicle  which  steadily  increased,  without  pain  or  tenderness. 
When  he  came  under  my  observation,  October  3,  1894, 
the  enlargement  of  the  organ  was  about  the  size  of  a  large 
goose  egg.  It  was  hard,  firm,  smooth,  non-elastic,  free  from 
adhesions  to  the  scrotal  tissues,  having  none  of  the  feel  of 
the  testicle  on  the  right  side.  There  were  no  indications  of 
inflammation,  such  as  pain,  tenderness  or  heat.  The  cord 
was  somewhat  thickened,  but  otherwise  normal.  The  epi- 
didymis seemed  fused  to  the  testis  ;  the  inguinal  glands 
were  not  enlarged. 

In  spite  of  active  treatment  the  testicle  continued  to  in- 
crease in  size  and  was  removed  November  7,  1894.  A 
section  of  the  organ  displayed  the  usual  macroscopic  appear- 
ance of  malignant  disease — cutting  crisply,  slightly  concave 
surfaces,  pearly  white,  no  defined  edge,  yielding  a  creamy 
fluid  on  pressure.  One  or  two  small  cysts  containing  serum 
were  found.  No  microscopic  examination  was  made.  Under 
antiseptic  treatment  the  wound  healed  without  difficulty,  and 
the  patient  soon  returned  to  his  business  and  continued  in 
good  condition  until  the  autumn  of  1900,  when  he  had  a 
recurrence  of  his  old  trouble  on  the  right  side,  the  other 
testicle  becoming  affected. 

In  November,  1900,  he  came  under  my  care  and  treat- 
ment. At  that  time  the  testis  was  three  times  as  large  as 
normal,  but  was  free  from  pain  or  tenderness.  It  was  solid, 
'smooth,  inelastic,  and  gave  him  no  inconvenience  except 
from  its  size  and  a  dragging  down  sensation.  He  reported 
that  the  functions  of  the  organ  were  somewhat  impaired. 
He  was  then  50  years  old.  No  improvement  resulting  from 
my  treatment,  the  cord  being  somewhat  thickened  and  the 
inguinal  glands  considerably  enlarged,  I  began  to  resort  to 
the  use  of  the  Alexander  fluid,  5  minims  every  second  day, 
iij\  cted  directly  into  the  external  surface  of  the  testicle 
which  was  not  adherent  to  the  tissues  of  the  scrotum.  This 
was  continued  for  six  weeks,  when  a  very  decided  improve- 
ment in  the  size  and  feel  of  the  testicle  and  cord  was 
apparent.  The  hypodermic  injections  were  then  made  every 
four  or  five  days  until  April  13,  when  the  organ  was  reduced 
to  the  usual  size,  and  felt  like  a  normal  testicle.  The 
thickening  of  the  cord  and  the  enlargement  of  the  inguinal 
glands  had  disappeared. 

As  a  precaution  he  receives  treatment  once  in  three  or 
four  weeks,  but  says  he  feels  like  himself  again. — Interna- 
tional Journal  of  Surgery. 


REMEDY   FOR  MALIGNANT   GROWTHS.  3O5 

A  TTEW   AND   EFFICIENT    REMEDY   FOR   MALIGNANT 
GROW^THS. 

BY   J.    G.   JUSTIN,    M.D.,    PH.D. 

Fellow  of  the  Monroe  Co.  Medical  Society,  New  Fork. 

The  recent  report  of  Professor  Gaylord  to  the  State 
authorities  at  Albany,  N.  Y.;  embodying  the  results  of  his 
researches  into  the  cause  of  malignant  tumours,  has  aroused 
widespread  interest  and  started  a  train  of  investigation  which 
is  certain  to  add  greatly  to  our  knowledge  of  the  disease. 

Leaving  the  distinguished  professor  to  prove  his  dis- 
covery and  trace  out  the  life  history  of  the  interesting  para- 
site, if  parasite  it  be,  that  from  time  immemorial  has  played 
such  havoc  with  human  anatomy,  permit  me  to  call  the  at- 
tention of  the  profession  to  what  I  conceive  to  be  a  far  more 
important  discovery  than  the  cause  of  malignant  tumours, 
namely,  an  efficient  remedy  for  their  relief,  a  remedy  capable 
of  lessening  the  mortality  from  this  dreadful  malady,  and  as 
potent  in  cancerous  affections  as  the  anti-toxin  serum  is  in 
diphtheria. 

Although  the  attention  of  the  profession  was  called  to  the 
new  agent  over  a  year  ago  by  its  discoverer.  Dr.  A.  C.  Alex- 
ander, who  submitted  ample  evidence  of  its  value,  it  has 
failed  to  attract  the  notice  it  deserves,  and  so  far  as  I  can 
determine  I  am  the  only  practitioner  in  Central  New  York 
who  has  made  anything  like  a  systematic  trial  of  its  virtues. 

My  own  experience  with  the  "Alexander  remedy"  for 
malignant  growths  extends  over  a  period  of  nine  months  ; 
and  the  results  have  been  so  remarkable  as,  in  my  judgment, 
to  justify  the  claims  made  for  it  by  its  discoverer  and  to 
remove  any  lingering  doubt,  in  my  own  mind,  that  it  pos- 
sesses a  marked  curative  value  in  cancer. 

As  a  preliminary  to  a  test  of  the  new  remedy  I  made 
a  visit  to  the  Alexander  Sanitarium,  where  I  became  con- 
versant with  Dr.  Alexander's  methods  and  witnessed  the 
daily  treatment  of  a  variety  of  malignant  tumours. 

On  my  return  to  Rochester  one  of  the  first  cancer  pa- 
tients to  come  under  my  care  was  a  man  with  a  recurrent 
epithelioma  of  the  nose  and  face  far  advanced. 

The  history  of  this  case  is  as  follows  :  Two  years  ago 
the  disease  began  as  a  small  ulceration  on  the  mucous  mem- 
brane of  the  right  cheek,  opposite  the  second  molar  tooth, 
and  gradually  extended  until  it  involved  the  gums  and 
alveolar  process  of  the  lower  jaw.  At  this  stage  his  phy- 
sician advised    an   operation,    which   was  performed    at  the 


306  REMEDY  FOR  MALIGNANT  GROWTHS. 

Homceopathic  Hospital,  the  whole  of  the  alveolar  process, 
together  with  the  diseased  tissue  on  the  right  side,  being 
removed.  He  made  a  good  recovery  and  for  a  time  believed 
himself  cured.  Some  months  later,  however,  the  disease 
appeared  in  the  nose  and  extended  rapidly  to  the  adjacent 
tissues. 

He  was  now  prevailed  upon  to  try  a  celebrated  cancer 
doctor  in  Rochester,  who  claimed  to  have  a  wonderful  paste 
that  would  only  attack  cancerous  tissue.  Two  applications 
destroyed  about  one-third  of  his  nose,  resulting  in  such  dis- 
figurement that  he  declined  further  treatment. 

When  he  presented  himself  to  me  he  was  a  most  dis- 
couraging-looking subject.  The  right  ala  of  the  nose  was 
entirely  gone,  and  a  portion  of  the  upper  lip,  on  the  right 
side,  had  sloughed  away ;  the  septum  was  destroyed,  and 
the  whole  interior  of  the  nose,  back  to  and  including  the 
turbinated  bones,  was  an  ulcerated,  sloughing  mass,' foul 
and  offensive.  His  face,  nose  and  upper  lip  were  the  colour 
of  raw  beef,  and  his  general  condition  was  so  bad  that  he  had 
given  up  his  occupation. 

I  was  unable  to  give  him  much  encouragement,  but 
advised  the  trial  of  the  Alexander  remedy  for  a  couple  of 
weeks  and  to  be  guided  by  the  result.  I  began  his  treat- 
ment by  the  hypodermic  injection  of  ten  minims  of  the 
fluid  into  the  cellular  tissue  of  the  abdomen  for  its  systemic 
effect,  four  minims  into  the  diseased  area  of  each  cheek,  and 
four  injections  of  two  minims  each  around  the  border  of  the 
triangular  opening  into  the  side  of  the  nose.  The  dosage 
in  the  abdomen  was  increased  five  minims  each  day  until 
the  maximum  dose  of  thirty  minims  was  reached,  after 
which  the  latter  dose  was  administered  every  other  day. 
The  diseased  tissues  of  the  nose,  lip  and  cheeks  were  injected 
every  fourth  day,  using  from  two  to  four  minims  according 
to  situation,  and  giving  not  more  than  four  injections  at  each 
sitting.  The  ethyl  chloride  spray  was  used  to  prevent  pain 
from  the  introduction  of  the  needle,  and  no  constitutional 
or  local  disturbance  of  any  moment  resulted,  the  fluid  being 
readily  and  quickly  absorbed.  The  interior  of  the  nose, 
after  being  cleansed  of  the  secretions,  was  washed  with 
hydrogen  dioxide  and  sprayed  with  the  Alexander  fluid. 

The  result  of  this  treatment  persisted  in  for  twelve 
weeks  has  been  the  apparent  arrest  of  the  disease.  The 
patient  has  gained  thirteen  pounds  in  weight,  has  a  good 
appetite,    is  strong  and  has  resumed  work.       There    is  now 


REMEDI*   FOR   MALIGNANT   GROWTHS.  30/ 

comparatively  little  discharge  from  the  nose,  and  it  is  no 
longer  offensive.  The  skin  covering  the  face,  nose  and 
upper  lip  has  lost  its  red  infiltrated  appearance,  and  where 
there  was  a  loss  of  substance  there  is  now  a  distinct  restitu- 
tion of  tissue. 

When  this  pati'ent  came  to  me  he  was  past  surgical  aid^ 
the  caustic  treatment  had  failed  to  ameliorate  his  condition, 
and  we  must,  therefore,  conclude  that  his  improvement  is 
due  to  the  Alexander  remedy. 

Mr.  S.,  aged  fifty-five  years  ;  mother  died  of  cancer  of 
the  liver,  and  father  of  cancer  of  the  throat.  This  patient  was 
referred  to  me  for  treatment  by  Dr.  F.  O.  Webber,  of 
Boston,  who  diagnosed  his  disease  primary  epithelioma  of 
the  tongue.  Examination  showed  a  papillary  growth  about 
the  size  of  a  silver  three-cent  piece,  with  a  hardened  base, 
situated  on  the  anterior  third  of  the  tongue  to  the  left  of 
the  raphe  On  either  side  of  the  growth  and  slightly  in 
advance  of  the  same  were  two  small  indurated  patches  of  a 
lighter  colour  than  the  surrounding  tissue. 

The  treatment  of  this  case  was  as  follows  :  Four  minims 
of  the  Alexander  fluid  was  injected  into  the  tongue,  just 
outside  the  growth,  the  needle  being  inserted  at  an  angle 
of  forty-five  degrees  and  directed  toward  the  centre  of  its 
base  and  penetrating  well  below  the  tumour.  Ten  minims 
were  injected  into  the  cellular  tissue  of  the  abdomen  for  its 
systemic  effect.  The  injections  into  the  tongue  were  made 
every  fourth  day,  as  described,  until  the  cancer  was  encircled 
by  ten  injections.  The  fluid  was  administered  in  the  abdo- 
men ever  other  day.  Following  the  tenth  injection  into  the 
tongue,  the  tumour  sloughed  out  entire,  leaving  a  healthy  look- 
ing wound,  which  in  ten  days  had  healed  perfectly,  leaving 
no  trace  of  the  site  of  the  growth.  The  case  is  still  under  ob- 
servation, but,  as  yet,  there  is  no  indicationof  further  trouble. 

Other  cases  of  cancer  under  my  care  are  progressing 
favourably,  but  are  not  far  enough  advanced  in  treatment  to 
enable  me  to  report  them. 

The  remedy  is  said  by  its  discoverer  to  be  a  solution 
of  a  new  organic  compound  formed  by  a  union  of  hydro- 
carbons and  a  dimethyl  ketone,  to  which  are  added  essential 
oils,  forming  a  solution  represented  by  the  formula  C27 
Hn02. 

It  is  a  clear,  almost  colourless  fluid,  with  a  strong  aro- 
matic odour. 


308  REMEDY   FOR  MALIGNANT  GROWTHS. 

But  be  the  formula  what  it  may,  the  agent  has  a  marked 
specific  action  on  cancerous  disease,  both  local  and  consti- 
tutional. No  deleterious  effects  result  from  its  introduction 
into  the  cellular  tissue,  the  only  care  required  being  to  avoid 
puncturing  of  important  nerves  and  blood-vessels. 

Used  hypodermically,  in  an  area  infiltrated  with  cancer 
cells,  the  fluid  works  a  prompt  transformation,  the  part  be- 
comes paler  and  less  vascular  and  if  broken  down  is  followed 
by  reparative  action. 

Cancerous  tumors,  as  a  rule,  are  distinguished  by  great 
vascularity  and  a  rapid  growth.  They  are  composed,  gen- 
erally speaking,  of  a  stroma  enclosing  the  tissue  elements 
of  an  embryonic  type  which  possess  feeble  vitality,  being 
prone  to  undergo  retrograde  changes  leading  to  ulceration 
and  gangrene. 

What  is  the  explanation  of  the  curative  action  of  the 
Alexander  remedy  ?  In  what  way  does  it  arrest  the  growth 
of  malignant  tumours? 

It  has  seemed  to  me  that  it  does  this  in  the  first  instance 
by  lessening  their  vascular  supply,  and  in  the  second  by  a 
vitalizing  influence  on  the  cells  themselves,  or,  possibly,  by 
destroying  some  parasitic  form  of  life  that  is  responsible  for 
the  morbid  phenomena.  At  any  rate,  the  use  of  the  remedy 
in  cases  where  the  system  retains  sufficient  vitality  to  respond 
to  the  treatment  is  attended  by  a  marked  improvement  in 
the  condition  of  the  patient,  both  local  and  general. 

Whereas,  a  few  months  ago,  I  dreaded  to  encounter 
the  sufferers  from  this  disease,  knowing  that  the  resources 
of  the  healing  art  were  powerless  to  afford  relief,  I  now 
undertake  their  treatment  confident  of  ameliorating  their 
condition,  and  in  cases  where  there  is  not  too  great  loss  of 
vitality,  of  effecting  a  cure. 

In  closing  this  report  of  my  experience  with  the  Alex- 
ander remedy,  I  am  aware  that  my  series  of  cases  is  too 
small  to  base  deductions  upon,  but  the  results  obtained  have 
not  been  duplicated  by  any  other  known  method  of  treat- 
ment, and  they  supplement  a  large  number  of  cases  reported 
by  Dr.  F.  O.  Webber,  of  Boston. 

In  view  of  the  above  I  cannot  too  strongly  commend  this 
remedy  to  the  attention  of  brother  practitioners. — New  York 
Medical  Times,  Sept.,  1901. 


Progress  of  Medical  Science. 


MKDICINK    AND     NEUROLOQY 

IN   CHARGE  OF 

J.  BRADFORD  McCONNBLL,  M.D. 

Associate  Professor  of  Medicine  and  Xeurology.  and  Professor  oi  Clinical  Medicine 
University  of  Bishop's  College;  Physician  Western  Hospital. 


CAMPHOR    DRESSING    FOR    VARICOSE    ULCERS. 

Caxaphor  is  a  drug  which  for  many  years  was  held  in 
;^reat  esteem,  especially  in  extra-professional  circles;  in- 
deed, the  late  M.  Raspail  founded  a  school  of  therapeutics 
which  still  rejoices  in  great  pojjularity  in  France,  based  on 
tlie  use  of  camphor  internally  and  externally  as  a  curative 
a;;ent.  Its  anti-spasmodic  proi^erties,  though  well  au- 
tlienticated,  have  of  late  fallen  into  disrepute,  or  at  any 
rate  into  disuse,  and  externally  it  is  only  employed  in  this 
country  in  the  form  of  a  liniment  of  which  it  is  but  a  sub- 
sidiary constituent-  Two  German  physicians  have 
recently  called  attention  to  the  value  of  camphor  dressings 
in  promoting  the  cicatrization  of  varicose  ulcers  of  the 
legs  which  are  notoriously  refractory  to  treatment.  They 
make  use  of  an  ointment  containing  2  per  cent,  of  camphor, 
with  from  fifteen  to  twenty  parts  of  oxide  of  zinc,  or,  if 
this  be  found  too  irritating,  they  prescribe  a  mixture  of 
two  parts  of  camphor  with  forty  parts  of  zinc  oxide,  and 
fifty  parts  of  olive  oil.  An  alternative  application  is  a 
solution  of  the  drug  in  spirit,  but  this  must  only  be  ap- 
plied after  the  ulcerated  surface  has  been  thoroughly 
cleaned  of  scabs  and  crusts  by  poultices.  It  is  asserted 
that  under  this  treatment  the  most  obstinate  ulcer  will 
cicatrize  within  three  weeks,  which  is  more  than  is  claimed 
for  the  much  lauded  oxygen  treatment,  over  which,  more- 
over, it  has  the  advantage  of  being  more  generally  appli- 
cable at  a  vastly  smaller  cost. — The  Medical  Press. 

HOME-TREATMENT    OF    PULMONARY    TUBERCULOSIS. 

Dr.  Robert  H.  Babcock,  in  discussing  this  subject,  be- 
lieves that  the  real  reason  for  the  hopelessness  on  the  part 
of  the  practitioner  in  nbtainingf  satisfactory  results  in  the 
home-treatment  of  tuberculosis  lies  in  the  fact  that  he  de- 
pended too  much  on  med'cinal  therapy.     The  most  success- 


3  10  PROGRESS  OF  MEDICAL  SCIEN'CE. 

ful  treatment  lies,  not  in  the  use  of  medicinal  agencies,  but 
in  the  hygiene  of  the  patient's  life.     Although  these  require- 
ments  can   be  best   secured   in   a   sanatorium,   thej'    can  be 
obtained    at   the   patient's   home   regardless  of  the   climatic 
conditions  that  prevail  there.       Food  should  be  taken    at 
short  intervals  ;   it  should  be  easily  digested  and  assimilated, 
and  should  be  of  the  most  nutritious  character  in  the  smallest 
bulk.   Good  results  are  obtained  from  the  use  ofmilk  and  raw 
eggs.     The  patient  is  ordered  to  drink  a  glass  of  heated  but 
not  boiled  milk  the  first  thing  after  waking  in  the   morning, 
and  thereafter  every  two  hours  during  the   day,  regardless 
of  his  meals.     Raw  eggs  are  taken,  beginning  with  one  after 
each    meal,   and    increasing  by   one  daily  until  as  many  as 
possible  are  consumed.      Exercise   is  to    be    permitted    only 
when  the  patient  is  free  from  fever  and  a  febrile  reaction  does 
not  follow   exercise.     The  patient  should  spend  the  entire 
day  out  of  doors,  without  regard    to  the  condition    of   the 
weather,  proper  precautions  being   taken  to  prevent  the  pa- 
tient from  taking  cold.      Hydrotherapy  is  highly  important. 
The  one  essential  condition  is  that  all  measures  should    be 
followed  by  a  good  reaction. — Medical  News. 

REMOVAL  OF  EAR-WAX. 

Baerens  (Regular  Medical  Visitor)  says  that  in  the 
removal  of  impacted  cerumen  as  little  instrumentation  as 
possible  should  be  indulged  in.  Much  harm  often  follows 
the  use  of  probes,  forceps  and  hooks  in  untrained  hands. 
Hardened  wax  may  be  softened  by  the  instillation  of  a 
solution  of  sodium  bicarbonate  and  glycerine  and  water, 
three  times  a  day.  In  syringing  the  stream  should  be 
directed  along  the  upper  wall  of  the  canal,  the  object  being 
to  force  the  water  behind  the  plug,  and  not  against  it.  If 
much  force  is  used  vertigo  often  results. 

TONSILLITIS. 

Dr.  J.  T.  Crowley,  of  San  Francisco,  Cal.,  writes  to  the 
Medical  World  that  the  following  combination  seems  to  be 
well-nigh  a  specific,  a  rheumatic  tendency  being  present  in 
most  cases  : — 

I^  Sodiisalicylatis... i^  drachms. 

Ferrous  sulphate ^  drachm. 

Liq.  ammon.   acet i^  ounces. 

Syr.  Tolu....cc..., q.  s.  ad  3  ounces. 

M.  Sig :  Teaspoonful  three  times  a  day  in  water  or 
milk. 


MEDICINE   AND    NEUROLOGY.  311 

A  REMEDY  FOR  NOSE-BLEED. 

Children  are  occasionally  troubled  with  bleeding  at  the 
nose,  and  in  some  instances  this  becomes  quite  alarming, 
especially  when  all  known  remedies  fail,  and  the  weakening 
llow  still  continues;  and  in  this  instance,  as  in  many  others, 
the  best  remedy  is  one  of  the  simplest  that  could  be  tried. 
A  celebrated  physician  has  claimed  in  one  of  his  lectures  that 
I  his  "  best  remedy"  is  a  vigourous  motion  of  the  jaws,  as  in 
the  act  of  chewing.  In  the  case  of  a  child,  he  recommends 
giving  a  wad  of  paper  to  chew,  as  the  rapid  working  of  the 
jaws  stops  the  flow  of  blood  ;  but  why  not  try  chewing  gum 
instead  of  paper  ? —  Westerji  Medical  Review. 

VERATRUM  VIRIDE  IN   lAANIA. 

^'^'Any  physician  who  has  not  employed  veratrum  viride  in 
acute  mania  has  missed  the  best  agency  which  is  available 
for  the  cure  ot  these  distressing  cases.  It  is  one  of  the 
greatest  advantages  a  physician  can  have  to  see  the  feverish 
sufferer,  under  the  application  of  this  remedy,  pass  from 
absolute  sleeplessness  into  a  state  of  quiet  rest.  That  many 
cases  which  would  otherwise  go  on  to  death  are  saved  by 
the  use  of  this  remedy  is  a  fact  beyond  question.  The  fear 
which  many  practitioners  have  of  using  veratrum  viride,  on 
account  of  the  varying  strength  of  its  various  preparations, 
must,  of  course,  be  met,  when  the  drug  is  employed,  by  the 
use  of  Norwood's  tincture. — American  Medical  Journal. 

BLOOD  FOR  BABIES. 

In  the  course  of  the  second  year  there  comes  a  time 
when  the  milk  diet  begins  to  be  insufficient  for  the  growing 
child,  and  Natures  calls  for  a  change,  while  yet  the  system 
is  in  many  eases  unprepared  for  solid  food.  This  kind  of 
deadlock  results  in  diarrhoea  or  constipation,  anaemia, 
restlessness,  fretfulness,  etc.  In  such  cases  the  fit  and  ra- 
dical remedy  will  be  found  in  the  administration  of  say  ten 
drops  of  bovinine  in  a  little  milk,  at  intervals  of  three 
hours. 

Little  Robert  Valverdie,  a  patient  who  came  under  my 
care  in  the  condition  of  malnutrition  above  described  (after 
trying  all  the  usual  medical  helps  with  no  benefit),  was  im- 
mediately restored  by  the  direct  blood  treatment.  On  the 
second  day  of  taking  bovinine,  the  constipation  and  other 
trouble  began  to  be  relieved,  and  on  the  third  day  all  signs 


312  FROGh  ESS  OF  MEDICAL  SCIENCE. 

of  ill-liealth  had  disappeared  as  if  by  magic.  This  simple 
treatment  was  continued  for  three  weeks,  the  child  thriv- 
ing beautifully. — Case  reported  by  Dr.  T.  J.  Biggs. 

HYSTERECTOMY  FOR  CANCER  OF  UTERUS. 

Mrs.  T.,  age  47,  American.  Diagnosis,  carcinoma  of 
uterus.  Entered  hospital  Oct.  10,  1901,  in  a  greatly  run 
down  condition.  She  was  put  on  an  absolute  bovinine  diet, 
until  Oct.  14,  when  at  one  o'clock  she  was  given  a  high 
rectal  injection  of  bovinine  and  salt  solution,  three  oz.  of 
each,  and  at  two  o'clock,  under  ether  anesthesia,  I  per- 
formed an  abdominal  hysterectomy.  Just  before  the  uterus 
was  detached  from  the  vaginal  wall,  the  patient  showed 
considerable  shock,  and  consequently  the  nurse  was  order- 
ed to  give  her  another  high  rectal  injection  of  bovinine  and 
salt  solution,  two  oz.  each.  -She  responded  to  this  beauti- 
fully. The  operation  was  completed  by  the  closure  of  the 
abdominal  wound,  the  pelvis  being  drained  through  the 
vagina.  Patient  was  put  to  bed  with  the  pulse  weak  and 
112.  She  was  given  another  high  rectal  injection  of  bovin- 
ine and  salt  solution,  three  oz.  of  each.  In  twenty-five 
minutes  she  was  conscious,  pulse  greatly  improved,  being 
100,  and  full  in  character.  No  nausea,  thirst  or  voniitinfi. 
The  second  day  the  vaginal  drain  was  removed,  the  wound 
and  the  vagina  treated  by  injections  of  bovinine  pure,  em- 
ployed t.  i.  d.  Previous  to  every  injection  of  bovinine  into 
the  vagina,  the  cavity  was  washed  out  with  borax  solution. 
These  injections  were  continued  three  times  a  day  up  to 
Oct.  16,  when  twice  in  twenty-four  hours  was  deemed  suf- 
ficient. She  was  now  allowed  a  light  general  diet  togethrT 
with  bovinine.  Oct  24,  the  stiches  were  removed  and  the 
abdominal  wound  found  to  be  healed.  From  this  time  on 
her  recovery  was  uninterrupted  and  she  was  discharged 
cured,  Nov.  16.— By  T.  J.  Biggs,  M.D.,  Sound  View  Hos- 
pital, Stamford,  Conn. 

PNEUMONIA. 

An  editorial  in  the  ArcMves  of  Pediatrics  for  January, 
1902,  states,  concerning  the  treatment  of  pneumonia  in 
children,  that  there  is  less  divergence  of  opinion  among 
pediatric  specialists  than  in  the  treatment  of  most  other 
diseases,  and  that  the  practice  adopted  by  them  differs  ra- 
dically from  that  adopted  by  a  large  number  of  general 
praticians  among  whom  the  prevailing  tendency  is  toward 
complexity  and  the  use  of  much  medicine,  while  the  ten- 


MEDICINE   AND  NEUKOLOGY,  313 

dency  of  treatment  among  men  of  broadest  experience  is 
toward  simplicity  and  the  use  of  few  drugs.  In  hospital 
practice,  under  physicians  of  extensive  experience,  the 
chest  is  protected  by  flannel  or  a  cotton  jacket  loosely  ap- 
plied, with  perhaps  the  occasional  use  of  a  mustard  paste 
with  the  desire  of  embarrassing  the  respiration,  which  is 
always  laboured  in  pneumonia,  as  little  as  possible.  In 
private  practice  the  chest  is  too  often  loaded  with  a  heavy 
poultice,  the  weight  of  which  must  be  lifted  from  thirty  to 
fifty  times  a  minute  by  respiratory  muscles  already  over- 
burdened. In  the  one  case  the  fact  being  recognized  that 
the  disease  is  one  marked  by  prostration,  depression  and 
exhaustion,  the  strength  is  conserved  in  every  way,  the 
child  is  disturbed  as  little  as  possible,  nauseating  medicines 
are  avoided,  and  nourishment  is  looked  upon  as  of  vital  im- 
portance. In  the  other  case  the  child  is  not  given  sufficient 
rest,  the  temperature  is  taken  too  often,  something  is  being 
constantly  done,  doses  are  unnecessarily  multiplied,  etc. 
The  author  protests  against  the  heavy,  hot  and  steaming 
poultices,  soon  cold  and  soggy,  the  forcing  down  of  nause- 
ating drugs,  and  the  frequent  disturbance  of  the  child  in 
overzealous  efforts  to  cure,  believing  that  they  actually 
save  less  than  the  simpler  methods  of  treatment.  As  fever 
is  a  necessary  feature  of  pneumonia  it  need  cause  no  alarm, 
unless  it  ranges  abnormally  high,  and  it  is  usually  worse 
than  futile  to  try  to  force  it  down  by  the  use  of  coal-tar 
antipyretics  which  add  to  the  depression  natural  to  the 
disease.  The  author  asserts  that  the  picture  is  not  over- 
drawn, as  such  errors  are  very  commonly  seen  by  consult- 
ants, and  emphasizes  the  importance  of  the  simpler  line  of 
treatment  in  this  disease. — Cleveland  Medical  Journal. 

Dr.  I.  L.  Van  Zandt  in  the  Southern  Practitioner  for  De- 
cember, 1901,  believes  that  in  pneumonia  in  a  large  per  cent. 
of  cases  creosote  has  a  decidedly  curative,  in  fact,  almost 
an  abortive  effect.  He  quotes  Prof.  A.  A.  Smith  as  assert- 
ing that  the  treatment  by  creosotal  or  similar  germicide  is 
capable  of  causing  an  early  lysis  before  the  time  for  crises 
arrives;  and  further  that  a  large  percentage  of  pneumonic 
cases  are  cut  short  or  aborted,  almost  all  the  rest  are  miti- 
gated, and  the  remainder,  a  very  small  percentage,  are  not 
affected  by  the  remedy.  He  gives  to  an  adult  seven  and 
one-half  grains  or  minims  every  three  hours,  and  in  urgent 
cases  gives  the  dose  more  frequently.  He  has  used  carbon- 
ate of  creosote  without  other  medication,  but  believes  that 
guaiacol  or  its  carbonate  cannot  be  used  instead  and  has  also 
found  thiocol  inefficient.  Dr.  W.  H.  Thompson  in  the 
Medical  Record  for    February  1,    1902,  also   advocates  very 


3^4  PROGRESS  OF  MEDICAL  SCIENCE. 

Strongly  the  use  of  carbonate  of  creosote  in  pneumonia,  and 
reports  eighteen  cases  of  lobar  pneumonia  in  patients  rang- 
ing from  ten  to  forty-five  years  of  age,  which  were  treated 
exclusively  by  this  drug;  of  these  but  one  alcoholic  died; 
certainly  a  very  satisfactory  showing,  as  in  three  of  the 
cases  both  lungs  were  involved,  and  these  recovered.  He 
gives  fifteen  grain  doses  every  two  hours,  one  hundred  and 
eighty  grains  in  the  twenty-four  hours,  which  is  three  times 
the  amount  given  by  Dr.  Leonard  Weber,  who  recently  re- 
ported nine  cases  so  treated  with  but  one  death.  Dr 
Tliompson  gives  the  drug  in  glycerine  and  peppermint  wa- 
ter, and  believes  that  it  exerts  a  special  etfect  upon  the 
course  of  the  disease.  It  also  favourably  influences  that 
very  undesirable  complication  in  pneumonia— tympanites 
It  is  in  his  opinion  better  borne  than  the  guaiacol  carbon- 
ate, and  he  has  never  noted  any  depressing  effects  nor  in- 
jurious action  upon  the  kidneys.  In  his  cases  the  disease 
terminated  by  lysis  in  twelve  and  by  crisis  in  only  five  days 
The  writer  has  used  guaiacol  carbonate  in  these  cases  with 
benefit,  but  usually  gives  three  to  five  grains  every  few 
hours,  and  as  the  guaiacol  is  the  main  active  constituent  of 
creosote  it  probably  matters  but  little  in  what  form  it  is 
given. — Cleveland  Medical  Journal. 

SYPHTLIS. 

Dr.  G.  Frank  Lydston  in  the  Medical  News  for  January 
18,  1902,  emphasizes  the  cardinal  principle  in  the  therapy 
of  syphilis  that  the  physician  should  remember  that  he  has 
to  deal  with  three  factors;  first,  a  specific  disease  to  be  con- 
trolled by  specifiic  medication;  second,  a  distict  individual 
personality  in  each  patient;  third,  the  results  of  antiseptic 
medication.  There  is  too  great  a  tendency  to  treat  syphilis 
and  absolutely  ignore  the  individual  afflicted  by  it.  Pty- 
alism  and  iodism  may  both  be  avoided  in  many  cases  by 
attention  to  the  eliminative  functions.  A  useful  point  too 
frequently  neglected  is  the  ingestion  of  large  quantities  of 
water.  He  has  succeeded  in  avoiding  iodism  in  certain 
cases  by  mixing  the  daily  dose  of  the  drug  with  from  two 
quarts  to  a  gallon  of  water,  and  instructing  the  patient  to 
drink  the  entire  amount,  a  glassful  at  a  time,  during  the  24 
hours.  Hot  baths  are  a  very  useful  adjunct  to  the  treat- 
ment, increasing  tissue  metamorphosis,  favouring  elimina- 
tion, and  necessarily  enhtincing  the  therapeutic  action  of  the 
mercury  and  iodide  while  attention  to  the  bowels  is  very 
important.  When  digestive  disturbances  exist  and  gastric 
symptoms  are  stubborn,  the  substitution  of  the  hypodermic 


MEDICINE   AND   NEUROLOGY.  315 

01-  inunction  method  is  imperative.  When  lesions  of  the 
mucous  membranes  are  very  resistant  to  treatment,  and  the 
patient  does  not  tolerate  mercurv  and  iodide  well,  he  advises 
the  substitution  of  the  potassium  chlorate  for  these  reme- 
dies, believing  that,  while  in  no  sense  a  specific,  it  has  a 
marked  and  positive  action  of  its  own  in  syphilitic  lesions, 
having  seen  most  beneficial  results  follow  its  use.  He  re- 
commends the  combination  of  the  preparations  of  iron  with 
the  mercurials  to  obviate  the  debilitating  effects  of  mer- 
cury, and  in  long-standing  cases  considers  the  syrup  of  the 
iodide  of  iron  the  most  eligible  preparation  of  the  drug.  In 
the  same  journal  Bonveyron  and  Siraud  are  quoted  as  hav- 
ing given  orthoform  in  total  daily  doses  of  two  to  three 
grams,  divided  into  four  or  six  powders,  with  decided  suc- 
cess in  the  essential  headache  of  syphilis.  Most  frequently 
the  smaller  dose  of  the  two  grams,  or  thirty  grains,  in  24 
hours,  is  sufficient  to  quiet  all  this  rebellious  pain.  Usually 
a  decrease  takes  place  during  the  first  night  and  after  that 
the  pain  disappears  entirely.  For  the  intermittent  head- 
aches, one-half  grain  is  given  one  hour  before  the  expected 
return  of  pain,  and  two  similar  doses  through  the  night. 
For  the  continuous  pain  four  such  powders  should  be  given 
at  regular  intervals,  say  six  hours. — Cleveland  Medical 
Journal. 

CEREBRAL  HEMORRHAGE. 

In  Mercys  Archives  for  March,  1002,  Dr.  William 
Browning  presents  a  series  of  "dont's"  to  be  remembered  in 
the  treatment  of  cerebfal  hemorrhage.  Don't  give  stimu- 
lants. Their  use  in  such  cases  is  most  reprehensible. 
J)on't  resort  to  saline  injections.  During  the  acute  stage  a 
limitation  of  fluids  is  in  order.  Don't  use  the  depressant 
diaphoretics  such  as  ipecac,  pilocarpin  or  apomorphin.  They 
tend  to  nauseate,  an  inclination  otherwise  too  common,  and, 
in  the  degree  of  attempts  at  vomiting,  most  undesirable. 
Don't  prescribe  digitalis.  The  author  has  repeatedly  seen  it 
bring  on  another  attack.  It  is  a  dangerous  drug  in  any 
individual  with  a  liability  to  apoplexy,  and  for  this  if  for 
no  other  reason  of  questionable  utility  in  nephritis.  When 
anything  of  the  sort  must  be  used,  strophanthus  is  safer. 
Don't  resort  to  opiates.  They  are  likewise  contra-indicat- 
ed. Don't  try  nitrites,  as  their  use  in  any  form  is  here  out 
of  place.  Don't  permit  any  muscular  exertion  on  the  pa- 
tient's part,  and  moving  by  others  should  be  limited  as 
much  as  possible. — The  Cleveland  Medical  Journal. 


SURQKRY. 


IN   CHARGE    OF 

ROLIiO  CAMPBELL.IM.D., 

Lecturer  on  Surgery,  University  of  Bishop's  College  ;  Assistant  Surgeon,   Western  Hospital  ; 

AND 

GEORGE  PISK,  M.D. 

Instructor  in  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeon,  Western  Hospital. 


INTESTINAL  OBSTRUCTION. 

In  very  bad  cases  of  intestinal  obstruction,  in  which,  for 
any  reason,  operation  has  been  very  long  delayed,  we  may 
feel  like  giving  the  patient  the  benefit  of  the  only  chance 
that  remains  to  him.  These  patients  are  practically  unable 
to  feel  pain,  and  administration  of  a  general  anaesthetic  to 
them  is  exceedingly  dangerous.  Use  local  anaesthesia, 
rapidly  open  the  abdomen,  draw  out  the  nearest  coil  of  dis- 
tended intestine,  stitch  it  rapidly  to  the  external  wound, 
and  open  into  the  gut  at  once.  Use  hot  saline  injections  by 
the  rectum  and  intravenously.  If  we  can  thus  tide  the 
patient  over  a  couple  of  days  we  may  later  on  deal  with  the 
obstruction  itself. — International  Journal  of  Surgery. 

THE   DISADVANTAGES    OF    GAUZE   PACKING   IN 
APPENDICITIS  AVORK. 

R.  T.  Morris,  New  York,  states  that  gauze  packing 
sometimes  causes  ileus  and  bowel  obstruction  by  simple  and 
direct  mechanical  pressure.  It  more  often  causes  an  exces- 
sive exudation  of  reparative  lymph,  which  may  result  in 
annoying  peritoneal  adhesions  and  life-long  discomfort  for 
the  patient.  Its  employment  usually  leaves  a  very  weak 
place  in  the  patient's  abdominal  wall,  and  invites  the  de- 
velopment of  post-operative  ventral  hernia.  In  the  opinion 
of  the  author  the  worst  feature  of  gauze  packing,  however,  is 
the  tendency  it  seems  to  possess  to  depress  the  patient's  gen- 
eral resistance  and  to  prolong,  if  it  does  not  sometimes  also 
cause,  the  condition  of  surgical  shock.  The  great  misery 
caused  by  the  removal  of  the  gauze  packing,  when  a  change 
of  dressing  is  made,  can  be  described  only  by  the  patient. 
Since  the  use  of  iodoform  has  become  so  widespread,  the 
danger  of  iodoform  poisoning  has  been  added  to  that  of  the 


SURGERY.  317 

formerly  used  plain  gauze.  Many  of  these  cases  have  been 
and  are  still  regarded  as  being  cases  of  septicaemia  ;  while  the 
symptoms  of  these  two  states  are  very  similar,  in  iodoform 
poisoning  the  wound  is  apt  to  look  remarkably  well,  while 
the  patient  does  not  ;  whereas  in  septicaemia,  neither  the 
wound  nor  the  patient  looks  remarkably  well.  In  the  former 
condition,  free  iodine  can  be  found  in  the  patient's  urine,  and 
a  simple  test  consists  in  adding  calomel  to  a  specimen  of  the 
urine,  and  noting  the  reaction  as  iodide  of  mercury  is  formed 
when  the  mixture  is  stirred.  The  author  believes  that  it  is 
not  safe  to  teach  that  gauze  packing  should  be  at  once  given 
up,  but  that  one  should  work  toward  the  point  of  giving  up 
gauze  drainage  as  rapidly  as  experience  proves  that  it  can  be 
safely  done. — New  York  Medical  Rec,  St.  Louis  Medical 
Review. 

TREATMENT   OF  FOREIGN   BODIES  IN   THE  ESOPHAGUS. 

X'  stone  Scott  {The  Cleveland  Medical  Journal,  March, 
11)02)  says:  Treatment  of  foreign  bodies  in  the  esophagus 
will  vary  materiall}-  with  the  kind  of  body  and  complica- 
tion of  the  case.  Thus,  a  hard  substance  should  be  imme- 
diately removed.  Notliing  is  gained  by  delay,  and  if  allow- 
ed to  remain,  infection  and  inflammation  supervene  and  add 
to  the  difficulties  of  the  case.  When  the  patient  is  anes- 
thetized the  foreign  body  can  frequently  be  grasped  by  for- 
ceps or  coin-catchers,  and  withdrawn  through  the  mouth. 
If  lodged  as  far  down  as  the  diaphragm,  it  can  usually  be 
pushed  on  into  the  stomach,  provided  there  be  no  patholo- 
gic thickening  of  the  esophagus  at  this  point.  Subse- 
quent treatment  of  such  cases  will  depend  upon  the  symp- 
toms. The  patient  should  be  allowed  to  recover  from  the 
anesthetic,  and  if  no  further  symptoms  warranting  inter- 
ference supervene,  nothing  further  should  be  done.  The 
foreign  body  will  usually  pass  through  the  pylorus  and  the 
rest  of  the  alimentary  track  without  difficulty.  Should  it 
become  lodged  lower  dowm,  operative  interference  may  be 
required  for  its  removal. 

When  the  cause  of  obstruction  can  neither  be  grasped 
by  the  forceps  and  withdrawn,  nor  pushed  on  into  the 
stomach,- the  simplest  and  best  method  of  relief  is  by  an 
external  esophagotomy  Even  should  it  be  possible  to  re- 
move the  body  through  the  mouth,  this  same  procedure  in 
order  to  provide  for  drainage  in  advisable  in  cases  in  which 
the  foreign  body  has  been  allowed  to  remain  until  the  pa- 
tient has  become   septic.     The  incision  is   made   upon   the 


3l8  SURGERY. 

left  side  M  the  internal  border  of  the  sternocleidomastoid, 
the  dissection  carried  down  to  the  esophagus  by  means  of 
the  blunt  instruments  rather  than  by  cutting,  the  various 
structures  being  pushed  to  one  side,  the  esophagus  is  open- 
ed with  a  sharp  instrument  by  a  clean  cut,  and  the  foreign 
body  extracted  with  as  little  laceration  of  the  tissues  as 
possible.  The  incision  in  the  esophagus  should  be  closed 
with  a  catgut,  and  a  strand  of  gauze,  horsehair,  or  other 
means  of  drainage  inserted,  the  external  skin  incision 
being  closed  throughout  most  of  its  extent.  It  is  a  tech- 
nical error  to  entirely  close  the  skin  incision,  because  the 
structure  of  the  esophagus  renders  its  sterilization  impos- 
sible, and  infection  is  liable  to  occur  from  the  wound  in  the 
esophagus.  An  esophageal  fistula  is  apt  to  result  from  the 
operation,  but  as  a  rule  is  of  slight  moment  and  will  spon- 
taneously close  in  the  course  of  a  few  weeks.  The  after- 
treatment  of  these  cases  is  simple.  Nothing  should  be 
given  by  mouth  for  a  number  of  hours  until  the  first  efforts 
at  repair  have  been  accomplished,  although  as  a  rule  the 
patient  will  be  able  to  swallow  with  little  or  no  difficulty. 

INDICATIONS  FOR  OPERATION  IN  GASTRIC  ULCER. 

1.  Acute  hemorrhage  should  rarely  be  treated  by  opera- 
tion. The  results  of  interference  have  not  been  good, 
while  the  results  of  medical  treatment  have  been  satisfac- 
tory. When,  however,  a  hemorrhage  frequently  repeats  it- 
self, even  though  not  severe  in  amount,  it  will  demand 
operative  treatment  as  soon  as  its  recurrent  character  is 
plain. 

2.  Small  frequent  hemorrhages,  threatening  anaemia 
give  a  clear  indication  for  operation. 

3.  Perforation  of  the  stomach,  either  acute  with  gen- 
eral peritonitis  or  chronic  with  surrounding  adhesions  and 
perigastritis,  demands  instant  operation. 

4.  When  an  ulcer  runs  a  chronic  course  with  a  strong 
tendency  to  recurrence,  and  gradually  diminishes  the  pa- 
tient's capacity  for  work  and  the  enjoyment  of  life,  an  oper- 
ation is  indicated,  especially  when  the  patient  is  so  situated 
as  to  be  dependent  on  his  daily  work  for  support,  and  un- 
able closely  to  regulate  his  diet. — A.  T.  Cabot,  Trans.  Mass. 
Med.  Soc. 

CORNS. 

Perhaps  the  best  method  for  securing  the  partial  re- 
moval of  corns,  by  the  application  of  chemical  substances, 
is  that  recommended  by  Unna.     A  ring  of  glycerine  jelly 


SURGERY.  '319 

is  painted  around  the  circumference  of  tlie  corn  so  as  to 
form  a  raised  rampart.  A  piece  of  salicylic  plaster-mull 
is  then  cut  to  the  size  and  shape  of  the  central  depression, 
and  applied  to  the  surface  of  the  corn.  This  is  then 
covered  with  a  layer  of  glycerine  jelly,  and  before  it  sets, 
a  pad  of  cotton-wool  is  applied  to  the  surface-  This  pro- 
cess is  repeated  as  often  as  is  necessary,  until  the  horny 
layer  of  the  corn  separates  and  is  cast  off. 

If  the  point  of  a  sharp,  thin-bladed  knife  be  introduced 
at  the  groove  which  runs  round  the  margin  of  the  corn, 
and  be  made  to  penetrate  toward  its  central  axis,  by  the 
exercise  of  a  little  manual  dexterity  the  horny- part  of  the 
corn  can  be  easily  made  to  separate  from  the  parts  be- 
neath. This  method  of  removal  is  one  which  is  much  in 
favour  with  chiropodists. 

Any  method  of  treatment,  however,  to  be  curative, 
must  secure  the  removal  of  the  entire  corn  together  with 
the  underlying  bursa. 

Having  taken  every  precaution  to  render  the  operation 
aseptic,  a  spot  is  selected  for  the  injection  of  the  anaes- 
thetic solution.     At  this  point  the  skin  is  rendered  insensi- 
tive by  the  application  of  ethyl-chloride,  and  5  minims — 
more  or  less — of  a   4-per-cent.    solution    of  eucaine  is   in- 
injected  into  the  subcutaneous   tissue   beneath    the   corn. 
Having  waited  a  few  minutes,  the  superficial  parts  at  the 
site    of   the   incision    are   rendered   insensitive   by    ethyl- 
chloride.     Anaesthesia  is  now  complete,  the  process  itself 
being  painless,  and  the  operation  may    at   once   be    com- 
menced.    Two  hemi-elliptical  incisions  meeting    at    their 
extremities  are  made  through  the  skin  around  the  circum- 
ference of  the  growth,  care  being  taken  that  they  penetrate 
well  into  the  subcutaneous  tissue.     Seizing  the  parts  in- 
cluded in  the  incision  with  a  pair  of  dissecting  forceps,  a 
wedge-shaped  piece  of  tissue — including  the  corn,  a  layer 
of  skin  and  subcutaneous  tissue,  and  the  bursa,  if  present 
— is  dissected  out-     The  oozing   is   pretty   free,  and   it   is 
sometimes  necessary  to   torsion   a   small   vessel;  but   the 
haemorrhage  is  never  severe.     The  edges  of  the  w^ound  are 
brought  together  by  one  or  two  fine  sutures;  an  antiseptic 
dressing  is  applied,  and  the  wound  left  to  heal — primary 
union  in  a  few  days  being  the  rule.     The  net  result  is   the 
production  of  a  layer  of  scar-tissue  at  the  former  site    of 
the  corn.     It  might  be  thought,  perhaps,  that  the  forma- 
tion of  a  scar  on  an  exposed  position,  where  it  was  liable 
to  be  subjected  to   pressure   and   friction,  would    lead   to 
untoward  results;  but  such  in  practice  is  not  the  case. 

The  chief  advantages  to  be  derived  from  the  complete 
excision  of  corns  are  that,  as  a  method  of  treatment,  it  is 


320  SURGERY. 

safe,  speedy  and  painless;  while  the  results,  as  far  as  a 
cure  is  concerned,  are  permanent  and  effected  at  a  mini- 
mum of  time  and  trouble.  E.  H.  Freeland  {Edinburgh 
Med.  Jour.,  Nov.,  1901)- 

WOUNDS  OF  THE  THORACIC  DUCT  OCCURRING  IN  THE 

NECK. 

Drs.  D.  P.  Allen  and  C.  E.  Briggs  make  a  report  of 
two  cases,  with  a  r^sum6  of  seventeen  cases  in  American 
Medicine,  of  Wept.  21,  1901. 

The.  writers  have  made  a  careful  and  interesting  study, 
of  wounds  of  the  thoracic  duct,  and  offer  some  valuable 
suggestions  as  to  methods  of  procedure  in  dissections  oi 
the  neck,  and  the  operative  treatment  advisable  if  the 
large  lymphatics  are  wounded.  In  operations  in  thi^ 
region,  where  there  is  a  probability  of  wounding  the  duct, 
they  suggest  that  about  three  hours  before  the  operation 
the  patient  be  given  four  to  six  ounces  of  cream.  They 
advise  this,  since,  in  the  intervals  of  digestion,  lymph  so 
closely  resembles  serum  that  its  presence  is  often  not  re- 
cognized, and  wounds  of  the  lymphatics  pass  unnoticed 
until  some  days  before  the  operation.  But  by  giving 
cream  a  few  hours  before  operating,  the  absorption  of  fat 
is  induced,  and  chyle  is  so  characteristic  in  appearance 
that  its  presence  in  a  wdund  would  be  iinmediately 
noticed  and  search  made  for  the  injured  lymphatic.  As  a 
result  of  their  studies  they  conclude: 

1.  The  increasing  frequency  of  extensive  dissections 
of  the  neck  makes  it  desirable  to  consider  means  of  avoid- 
ing injury  to  the  thoracic  duot. 

2.  It  is  desirable  that  if  wounds  of  the  thoracic  ducts 
or  its  branches  occur,  they  would  be  recognized  at  the  time 
of  the  operation.  If  there  is  a  probability  of  wounding 
the  duct  four  to  six  ounces  of  cream  should  be  given  to 
the  patient  about  three  hours  before  operating.  This  is 
especially  desirable  in  secondary  operations  undertaken 
for  the  purpose  of  locating  point  of  injury. 

3.  That  suture  of  the  duct  with  fine  silk  or  catgut  be 
accomplished  when  possible;  that  all  small  discharging 
lymph  radicles  be  ligated;  that  the  ligating  and  clamping 
of  lymphatic  vessels  of  considerable  size  be  avoided,  unless 
the  integrity  of  the  thoracic  duct  itself  has  been  demon- 
strated; that  where  suture  of  the  duct  or  large  radicles  is 
impossible,  gauze  packing,  firmly  and  accurately  applied, 
be  used;  that  the  head  and  neck  be  kept  at  rest,  the  use 
of  morphine  to  a  considerable  degree  being  recommended 
if  necessarv.     ' 


SURGERY.  32 1 

4.  That  until  the  repair  of  the  duet  is  thought  to  be 
complete,  nutrition  should  be  sustained  on  albuminous 
material,  with  possibly  a  small  amount  of  carbo-hydrates, 
but  with  an  absolute  exclusion  of  fats. — Maryland  Medical 
Journal. 

RESULTS   OBTAINABLE  IN  THE  TREATMENT   OF  DENSE, 
TIGHT.    DEEP-LYING    STRICTURES    OF    THE 
URETHRA. 

L.  S.  Pilcher  (Annals  of  Surgery).  In  cases  of  reten- 
tion due  to  a  deep  stricture,  prolonged  efforts  are  not  made 
to  secure  the  passage  of  instruments.  If  a  No.  2  or  No.  3 
French  olive-pointed  bougie  does  not  pass  readily,  the 
bladder  is  aspirated  and  preparation  made  for  urethro- 
tomy, usuall}-  without  a  guide.  A  free  incision  is  made 
in  the  perineum,  and  if  the  urethra  is  found  to  be  a  dis- 
torted, hardened  mass  of  cicatrical  tissue,  from  one-half 
to  three-quarters  of  an  inch  maj'  be  excised  and  the  divided 
ends  brought  together.  In  the  majority  of  the  cases  the 
urethra  is  split  along  its  floor  and  a  gorget  introduced 
into  the  bladder,  followed  by  the  introduction  of  the 
finger.  The  first  joint  of  the  index  finger  corresponds  to 
about  a  No.  60  sound  of  the  French  scale,  and  dilatation 
short  of  this  is  not  advisable.  The  meatus  and  penile 
urethra  is  cut  until  it  admits  a  No.  40  sound,  and  a  sound 
of  that  size  is  passed  through  the  entire  urethra  into  the 
bladder.  A  rubber  tube  of  about  the  same  size  is  passed 
through  the  perineal  wound. into  the  bladder  and  held  in 
place  by  sutures  passed  through  the  sides  of  the  wound. 
A  packing  of  iodoform  gauze  is  placed  around  the  tube. 
After  four  days  the  tube  is  removed;  sounds  Nos.  36,  38, 
and  40  are  passed  in  succession.  The  tube  is  not  replaced, 
and  the  sounds  are  passed  every  third  day  for  two  weeks, 
then  once  a  week,  then  at  rapidly-increasing  intervals — 
once  a  month,  once  in  six  months,  once  in  twelve  months. 
There  is  no  theoretical  reason  why  these  old  strictures 
should  not  be  cured  permanently,  as  overstretched  scar 
tissue,  as  seen  in  ventral  hernia,  has  no  tendency  to  con- 
tract. Some  cases  which  have  been  followed  for  several 
years  show  that  the  cure  has  been  perfect. — Georgia 
Journal  of  Medicine  and  Surgery. 

CUBE  or  CHRONIC  BRIGHT'S  DISEASE  BY  OPERATION. 

Edebohls  {Med.  Record,  Decrmber  21,  1901).— The 
author  first  operated  upon  chronic  nephritis,  November  29, 
1901.  and  while  the  operation  was  primarily  a  nephropexy, 
done  for  the  relief  of  a  loose  kidney  with  nephritis,  the  re- 


322  SURGERY. 

suit  was  a  cure  of  the  nephritis.  In  all  he  has  operated 
upon  six  cases  of  nephrotosis  with  nephritis,  obtaining 
favourable  results  in  four.  On  January  10,  1898,  he  under- 
took for  the  first  time  this  operation  for  the  purpose  of 
curing  chronic  Bright's  disease,  doing  a  bilateral  nephro- 
pexy, with  radical  cure  of  the  Bright's  disease.  He  re- 
ports eighteen  cases  operated  upon  for  chronic  Bright's 
disease,  five  of  which  had  right  chronic  interstitial  nephri- 
tis; four  had  left  chronic  interstitial  nephritis;  four  had 
right  and  left  chronic  interstitial  nephritis,  two  had  right 
and  left  chronic  parenchymatous  nephritis;  three  had 
I'ight  and  left  chronic  diffuse  nephritis.  In  fourteen  of 
the  eighteen  both  kidneys  were  operated  upon;  in  twelve 
at  one  sitting,  and  twice  at  two  sittings.  In  four  cases 
operation  was  performed  on  one  kidney  only,  in  every 
instance  the  right.  Two  of  them  recovered  complete  and 
lasting  health. 

Chronic  Bright's  disease  was  unilateral  in  nearly  one- 
half  of  all  the  cases,  which  fact  was  somewhat  of  a  sur- 
prise and  revelation  to  the  author.  He  finds  no  difiicultj'^ 
in  recognizing  the  disease  in  the  kidney  as  it  lies  pulled 
through  the  wound  before  him  with  the  blood  circulating 
through  it.  From  two  cases  a  piece  of  the  kidney  was  ob- 
tained, and  the  diagnosis  verified  by  the  pathologist. 

While  ,  extensive  denudation  of  the  kidney  was  a 
factor  in  all  the  nephropexies,  in  the  last  two  cases  total 
extirpation  of  the  capsule  was  done;  in  one,  bilateral  at 
one  sitting;  in  the  other  the  patient  had  but  one  kidney. 
The  right  had  been  removed  for  a  septic  process  some 
months  prior. 

The  method  of  operating  is  in  part  as  follows:  After 
cutting  down  to.  the  kidney,  it  is  freed  from  its  fatty 
capsule  and  brought  out  through  the  wound  to  full  view. 
The  capsule  proper  is  incised  along  the  entire  length  of  the 
convex  external  border  and  clean  around  the  extremity 
of  either  pole.  Each  half  of  the  capsule  is  now  dissected 
from  the  organ  and  cut  off  clean  to  its  junction  with  the 
pelvis,  and  removed.  The  kidney  is  dropped  back  in  place 
and  the  wound  closed  without  drainage,  unless  there  is 
extreme  edema  of  the  parts,  when  drainage  is  used. 
Ether  was  the  anaesthetic  used  in  all  cases  except  one. 

Of  nine  cases  operated  upon  one  year  or  longer  ago, 
one  only  failed  of  radical  cure  of  the  Bright's  disease. 
This  one  had  the  left  kidney  removed  by -another  surgeon 
three  years  later,  and  the  right  kidney,  which  the  author 
had  operated  upon,  sustained  life  for  five  years  longer, 
when  a  third  surgeon  did  a  hysterectomy,  from  which  the 


SURGERY.  323 

patient  died.  Four  cases  were  operated  upon  six  months 
ago:  two  are  free  from  casts  and  albumen;  the  other  two 
show  improvement.  In  the  two  last  cases  operated  upon, 
the  time  is  too  short  for  deductions.  ' 

The  author  believes,  especially  from  the  above  eight 
cases  of  cure  operated  upon  one  year  or  longer  ago,  that 
chronic  Bright's  disease  is  curable  by  operation,  but  as  the 
time  required  for  improvement  to  begin  to  show  itself  is 
ten  days  or  more,  and  as  this  improvement  is  gradual,  the 
late  stages  of  the  disease  may  not  be  fitted  for  the  pro- 
cedure. 

While  operatin-g  on  a  kidney  on  which  a  nephro- 
pexy had  formerly  been  done,  he  observed  numerous 
arteries  large  enough  to  require  ligation,  passing  between 
the  fatty  capsule  and  the  kidney  with  the  flow  of  blood 
towards  the  kidney.  This  increased  blood  supply,  most 
probably,  leads  to  gradual  absorption  of  the  adventitious 
tissue  in  the  diseased  kidney,  giving  relief  to  the  tubules 
from  pressure,  and  allowing  the  epithelia  to  regenerate. 
The  cure  is  gradual,  requiring  from  one  to  twelve  months. 
It  is  not  a  relief  of  kidney  tension  from  removing  the 
capsule,  but  of  vascularization.  The  capsule  in  chronic 
Bright'S  disease  never  compresses  the  organ,  although  it 
may  be  adherent,  but  may  even  sit  loosely  upon  the  kidney. 
The  fatty  capsule  and  the  kidney  are  both  liberally  sup- 
plied with  blood  vessels,  and  the  denuded  kidney  furnishes 
an  extensive  surface  for  intercommunication,  while  the 
fibrous  capsule  proper  is  an  impenetrable  barrier  to  the 
passage  of  the  blood  vessels. 

The  author  operates  if  the  expectancy  of  life  is  more 
than  a  month,  if  there  are  no  incurable  complications,  andi 
an  anaesthetic  is  not  contra-indicated. — Interstat.  Med. 
Journal. 

THE  OPERATIVE   TREATMENT   OF   TRAUMATIC 
INTRACRANIAL  LESIONS. 

C.  Phelps,  New  York,  after  a  brief  review  of  the  prin- 
ciples of  treatment  of  cranial  fracture,  discusses  the  rules  of 
procedure  for  the  treatment  of  intracranial  injuries.  Suc- 
cessful treatment  depends  upon  correct  diagnosis,  and  the 
diagjnosis  in  turn  upon  accurate  knowledge  of  existing 
pathic  conditions.  The  primary  traumatic  intracranial 
lesions  are  classified  by  the  author  as  follows: — i.  Haemor- 
rhages. 2.  Contusions ;  3.  Brain  lacerations.  Haemorrhages 
are  subdivided  into  :  (a)  Supradural  or  epidural ;  (h)  Pial ; 
{c)  Cortical.     Contusions  are :  (a)  Meningeal  ;  (d)  Cerebral. 


324  JOTTINGS. 

Each  of  these  conditions  are  briefly  discussed,  together  with 
the  treatment  indicated.  The  justifiable  use  of  operation  in 
head  injuries  is  shown  to  be  very  limited.  It  may  be  sum- 
marized as  properly  general  in  depressed  cranial  fractures, 
frequent  in  comparatively  uncomplicated  epidural  haemor- 
rhages, and  exceptional  in  subdural  lesions,  whether  of  the 
brain  or  of  the  pio-arachnoid  membrane.  The  resort  to 
operative  measures,  which  is  essential  under  favourable  con- 
stitutional conditions  in  abscess  of  the  brain  and  in  intra- 
cranial gunshot  wounds,  is  not  considered  in  this  article.  If, 
in  the  general  class  of  intracranial  injuries,  operation  is  to  be 
but  infrequently  done,  the  question  of  operation  will  often 
be  raised,  and  decision  as  to  the  course  then  to  be  pursued 
will  entail  grave  responsibility,  since  error  in  judgment  may 
deprive  the  patient  of  a  chance  for  life,  by  increasing  the 
danger  of  an  already  critical  condition. — N.  V.  Medical 
Journal. 


Jottings, 


Styes. 

When  repeated  attacks  have  occurred  the  lid-edges 
should  be  thoroughly  smeared  every  day  for  three  months, 
with 

Aristol Tyi  grains 

Vaselin 

Lanolin aa  75  grains. 

— System   of  Practical    Therapeutics,    2nd    Edition,    1901. 
Edited  by  Dr.  H.  A..  Hare. 

Acute  Rheumatc  Pharyngitis. 

In  cases  in  which  the  pain  and  muscle  soreness  are 
limited  to  the  region  of  the  throat,  three  to  five  grain  doses 
of  Salophen  every  three  or  four  hours  will  quickly  relieve 
the  soreness  and  pain. — System  of  Practical  Therapeutics^  2nd 
Edition,   1901.     Edited  by  Dr.  H.  A.  Hare. 


LINSEED  MEAL  POULTICE. 

Warm  a  basin,  pour  in  boiling  water,  sprinkle  in  the 
meal,  stirring  vigorously,  till  it  becomes   of  the  consist- 


JOTTINGS  325 

ency  of  thick  porridge;  spread  on  tow  or  old  linen,  turning 
in  the  edges  all  around;  before  applying  put  it  against 
one's  cheek  to  feel  that  it  is  not  too  hot.  Retain  in  posi- 
tion with  a  broad  flannel  roller,  secured  with  safety-pins. 
Renew  every  four  hours  or  oftener.  The  poultice  should 
not  exceed  half  an  inch  in  thickness.  Caution  is  necessary 
in  poulticing  the  chest  of  infants  in  order  not  to  overload 
the  chest  and  tire  out  the  respiratory  muscles.  Ashby  and 
Wright  {Pediatrics). 

For  puerperal  eclampsia  give  green  root  tincture 
of  gelsemium,  hypodermically,  in  thirty  to  sixty  drop  doses. 

A  SMALL  QUANTITY  of  acetanilid  dissolved  in  the 
mouth  in  contact  with  an  aching  tooth  will  often  give  quick 
relief. 

Hypodermic  injections  of  pilocarpine,  fifteen  or 
twenty  minutes  apart,  have  relieved  severe  cases  of  edema 
glottitis. 

GUAIACOL  mixed  with  an  equal  part  of  glycerine  and 
applied  over  the  seat  of  a  neuralgic  or  muscular  pain  will 
often  give  quick  relief. 

A  SPOON  IN  A  GLASS  filled  With  hot  water  prevents  the 
breaking  of  the  glass,  because  the  metal  rapidly  absorbs  a 
large  part  of  the  heat. 

A  SOLUTION  OF  five  grains  of  tannin  to  an  ounce  of 
water  is  a  very  serviceable  application  to  sore  nipples. 
Apply  night  and  morning. 

In  SPASMODIC  urethral  STRICTURE  give  cimicifuga 
and  gelsemium  in  full  and  frequent  doses.  Good  results  may 
be  looked  for  in  three  hours. 

Aloes  applied  to  an  ulcer  or  denuded  spot  will  as 
effectually  and  as  promptly  prove  cathartic  as  when  ad- 
ministered in  the  usual  way  in  pill. 

An  incipient  cold  in  the  head  can  be  checked  every 
time  if  the  nose  is  thoroughly  rinsed  out  with  a  weak  solu- 
tion of  potassium  permanganate. 

It  is  stated  that  75  grains  of  picric  acid  dissolved  in 
two  ounces  of  alcohol,  to  which  a  quart  of  water  is  added, 
makes  an  excellent  application  for  burns. 


326  THERAPEUTIC  NOTES. 

For  moist  condylomata  appearing  on  the  genital 
organs,  a  powder  composed  of  equal  parts  of  burnt  alum 
and  tannic  acid  is  said  to  be  an  admirable  remedy. 

Lobelia  in  small  and  often  repeated  doses,  especially 
when  used  in  combination  with  ammonium  carbonate, 
ipecac  or  grindelia,  is  a  stimulating  expectorant. 

Ten  drops  each  of  chloroform  and  tr.  aconite  mixed 
and  applied  locally  will  instantly  relieve  pain,  especially  of 
sciatica,  and  this  disease  when  treated  thus  two  or  three 
times  a  week  will  soon  cease  to  return. 

Dr,  Rumboldt  says  that  he  always  sprays  the  nasal 
cavity  with  vaseline  as  hot  as  can  be  borne  by  the  patient, 
after  any  operation  in  the  nose  which  causes  hemorrhage. 
No  matter  what  the  amount  of  hemorrhage.  Dr.  Rumboldt 
says  this  will  always  promptly  check  it. 

^  A  paroxysm  of  pertussis  may  be  prevented  or  cut 
short  by  placing  the  forefinger  on  the  root  of  the  tongue  and 
pressing  gently  downward  and  outward  till  the  spasm  of 
the  epiglottis  is  overcome  and  the  larynx  opened  for  the 
admission  of  air.  This  will  save  many  a  moment  of  terrible 
agony,  and  many  a  child  from  death  by  asphyxia. 


Therapeutic  Notes. 


ACUTE  NASAI.  CATARRH. 

R  Carbolic  acid,  8  minims. 
Ichthyol,  1  drachm. 
Diluted  alcohol,  2^/^  drachms. 
Aquae  destillatae,  ad  3  ounces. 
M.  Sig. :     Use  as  a  spray,  by  means  of  atomizer,  two 
or  three  times  a  day.     (Journal   of   the  American  Medical 
Association. 

TO  ABORT  FURUNCLES. 

Calcium  sulphide  in  doses  of  lU  grains  will  usually 
answer  this  purpose;  increased  to  ^  grain,  pus  formation 
is  inhibited  with  almost  certainty. 


tme; 


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Editorial. 


Charges  of  carelessness  against  hospitals,  accompanied 
by  suits  for  damages,  have  fortunately  been  rare  in  Canada. 
They  are,  however,  not  unknown,  though  we  think,  in  most 
cases,  the  suit  for  damage  has  been  brought  against  one  of 
the  hospital's  medical  officers,  Such  a  case  was  recently 
tried  in  Montreal,  where  a  medical  man  attached  to  our  lar- 
gest hospital  was  charged  with  removing  a  foot  without 
the  patient's  consent.  The  case  fortunately  failed,  inasmuch 
as  it  was  proved  beyond  any  doubt  that  the  action  of  the 
surgeon  was  in  the  best  interest  of  the  patient.  Still,  from 
some  remarks  which  were  made  by  the  judge,  it  was  clear 
that  in  the  case  before  him,  the  line  of  demarkation  was 
closely  touched,  and  that  it  would  not  have  taken  much  to 
turn  his  judgment  in  the  opposite  direction.  Medical 
opinion  as  to  justifiable  action  does  not  always  commend 
itself  to  the  legal  mind.  In  cases  which  we  have  known, 
and  where  it  seemed  clear  that  the  action  of  Medical  Cor- 
porations was  in  the  very  best  interest  of  the  public — the 
Courts  have  decided  that  the  action  taken  was  not  legal.  It 
must  be  remembered  that  the  mental  education  of  the 
medical  and  legal  profession  is  different.     The  former  looks 


328  EDITORIAL. 

upon  himself  as  a  proctor  of  the  pubh'c — the  latter  simply  as 
the  administrator  of  the  law.  Whether  that  law  is  in  the 
interest  of  the  public  is  not  taken  into  consideration,  and 
though  those  who  passed  it  may  have  so  intended,  its  word- 
ing may  fail  to  have  it  so  interpreted.  We  find  that  our 
brethern  in  New  York  and  Buffalo  have  had  some  reason 
of  late  to  conclude  that  law  is  not  always  justice.  In  the 
Buffalo  Medical  Journal  for  May  we  find  the  following  article, 
which  we  commend  to  the  very  cartful  consideration  of  our 
readers,  but  more  especially  Hospital  Surgeons.  It  would 
also  be  well  if  these  gentlemen  brought  it  to  the  serious 
attention  of  the  Lady  Superintendents  of  Hospitals.  If 
such  actions  were  to  be  taken  against  our  Canadian  Hos- 
pitals, and  the  same  legal  decision  arrived  at,  it  would  indeed 
be  a  serious  matter. 

"There  has  been  decided  in  New  York  City  a  case  which 
has  a  peculiar  interest  in  Buffalo,  inasmuch  as  it  will  affect 
the  question  of  the  paymertt  of  damages  by  two  Buffalo 
hospitals. 

"Something  over  two  years  ago  Helen  G.  Ward  was 
taken  to  St.  Vincents'  Hospital  for  operation.  At  the  con- 
clusion of  surgical  procedures  she  was  placed  in  bed  and  a 
nurse  in  charge  of  the  case  put  hot  water  bags  about  her. 
She  suffered  burns  more  or  less  severe  from  these  hot  water 
bags.  When  she  left  the  hospital  she  brought  suit  for 
damages  against  the  hospital  and  was  by  direction  of  the 
court  non-suited.  An  appeal  resulted  in  a  new  trial  being 
ordered,  in  which  case  the  jury  disagreed.  A  third  trial  was 
secured,  and  the  jury  gave  Miss  Ward  a  verdict  of  $10,000. 
The  hospital's  attorneys  prepared  papers  in  appeal  and 
carried  up  the  case.  The  Appellate  Division  set  aside  the 
$10,000  verdict  and  ordered  a  new  trial  on  errors.  The 
case  was  tried  before  Justice  Beach,  in  New  York  City,  and 
resulted  in  an  increased  verdict  of  $18,000  for  Miss  Ward. 

"The  hospital  authorities  will  now  probably  pay  the 
verdict,  for,  according  to  the  opinions  of  Buffalo  lawyers  who 
have  been  watching  the  progress  of  this  remarkably  well- 
fought   case,  there   is  nothing   on    which   to   base   another 


EDITORIAL.  329 

appeal,  the  last  case  having  been  tried  with  a  rigid  obser- 
vance of  the  rules  of  evidence,  and  great  care  having  been 
exercised  by  the  trial  judge  with  a  view  to  preventing  either 
side  from  taking  advantage  of  any  errors  of  judgment.  The 
main  contention  of  the  hospital  was  to  the  effect  that  all 
necessary  care  was  exercised  in  the  treatment  of  the  patient ; 
that  the  burns  were  unavoidable.  The  plaintiff  set  up  that 
the  nurse  in  charge  of  her  case  after  the  operation  was  an 
undergraduate,  and  therefore  not  wholly  qualified  to  act. 
A  novel  proposition  raised  by  the  hospital's  attorneys  was 
that  the  placing  of  a  hot  water  bag  did  not  require  any 
special  degree  of  qualification  ;  hence,  the  question  of  inex- 
perience was  not  to  be  raised.  The  jury  appears  to  have 
held,  however,  that  the  nurse  was  an  agent  of  the  hospital, 
and  that  the  latter  was  therefore  liable  for  her  acts, 

"There  are  two  similar  cases  in  Buffalo  which  will  now 
either  be  brought  to  trial  or  settled  on  the  strength  of  this 
verdict.  In  each  case  patients  were  burned  more  or  less 
severely  by  the  application  of  hot  water  bottles  placed  by 
undergraduate  nurses.  In  one  case  it  is  stated  that  consider- 
able deformity  has  resulted." 


CANADIAN    MEDICAIi   ASSOCIATION. 
MONTREAL  MEETING,  SEPT.,  16,  17,  18,  1902. 

Below  will  be  found  a  list  of  papers  already  promised 
for  the  annual  meeting  at  Montreal  in  September  next. 
Members  and  others  contemplating  contributing  to  the  suc- 
cess of  this  meeting  should  notify  the  General  Secretary  at 
an  early  date  of  their  intention.  Arrrangements  as  to  rail- 
road and  steamship  rates,  entertainments,  clinics,  etc.,  will 
be  announced  in  due  time. 

"Address  in  Medicine  " — Professor  William  Osier,  Balti- 
more. 

"Address  in  Surgery" — Dr.  John  Stewart,  Halifax^ 
N.S. 

"  Lantern  Demonstration  on  the  Exanthemata  " — Dr. 
Corlett,  Cleveland,  Ohio. 


330  EDITORIAL. 

Paper  by  Dr.  D.  Campbell  Meyers,  Toronto, 

Paper  by  Dr.  Geo.  S.  Ryerson,  Toronto.  Subject  not 
yet  decided  on. 

Paper  by  Dr.  A.  Lapthorn  Smith,  Montreal,  also  card 
specimen. 

Paper  by  Dr.  F.  A.  L.  Lockhart,  Montreal. 

"  On  some  points  in  Cerebral  Localization,  illustrated 
by  a  series  of  Morbid  Specimens  and  some  Living  Cases," 
Dr.  James  Stewart,  Montreal. 

Paper  and  specimens  by  Dr.  Geo.  A.  Peters,  Toronto. 

"  The  Country  Practitioner  of  To-day,"  Dr.  J.  R. 
Clouston,  Huntingdon,  Que. 

Paper  by  Dr.  P.  Coote,  Quebec. 

"  The  Pathologic  Prostate  and  its  removal  through  the 
Perineum,"  Dr.  A.  H.  Ferguson,  Chicago. 

Paper  by  Dr.  Geo,  E.  Armstrong,  Montreal. 

Paper  by  Dr.  IngersoU  Olmsted,  Hamilton. 

Paper  by  Dr.  Casey  A.  Wood,  Chicago,  "Empyema 
of  the  Frontal  Sinus," 

"On  Tuberculosis" — Dr.  J.  F.  Macdonald,  Hopewell, 
N.S. 

"X-ray  in  Cancer" — Dr.  A.  R.  Robinson,  New  York. 

"On  Degeneration  of  the  Spinal  Cord,  Anaemia,  Mal- 
nutrition with  Microscopic  Specimens  " — Dr.  David  A. 
Shirres,  Montreal. 

George  Elliott, 

General  Secretary. 

129  John  street,  Toronto. 


OBITUARY. 


In  the  death  of  Dr.  Wyatt  Johnston,  which  occurred  on 
the  19th  of  June  last,  not  only  Montreal,  but  the  entire  pro- 
fession of  the  Dominion,  sustained  a  severe  loss.  For  a  con- 
siderable time  before  he  was  compelled  to  take  a  private 
ward  in  the  Montreal  General  Hospital,  of  which  staff  he 
was  a  member,  Dr.  Johnston  had  suffered  from  local 
•manifestations   of  blood    poisoning    contracted    in    his  post 


EDITORIAL  331 

mortem  work.  This  eventually  manifested  itself  in  a  severe 
attack  of  phlebitis,  from  which  he  was  apparently  rapidly 
recovering,  when  an  embolus  was  carried  to  the  pulmonary 
artery,  and  death  immediately  ensued.  He  was  of  a 
peculiarly  retiring  nature  and  had  a  most  amiable  disposi- 
tion, which  made  him  a  universal  favourite.  Of  his  peculiar 
fitness  to  fill  the  important  positions  to  which  he  was 
assigned  not  only  in  the  Medical  Faculty  of  McGill,  of  which 
University  he  was  a  graduate,  but  as  specialist  in  pathological 
work  for  the  Government,  there  was  no  doubt.  He  knew 
his  work  most  thoroughly,  and  he  did  it  well.  His  greatest 
discovery,  and  one  with  which  his  name  will  ever  be  asso- 
ciated, is  Johnston's  modification  of  Widal's  re-action  of  the 
typhoid  bacillus.  The  method  devised  by  Dr.  Johnston  is 
now  universally  employed  as  the  most  reliable  means  of 
diagnosing  this  disease.  His  memory  will  remain  green 
for  many  a  day  among  his  numerous  friends.  A  good  man 
has  been  cut  off  in  the  very  midst  of  his  usefulness. 


FERSONAIiS. 


Drs.  Dorion  and  Walker  (M.  D.,  McGill,  1902),  have  been 
appointed  House  Surgeons  to  the  Western  General  Hospital. 

Mr.  J.  E.  Morrison  has  been  appointed  Lecturer  in 
Chemistry  at  Bishop's  College  and  Assistant  to  Professor 
Donald. 

Dr.  George,  Hall  (M.D.,  Bishops,  1896)  has  been  ap- 
pointed Lecturer  in  Physiology  in  his  Alma  Mater,  in  place 
of  Professor  Bruere  resigned. 

Dr.  F.  O.  Anderson  (M.  D.,  Bishop's,  1900),  sailed  for 
Europe  on  the  31st  July.  He  will  visit  Edinburgh  and 
devote  a  few  months  to  special  work. 

Surgeon-Major  Elliott  (M.D.,  Bishop's,  1889),  who  went 
to  South  Africa  as  medical  officer  to  one  of  the  regiments  of 
the  Mounted  Rifles  which  sailed  from  Halifax  early  in  May 
last,  returned  with  his  regiment,  arriving  in  Halifax  on  the 
29th  July.  We  hear  that  he  has  been  appointed  by  the 
Imperial  authorities.  Principal  Medical  Officer  to  the  troops 
in  Bermuda,  for  which  place  he  has  already  sailed. 


332  BOOK   REVIEWS. 

Dr.  Alexander  Macdonald  (M.  D.,  Bishop's,  1900)  after 
filling  most  acceptably  for  over  a  year  the  position  of 
Medical  Superintendent  of  the  Western  General  Hospital, 
has  resigned  to  commence  practice  in  Montreal. 

Drs.  McGregor  and  Cowley  (M.  D.,  Bishop's,  1902)  have 
resigned  their  positions  of  House  Surgeons  to  the  Western. 
General  Hospital  to  become  surgeons  on  the  Elder-Dempster 
line  of  steamships.  They  sailed  for  Liverpool  on  the 
24th  July. 


Book   Reviews. 


The  Diagnosis  of  Surgical  Diseases.  By  Dr.  E.  Albert, 
late  Director  and  Professor  of  the  first  tiurgical  Clinic  at  the 
University  of  Vienna.  Authorized  translation  from  the  eighth 
enlarged  and  revised  edition,  by  Robert  T.  Frank,  A.M.,  M.D., 
with  fifty-three  illustrations.  D.  Appleton  &  Co.,  New  York, 
1902. 

This  book  has  our  complete  endorsation.  It  is  certainly  one  of 
the  most  valuable  and  fascinating  volumes  which  we  have  seen 
among  recent  medical  publications.  Students,  practitioners  and 
teachers  in  particular  are  under  deep  debt  of  gratitude  to  Dr.  Frank 
for  giving  us  in  the  English  language,  one  may  say,  the  life  work  of 
such  a  keen  observer  and  noted  clinical  teacher  as  Professor  Albert. 
We  have  not  heretofore  seen  any  work  on  surgical  diagnosis  which 
can  compare  with  it.  Diseases  and  diseased  conditions  are  taken  up 
and  grouped  according  to  points  of  resemblance,  and  not  ac- 
cording to  any  theoretical  classification.  A  valuable  feature  in 
the  work  is  the  great  number  of  interesting  cases  reported  and 
followed,  to  the  operating  table,  or  to  autopsy,  either  to  confirm  or 
to  correct  the  diagnosis.  The  chapter  on  injuries  to  the  skull  and 
brain  is  specially  interesting.  Many  cases  are  cited  and  analysed 
from  a  diagnostic  point  of  view.  The  following  two  cases  will  serve 
as  an  illustration  of  the  character  of  the  work.  Case  i,  "  a  brick 
fell  upon  the  right  frontal  region  of  a  man  35  years  of  age.  Uncons- 
ciousness for  10  minutes,  followed  by  headache  and  dizziness.  In 
four  days  those  symptoms  disappeared,  but  after  the  accident  the 
left  arm  could  not  be  properly  moved.  On  the  fourth  day  invol- 
.  untary  twitchings  appeared  in  this  arm." 

In  discussing  this  injury  he  says:  "The  rest  of  the  history 
could  not  be  quoted,  but  from  what  has  been  obtained  it  is  evident 
that  a  very  moderate  degree  of  concussion  had  been  sustained.  As 
paralysis  in  the  left  arm  followed  the  injury,  some  local  lesion  of  the 
right  hemisphere  must  have  occurred.  It  is  probable  that  this  was 
situated   in  the   upper   part  of  both  ascending  frontal  and  parietal 


BOOK  REVIEWS  333 

convolutions.    The  spasms  noticed  on  the  fourth  day  were  the  result 
of  reactive  processes  at  the  site  of  injury. 

Case  2.  A  man  run  over  by  a  cab  was  brought  to  the  hos- 
pital without  any  skin  wound,  depressed  fracture  or  disturbance 
of  general  condition.  After  six  hours,  paralysis,  first  of  the  left, 
next  of  the  right,  extremities  supervened.  This  was  followed  by 
coma  and  death  within  three  days.  Autopsy  showed  extravasation 
of  blood  between  the  left  parietal  bone  and  the  dura.  I'he  blood 
clot  weighed  140  grammes  and  caused  a  flattening  of  the  brain. 
The  surface  of  the  right  hemisphere  was  bruised  by  contra  coup. 
This  case  is  then  discussed  from  a  diagnostic  standpoint  as  fol- 
lows : 

The  symptoms  of  paralysis  increased  with  such  rapidity  that 
but  one  cause  could  be  assigned.  This  cause  is  arterial  hemor- 
rhage, which  is  always  rapid.  It  has  been  proven  that  the  middle 
meningeal  artery  can  rupture  even  without  injury  to  the  cranial 
bones.  This  rupture  may  occur  on  the  side  opposite  to  the  blow, 
merely  as  a  result  of  the  momentary  change  in  the  contour  of  the 
bones.  A  sinus  may  tear,  tvithout  consequent  hemorrhage,  but 
the  bleeding  is  never  as  extensive.  VVhy  did  the  paralytic  symp- 
toms not  manifest  themseves  at  once  ?  This  fact  is  characteristic 
of  injury  to  the  middle  meningeal  artery.  The  blood  must  first 
separate  the  dura  from  the  bones  before  it  can  baloon  out  the 
membranes  and  thus  exert  pressure  upon  the  brain.  As  soon  as 
this  is  accomplished  pressure  symptoms  rapidly  develop.  But 
why  did  paralysis  first  appear  in  the  left  extremity  when  the  left 
hemisphere  was  injured?  With  compression  of  the  left  hemi- 
spheie  a  right-sided  hemiplegia  was  to  be  expected.  Probably 
the  contusion  had  previously  impaired  the  circulation  of  the 
right  hemisphere,  and  the  pressure  was  therefore  more  readily  felt 
in  that  region.  Was  the  left  hemiplegia  not  the  result  of  the 
right-sided  contusion  of  the  brain?  No,  for  if  it  had  been,  this 
hemiplegia  would  have  appeared  immediately  after  the  injury. 

F.  R.  E. 

Progressive  Medicine — A  quarterly  digest  of  advance?,  dis- 
coveries and  improvements  in  the  Medical  and  Surgical 
Sciences.  Edited  by  Hobart  Amory  Hare,  M.  D.,  Professor 
of  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical 
College,  Philadelphia ;  assisted  by  H.  R.  M.  Landis,  M.  D., 
Assistant  Physician  to  the  out-patient  department,  Jefferson 
Medical  College  Hospital.  Vol.  i.,  March,  1891,  and  vol.  ii., 
June,  1902. 

We  regret  that  the  March  number  only  reached  us  at  the  same 
time  as  did  the  June  number,  although  it  was  issued  by  the 
publishers  on  time.  We  have  so  repeatedly  spoken  favourably  of 
this  quarterly,  that  we  can  only  afiirm  our  previous  opinion.  It  is 
particularly  well-gotten  up,  and  makes  a  handsome  appearance  on 
the  library  shelf.  The  March  volume  takes,  up  the  Surgery  of  the 
Head,  Neck  and  Chest ;  Infectious  diseases ;  Croupous  Pneumonia 
and  Influenza ;  Diseases  of  Children  ;  Pathology  ;  Laryngology  and 
Rhinology  ;  Otology.   The  June  number  takes  up  the  Surgery  of  the 


334  BOOK    REVIEWS. 

Abdomen,  including  Hernia,  Gynaecology  ;  Diseases  of  the  Ductless 
Glands;  the  Haemorrhagic  diseases;  Metabolic  diseases ;  Opthal- 
mology.  The  contributors  to  both  these  volumes  are  men  well 
known  in  their  respective  fields  of  special  research,  and  they  have 
brought  together,  in  a  compact  form,  the  latest  literature  on  the 
subject. 

F.  W.  C. 

Stricture  of  the  Urethra  and  Hypertrophy  of  the 
Prostate.  By  J.  G.  Freyer,  M.  A.,  M.  1).  M.  Ch.,  Surgeon 
to  St.  Peter's  Hospital,  Lieut.-Colonel  Indian  Medical  Service 
(retired).  Bailliere,  Tindall  &  Cox,  21  King  William  street, 
Strand,  London,  England,  1902. 

In  May,  ipoi,  we  reviewed  this  work,  and  now  we  are  favoured 
with  a  copy  of  a  new  edition.  That  a  new  issue  has  been  called  for 
so  soon  is  convincing  evidence  that  it  has  been  appreciated  by  the 
profession.  This  is  not  to  be  wondered  at,  because  the  author,  for 
many  years,  has  occupied  a  very  distinguished  position  as  a  surgeon 
in  the  British  India  Medical  Service.  In  this  service  he  has  had 
ample  opportunity  of  putting  to  the  test  the  many  practical 
suggestions  which  his  book  contains.  He,  therefore,  speaks  with 
no  uncertain  sound.  The  style  is  most  pleasing,  and  as  it  is  not 
very  voluminous,  a  few  sittings  will  enable  any  one  to  thoroughly 
master  its  technique. 

F.  W.  C. 
International  Clinics.— A  quarterly  of  clinical  lectures  and 
especially  prepared  articles  on  all  branches  of  Medicine  and 
Surgery  and  other  topics  of  interest  to  students  and  practi- 
tioners. By  leading  members  of  the  Medical  profession 
throughout  the  world;  Edited  by  Henry  W.  Cattell.  A.M., 
M.D.,  Philadelphia,  U.S  A.,  with  the  collaboration  of  John  B. 
Murphy,  M.D.,  Chicago;  Alex.  D.  Blackader,  M.D.,  Mont- 
real; H.  C.  Wood,  M.D.,  Philadelphia;  T.  M.  Rotch,  M.D., 
Boston;  E.  Landort,  M.D.,  Paiis;  Thos.  G,  Morton,  M.D., 
of  Philadelphia,  and  Cha=.  H.  Reed,  M  D.  ;  J.  B.  Ballantyne' 
M.D.,  of  E^dinburgh  ;  and  John  Harold,  M.D.,  of  London; 
with  regular  correspondents  in  Montreal,  London,  Paris, 
Leipsic  and  Vienna  ;  volume  I.,  12th  series.  J.  B.  Lippincott 
&  Co.,  Philadelphia,  1902.  Canadian  Agent:  Charles 
Roberts,  1524  Ontario  street,  Montreal. 

This,  volume  contains  some  nineteen  articles  and  a  review  of 
the  progress  of  medicine  during  the  year  1901.  The  first  two  of  a 
series  of  biographical  sketches  of  living  physicians  are  given, 
S.  Weir  Mitchell,  M.D.,  LL.D.,  and  John  A;  Wyeth,  M.D., 
LL.D.,  being  the  subjects.  In  these  sketches  an  insight  is  given 
into  the  character,  history,  methods  of  working,  work  accomplished 
and  literary  efforts  of  members  of  the  profession  who  stand  as  our 
recognized  leaders.  The  elements  of  success  are  seen  to  be  in 
these  instances  chiefly  persistent  and  intelligent  application, 
quick  perception,  self-confidence,  common  sense,  diversity  in  work 
and  conservation  of  strength.     The    biographer,   Guy    Hinsdale, 


BOOK  REVIEWS.  335 

A.M.,  M.D.,  deems  waste  of  time  and  waste  of  energy  to  be  the 
two  chief  causes  of  failure.  Photogravures  are  given  of  the  men, 
their  clinics,  operating  rooms,  etc. 

Dr.  Horatio  C.  Wood,  jun.,  contributes  part  II.  on  a  descrip- 
tion of  the  methods  of  investigating  the  action  of  drugs.  How  to 
study  the  effects  of  drugs  on  respiration,  the  blood  and  nervous 
system  is  fully  discussed,  accompanied  with  cuts  of  the  apparatus 
employed. 

An  interesting  article  is  that  On  the  Significance  of  Basophilic 
Granules  in  Red  Corpuscles,  with  Special  Reference  to  Their  Occur- 
rence in  Chronic  Lead  Poisoning,  by  Charles  E.  Simon,  M.D.  He 
traces  the  observation  made  in  regard  to  these  granules  from  the 
time  of  their  discovery,  by  Marchiafava  and  Celli  in  1884,  to  his 
own  work  during  the  last  three  years,  giving  the  technique  in  de- 
tail. They  are  found  mostly  in  cases  of  pernicious  anjemia, 
malaria,  myelogenous  and  lymphatic  leukaemia  and  in  lead  poisoning. 
The  origin  of  the  cells  and  their  clinical  significance  is  discussed. 
The  article  by  John  C.  Hemmeter,  M.D.,  Ph.D.,  on  Gastro- 
intestinal Auto  Intoxicationj's  very  instructive.  Part  I.  appears  in 
this  volume  and  the  subject  is  considered  under  such  heads  as  : 
Nature  and  Concept,  Terminology,  Classification,  Definition,  Signifi- 
cance of  the  Doctrine,  Criticism  of  Experimental  Evidences,  Auto- 
infeciion  versus  Auto-intoxication,  Criticism  of  the  Clinical  argu- 
ments in  Favour  of  Auto-Intoxication,  Protective  Function  of  the 
Liver,  Causes  and  Types. 

Other  valuable  contributions  are :  Habitual  Constipation,  by 
I.  Boas,  M.D. ;  The  Climate  of  New  England,  by  Guy  Hinsdale, 
A.M.,  M.D,;  The  Treatment  of  Acne,  by  Prof.  H.  Hallopeau  ; 
The  Surgical  Treatment  of  Infantile  Palsy,  by  Drs.  J.  K.  Young 
and  James  Kelly ;  The  Contest  between  the  Advocates  of 
Symphysiotomy  and  the  Partisans  of  Caesarean  Section,  by 
A.  Boissard,  M.D. 

One-third  of  the  volume  is  taken  up  with  a  review  of  the 
Progress  of  Medicine  during  1901,  by  Edward  Willard  Watson-, 
M.D.  Besides  a  review  of  the  chief  advances  in  Medicine,  Surgery, 
Therapeutics,  Pathology,  Neurology,  Obstetrics  and  Gynaecology 
reference  is  made  to  the  present  status  of  X-rays,  Medical  Legisla- 
tion, New  Instruments  and  Devices,  the  eightieth  birthday  of 
Prof.  Virchow  and  the  death  of  President  McKinley.  The  pub- 
lishers and  editors  are  to  be  congratulated  upon  the  wisdom  dis- 
played in  the  character  of  the  contributions  secured,  and  the 
attractive  and  practical  style  of  the  contents  of  the  present  number 
of  this  popular  quarterly. 

J.  B.   McC. 

The  Practical  Medical  Series  of  Year  Books.  General 
Surgery.     Edited  by  John  B.   Murphy,  M.D,,  Professor   of 
Surgery,  Northwestern  University  Medical  School.  Year  Book 
publishers,  Chicago,  U.  S.,  1902.     Vol.  2. 
After  carefully  examining  this  book  we  can  recommend  it 

and  believe  it  will  be  found  of  great  advantage  to  all  busy  practi- 


33^  PUBLISHERS'   DEPARTMENT. 

tioners.  A  wide  range  of  surgery  has  been  faithfully  surveyed,  and 
good  abstracts  of  many  valuable  papers  which  have  appeared  in 
the  surgical  literature  of  the  year  have  been  presented.  Excellent 
digests  have  also  been  given  on  important  subjects  by  the  editor. 
His  risume  on  appendicitis  is  particularly  interesting,  and  this 
important  disease  is  handled  Ln  no  uncertain  manner.  A  study  of 
the  pathology  is  made  to  indicate  clearly  that  operative  treaiment 
is  the  only  safe  and  rational  practice.  One  is  told  that  safety  lies 
in  early  surgical  intervention ,  and  not  as  z.  dertiier  resort.  The 
question  :  Should  cases  of  general  suppurative  peritonitis  be  operated 
upon  ?  must  be  answered  by  "  yes."  If  no  evidence  of  intense 
toxaemia  and  collapse,  the  quantity  of  pus  and  extent  of  infection 
do  not  count  against  operation.  The  non-operable  cases  are  those 
where  there  is  present  meteorism,  intestinal  paralysis,  projectile 
vomiting,  cold  and  clammy  extremities,  anxious  expression  and  low 
pulse  tension.  The  at  tide  on  diseases  of  the  upper  extremity  is 
most  interesting  and  important.  Carl  Beck's  valuable  paper  is 
epitomized  in  which  the  importance  of  using  the  X-rays  for  diag- 
nostic purposes  is  urged  in  all  injuries  in  the  neighbourhood  of 
the  wrist  joint.  Beck  reports  in  nis  paper  104  cases  of  fracture 
of  the  carpal  end  of  the  radius  (Colles  fracture)  which  he  had 
examined  with  the  X-rays  ;  21  of  these  cases  showed  fracture  of  the 
head  of  the  ulna  as  well.  He  points  out  the  importance  ot  an  ac- 
curate knowledge  of  tne  exact  lesion,  and  he  maintains  that  fre- 
quently the  X-rays  is  our  only  means  of  settling  whether  a  given 
Case  is  to  be  treated  by  immobilization  or  by  massage. 

F.  R.  E. 


PUBI^ISHBRS  DKPARXMENT, 


Office  of 
Dr.  C.  W.  Price,  President  U.  S.  Board 

Richmond,  Pension  Examiners. 

Maine.  Bath,  Maine. 

Messrs.  Bovinine  Co. 

Dear  Sirs: — I  desire  to  send  you  this  unsolicited  testimonial.  I  regard 
Bovinine  as  one  of  the  most  valuable  foods  1  have  ever  used  in  my  practice, 
covering  over  thirty  years.  I  have  had  most  wonderful  results  in  saving  starv- 
ing bottle-fed  babies.  As  a  dressing  in  old  chronic  leg  ulcers,  it  has  no  peer. 
I  have  healed  some  very  large,  deep  tubercular  ulcers  this  past  winter,  which 
would  yield  to  no  other  treatment.  In  deep-seated  abscesses  and  in  traumatic 
lacerations,  carbuncles,  etc.,  my  chief  dependence  is  "  Bovinine." 

1  wish,  as  a  boon  to  humanity,  that  every  physician  in  America  would  use 
it  in  these  troublesome  cases. 

Very  truly  yours, 

C.  W.  Price. 


CAN  AID  A 

MEDICAL  RECORD 


AUGUST.     1902. 


Original  Communications, 

gynecoiiogical  cases. 

At  the  Samaritan  Hospital  for  Women,  Montreal. 

Under  the  care  of  A.  Lapthorn  Smith,  M.D.,  Surgeoii-in-Chief  of  the  Samaritan  iTospital; 
Gynecologist  to  the  Western  Hospital  ;  Gynecologist  to  the  Montreal  Dis- 
pensary;   Professor   of   Gynecology   in    the    University    of 
Vermont,  Burlington;  Professor  of  Clinical  Gyne- 
cology, Bishop's  University,  Montreal. 

The  following  cases,  although  of  no  particular  interest 
on  account  of  rarity,  are  worth  while  reporting,  because  they 
are  just  the  ones  which  are  constantly  coming  under  the  care 
of  the  general  practitioner,  by  whom  indeed  many  of  them 
were  sent  to  the  hospital. 

On  the  first  of  January,  1902,  there  was  admitted  Miss  T., 
who  had  come  to  my  oflfice  a  week  before,  complaining  for  two 
years  of  pain  in  her  back  and  side,  which  prevented  her  from 
earning  her  living.  On  examination  I  found  a  large  mass  on 
one  side  of  the  pelvis  and  a  smaller  one  on  the  other  side.  1 
diagnosed  pus  tubes,  and  possibly  that  the  appendix  was  in- 
volved, as  she  had  greatest  tenderness  over  MacBurney's  point. 
A  fter  the  usual  preparation,  including  three  hot  baths  and 
strychnine  and  laxatives  until  the  bowels  were  thoroughly 
emptied, the  abdomen  was  opened; there  were  no  adhesions  of 
the  bowels,  and  without  any  difficulty  I  enucleated  a  pus  tube 
as  large  as  an  orange  from  Douglas'  culde  sac.  The  ovary  on 
this  side  was  so  densely  connected  with  the  tube  that  I  remov- 
ed the  whole  of  it,  but  the  ovary  on  the  left  side  was  not  so 
much  involved,  so  only  three-quarters  of  it  was  removed  with 


338  GYNECOLOGICAL  OASES. 

the  tube,  which  was  hard  and  swollen,  and  closed.  The  quarter 
of  an  ovary  was  allowed  to  remain,  as  she  was  only  twenty- 
four  years  of  age,  and  was  engaged  to  be  married.  She  made 
an  excellent  recovery  and  was  hard  at  work  in  a  wholesale 
millinery  store  seven  weeks  after,  and  has  had  no  pain  or 
inconveniences  of  any  kind  since. 

On  the  second  of  January  Mrs.  M.  was  admitted  for 
cystitis  ;  she  was  a  working  woman  exposed  to  cold  ;  she 
was  kept  in  bed  for  one  week  On  Buchu  tea,  hot  lemonade 
and  hot  douches,  with  the  result  that  she  was  quite  cured, 
and  has  had  no  return  of  it  since. 

On  the  fifth  of  January  Mrs,  McN.  was  sent  by  Dr.  Sharpe 
for  a  femoral  hernia,  for  which  she  had  been  wearing  a  truss 
for  fifteen  years  until  there  was  a  raw  ulcerated  surface  the 
size  of  a  silver  dollar.  Some  of  the  stafT  raised  the  question 
whether  it  was  safe  to  open  the  peritoneal  cavity  in  the  pres- 
ence of  an  ulcerating  surface  on  the  skin.  I  might  mention 
here  that  this  never  debars  me  from  operating,  as  I  have  abso- 
lute faith  in  my  ability  to  disinfect  even  such  a  surface  with  per- 
manganate, oxalic  acid  and  bichloride  of  mercury.  The  sac  was 
found  and  the  ring  formed  by  Gimbernat's  ligament  and  Pou- 
part's  was  divided  ;  the  sac  was  opened  ;  the  bowel,  which  was 
adherent,  was  replaced  in  the  abdomen,  the  sac  was  tied  off 
and  the  femoral  ring  closed  by  four  interrupted  chromacized 
catgut  stitches,  one  of  which  lasted  so  long  that  it  was  thrown 
off  by  nature  three  months  later,  without,  however,  causing 
much  inconvenience.  She  has  been  working  hard  ever  since, 
keeping  a  grocery  store  and  supporting  nine  children.  I  might 
also  add  that  I  have  done  more  than  fifty  hernia  operations, 
inguinal,  femoral,  omental  and  ventral,  every  one  of  which  has 
been  a  perfect  success,  some  of  them  on  quite  old  women,  and 
all  of  them  wearing  a  truss  and  incapacitated  from 
doing  hard  work  until  they  were  operated  on,  since  which 
they  have  been  completely  cured. 

On  the  7th  January  a  Mrs.  B.  came  in  for  metritis  ;  she 
had  had  double  hydrosalpina  removed  five  years  before  by  me 
at  the  Western  hospital,  since  which  she  has  been  troubled  off 


GYNECOLOGICAL  CASES.  339 

and  on  with  digestive  troubles  partly  due  to  intestinal  adhe- 
sions, but  also  to  excessive  eating.  She  was  relieved  by  hot 
douches. 

On  the  8th  January  Mrs.  W.  W.,  aet.  24,  came  in  for 
retroversion  with  fixation,  which  always  means  diseased  tubes. 
She  suffered  intensely  at  her  periods  and  also  from  dyspar- 
eunia,  which  caused  great  unhappiness  in  her  home  ;  she  had 
never  experienced  any  sexual  feeling,  as  her  trouble  dated 
back  since  she  was  a  young  girl  working  in  a  factory  fot  long 
hours.  As  both  tubes  were  closed  and  the  ovaries  were  hard 
and  cystic,  and  I  was  anxious  that  she  would  not  have  any 
more  periods,  I  removed  both  ovaries,  and  did  ventrofixation, 
using  two  silk-worm  gut  stitches.  Her  nervous  system  was 
completely  shattered  so  that  it  was  several  months  before  she 
was  quite  well,  her  convalescence  being  retarded  somewhat 
by  the  buried  stitches  causing  a  sinus,  which  necessitated  their 
removal.  She  is  now  in  good  health  and  lives  very  happily 
with  her  husband,  her  sexual  feeling  having  appeared  soon 
after  her  operation  and  being  stronger  than  the  average  ever 
since.  I  mention  this  because  there  is  a  general  opinion  that 
sexual  feeling  is  lost  by  removal  of  the  ovaries,  while  our 
experience  here  has  been  quite  the  contrary. 

Mrs.  H.  W.,  a  sister-in-law  of  the  previous  patient,  also 
came  on  the  8th  January,  principally  for  dyspareunia,  which 
was  so  severe  that  she  had  made  up  her  mind  to  leave  her 
husband,  as  married  life  caused  her  such  torture.  I  had 
already  treated  her  for  nearly  a  year,  during  which  time  I 
repaired  a  lacerated  cervix,  which  was  immediately  followed 
by  pregnancy  and  confinement  in  due  course  ,  but  she  con- 
tinued to  suffer  so  much  with  menstruation  and  intercourse 
that  I  believed  that  I  was  justified  in  removing  the  ovaries. 
The  result  has  been  most  satisfactory  ;  a  perfect  convales- 
cence and  a  happy  home  ever  since.  These  two  patients 
and  their  husbands  are  most  grateful. 

On  the  13th  January  Mrs.  R.,  aet.  34,  was  sent  by 
Dr.  Carmichael,  principally  for  sterility.  There  was  a  long 
conical  cervix,  and  the  uterus  was  retroverted,  but  easily  re- 
placed.    The  cervix  was  amputated,  the  uterus  curetted  and 


340  GYNECOLOGICAL  CASES.' 

the  round  ligaments  were  shortened.  The  uterus  is  well  up, 
but  she  had  a  little  trouble  with  one  buried  silk- worm  gut 
stitch  which  worked  its  way  out  two  months  later.  So  far  she 
has  not  become  pregnant,  although  many  other  Alexander 
cases  have  done  so.  Patients  attach  so  much  importance  to 
this  little  inconvenience,  quite  forgetting  that  the  operation 
has  restored  them  to  health,  that  I  now  feel  very  loath  to  leave 
any  buried  non-absorbable  ligatures,  preferring  to  use  chro- 
macized  catgut. 

On  the  15th  of  January  three  patients  were  admitted. 
A  Mrs.  B,,  29  years  of  age,  came  to  the  Montreal  Dispensary, 
stating  that  she  was  obliged  to  earn  her  own  living,  as  her 
husband  had  deserted  her  three  months  before,  and  that  for 
two  years  she  had  been  suffering  almost  constant  pain  in  her 
ovaries,  which  was  worse  at  her  periods.  I  removed  them  a 
few  days  later,  and  has  been  heard  of  since  much  better. 

Mrs.  S.  had  her  tubes  and  ovaries  removed  two  years 
before  for  large  pus  tubes,  from  which  operation  she  made  a 
very  good  recovery,  so  that  she  was  able  to  work  as  cook  in  a 
large  boarding-house.  She  came  in  for  a  week's  rest,  and 
then  returned  to  her  work,  and  I  mention  the  case  because 
there  is  a  popular  impression  that  a  woman  is  never  good  for 
much  after  a  laparotomy.  I  could  recall  several  hundred 
cases  to  prove  the  contrary, 

Mrs,  G.,  age  50,  the  mother  of  eighteen  children,  was 
the  third  case  admitted  that  day.  A  few  days  later  she  was 
operated  on  for  piles,  which  were  very  large,  and  which  I  re- 
moved by  the  method  I  always  employ :  a  Whitehouse 
operation  by  which  the  whole  of  the  pile-bearing  area  was 
removed,  after  tying  off  in  four  segments  ;  and  then  the  mu- 
cous membrane  of  the  rectum  was  united  to  the  skin  with  a 
running  black,  silk  stitch.  The  result  was  all  that  could  be 
desired  ;  she  has  been  seen  since  and  has  no  trouble.  We 
take  care  in  all  cases  of  piles  to  keep  the  bowels  liquid  with 
compound  liquorice  powder. 

On  the  20th  a  Miss  A,  came  in  for  a  week's  rest.  She 
had  had  fixation  of  a  floating  kidney  two  years  before,  but 


GYNECOLOGICAL  CASES.  34  I 

had  to  work  very  hard  ever  since,  and  never  got  into   robust 
health.     She  was  able  to  go  back  to  her  work  in  the  factory. 

On  the  23rd  a  Mrs.  J.,  38  years  old,  came  in  and  was 
curetted  for  menorrhagia  by  one  of  the  staff,  but  a  week  later 
bleeding  began  again  ;  so  at  the  request  of  her  physician  I 
curetted  and  applied  equal  parts  of  Churchill's  iodine  and  car- 
bolic acid,  and  then  removed  a  large  lacerated  and  everted 
cervix.  The  effect  on  her  general  health  was  excellent,  and 
a  few  weeks  later  she  became  pregnant,  which  is  a  good  proof 
of  the  benefit  of  the  operation,  as  she  had  had  no  child  for 
ten  years  before. 

On  the  29th  January  a  Mrs.  B.  was  sent  in  by  Dr. 
Harvey  for  symptoms  of  tubal  pregnancy,  but  after  watching 
her  for  three  weeks  we  decided  that  it  was  a  normal  preg- 
nancy. 

On  the  same  day  a  Mrs.  W.  was  sent  in  by  Dr.  Decks 
for  symptoms  of  tubal  pregnancy,  but  after  careful  observa- 
tion I  came  to  the  conclusion  that  the  irregular  hemorrhage 
and  pain  were  due  to  some  other  cause,  which  was  treated, 
and  she  is  now  well.  These  two  gentlemen  deserve  the 
credit  of  being  on  the  lookout  for  tubal  pregnancy.  I  am 
sure  that  no  case  of  this  disease  could  escape  their  notice. 

On  the  31st  of  January  Mrs.  S.,  aet.  42,  had  been  in  be- 
fore sixteen  months  ago  when  she  had  dilatation,  curetting 
lacerated  cervix  and  complete  laceration  of  perineum  opera- 
tions, which  were  most  successful.  She  also  had  Alexander's 
operation  on  the  round  ligaments,  which,  although  successful 
in  keeping  the  uterus  up,  did  not  relieve  her  pain.  So  I  de- 
cided that  I  would  open  the  abdomen  and  look  for  adhesions, 
which  were  found  and  freed,  and  one  cirrhotic  ovary  was 
removed  and  the  uterus  fixed  to  the  abdominal  wall.  She 
made  an  excellent  recovery,  and  is  now  working  as  general 
servant,  at  very  hard  work. 

This  comprises  all  the  cases  admitted  in  January,  1902. 
In  my  next  article  I  will  report  an  interesting  series  of  cases 
operated  on  in  February. 


Selected  Articles. 


THE  ILLNESS  OF  THE  KING. 

The  Lancet  (London),  of  July  5,  writing  upon  King 
Edward's  illness,  says  :  The  present  condition  of  His  Majesty 
the  King  and  the  future  progress  of  his  health  can  be  gauged 
best  by  a  full  consideration  of  the  case  from  the  very  begin- 
ning. Our  readers  will  be  able  to  follow  the  thread  of  our 
remarks  if  they  read  in  connection  with  them  the  brief  ac- 
count of  His  Majesty's  illness  which  appeared  in  our  second 
edition  last  week,  and  which  we  reprint  below.  Firstly,  was 
there  any  condition  present  which  might  predispose  to  the 
developments  of  perityphlitis?  Although  no  reference  ap- 
pears to  have  been  made  to  it,  it  is  far  from  unlikely  that  the 
severe  attack  of  typhoid  fever  from  which  the  King  suffered 
in  1 87 1  may  have  had  some  etiological  connection  with  his 
present  illness.  The  ulceration  of  the  bowel  in  typhoid  fever 
is  especially  severe  near  the  ileo-cecal  valve,  and  adhesions 
occurring  as  a  result  of  the  intestinal  ulceration,  especially 
when  the  attack  has  been  prolonged,  are  not  uncommon. 
Adhesions  of  this  nature  are  liable  to  produce  displacement 
and  torsion  in  the  neighbourhood  of  the  cecum,  and  it  is  now 
recognized  that  in  this  way  the  circulation  may  be  distinctly 
interfered  with,  and  that  such  disturbances  of  position  and  cir- 
culation are  important  predisposing  causes  in  the  produc- 
tion of  perityphlitis.  So  that  it  is  quite  possible  that  the 
attack  of  enteric  fever  from  which  the  King  suffered  more 
than  thirty  years  ago  may  be  really  connected  with  the 
illness  from  which  he  is  suffering  now. 

The  present  attack  appears  to  date  from  some  ten  days 
earlier  than  the  operation.  For  it  was  on  June  14  that  the 
King  first  complained  of  abdominal  discomfort,  but  it  wa  s 
slight,  and  did  not  interfere  with  the  journey  to  Aldershot. 
At  midnight  of  the  same  day  abdominal  pain  came  on,  and 
Sir  Francis  Laking  was  summoned  and  was  able  to  relieve 
the  urgency  of  the  symptoms;  and  on  the  next  day,  June 
15,  His  Majesty  was  seen  by  Sir  Thomas  Barlow.  Up  to 
this  time  the  signs  and  symptoms  were  indefinite,  and  though 
they  were  sufficient  to  suggest  the  possibility  of  perityphlitis, 
no  trustworthy  diagnosis  could  be  made.  On  the  afternoon 
of  the  13th  a  chilly  fit  occurred  ;  this  was  in  all  probability 
a  real  rigour,  and  marks  the  time  at  which,  from  the  after- 
history  of  the  case,  we  may  conclude  that  suppuration  com 


THE  ILLNESS  OF  THE  KING.  343 

menced.  We  may  interpret  these  symptoms  by  the  light 
of  our  later  knowledge  as  follows  :  The  commencement  of 
the  perityphlitis  dates  from  the  first  abdominal  discomfort 
of  which  the  King  complained  on  Saturday,  June  14.  It 
may  have  been  connected  with  the  great  fatigue  of  the 
previous  day,  and  the  taking  of  a  late  supper;  but  it  is  quite 
possible  that  neither  had  anything  to  do  with  it.  During 
Saturday  and  Sunday  the  inflammation  extended  and  set  up 
an  adhesive  peritonitis.  To  this  was  doubtless  due  most  of 
the  pain  of  which  the  King  complained.  Then  pus  began  to 
form  around  the  cecum.  This  suppuration  was  localized 
by  the  adhesions  which  had  already  formed  between  the 
adjoining  coils  of  intestine,  and  if  our  suggestion  be  correct 
as  to  the  influence  of  the  attack  of  typhoid  fever,  old  ad- 
hesions remaining  from  that  illness  may  have  assisted  in  con- 
fining the  suppurative  process.  By  Monday,  June  i5,  the 
King  had  recovered  sufficiently  to  bear  well  the  drive  to 
Windsor,  for  he  arrived  there  without  fatigue.  On  Tuesday 
signs  began  to  appear  which  rendered  certain  the  nature  of 
the  affection,  and  when  he  was  seen  on  Wednesday,  June  18, 
the  local  manifestations  were  well  marked.  In  the  right  iliac 
fossa  there  was  a  well-defined,  somewhat  firm  swelling, 
with  distinct  tenderness,  but  no  very  marked  pain  inde- 
pendently of  pressure.  The  temperature  was  raised  and  the 
diagnosis  could  be  made  with  ease  and  certainty.  Then 
would  arise  the  question  of  operation.  There  are  some  in 
this  country,  and  still  more  abroad,  who  advocate  operative 
measures  at  the  earliest  possible  moment,  but  by  indiscrim- 
inate operation  in  all  cases,  without  regard  to  the  exact 
nature  of  the  local  condition,  the  best  results  are  not  ob- 
tained. It  cannot  be  disputed  that  a  large  number  of 
cases  of  perityphlitis  recover  without  surgical  aid,  and  that 
many  others  result  in  the  formation  of  a  localized  abscess 
which  may  be  evacuated  without  necessarily  disturbing  the 
cecum,  without,  indeed,  it  ever  being  established  that  in- 
flammation in  its  vicinity  was  the  cause  of  the  trouble.  The 
great  danger  in  perityphlitis  is  general  septic  peritonitis. 
What  may  be  called  the  "natural"  method  of  prevention  of 
this  complication  is  by  the  formation  of  peritoneal  adhesions, 
shutting  off  the  focus  of  infection  from  the  rest  of  the  peri- 
toneal cavity.  To  attempt  to  disturb  the  cecum  while  this 
process  of  localization  of  the  suppuration  is  going  on,  can  only 
lead  to  the  hastening  of  the  evil  which  it  is  desired  to  avert, 
for  the  breaking  down  of  the  protective  adhesions  will  almost 


344  THE  ILLNESS  OF  THE  KING. 

certainly  cause  the  generalization  of  the  peritoneal  infection. 
There  is  the  less  need  to  discuss  the  question  of  the  supe- 
riority of  early  or  late  operation,  seeing  that  we  have  no 
proof  in  the  King's  case  that  the  appendix  was  inflamed,  but 
we  may  be  permitted  to  express  our  complete  approval  of 
the  course  adopted  by  His  Majesty's  medical  advisers. 

With  complete  rest  on  Thursday,  Friday  and  Saturday 
the  King's  condition  improved,  the  temperature  fell  to  nor- 
mal, and  he  felt  better  in  himself,  and  the  improvement 
continued  during  the  Sunday  so  that  on  Monday  His  Majesty 
was  able  to  journey  to  London  by  train.  Up  to  Monday, 
June  23,  it  had  been  hoped  that  care  and  rest  had  served 
the  patient  so  well  that  the  necessity  for  active  surgical 
treatment  had  passed  away.  This  was  only  in  accord  with 
the  earnest  wish  of  the  King,  who  was  extremely  anxious 
to  carry  out,  at  whatever  pain  to  himself,  the  arrangements 
that  had  been  made.  On  Monday,  however,  the  probability 
of  the  presence  of  pus  in  the  right  iliac  fossa-  was  suspected, 
and  on  the  morning  of  Tuesday,  June  24,  it  became  clear 
that  suppuration  had  occurred.  The  iliac  swelling  was 
again  obvious,  the  pain  had  increased,  and  the  temperature 
was  once  more  elevated.  All  these  signs  pointed  clearly 
to  the  formation  of  a  localized  abscess.  The  danger  of  delay 
was  great.  The  formation  of  pus  was  evidently  proceed- 
ing rapidly,  and  the  abcess  was  extending.  In  such  cir- 
cumstances the  impossibility  of  sanctioning  any  attempt  at 
carrying  out  the  coronation  ceremony  was  at  once  obvious. 
Nay,  more,  the  necessity  for  the  immediate  evacuation  of 
the  pus  was  urgent,  for  if  no  outlet  for  it  were  provided 
the  far  greater  danger  of  general  septic  peritonitis  was  im- 
minent, a  condition  in  which  surgical  interference  is  too 
often  of  small  avail.  Lord  Lister  and  Sir  Thomas  Smith 
agreed  that  an  operation  was  imperative,  and  the  King 
gave  his  assent  reluctantly,  not  because  of  the  pain  or  the 
risk  to  himself,  but  because  he  knew  the  severe  disappoint- 
ment the  change  of  plan  would  occasion  to  the  many  thou- 
sands who  were  assembling  in  honour  of  his  coronation. 

To  Sir  Frederick  Treves  was  committed  the  heavy 
responsibility  of  performing  the  operation.  An  incision  was 
made  a  short  distance  above  Poupart's  ligament  on  the  right 
side;  the  wound  was  steadily  deepened,  but  it  was  not  until 
it  had  obtained  a  depth  of  some  four  and  a  half  inches  that 
pus  was  reached.  This  was  evacuated,  and  the  abscess  cavity 
drained  by  means  of  two   rubber  tubes-     By  the  evacuation 


THE  ILLNESS  OP  THE  KING.  345 

of  the  pus  and  the  subsequent  drainage  the  immediate  risk 
of  the  involvement  of  the  general  peritoneal  cavity  was 
averted,  and  thus  the  danger  of  the  disease  was  greatly 
reduced.  The  efifects  of  the  operation  soon  showed  them- 
selves. The  pain  from  which  the  patient  had  suffered  se- 
verely was  markedly  relieved,  the  temperature  rapidly  fell, 
and  it  was  evident  that  the  septic  absorption  had  ceased.  It 
was  possible  for  his  medical  attendants  to  announce  on  the 
same  evening  that  the  King's  condition  was  as  good  as  could 
be  expected  after  so  serious  an  operation,  that  his  strength 
was  well  maintained  and  that  the  pain  had  diminished. 
There  was  an  addendum  to  the  efifect  that  it  would  be  some 
days  before  it  could  be  said  that  the  King  was  out  of 
danger;  this  was  a  necessary  warning  to  the  public,  for  it 
may  happen  that  the  extension  of  the  suppurative  process 
does  not  cease  with  the  evacuation  of  the  pus. 

During  the  earlier  part  of  the  first  night  after  the  oper- 
ation His  Majesty  was  restless  and  did  not  sleep,  but  after 
one  o'clock  some  sleep  was  obtained.  A  fairly  comfortable 
day  followed  and  but  little  pain  was  experienced  except  at 
the  dressing  of  the  wound.  His  strength  was  fairly  well 
maintained.  On  the  second  night  he  had  some  refreshing 
sleep,  and  he  improved  in  all  respects,  and  the  state  of 
the  wound  continued  satisfactory.  On  Friday,  June  27,  it 
was  announced  that  a  fair  night  had  been  passed,  and 
that  the  temperature  remained  normal.  On  Sunday,  the 
fifth  day  after  the  operation,  the  King  was  sufficiently 
recovered  to  permit  his  being  moved  on  to  a  couch  for  a 
few  hours,  and  up  to  the  time  of  writing  the  improvement 
has  steadily  continued.  A  fair  amount  of  sleep  is  obtained, 
the  King's  strength  increases,  and  the  wound  continues 
to  progress  in  a  satisfactory  manner.  It  is,  of  course,  most 
important  that  the  abscess  cavity  should  close  completely, 
and  from  the  bottom  ;  otherwise  an  intractable  sinus  would 
be  not  unlikely  to  result.  The  wound  is,  therefore,  packed 
with  gauze,  and  this  necessarily  occasions  no  small  amount 
of  pain.  This  is  unfortunate,  but  cannot  be  avoided,  and 
it  is  consoling  to  remember  that  the  pain  will  decrease 
with  each  dressing. 

We  have  followed  the  illustrious  patient's  progress  from 
the  commencement  of  his  illness  to  the  present  time  and  we 
are  now  in  a  position  to  consider  the  prognosis.  The 
dangers  which  may  arise  may  proceed  from  the  patient's 
constitution,  or  be  connected  with  the  local  lesion.       As  to 


34^  THE  ILLNESS  OP  THE  KING. 

the  King's  general  constitution   there  is  but  little  cause  for 
anxiety.    At  his  age,  sixty-one  years,  he  is  probably  as  strong 
as  the  average  of  his  subjects,  and,  apart  from  the  harassing 
nature  of  his  duties  and  the  energy  and  zeal  with  which  he 
has  ever  undertaken  all  that  he  is  called  upon  to  do,    there 
has  been  nothing  materially   to  impair  his  general  health. 
The  severe  attack  of  typhoid    fever  in    1871,   to  which  we 
have  already    alluded,  served  for  a  time  to  weaken  him,  but 
the  effect    was    transient.     It    cannot,  however,  be  doubted 
that    the   grave    disappointment    which    the  King  feels   at 
having  to  postpone  the  coronation   may  exert  some  depres- 
sing effect  on  him.       To  dispel  as  far  as    possible    any  un- 
toward mental  or  sentimental  condition  must  be  the  best  en- 
deavour of  those  around  his  bedside.     Turning  to  the  local 
conditions,  we  find  several  possibilities  of   harm.     The  wall 
of  the  abscess  cavity  is  formed  by  coils  of  small   intestine, 
which  have  become  adherent  owing  to  adhesive  peritonitis ; 
some  of  these  adhesions  have  probably  already  commenced 
to  organize.     Somewhere  in   this  wall  there  may  be  a  pec- 
cant appendix   matted   to  the  intestine  by  exuded  lymph ; 
from    it  and   from  the  other  parts  of  the  wall  of  the  abscess 
cavity  pus  may  be  still  secreted.     The  chief  danger  is  the 
extension  of  the  suppurative  process  to  the  general  peritoneal 
cavity,  but  day  by  day  the  adhesions  localizing  the  mischief 
are    growing   stronger,  organization    proceeds  rapidly    and 
before  long   they  will  be  strong  enough  to    resist  any  strain 
to  which  they  may  be   subjected.       The  danger    from   this 
cause  has  steadily  grown  less  and  less  with  every  favourable 
bulletin.    Again,  the  risk  of  the  absorption  of  septic  products 
from  the  abscess  cavity  is  now  very  small,  as  all  tension  has 
been  removed  and  the  granulations  which  have  formed  offer 
an  effective  resistance  to  the  passage  of  the  toxins  into  the 
blood-vessels   and  lymphatics  ;    at  any  rate,  the  state  of  the 
temperature  shows  that  now  no  absorption  is  taking  place. 
The  chance  of  the  occurrence  of  general  septicemia  may  be 
disregarded.     On   the  critical  view  of  the  situation  of  the 
King  it  may  be  said  that  there  is  great  promise  of  a  speedy 
and  safe  recovery  from  his  illness ;  speedy,  we  say,  though 
many  weeks  must  elapse  before  he  is  well,  for  we  must  bear 
in   mind    the   severity  of  the   illness  and    of  the  operation 
performed  for  its  relief;  and  safe  because  the  probability  of 
any  complication    supervening  is    remote.       On    the  main- 
tenance   of   his   strength,    apart    from    care  in  dressing  the 
wound,  depends  mainly  the  recovery  of  His  Majesty. 


VALUE    OF   AN   OCCASIONAL   CONVULSION.  347 

One  further  point  requires  consideration.  If,  as  we  may 
not  unreasonably  hope  and  expect,  the  King  recovers  from 
his  illness,  will  a  recurrence  be  likely  or  will  it  never  be 
necessary  to  interfere  with  the  appendix  ?  The  answer 
which  would  be  given  by  those  surgeons  who  have  had  most 
experience  in  abdominal  surgery  would  surely  be  "  No." 
When  an  abscess  has  developed  in  connection  with  the  ap- 
pendix and  has  been  successfully  drained,  it  is  rare,  indeed, 
for  any  recrudescence  of  mischief  or  for  any  further  oper- 
ation to  be  required. 


THE  VALUE  OF  AN  OCCASIONAL  CONVULSION  IN 
CERTAIN  CASES. 

By  William  P.  Sprattling,  M.  D. 

Medical  Superintendent  of  the  Craig  Colony  for  Epileptics,  Secretary  of  the  National 

Association  for  the  Study  of  Ji,pilepsy,  etc., 

Sonyea,  N.  Y. 

It  is  hard  to  imagine  anything  more  contradictory  on  its 
face  than  to  say  that  a  convulsion  could  ever  be  of  value  ;  yet 
I  am  convinced  that  such  is  sometimes  the  case,  for  two  classes 
of  individuals  have  come  under  my  obseivation  in  which 
occasional  convulsions  were  productive  of  good.  The  first 
includes  epileptics  in  which  prolonged  periods  of  mental  dis- 
turbance or  insanity  are  prevented  through  the  occurrence 
of  a  fit  ;  the  second,  selected  cases  of  insipient  alcoholism  in 
which  a  persistence  in  the  drinking  habit  would  probably 
lead  to  confirmed  epilepsy,  were  it  not  for  the  emphatic 
warning  given  by  the  convulsion. 

Epileptics  of  a  certain  type  make  up  the  first  class,  and 
includes  those  in  which  the  disease  seems  dependent  on  fluc- 
tuating internal  causes ;  on  the  action  of  certain  toxines  as 
yet  unisolated,  and  but  little  understood,  and  which  grow  in 
intensity  until  a  limit  is  reached,  when  their  toxicity  is  in 
some  manner  neutralized  or  destroyed  by  a  convulsion,  only 
to  repeat  again  and  again  the  same  process  of  development, 
growth  and  decadence,  the  latter  occurring  each  time  as  the 
result  of  one  or  more  epileptic  convulsions.  These  periods 
of  exacerbation  are  not,  as  a  rule,  fixed  in  time,  although  I 
have  seen  a  few  cases  in  which  there  seemed  to  be  some  evi- 
dence of  periodicity. 

Epilepsy  generally  manifests  itself  by  a  sudden  and  more 
or  less  appreciable  discharge  of  nervous  energy  in  some  part 
of  the  brain,  and  we  know  that  experimental  epilepsy  may  be 
produced  in  the  lower  animals  in  various  ways,    as,  for  in  - 


348  VALUE    OF   AN    OCCASIONAL   CONVULSION. 

stance,  by  the  application  of  electricity  to  the  brain  cortex, 
and  by  introducin,::  certain  substances  into  the  circulation, 
such  as  ammonium  carbammate,  alcohol  and  other  toxic  fluids. 
Now  the  action  of  toxic  substances  introduced  from  without 
is  not  essentially  different  from  those  produced  within,  and, 
relatively,  they  are  of  importance  to  the  individual  only  in  so 
far  as  he  may  or  may  not  have  power  of  control  over  them. 
In  the  former  cases,  those  in  which  toxic  agencies  are  intro- 
duced from  without,  his  control  over  them  may  reasonably 
be  assumed  to  be  absolute,  i.  e.,  he  may  introduce  them  or 
not,  just  as  he  chooses  ;  while  in  the  latter,  in  the  case  of 
agencies  having  a  like  action  and  generated  within,  he  may 
or  may  not  be  able  to  prevent  their  origin. 

When  a  man  who  is  well  along  in  years  begins  to  drink 
and  has  a  convulsion  as  the  result,  he  had  better  let  alcohol 
alone  at  once,  for  that  convulsion  meant  an  emphatic  protest 
on  the  part  of  the  brain  that  it  cannot  be  subjected  to  such 
evil  influences  without  the  risk  of  pronounced  injury  to  the 
general  welfare  of  the  individual.  All  amateur  alcoholics 
would  not  have  such  a  warning,  and  only  those  who  suffer  a 
constitutional  loss  of  resistance  on  the  part  of  the  nervous 
system  to  the  action  of  alcohol,  especially  need  it,  and  such 
individuals  ought  to  admire  the  wisdom  of  Nature  in  provid- 
ing it. 

In  some  cases,  perhaps  in  most  of  them,  a  convulsion* 
after  all,  may  be  regarded  as  only  a  protest  on  the  part  of 
Nature  against  the  presence  of  an  irritant  of  some  kind  in  a 
part  of  the  body  where  it  ought  not  to  be,  and  it  only  remains 
for  science  to  locate  and  determine  the  nature  of  the  irritant. 

A  man  of  40 — the  exponent  of  an  eminent  calling — an 
athlete  in  proportion,  strong,  vigorous,  robust,  and  in  every 
respect  the  picture  of  health,  consulted  me  some  five  years 
ago  for  what  he  called  "  fainting  spells."  A  thorough 
examination  of  his  condition  left  me  at  a  loss  at  first  to 
account  for  his  convulsions,  but  on  close  questioning  he 
shortly  admitted  occasional  over-indulgence  in  strong  drink 
at  times  when  "good  fellowship  was  being  put  to  the  test." 
I  warned  him  earnestly  ;  told  him  that  as  often  as  he  applied 
the  match,  just  so  often  would  the  powder  probably  explode  ; 
but  he  was  unable  at  first  to  quit  the  practice,  and  about 
every  two  months,  for  a  period  of  two  years,  he  would  have 
one  and  sometimes  two  well  marked  convulsions  after  his 
periods  of  dissipation.  Finally — being  a  man  who  often 
spoke   in   public — he   had  a  very   marked    convulsion  in  a 


VALUE    OF   AN    OCCASIONAL   CONVULSION.  349 

place  and  manner  that  embarrassed  him  exceedingly,  but 
which  had  the  salutary  effect  of  bringing  him  to  his  senses, 
for  after  that  he  submitted  to  proper  treatment,  abstained 
from  further  indulgence  in  alcoholic  drink,  and  for  three 
years  now  has  not  had  a  convulsion.  This  man  stood  in 
danger  of  sooner  or  later  becoming  a  confirmed  epileptic;  not 
because  there  was  any  distinctive  cause  in  his  condition 
capable  in  itself  of  producing  epilepsy,  but  because  there 
was  in  him  an  inherer.t  tendency  to  convulsions  which  would 
only  appear  under  proper  excitation,  and  which,  being  forced 
to  appear  a  sufficient  number  of  times,  would  give  rise  to  a 
condition  that  might  continue  to  create  them  independent 
of  the  action  of  an  immediate  excitant. 

Such  convulsions,  once  established,  are  termed  "  Habit 
Epilepsy,"  and  they  express  conclusively  the  power  of  edu- 
cation possessed  by  the  central  nervous  system. 

In  the  second  class  of  cases  in  which  an  occasional 
convulsion  helps  to  preserve  the  mental  life  of  the  patient,  it 
is  far  more  difficult  to  determine  and  remove  the  cause.  In 
many  of  them  the  convulsion  seems  to  come  as  the  termina- 
tion of  an  obscure  auto-toxic  cycle  that  varies  in  duration  in 
different  individuals  and  that  bears  some  similarity,  in  its 
upward  period,  at  least,  to  the  "  Folie  Circulaire "  or  the 
Circular  Insanity  of  the  French.  It  seems  evident  that  the 
specific  cause  of  the  fit  in  these  cases  is  something  that 
permeates  the  entire  organism  ;  something  that  comes  and 
goes,  causing  a  sort  of  Psychic  tide  that  rises  and  falls;  that 
grows  and  develops  in  intensity,  exerting  a  pernicious  influ- 
ence on  the  daily  life  of  the  patient  by  making  him  do  and 
say  things  not  in  harmony  with  his  normal  state,  which 
abnormalities  the  patient  will  exhibit  in  proportion  to  his 
powers  of  inhibition,  until  the  limit  is  reached  and  the  mind 
loses  its  direction  and  control.  The  powers  of  further 
inhibition  finally  being  destroyed,  the  nervous  storm  breaks 
with  great  force  and  violence,  the  poison  is  neutralized  or 
destroyed,  equilibrium  is  restored,  and  all  is  quiet  and  serene 
once  more. 

A  fairly  typical  illustration  of  this  class,  in  her  own 
language,  by  E.  M.,  an  intelligent  woman  of  43,  and  now  a 
patient  at  the  Craig  Colony,  is  of  interest, 

"This  is  now  the  22nd  of  February,  1902.  I  had  four 
very  severe  attacks  on  the  31st  of  last  January.  I  felt  the 
attacks  coming  for  a  long  time  before  they  came.  I  was 
exceedingly  nervous  and  irritable  ;  things  did  not  go  right. 


350  VALUE    OF   AN    OCCASIONAL   CONVULSION. 

I  scolded  about  everything,  and  was  unable  to  hold  things  in 
a  proper  manner.  When  I  picked  up  my  brush  and  comb  I 
would  drop  them,  and  when  I  walked  I  stepped  crooked — 
one  foot  would  keep  making  mistakes,  and  I  didn't  know 
which  foot  it  was.  They  said  it  was  the  left.  I  could  not 
sleep  at  all.  I  lay  thinking  of  things  that  had  happened  and 
that  was  not  pleasant.  I  tried  to  put  them  out  of  my  mind 
by  thinking  of  what  I  had  read.  I  like  history,  and  I  tried 
to  think  of  some  character  in  English  history  about  which  I 
had  read.  I  have  a  strong  will  and  feel  that  I  can  control 
my  thought  at  most  times,  but  for  days  before  the  attacks 
come  on  I  am  unable  to  do  so.  They  go  ofT  about  every- 
thing, and  I  try  to  make  them  come  back,  but  they  won't. 
They  get  worse  every  day  and  night,  and,  finally,  they  all 
get  jumbled  up  together  and  I  don't  know  anything.  Then 
the  attacks  come  on  and  after  that  I  am  all  right — every- 
thing clears  up  and  I  see  things  as  they  really  are.  I  lose 
all  my  nervousness  and  can  act  naturally." 

The  same  psychic  phenomena  are  witnessed  in  insane 
epileptics,  who  are  prone  to  show  indications  of  an  ap- 
proaching seizure.  "  In  asylum  life,"  says  Bevan  Lewis, 
"amongst  the  intelligent  class  of  nurses  the  fact  is  univer- 
sally recognized  that  a  premonitory  stage  of  great  irritability 
is  often  seen,  and  the  effect  of  a  convulsive  attack  will  be 
to  clear  up  the  mental  atmosphere."  In  our  experience, 
delusions,  hallucinations  and  illusions  are  very  rare  in  the 
average  epileptic,  sane  or  insane,  during  the  inter-paroxys- 
mal period,  but  are  more  Common  during  thepre-paroxysmal 
stage,  nearly  always  disappearing  with  the  fit.  Personally 
I  come  in  contact  with  large  numbers  of  epileptics  at  regular 
times  each  week,  and  it  is  easy  to  detect  psychic  evidences 
of  an  oncoming  attack,  in  many  cases  days  and  even  weeks 
before  the  attack  occurs.  Such  cases  would  seem  to  offer 
an  inviting  field  in  which  the  comparative  study  of  living 
matter  in  the  most  comprehensive  manner,  during,  as 
well  as  between,  the  periods  of  disturbance  that  culminate 
in  convulsions,  might  be  pursued  to  advantage;  and  espe- 
cially do  they  emphasize  the  necessity  for  studying  and 
treating  the  epileptic  strictly  on  an  individual  basis. 

Nor  is  it  enough  now  to  speak  simply  of  epilepsy,  for 
our  knowledge  of  its  manifold  types  and  causes  would 
seem  to  require  that  we  make  every  effort  to  be  more  specific 
and  define  which  one  of  the  epilepsies  we  may  have  under 
consideration. — Albany  Med.  Annals. 


Progress  of  Medical  Science. 


MEDICINE    AND     NEUROLOGY 

IN  CHARGE   OF 

J.  BRADFORD  McCONNBLL,  M.D. 

Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College ;  Physician  Western  Hospital . 


TINNITUS  AURIUM. 

This  annoying  and  persistent  symptom  is  dependent 
upon  a  variety  of  conditions.  In  the  experience  of  many 
otologists,  nearly  as  many  patients  apply  for  treatment  for 
this  condition  as  for  impaired  hearing.  The  relief  of 
deafness  is  often  easier  than  the  abatement  of  subjective 
noises.  A  classification  of  the  symptoms  should  relate  to 
the  underlying  conditions,  but  this  is  impossible.  The 
following  may  be  regarded  as  a  convenient  provisional 
arrangement : 

1.  Conduction  sounds  or  noises  due  to  occlusion  or 
impaired  mobility  of  some  portion  of  the  sound-conducting 
apparatus. 

2.  Blood  sounds  or  noises  produced  by  the  blood- 
current  in  vessels  in  or  near  the  ear,  and'  due  either  to  distur- 
bance of  the  local  or  general  circulation,  and  to  abnormalities 
in  the  size,  shape  or  position  of  the  vessels. 

3.  Labyrinthine  sounds  or  noises  due  to  alterations  in 
the  pressure  within  the  labyrinth. 

4.  Neurotic  sounds  or  noises  due  to  increased 
irritability  of  the  auditory  nerve. 

5.  Cerebral  sounds  or  noises  due  to  lesions  of  the 
auditory  centers  in  the  cerebral  cortex. 

In  the  search  for  these  various  causes,  evidences  of 
disease  in  any  portion  of  the  conducting  apparatus  should 
be  carefully  looked  for  by  a  thorough  physical  examination. 
The  history  of  the  case  should  be  obtained  and  an  accurate 
description  taken  of  the  character  of  the  sound.  A  careful 
functional  examination  should  be  made,  and  diseases  of 
other  organs  or  the  digestive  tract,  or  circulatory  disturbance, 
should  be  looked  for.  In  addition,  the  effects  of  certain 
drugs  in  relieving  or  aggravating  the  tinnitus  should  be  noted. 

A  physical  examination  of  the  ear  is  never  to  be  omitted, 
because  any  lesion  of  the  conducting  apparatus  is  an  impor- 


PROGRESS  OF  MEDICAL  SCIENCE. 

tant  contribu.  factor  to  the  production  of  tinnitus.  From 
the  patient  we  can  learn  the  character  of  the  noises,  whether 
unilateral  or  bilateral,  simple  or  elaborated,  constant  or 
intermittent,  pulsating  or  uniform,  and  the  pitch.  The  latter 
is  of  importance,  for,  generally  speaking,  low  sounds  suggest 
tympanic  and  high  sounds  labyrinthine  involvement.  The 
pitch  is  best  determined  by  holding  a  tuning-fork,  256  D,  V., 
opposite  the  patient's  ear  and  requiring  him  to  decide 
whether  the  pitch  of  the  subjective  sound  is  higher  or  lower 
than  that  of  the  fork. 

The  length  of  time  during  which  tinnitus  persists  is  of 
some  importance,  as  sounds  of  tympanic  origin  rarely  persist 
for  a  great  length  of  time.  The  subjective  noise  persisting 
constantly  from  childhood  to  adult  life  suggests  an  anoma- 
lous position  of  the  vessels.  Elevation  of  the  lower  tone 
limit  suggests  tympanic  disease,  while  the  lowering  of  the 
upper  tone  limit  points  to  labyrinthine  disturbance. — ^Philip 
D.  Kerrison,  Laryngoscope. 

TREATMENT  OF  GASTROPTOSIS. 

A  lengthy  article  upon  the  displacements  of  the 
stomach,  together  with  a  discussion  of  the  diagnostic  criteria, 
is  concluded  by  some  excellent  remarks  upon  treatment, 
Tight  lacing  and  heavy  clothing  hanging  from  the  waist- 
bands should  be  forbidden.  Clothing  should  be  supported 
from  the  shoulders.  The  patient's  habits  should  be  rigidly 
scrutinized.  Rest  for  at  least  an  hour  after  meals,  flat  upon 
the  back,  with  the  clothing  loosened,  is  a  useful  measure. 
Food  should  be  taken  in  small  quantities  and  should  be 
digestible  and  adapted  to  the  gastric  secretions.  A  diet 
applicable  to  all  cases  cannot  be  given,  as  the  amount  of 
food  is  dependent  upon  the  amount  of  hydrochloric  acid 
secreted,  and  this  is  largely  determined  by  the  presence  or 
absence  of  dilatation.  Two  measures  are  to  be  insisted  upon, 
namely,  that  the  food  shall  not  be  too  great  at  one  time, 
and  that  there  shall  be  a  period  of  rest  after  each  meal. 
Lavage  is  not  required  unless  retention  demands  it. 

The  stomach  is  to  be  held  in  place  by  a  belt  or  abdo- 
minal bandage,  so  as  to  exert  pressure  from  below  upward 
and  backward  ;  the  ordinary  elastic  supporter  is  best  for  the 
purpose.  A  simple  binder  is  usually  not  sufificient.  The 
lower  edge  of  the  belt  must  be  firmly  held  against  the  pubis 
by  perineal  bands.  Jf  this  counter-force  is  not  employed, 
the  belt  invariably  slips  upward,  and  the  satisfactory  efifects 


MEDICINE   AND   NEUROLOGY.  353 

of  upward  pressure  cannot  be  obtained.     Pads  are  useful  in 

connection  with  the  belt;  they  should  be  from  three-fourths 

to  one  and  three-fourths  inches  in  thickness,  so  placed  as  to 

exert  upward  pressure.     Such  a  pad  may  be  advantageously 

placed  below  the  displaced  pylorus.     In  total  descent  it  is 

well   to    employ    two  pads  parallel  to    and   a   little   above 

Poupart's  ligament.     Without  pads  it  is  rarely  possible  to 

restore  the  stomach  to  its  normal  position.     In  cases  where 

the  abdominal  walls  are  thin,  it  is  difficult  to  exert  sufficient 

upward  pressure  by  a  belt  alone,  and  in  such  individuals  the 

pads  are  indispensable.     Any   apparatus  for  retaining    the 

stomach  cannot  be  shown  to  be  satisfactory  until  the  organ 

is  shown  by  inflation  to  be  in  its  normal  position  when  the 

apparatus  is  in  place.     The  belt  should  be  snugly  fitted  and 

worn  fairly  tight  around  the  hips,  while  the  upper  border 

should  be  loose.     The  proper  application  of  such  a  belt  is 

shown  by  almost  instant  relief  of  the  symptoms.     Such  an 

apparatus,  however,  does  not  produce  a  cure.     It  only  aids 

the  stomach  wall  in  recovering  its  tone. 

Operative  measures  in  this  condition  are  advised  hesitat- 
ingly, as  it  is  impossible  to  state  of  what  value  they  may  be 
in  permanently  relieving  the  condition.  Until  such  time  as 
the  indications  for  operation  are  more  clearly  defined  than 
at  present,  it  is  wise  to  restrict  the  surgical  treatment  of  the 
condition  to  those  cases  in  which  the  symptoms  are  clearly 
traceable  to  peritoneal  adhesions,  or  those  which  are  not 
amenable  to  more  conservative  measures.  When  the 
trouble  is  aggravated  by  a  relaxed  pelvic  floor  this  should 
be  remedied,  and  where  there  is  much  separation  of  the 
recti  Webster's  operation  is  to  be  recommended. — J.  D. 
Steele,  PhiladelpJiia  Medical  Journal. 

TREATMENT  OF  RINGViTORM. 

At  the  Vanderbilt  Clinic,  in  which  a  large  number  of 
cases  of  ringworm  are  treated  every  year,  a  preparation 
composed  of  one  drachm  of  crystals  of  iodine  to  an  ounce  of 
goose  grease  has  proven  to  be  the  most  efi"ective  remedy.  It 
is  applied  twice  a  day  until  it  produces  a  reaction,  as  shown 
by  a  little  swelling  of  the  patch  ;  then  once  a  day  is  sufficient. 
In  two  or  three  weeks  the  hair  falls  from  the  patch,  but  it 
grows  again,  after  which  the  aff'ected  area  is  restored.  The 
first  application  of  the  remedy  may  cause  a  little  pain,  but 
this  l.asts  only  a  few  moments,  and  even  children  do  not 
complain.     When  used   upon  the  bearded   portions  of  the 


3  54  PROGRESS  OF  MEDICAL  SCIENCE. 

face,  the  applications  are  more  painful  than  when  the  scalp  is 
the  part  treated.  If  such  reaction  occurs  the  remedy  can  be 
suspended  for  a  day  or  two,  substituting  some  bland  oint- 
ment. Many  cases  of  ringworm  of  the  face  have  been  cured 
in  three  weeks.  The  goose  grease  is  regarded  as  an  essential 
in  the  preparation  of  the  ointment,  and  this  is  sometimes 
difficult  to  obtain,  as  commercial  samples  of  goose  grease  are 
often  made  from  other  fats  which  have  a  low  melting  point. 
— G.  T.  ]  dckson,  Medica/  Record, 

URIC  ACID  FALLACIES. 

Dr.  Frank  Billings,  of  Chicago,  thus  sums  up  from  me- 
dical literature  the  theories  concerning  uric  acid,  gout  and 
the  morbid  conditions  which  occur  co-incidentally  with 
gouty  states: 

1.  Uric  acid  probably  does  not  exist  in  the  blood  in 
health. 

2.  Uric  acid  is  probably  formed  in  the  kidney  from  two 
sources :  (a)  From  urea  interacting  with  some  antecedent  of 
urea,  probably  glycocine  in  the  kidney.  The  large  amount 
of  uric  acid  excreted  by  birds  and  reptiles  and  the  presence 
in  the  blood  of  these  animals  of  urea,  and  not  uric  acid, 
points  rationally  to  this  source  of  uric  acid  in  these  ani- 
mals, and  it  is  rational  to  infer  that  a  part  at  least  of  the 
uric  acid  excreted  by  mammals,  including  man,  is  formed 
in  the  kidney  in  this  way.  (&)  From  the  nucleins  of  the 
body  by  oxidation  probably  in  the  kidney. 

3.  That  uric  acid  is  not  poisonous.  That  the  presence 
of  uric  acid  in  the  blood  as  the  quadriurate  or  biurate  pro- 
bably means  it  has  been  absorbed  from  the  kidneys. 

4.  That  defective  kidneys  are  the  cause  of  the  accumula- 
tion of  urates  in  the  blood  because  of  insufficient  excre- 
tion. 

5.  That  antecedent  kidney  disease  is  commonly  formed 
in  so-called  lithemic  states  which  have  often  been  attribut- 
ed to  the  irritating  effects  of  uric  acid  upon  the  kidney  cap- 
illaries and  the  cells  of  the  tubules. 

6.  That  the  lesions  formerly  attributed  to  uric  acid  are 
probably  due  to  the  toxic  effect  of  the  alloxuric  bases. 

7.  That  the  presence  of  these  lesions  in  the  kidneys 
and  in  the  connective-tissue  elements  of  the  body  leads  not 
only  to  accumulation  of  the  urates  in  the  blood,  but  also 
furnishes  a  proper  condition  of  tissue  for  the  deposition  of 
the  urates  as  concretions  in  joints  and  fibrous  tissues. 

8.  That  the  degree  of  alkalinity  of  the  blood  has  no  in- 
fluence upon  the  presence  of  the  urates  in  the  blood.  • 


MEDICINE   AND    NEUROLOGY.  355 

9.  That  the  deposited  biurate  concretions  cannot  be  re- 
dissolved  out  of  the  tissues  by  an  attempt  to  increase  the 
alkalinity  of  the  blood  and  fluid  by  the  use  of  alkaline  me- 
dication. 

10.  That  the  presence  of  concretions  of  the  urates  in 
the  body  comprises  the  sum  total  of  its  pathologic  effects. 

11.  That  the  so-called  uric  acid  diathesis,  the  influence 
of  heredity,  the  bad  habits  of  life,  alcoholic  indulgence,  lead 
poisoning,  etc.,  consists  in  a  condition  or  tendency  to  dis- 
integrate a  quantity  of  neuclein  far  in  excess  of  the  amount 
usually  split  up,  with  resulting  increase  of  uric  acid  and 
alloxuric  base  formation, 

12.  That  the  condition  of  the  urine  as  to  the  presence 
of  uric  acid  is  in  single  specimens  not  indicative  of  the 
blood  state  in  relation  to  the  presence  of  urates. 

13.  The  chemical  reaction  of  the  urine  bears  no  rela- 
tion to  the  presence  of  uric  acid  in  the  urine  and  blood,  nor 
does  it  indicate  the  chemical  reaction  of  the  blood. 

Some  of  the  fallacies  of  uric  acid  are  therefore: 

1.  That  uric  acid  is  toxic. 

2.  That  it  is  a  causative  factor  in  any  disease  except 
gout. 

3.  That  "uricacidemia,"  meaning  acid  blood,  does  not 
exist. 

4.  That  the  chemical  reaction  of  the  blood  may  be  al- 
tered by  the  use  of  medicinal  quantities  of  the  alkalies  or 
by  diet.  • 

5.  That  uratic  deposits  may  be  dissolved  out  by  the  ad- 
ministration of  alkalies. 

6.  That  lithia  is  a  uric  acid  solvent  of  unusual  potency. 

7.  That  uric  acid  is  an  abnormal  constituent  of  the 
urine. 

8.  That  an  excess  of  uric  acid  in  the  urine  at  one  time, 
or  a  deflciency  at  another  time,  indicates  an  abnormal  con- 
dition in  reference  to  uric  acid. 

9.  That  rheumatism  is  due  to  uric  acid. — Northwestern 
Lancet. 

THE  TREATMENT  OF  PNEUMONIA  BY  ANTTPNEUMO- 
COOCITS  SERUM. 

Sears  (Boston  Medical  and  Surgical  Journal,  December  12, 
1901,  Maryland  Medical  Journal)  reports  twelve  cases  of 
lobar  pneumonia  treated  by  the  antipneumococcus  serum, 
the  effort  being  made  to  select  only  those  cases  of  which 
treatment  seemed  likely  to  modify  the  outcome,  thus  ex- 
cluding those  in  which  death  seemed  practically  inevitable, 
and  also  those  whose  age  or  general  condition  made  recov- 


356  PROGKESS  OF  MEDICAL  SCIENCE. 

ery  liighly  probable.  An  attempt  was  also  made  to  select 
only  those  cases  which  entered  the  hospital  early  in  the 
course  of  their  illness,  although  this  requirement  could  not 
be  rigorously  fulfilled. 

Other  measures  were  not  excluded,  and  cold  sponging, 
oxygen  inhalation,  salt  infusion  and  various  stimulants 
were  used  in  the  cases  when  their  administration  seemed 
•desirable.  Eight  of  the  twelve  cases  were  over  thirty  years 
old;  of  the  other  four  cases,  one  was  excessively  alcoholic, 
and  two  others  confessed  to  its  moderate  use. 

Of  the  eight  cases  over  thirty  years  of  age,  three  used 
alcohol  to  excess,  two  others  had  mitral  regurgitation  and 
nephritis,  and  one  arteriosclerosis.  Albumen  was  found 
in  the  urine  in  ten  cases,  in  four  in  considerable  amount. 

Three  patients  died,  i.e.,  the  mortality  was  about  the 
same  as  the  usual  hospital  rate  of  all  patients  with  this 
disease. 

In  the  nine  recoveries  the  temperature  returned  to  nor- 
mal, in  one  of  the  fifth  day,  in  one  on  the  sixth,  two  on  the 
seventh,  three  on  the  eighth,  and  two  on  the  ninth.  Thus 
the  serum  treatment  did  not  seem  to  shorten  the  course  of 
the  disease,  and  the  only  conclusion  that  can  be  drawn  in 
this  connection  is  that  the  course  of  the  disease  is  not 
lengthened. 

The  treatment,  according  to  Sear's  experience,  is  cer- 
tainly no  specific  against  the  pain  resulting  from  the  in- 
flamed pleura,  and  "yet  it  seemed,  even  in  the  fatal  cases, 
that  the  patients  were  peculiarly  comfortable''  under  its 
use. 

It  was  impossible  to  assert  that  the  injections  had  any 
effect  upon  the  fever  in  these  cases. 

No  ill-effects,  except  occasional  skin  eruptions,  with 
pain  and  swelling  of  the  joints,  were  met  with.  "A  great 
practical  objection  to  its  use  is  our  ignorance  of  the 
strength  of  the  serum  and  the  consequent  inability  to  mea- 
sure the  dose." 

Taking  all  things  into  consideration,  however,  the  un- 
favourable character  of  the  material,  and  the  fact  that  in  but 
four  cases  the  injection  was  given  before  the  third  day, 
Sears  concludes  that  the  results  of  the  use  of  the  serum  in 
these  twelve  cases  justifies  a  further  trial  of  this  form  of 
treatment. 

SPEECH  AS    A  FACTOR  IN    THE  DIAGNOSIS  AND  PROG- 
NOSIS  OF  BACKWARDNESS  IN   CHILDREN. 

G.  Hudson  Makuen.  (Journal  American  Medical  Asso- 
ciation, October  12,  1901.     Maryland  Medical  Journal). 

The  subject  of  this  paper  is  one  of  more  than  usual  im- 


MEDICINE   AND  NEUKOLOGV.  357 

portance.  The  expression  "backwardness  in  children''  has 
a  rather  indefinite  scientific  meaning.  According  to  the 
common  acceptance  of  the  term,  the  bacl^ward  child  is  one 
who  is  below  the  average  intelligence  of  children  of  the 
same  age.  A  more  scientific  definition  would  make  the 
term  ''backward  child"  mean  one  who  is  not  living  up  to 
his  own  possibilities  or  capabilities.  In  the  present  paper 
Makuen  regards  backwardness  as  a  disease. 

The  diagnosis  of  backwardness  is  not  difficult.  All 
children  who  do  not,  cannot  or  will  not  keep  up  with  their 
classes  must  be  regarded  as  backward  and  should  have 
careful  attention.  The  object  of  Makuen's  paper  is  to  con- 
sider to  what  extent  a  study  of  the  speech  of  children  will 
aid  us  in  a  diagnosis.  Freedom  of  speech  is  an  absolute 
essential  to  the  normal  development  of  children,  and  de- 
fect of  speech,  however  slight,  makes  an  impress  on  the 
child's  mentality  and  prevents  him  from  doing  all  that  he 
would  otherwise  be  capable  of  doing.  The  author  cites 
several  cases  in  point. 

A  young  man,  aged  nineteen  years,  was  regarded  as  an 
imbecile.  He  could  not  speak,  read  or  write  intelligently; 
his  expression  was  vacant  and  staring.  His  speech  was 
wholly  unintelligible.  His  whole  mental  condition  was 
thought  to  be  due  to  his  lack  of  power  of  expressign.  On 
examination  it  was  found  that  the  patient  had  a  defective 
tongue.  The  genio-hyoglosus  muscle  was  too  short,  and 
bound  the  tongue  down  to  the  floor  of  the  mouth.  A  simple 
operation  was  performed  to  give  a  free  tip  to  the  tongue, 
A  systematic  course  of  training  for  the  purpose  of  using 
the  tongue  followed  for  about  one  year.  The  imbecile 
youth  soon  became  one  of  the  leading  business  men  of  the 
city. 

From  a  study  of  a  series  of  similar  cases  he  draws  the 
following  conclusions: 

1.  It  is  not  always  possible  to  determine  at  a  glance 
the  cause  of  backwardness  in  children. 

2.  Backwardness  in  children  is  not  always  due  to  a 
central  lesion,  but  may  be  the  result  of  arrested  cerebral 
development,  due  to  some  abnormality  of  structure  in  the 
peripheral  organs. 

3.  A  very  common  cause  of  backwardness  in  children 
may  be  some  abnormality  of  structure  in  the  peripheral 
organs  of  speech, 

4.  So  closely  are  the  speech  centers  related  to  the  idea- 
tional centers  of  the  brain  that  any  impairment  of  the  one 
generally  results  in  a  corresponding  impairment  of  the 
other. 


358  PROGRESS  OF  MEDICAL  SCIENCE. 

5.  The  best  method  of  arriving  at  even  a  proximately 
correct  prognosis  in  case  of  backward  children  is  to  apply 
the  speech  test,  or,  in  other  words,  to  ascertain  by  careful 
study  and  experiment  to  what  extent  the  faculty  of  speech 
may  be  impressed,  and  it  will  be  found  that  in  those  who 
are  susceptible  to  training  in  what  may  be  called  the  refine- 
ments of  speech  are  the  ones  for  whom  we  may  promise  the 
best  results,  and  that  possibilities  for  general  development 
will  be  proportional  to  the  capacity  for  speech  develop- 
ment. 

TUBERCULOSIS. 

Dr.  B.  K.  Rachford  in  the  Archives  of  Pediatrics  for  De- 
cember, believes  that  the  keynote  of  treatment  of  tubercu- 
losis in  infancy  and  childhood  is  to  maintain  nutrition  by  a 
proper  diet.  As  the  importance  of  nutrition  becomes  more 
and  more  paramount  the  younger  the  patient  and  in  arti- 
ficially fed  infants,  the  problem  presented  is  one  of  the 
greatest  difficulty.  Milk  and  cod-liver  oil  remain  the 
foundation-stones  of  the  treatment,  and  the  next  most  im- 
portant agents  are  fresh  air  and  sunshine.  The  fresh-air 
treatment  of  tuberculosis  is,  he  thinks,  even  more  import- 
ant in  the  infant  and  child  than  in  the  adult,  and  if  faith- 
fully carried  out  will  give  better  results.  He  especially  in- 
sists upon  the  great  value  of  guaiacol  in  the  treatment  of 
tuberculosis  in  infancy  and  childhood,  and  believes  that  it 
far  out-classes  all  other  drugs  in  this  condition.  He  re- 
commends its  use  by  inunction  in  the  form  of  this  prescrip- 
tion : — 

R         Guaiacol ^   i 

Lanolin .5  4 

Lard   ^  4 

One  level  teaspoonful  to  be  rubbed  into  the  chest  at 
bedtime  each  day.  He  has  used  this  prescription  for  eight 
years  in  these  cases  in  infancy  and  childhood,  and  is  con- 
vinced of  its  great  value.  Guaiacol  is  one  of  the  few  drugs 
which,  when  applied  to  the  skin,  is  rapidly  absorbed  by  the 
lymph-channels  and  so  carried  into  the  general  circulation. 
Its  great  value  in  the  treatment  of  lymph-node  tuberculosis 
in  infancy  and  childhood  probably  depends  on  the  fact 
that  by  inunction  it  can  readily  be  brought  into  contact 
with  the  diseased  lymph-nodes  and  so  act  as  a  lymphatic 
antiseptic.  While  of  great  value  in  children,  it  is  of  com- 
paratively little  value  in  adults,  because  in  the  first  place 
the  lymphatic  glandular  system  is  more  active  in  the  child, 
and  in  the  second  place  adult  tuberculosis  is  as  a  rule  not 
that  of  the  lymph-nodes.     In  acute  tubercular  conditions 


MEDICINE   AND    NEUROLOGY.  359 

he  directs  that  a  level  teaspoonful  of  the  ointment  be  rub- 
bed into  the  skin  over  the  abdomen  and  chest  night  and 
morning  for  ten  or  fifteen  minutes,  after  the  fever  and 
symptoms  have  been  controlled,  then  two  or  three  times  a 
week  as  long  as  may  be  necessary.  In  tubercular  peritoni- 
tis the  good  results  are  equally  evident,  and  when  the  ac- 
tive symptoms  are  in  abeyance  he  frequently  substitutes  the 
carbonate  of  guaiacol  internally  for  the  inunction.  A  mix- 
ture of  the  carbonate  and  milk  sugar  is  readily  taken  by 
children,  and  it  is  especially  valuable  in  the  treatment  of  in- 
testinal and  mesenteric  tuberculosis. — The  Cleveland  Medical 
Journal. 

THE    OBSTETRIC    FORCEPS  :   MAY   W^E   NOT   SAFETY  USE 
THEM  IN   EVERY   CASE    OF   LABOR  ?  * 

By  Frederick  Leavitt,'  M.  D. 

clinical  ixstructor  in  obstetrics,   university  of  minne- 
sota^ obstetrician  to  the  city  and  county  hos- 
pital, free  dispensary,  etc.,  etc 

ST.   PAUL. 

As  long  ago  as  the  begiuning  of  the  11th  century, 
AviCENNA,  that  most  celebrated  Arabian  physician,  is  said 
to  have  described  the  use  of  an  instrument  which  could  be 
applied  to  the  head  of  the  fetus  and  thereby  aid  delivery. 
Not  until  the  time  of  the  Chamberlens,  however,  more 
than  500  years  later,  was  the  modern  forceps  invented. 
For  several  generations  this  family  of  physicians  kept  the 
"art  of  delivering  pregnant  women  in  difficult  cases  by 
means  of  instruments"  a  secret,  and  it  was  many  years  after 
their  death  that  models  of  the  obstetric  forceps  were  found 
in  a  secret  room  of  Chamberlens'  house.  Since  then  im- 
provements have  been  made  from  time  to  time,  till  now 
the  forceps  seem  to  fulfill  every  requirement. 

When  the  forceps  must  be  used,  though  an  important 
theme  for  consideration,  is  a  phase  of  the  subject  that  I 
shall  not  discuss  at  this  time.  However  essential  it  may 
be  for  one  to  know  when  the  operation  is  imperative,  at 
present  I  wish  only  to  inquire  how  freely  we  may  apply 
them-  So  then,  putting  to  one  side  the  accepted  rules  as 
to  when  forceps  are  demanded,  let  us  consider  when,  if  ever, 
their  use  is  denied. 

You  will  find  that  many  of  the  rules  laid  down  by  dis- 
tinguished obstetricians  of  a  century  ago  were  promulgated 
with  the  idea  of  discouraging  the  abuse  rather  than  the 


•Read  at  the  34th  annual  meeting  of  the  Minnesota  State  Medical 
Society  at  Minneapolis,  June  18,  1902. 


360  PROGRESS  FO  MEDICAL  SCIENCE. 

conservative  use  of  the  forceps.  It  is  stated  that  at  one 
time  instrumental  interference  was  frequently  had  re- 
course to  unnecessarily;  that  nature  was  seldom  or  never 
allowed  to  accomplish  her  object.  The  hand  was  constant- 
ly thrust  into  the  uterus,  instruments  were  employed  to 
extract  the  child,  and  the  rudest  means  used  to  bring  away 
the  placenta.  Thus  a  great  revolution  was  effected  in  the 
practice  of  the  age,  and  obstretricians  were  taught  to  rely 
more  implicitly  on  the  power  and  beneficence  of  nature. 
Dbnham,  who  flourislied  during  the  first  quarter  of  the  19th 
century,  states  in  his  work  on  Midwifery,  that  however 
cautiously  applied,  the  evils  arising  from  the  unnecessary 
and  improper  use  of  forceps  are  so  great  that  the  world 
would  doubtless  be  better  off  if  no  such  instrumeut  had  ever 
been  contrived  for,  or  recommended  in,  the  practice  of 
obstetrics.  A  rule  that  he  considered  practical  is  stated 
thus  :  ''The  head  of  the  child  shall  have  rested  for  six 
hours  as  low  as  the  perineum,  that  is  a  situation  which 
would  allow  of  their  application,  before  the  forceps  are 
applied,  though  the  pains  should  have  altogether  ceased 
during  that  time."  A  generation  later  we  find  obstetri- 
cians teaching  more  liberty  in  the  use  of  the  forceps.  For 
example,  in  1841,  Kamsbotham  wrote,  ''if  the  head  have 
been  locked  for  four  hours,  and  made  no  progress  for  six 
or  eight  hours,  without  waiting  the  limited  twenty-four 
hours,  or  even  twelve,  the  forceps  may  be  applied."  Some  of 
the  indications  for  instrumentation  as  laid  down  by  him  were 
subsiding  pains,  failing  strength,  sinking  spirits,  anxious 
countenance,  rapid  pulse,  rigor,  great  tenderness  of  the 
abdomen  over  the  uterus,  green  discharges,  preternatural 
soreness  of  the  vulva,  with  heat  and  tumefaction  of  the 
■\-iagina.     Teachings  that  hold  good  to-day. 

The  satement  was  made  in  a  recent  article  by  Lap- 
thorn  Smith,  that  while  the  forceps  has  saved  the  lives  of 
hundreds,  it  has  shipwrecked  the  lives  of  thousands. 
While  I  cannot  believe  this  to  be  true,  I  do  believe  that 
many  of  the  bad  results  accompanying  parturition  are 
wrongfully  charged  to  instrumental  interference. 

Ever  since  the  days  of  Israel,  when  Sarah,  the  patri- 
arch Jacob's  wife,  perished  at  the  hands  of  a  midwife, 
medical  history  has  been  full  of  warnings;  and,  indeed,  we 
are  still  far  from  always  knowing  when  nature  may  be 
aided  by  art.  It  may  properly  be  contended  that  the  best 
success  comes  through  conservatism,  and  that  the  physi- 
cian who  is  inclined  to  apply  radical  measures  in  the  treat- 
ment of  his  cases  stands  in  danger  of  doing  more  harm 
than  good.  On  the  other  hand,  I  dare  say,  many  of  us  err 
now  and  then  in  allowing  things  to  take  their  own  course. 


MEDICINE   AND    NEUROLOGY.  36 1 

Writers  and  instructors  of  to-day,  like  those  of  old, 
have  thrown  into  their  teachings  an  element  of  precaution, 
while  in  their  own  practice  they  make  use  of  the  forceps 
with  the  greatest  freedom.  I  have  known  this  to  be  the 
case  in  some  instances.  Would  it  be  safe  to  teach  our 
students  differently?  This  leads  up  to  the  inquiry.  Does 
instrumental  delivery  add  greatly  to  the  dangers  of  labour? 
Are  the  complications  and  sequelae  enhanced  by  the  proper, 
or,  to  make  it  less  exact,  the  careless  use  of  the  forceps? 
The  point  I  aim  to  make  is,  that  physicians  may  safely 
apply  forceps  in  every  case  where  time  will  permit,  after 
the  completion  of  the  first  stage  of  labour;  that  when  this 
stage  is  over  the  obstetric  moment  has  arrived  when  Uie 
patient  may  be  placed  in  position  and  instrunieats  em- 
ployed with  benefit. 

The  advanced  stand  taken  in  the  practice  of  obstetrics 
must  ultimately  bring  the  art  entirely  within  the  realm  of 
surgery.  It  is  only  when  viewed  from  this  standpoint  that 
we  note  any  marked  progress  being  made  in  the  past  or 
towards  which  we  may  look  for  greater  perfection  in  the 
future.  In  this  age  of  cleanliness  we  dare  do  things  that 
might  not  safely  have  been  undertaken  years  ago.  Tt  is 
barely  half  a  century  since  the  blades  of  the  forcep>!,  in 
order  that  the  patient  should  not  be  shocked  by  their  metal 
clang,  and  that  their  introduction  might  be  less  likely  to 
injure  the  parturient  structures,  were  covered  with  leather 
and  kept  well  lubricated  with  neat's  foot  oil.  Could  one 
imagine  a  more  favourable  nidus  for  bacterial  growth  out- 
side a  culture  tube  ! 

Personally  it  is  my  experience  that  where  the  forceps 
has  been  used  no  bad  results  have  followed,  neither  in  the 
immediate  consequences  to  the  soft  parts,  nor  in  delaying 
convalescence.  In  fact,  it  is  frequently  noted  that  the 
patient's  strength  is  less  dissipated,  and  the  puerperal 
period  passed  with  greater  comfort,  following  instrumental 
aid,  than  when  exhausted  by  tedious  though  spontaneous 
delivery  Of  course  it  goes  without  saying  that  in  many 
instances  there  is  little  demand  for  forceps,  and,  in  fact, 
time  will  not  permit  of  their  application  But  where  the 
second  stage  has  lasted  long  enough  to  make  proper  prepar- 
ations for  the  operation,  their  use  need  not  be  delayed  until 
some  note  of  warning  informs  us  of  danger.  At  the  City  and 
County  hospital  it  has  been  my  custom  to  deliver  nearly 
every  case  with  instruments,  and  during  a  service  of  five 
years  we  have  had  no  complications  resulting  therefrom. 
It  may  be  claimed  that  obstetrics  as  practiced  in  institu- 
tions permits  of  more  interference  with  less  evil  results 
than  in  private  practice.     In  a  measure  this  is  true,  yet 


362  PROGRESS   OF  MEDICAL  SCIENCE. 

we  are  all  able  to  bear  testimony  to  the  astonishingly  good 
results  amongst  the  lowly.  Even  in  the  hovel,  where  not 
a  single  thing  is  sterile,  except,  perhaps,  a  pot  of  boiling 
water  on  the  kitchen  stove,  we  have  seen  our  cases  recover 
rapidly  and  satisfactorily.  If  in  maternity  hospitals  in- 
strumentation is  a  rational  procedure,  then  why  is  it  not 
even  more  so  in  the  homes  of  our  patients?  If  we  look 
upon  accouchment  as  a  surgical  measure  and  conduct  it 
accordingly,  I  believe  that  results  will  be  better  than  if 
treated  otherwise.  The  practice  of  conducting  parturition 
under  the  bed  clothes,  to  my  mind,  is  reprehensible.  It 
may  be  esthetic,  but  it  is  not  surgical  nor  even  sanitary. 

Let  me  draw  a  picture  or  two.  Mrs.  A.  and  Mrs.  B. 
are  both  about  to  be  confined-  Mrs.  A.  has  engaged  the 
services  of  a  physician  who  looks  upon  parturition  from 
a  medical  standpoint;  who  considers  his  responsibility  at 
an  end  when  the  cord  is  severed  and  the  parents  congrat- 
ulated. During  labour  he  urges  voluntary  effort  on  the  part 
of  the  patient,  contriving  appliances  whereby  she  may  lay 
out  her  strength  upon  the  footboard  of  the  bed,  or  possibly 
he  may  volunteer  to  be  the  other  contestant  in  the  tug  of 
war  going  on.  In  vain  does  she  beg  of  him  to  help  her 
and  in  vain  does  he  assure  her  that  he  is  doing  all  that 
he  can.  If  everybody's  strength  holds  out  baby  is  finally 
born.  With  slight  variations  this  is  the  common  conduct 
of  normal  laboui-.  On  the  other  hand  Mrs.  B.  is  to  be  at- 
tended by  a  physician  who  assures  her  that  straining  and 
struggling  serve  only  to  tire  her  out  and  that  it  is  unneces- 
sary. Her  prayers  for  help  are  not  unheard.  An  anes- 
thetic is  given,  she  is  placed  crosswise  of  the  bed,  the  hips 
well  to  the  edge  of  the  mattress,  and  the  feet  placed  upon 
the  knees  of  the  accoucheur  or  supported  on  either  side  by 
assistants.  The  external  .parts  are  cleansed,  the  instru- 
ments which  have  been  boiled  and  brought  to  hand  are 
cooled  in  a  solution  of  lysol,  the  physician  draws  on  a  pair 
of  rubber  gloves,  the  forceps  are  slipped  over  the  head  of 
the  fetus  and  the  labour  concluded  completely  under  control. 
Progress  may  be  closely  watched,  the  parts  kept  clean, 
the  perineum  more  easily  protected,  repaired  if  lacerated, 
the  placenta  delivered,  and  the  toilet  made  with  a  minimum 
of  contamination.  Furthermore,  much  time  may  be  saved 
and  the  patient's  strength  husbanded. 

If  I  were  asked  to  select  from  my  armamentarium  the 
instrument  with  which  I  would  most  unwillingly  part,  I 
assure  you,  fellow  practitioners,  there  would  be  no  falter- 
ing decision.  Directly  I  should  go  to  my  case  and  grasp 
those  dual  blades,  and  nothing  but  a  losing  fight  could 
wrest  them  from  me — St.  PauVs  Medical  Journal. 


MEDICINE  AND  NEUROLOGY.  363 

HINTS  ON  TREATMENT  OF  SCIATICA. 

Stevens'  "Manual  of  Practice  of  Medicine"  gives  the 
following  terse  and  valuable  hints  on  the  treatment  of 
sciatica: — ''In  the  acute  stage  rest  is  essential.  Hot  fo- 
mentations or  linear  blisters  may  be  applied  along  the 
course  of  the  nerve.  Deep  injections  of  morphine,  anti- 
pyrin  or  cocaine  may  be  required  to  relieve  the  pain.  In 
rheumatic  cases,  full  doses  of  the  salicylate  of  sodium  are 
useful.  In  chronic  cases,  prolonged  rest  is  desirable- 
Counter  irritation  should  be  made  by  frequent  small  blis- 
ters, by  the  actual  cautery,  or  by  acupuncture.  Deep  injec- 
tions along  the  course  of  the  nerve  give  much  relief,  and 
one  of  the  following  remedies  may  be  employed:  MorT)hine 
and  atropine,  cocaine,  antipyrin  or  plain  water.  Electric- 
ity sometimes  does  good.  Internalh,  iodide  of  potash  in 
small  doses  is  useful;  in  syphilitic  cases  it  should  be  given 
in  large  doses.     The  following  combination  is  efficient: 

R    Tinct.  aconite     root 3  ij 

"      belladona 3  ij 

"       cimicifuga       3  ij 

M.     Sig. — Twelve  drops  every  four  to  eight  hours." 

TREATMENT   OF  ACNE. 

Dr  Lusk,  in  a  case  of  acne,  characterized  by  papules, 
pustules  and  comedones,  and  caused  by  errors  of  diet,  con- 
stipation and  menstrual  disturbance,  recommended  proper 
treatment  for  the  general  condition  and  used  locally  the 
following  lotion  : 

R  Zinc  sulphate     .3 — ij 

Sulphuret  of  potash 3 — ij 

Sulphur,   precip q.  s.  ad.  3  iv 

Aqua  rosae q.  s.  ad. 

M  Sig. — The  zinc  and  potash  should  each  be  dis- 
solved in  half  the  quantity  of  water,  and  the  second  added 
to  first  slowly,  with  constant  stirring.  The  sulphur 
should  be  first  made  into  a  paste  with  the  resulting  solu- 
tion, and  then  thoroughly  mixed  in  mortar. — Post -Graduate- 

TUBERCULOSIS    AND    CHILDHOOD A    RESUME. 

(By  William  Jacobsox.  Journal  of  Tuberculosis,  Jan.,  1902). 
The  author  calls  attention  to  the  early  recognition  of 
the  disease:  "The  child  is  the  father  of  the'  man,  whatever 
knowledge  is  disseminated  for  the  good  of  the  child  will 
certainly  make  a  stronger  man,"  "Human  cells  are  the  de- 
fenders against  incoming  agents  of  destruction."  Heredity 
is  our  inheritance  of  these  cells;  if  these  are  powerful,  i.e., 
our  heredity   is    good,  we   shall  conquer  these  enemies;  if 


364  PROGRESS  OF  MEDICAL  SCIENCE. 

not  they  will  overpower  us.  Cell  activity  is  marked  in 
childhood;  in  disease  the  task  to  be  overcome  will  be  pro- 
portionate to  the  relative  heredity  strength.  Our  endeav- 
ours should  be  to  fortify  this  cellular  resistance  and  avoid 
cellular  irritability,  and  thus  prevent  or  stay  the  disease. 

He  speaks  of  the  difficulty  of  diagnosis  because  of  the 
absence  of  bacilli  from  the  sputum,  these  being  swallowed 
by  young  children.  Also  of  the  dangers  of  test  injections. 
Calls  attention  to  our  early  recognition  in  the  diagnosis  of 
the  parts  involved  in  tuberculosis,  viz.,  skin,  subcutaneous 
tissues,  mucous,  serous  and  synovial  membranes,  pia  mater, 
glands,  bones,  lungs,  liver,  spleen,  kidneys,  testes.  We 
should  be  able  to  differentiate  between  tuberculosis  and 
other  diseases  in  which  they  are  involved. 

Glands  are  infected  first,  proved  by  finding  bacilli  in 
them  and  not  in  the  lungs.  Glandular  enlargements  in 
children  are  the  forerunners  of  more  serious  future 
troubles.  Bearing  in  mind  these  facts,  diagnosis  can  be 
made.  Calls  special  attention  to  hectic  fever,  emaciation, 
ulceration  of  skin,  mucous  membranes,  swellings  of  the 
joints.  Lungs,  if  suspected,  may  show  only  a  few  crackling 
rales  below^  the  nipples  and  in  the  scapular  region.  The 
lower  lobe  of  the  lung  in  young  children  may  show  a  cav- 
ity, whereas  in  adults  we  seek  the  upper  lobe.  Enlarge- 
ments of  abdominal  glands,  diarrhoea,  griping  after  food, 
are  common.  Loss  of  appetite,  fretfulness,  pyrexia,  dis- 
turbed sleep,  clenched  hands,  point  to  tuberculous  menin- 
gitis. After  this  the  rapid  pulse,  headache,  vomiting  and 
pupillary  signs.  Then  follow  the  contracted  pupils  and 
slow  pulse,  stupor,  hemiplegia  and  coma. 

Tubercular  iritis  is  rare;  the  diagnosis  is  made  chiefly 
by  its  chronicity.  Middle  ear  disease  may  be  due  to  the 
bacilli;  again,  mastoid  disease  is  often  due  to  them.  It  is 
wrong  not  to  interfere  surgically  with  them.  Cold  ab- 
scesses are  often  present  in  infants.  In  respect  to  treat- 
ment he  emphasizes  the  necessity  of  daily  bathing  with 
cool  water  as  one  of  the  best  stimulants  to  cell  activity. 
Exercise  is  enjoined,  well  ventilated  rooms,  no  overcrowd- 
ing as  in  tenements.  He  calls  special  attention  to  building 
of  proper  tenements  with  roof  gardens,  where  children  can 
play  at  all  times  of  the  year.  Proper  medication,  and  in 
very  badly  diseased  children,  their  isolation  in  sanatoria  is 
advised.  By  these  means  we  can  combat  the  disease  and 
tend  towards  the  termination  of  this  dread  affection. — St. 
Paul  Medical  Journal. 


^MEDICINE  AND  NEUROLOGY.  365 

DILATATION  OF  THE  HEART  IN  CHILDREN. 

(Eustace  Smith,  M.  D.,  F.  K.  C  S.  The  Practitioner,  Lon- 
don, January,  1902). 
The  author  is  of  the  opinion  that  moderate  cardiac  di- 
latation in  children  is  not  infrequent  and  that  it  exists 
quite  apart  from  any  valvular  trouble.  It  may  arise  from 
over-exertion  at  play,  rapid  growth,  nephritis,  broncho- 
pneumonia and  infectious  fevers,  being  common  in  acute 
rheumatism  and  iniiuenza.  The  physical  signs  are  said  to 
closely  resemble  pericardial  effusion.  The  shape  of  the  car- 
diac dullness  is  said  to  be  characteristic,  reaching  upwards 
far  above  the  third  rib  and  its  right  border  is  continued 
downwards  and  outwards  to  the  right  fifth  interspace  to 
join  the  liver  dullness,  instead  of  curving  upwards  to  the 
infra-sternal  notch.  Attention  is  called  to  the  fact  that  in 
rheumatic  cases  the  dilatation  is  accompanied  by  endo- 
cardial murmurs  from  inflammatory  thickening.  In  mod- 
erate dilatation  the  discomfort  is  not  great,  the  heart  re- 
turning to  normal  as  the  general  nutrition  improves.  It  is 
in  the  cases  of  acute  illness  when  the  dilatation  is  rapid 
that  the  condition  becomes  serious,  the  dilatation  affecting 
the  auricles  as  well  as  the  ventricles,  and  is  due  to  degenera- 
tion of  the  heart  muscle,  the  danger  being  in  proportion  to 
the  degree  of  degeneration.  The  destruction  of  muscle 
fibre  is  said  to  be  greater  in  diphtheria  and  influenza  than 
in  rheumatism.  In  any  case  where  there  is  rapid  broaden- 
ing of  the  area  of  dullness,  especially  if  vomiting,  coldness 
of  the  surface  and  partial  collapse  co-exists,  the  prognosis  is 
regarded  as  grave.  In  all  cases  of  acute  disease  where  di- 
latation is  present,  the  patient  should  remain  constantly  in 
the  recumbent  position,  all  starchy  foods  avoided,  also 
grapes,  baked  apples,  oranges  and  acid  fruits,  relying  on 
milk,  custards,  strong  soups,  yolk  of  egg  and  stale  bread  or 
rusks  until  the  stomach  is  able  to  take  care  of  boiled  fish, 
chicken,  etc.  It  is  recommended  that  the  drug  treatment 
of  the  original  disease  be  continued.  Strychnia  pushed  to 
the  point  of  toleration  in  connection  with  a  suitable  prepar- 
ation of  iron  and  alcohol.  For  the  moderate  dilatation 
occurring  in  anemic  children,  nothing  is  required  in  addi- 
tion to  means  calculated  to  improve  digestion  and  general 
nutrition,  and  to  forbid  their  engaging  in  those  games  that 
require  violent  exercise. — St-  Paul  Medical  Journal. 

CREOSOTE  AND  CREOSOTE. 

Merck  &  Co.,  in  a  communication  to  the  American  Phar- 
maceutical Association,  call  attention  to  a  great  danger  in- 


3^6  PROGRESS  OF  MEDICAL  SCIENCE. 

to  which  the  careless  or  unwary  doctor  may  fall  in  pre- 
scribing creosote.  Only  beech  wood  creosote  should  be 
used  internally.  We  reproduce  a  Merck  label  in  which  is 
contained  the  caution :  "  Caution. — Whenever  creosote  is 
indicated  for  internal  medication,  this  kind  (wood  creosote) 
should  be  dispensed;  and  under  no  circumstances  should 
so-called  'creosote'  from  coal-tar  be  given  internal  use  un- 
less explicitly  so  directed.  Wood  creosote  and  'coal-tar 
creosote'  are  two  different  substances.  They  do  not  con- 
sist of  the  same  chemical  ingredients;  and  they  differ  very 
largely  in  their  action  on  the  human  body.  W^ood  creosote 
is  comparatively  harmless;  while  'coal-tar  creosote'  is  dis- 
tinctly poisonous.  A  substitution  of  'coal-tar  creosote'  for 
wood  creosote  may,  therefore,  cause  the  gravest  conse- 
quences."— Texas  Medical  Journal. 

HARMLESS   ALBUMINURIA. 

Wm.  Osier  (N.  Y-  Med.  Jour.)  records  a  number  of 
interesting  cases  of  men  past  fifty  who  were  found  to  have 
albuminuria  and  an  unfavourable  prognosis  given  accord- 
ingly, who,  nevertheless,  survived  this  discovery  for  many 
years.  He  concludes  that  at  this  period  of  life,  albu- 
minuria, or  even  the  presence  of  a  few  tube  casts  in  the 
urine,  is  not  at  all  infrequent  and  not  always  serious.  They 
are,  however,  always  danger  signals,  and  should  be  warn- 
ings to  "go  slow,"  especially  as  regards  the  quantity  of 
food  eaten.  The  points  on  which  one  should  lay  special 
stress  as  indicative  of  serious  disease  are  : 

1. — Persistent  low  specific  gravity  of  the  urine,  1.00$ 
to  1.012. 

2. — The  state  of  the  heart  and  arteries.  Marked  scler- 
osis of  the  peripheral  arteries,  with  the  apex  beat  of  the 
heart  an  inch  or  two  outside  of  the  nipple  line  and  a 
ringing,   highly  accentuated  aortic   second  sound. 

3 The  presence  of  albuminuric  retinitis. 

DIAGNOSIS  OF  BILIOUS  COLIC. 

The  first  sympton  of  gall-stone  colic  is  usually  pain  at 
the  pit  of  the  stomach,  which  in  some  instances  extends 
round  the  waist  ;  it  may  run  to  the  right  shoulder,  often- 
times down  into  the  right  iliac  fossa,  sometimes  in  the  back, 
and  sometimes  it  is  more  severe  just  beneath  the  heart. 
It  may  form  a  girdle  or  sense  of  constriction  around  the 
waist ;  cold  perspiration  breaks  out  over  the  patient,  owing 
to  the  intense  pain ;  a  waxy  palor  comes  on,  which  is  follow- 


MEDCNE  AND  NEUROLOGY.  367 

ed  by  reaction  in  a  few  hours,  fever  running  up  to  103-4°  or 
105 **  F.,  depending  largely  upon  the  idiosyncrasy  of  the 
patient.  We  may  find  the  temperature  to  reach  105°  F.  iq  a 
bad  attack  of  gall  stone  colic.  Every  evidence  of  approach- 
ing death  is  present.  There  is  often  a  deep-down  boring 
pain  in  the  epigastrium,  a  little  to  the  right.  If,  in  addition, 
we  find  jaundice  coming  on  within  a  few  hours  from  the 
beginning  of  the  attack,  we  can  say  that  it  is  due  to  occlusion 
of  the  bile  ducts.  If  we  find  an  enlarged  gall  bladder  there 
must  be  something  to  cause  it,  and  we  may  infer  that  the 
ducts  are  occluded,  and  if  it  be  the  first,  second,  or  third 
attack  it  is  most  likely  to  be  caused  by  a  stone.  We  may 
have  distension  of  the  gall  bladder  with  mucus,  perhaps 
some  muco  pus,  not  bile,  because  the  bladder  is  not  often 
distended  by  bile,  it  being  only  the  receptacle  for  the 
overflow  of  bile ;  when  it  can  not  get  out  of  the  common 
duct  it  dams  up  and  fills  the  bladder. — Amer.  Practitioner 
and  News. 

SEPSIS    FOLLO^VING    LABOUR   AND   ABORTION. 

W.  O.  Henry  gives  the  following  rules:  (i)  Remove 
early  with  the  finger,  sharp  curette  and  flushing,  all  debris, 
decidua,  blood  clots  and  sloughing  tissue  which  may  be 
infected  from  the  uterus,  and  from  all  raw  surfaces  in  cervix, 
vagina  and  vulva ;  (2)  Dry  all  these  raw  surfaces,  and  freely 
apply  to  them  ninety-five  per  cent,  carbolic  acid,  washing 
away  the  surplus  acid  with  sterile  water ;  (3)  Unless  hemor- 
rhage requires,  leave  no  tubes  or  packing  of  any  kind  in 
either  vagina  or  uterus ;  (4)  Have  simple  carbolized  two  per 
cent,  vaginal  douche  used  twice  a  day  thereafter ;  (5)  Open 
the  bowels  freely  with  calomel,  one-half  grain  every  hour  for 
four  hours,  then  follow  with  Rochelle  salts  until  sufficient 
action  has  occurred  ;  (6)  Give  three  grains  sulphate  of 
quinine  every  four  hours,  followed  by  fifteen  drops  tincture 
of  chloride  of  iron,  in  water ;  (7)  Give  good  nourishment 
with  milk,  eggs  and  stimulants  every  four  hours  ;  (8)  Let  this 
be  the  routine,  early  treatment,  and  more  radical  measures 
will  rarely  be  indicated  ;  (9)  Fixation  of  uterus,  with 
infiltration  in  Douglas'  cul  de  sac  or  ligaments,  or  pus  in 
tubes  or  ovaries  must  be  treated  by  opening  and  draining 
through  vagina  ;  (10)  Multiple  abscesses  in  uterine  walls,  or 
infection  of  walls  or  pelvic  cavity,  call  for  removal  of  uterus, 
and  all  else  necessary  by  the  vaginal  route.  The  abdominal 
route  in  all  acute  cases  is  dangerous,  and  seldom,  if  ever, 
justifiable. — Annals  of  GyncBcology  and  Pediatry. 


368  PROGRESS  OF  MEDICAL  SCIENCE. 

ACETOZONE   IN   THE  TREATMENT   OF   TYPHOID   FEVER. 

The  writer  reports  twenty- five  cases  of  typhoid  fever 
treated  with  this  new  intestinal  antiseptic.  The  duration 
of  the  disease  was  reduced  in  a  large  number  of  them  to 
fourteen  days,  the  time  being  reckoned  from  the  develop- 
ment of  definite  symptoms.  This  series  of  cases  was  re- 
markably free  from  bowel  complications,  and  where  they 
were  present,  in  those  admitted  after  the  disorder  had  per- 
sisted for  some  time,  they  quickly  disappeared.  There  were 
no  deaths  and  but  few  terminal  expressions  of  the  infection. 
The  treatment  pursued  in  all  cases  was  to  thoroughly 
move  the  bowels  by  grain  doses  of  calomel  combined  with 
aloin  and  guaiacol  every  two  hours  until  the  intestinal  canal 
was  emptied.  The  patient  was  then  given  from  1500  to 
2000  cubic  centimeters  of  a  solution  of  acetozone  that  had 
been  prepared  twenty-four  hours  before.  The  diet  was  re- 
stricted to  milk,  to  which  was  added  acetozone.  In  addition 
the  same  substance  was  atomized  and  inhaled.  In  some 
cases  the  acetozone  was  given  in  capsule,  five  grains  in  sugar 
of  milk,  three  times  daily. 

The  first  effect  of  the  acetozone  is  an  increased  secretion 
of  the  kidneys  .  This  is  soon  followed  by  a  pronounced  de- 
crease of  the  odour  of  the  stools  and  a  marked  diminution  of 
the  microorganisms  found  in  the  intestinal  dejecta.  As  a 
result  of  his  observations,  the  writer  concludes  that  aceto- 
zone is  an  efficient  germicide  that  is  innocuous  to  man  and 
is  readily  eliminated.  In  the  treatment  of  typhoid  fever  it 
will  destroy  the  source  of  the  infection  if  brought  in  contact 
with  it.  In  typhoid  it  obviates  the  intestinal  infection  and 
toxemia,  preventing  the  development  of  complications  and 
lessening  the  duration  of  the  disease. — £.  Wasdin,  Thera- 
peutic Gazette,  vol.  XXVI,  No.  5,  p.  289,  May  15,   1902. 


SURQKRY. 


IN  CHARGE    OF 

ROLIiO  CAMPBELL,  M,D., 

Lecturer  on  Surgery,  University  of  Bishop's  College  ;  Assistant  Surgeon,   Western   Hospital  ; 

ANU 

GEORGE  FISK,  M.D.  • 
Instructor  in  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeon,  Western  Hospital. 


THE  SIGNIFICANCE  PATHOLOGIC  AND  CLINICAL  OF 
ABDOMINAL  PAIN. 

A  lengthy  article  is  summarized    by   the   statement    that 
under  no  circumstances  should  the  pain  be  masked  by  opiates 
until  after  a  thorough  physical  examination.     In  all  cases  of 
abdominal  pain,  the  accompanying  physical  signs  should  be 
carefully    considered.     When    hemorrhage  is  suspected  the 
abdomen  should  always  be  explored.     If  the   patient  is  in 
collapse  and  too  weak  to  undergo  exploration,   preliminary 
infusion  of  salt  solution  should  be  made  into  the  veins  and 
under   the  skin.     When  the  pain  is  excruciating  and    the 
abdomen    shows    signs   of  infection,  exploration  should  be 
made  at  the  earliest  possible  moment.    The  site  of  the  initial 
pain,  as  described  by  the  patient  and  friends,  should  indicate 
the  place  for  the  incision  where  the   other  symptoms   leave 
the  operator  in   doubt.     The  history  and  signs  other  than 
pain  must  be  relied  upon  for  an  exact  or  reasonably  positive 
diagnosis.     When  some  of  the  unusual  abdominal  lesions  are 
suspected,  exploration  should  be  made.  In  some  cases  it  may 
be  useless,  but  if  resorted   to  as  a   routine  procedure  in  all 
cases  it  would  save  the  greatest  number  of  lives.  When  there 
is  the  least  doubt,  the  genuineness  of  the  pain  should   be 
tested  as  thoroughly  as  possible.     The  pain    of  an  atypical 
typhoid,    of  a  pleurisy,  of  a  pneumonia,  must  be  guarded 
against.     When  typhoid  is  prevalent   in   a  community  the 
greatest  precaution  must  be  taken  lest  the  surgeon  be  misled 
by  the  pain.     One  should  be  on  his  guard  lest  he  confuse  the 
pain  of  simple  functional  disturbances  with   that   of  organic 
disease.     When  uncertain  as  to  the  significance  of  pain,  the 
doubt  should  be  given  the  patient  and  a  surgical  exploration 
made.     Finally,  when  no  exploration  is  indicated  pain  should 
be  controlled    by  morphine,  hypnotics,  or,   if  necessary,  by 
general  anesthesia.     With  few  exceptions,  chiefly  cases  of 
renal  and  biliary  calculi,  the  pain  that  demands  general  anes- 
thesia   indicates    operation. — M,    H.   Richardson   in   Boston 
Medical  and  Surgical  Journal. 


370  yURGERY. 

THE    SURGICAI.   TREATMENT  IN   MITRAL   STENOSIS. 

Sir  Lauder  Brunton,  in  a  preliminary  note  [Lancet,  Feb^ 
8,  1902),  proposes  a  very  striking  innovation  in  the  field  o 
surgery,  it  being  no  less  than  an  attempt  to  relieve  mitral 
stenosis  by  surgical  means.  The  method  has  not  yet  been 
attempted  on  a  human  being,  but  he  has  carried  out  some 
experiments  upon  lower  animals,  which  would  lead  one  to 
think  that  the  method  is  possible.  The  clinical  history  of 
mitral  stenosis,  and  the  mechanical  impediment  offered  to  the 
circulation,  afford  an  inviting  field  for  surgical  speculation. 
These  patients,  when  in  hospital  and  under  treatment,  make  a 
partial  recovery,  there  is  improvement  in  the  circulation,  the 
edema  subsides,  and  they  leave  the  hospital  so  far  improved 
that  it  is  possible  for  them  to  take  up  their  usual  occupation. 
In  a  few  days  or  weeks  they  are  back  again  with  a  recrudes- 
cence of  all  of  the  symptoms.  This  is  repeated  for  months 
and  years  until  an  intercurrent  pneumonia  or  involvement  of 
the  kidneys  puts  an  end  to  the  chronic  ailment. 

The  experimental  work  of  Brunton  has  been  devoted  to 
solving  some  questions  connected  with  the  technique  of  such 
an  operation.  As  to  whether  the  valve  should  be  cut  through 
at  right  angles,  or  whether  the  opening  should  be  enlarged 
by  an  incision  between  the  leaflets,  is  a  matter  upon  which 
he  is  undecided,  but  thinks  that  the  latter  method  would  be 
preferable.  In  cats  he  has  used  knives  made  from  hat-pins, 
to  divide  the  valves.  He  has  not  decided  as  to  the  best  form 
of  knife  ;  this  depends  upon  whether  the  surgeon  decides  to 
operate  from  the  auricle  or  the  ventricle.  The  latter  is  less 
likely  to  bleed.  The  knife  need  not  be  much  thicker  than  a 
needle.  In  exposing  the  heart  in  a  human  being,  the  incision 
should  be  made  along  the  left  edge  of  the  sternum,  outward 
along  the  lower  borders  of  the  third  and  fifth  ribs,  connecting 
their  outer  ends  by  a  third  incision,  dividing  the  fourth  and 
the  fifth  ribs.  The  flap  thus  made  is  turned  back  on  the 
sternum,  the  external  attachments  of  the  ribs  being  sufficiently 
flexible  to  yield  to  the  pressure.  The  lung  is  then  pushed 
back  and  the  pericardium  freely  divided.  If  the  operation 
is  made  through  the  auricle,  it  would  probably  be  necessary 
to  incise  one  rib  higher. 

In  his  experiments  he  has  been  astonished  at  the  ease 
with  which  the  heart  goes  on  beating  in  spite  of  its  being 
handled.  He  ventures  to  suggest  this  operative  procedure 
in  view  of  the  excellent  results  in  surgical  wounds  of  the 
heart.  — Medicine. 


SURGERY.  371 

ADRENALINE  AS  AN  ADDITION   TO   SOLUTIONS  FOR 
LOCAL  ANESTHESIA. 

The  removal  of  a  sebaceous  cyst,  the  opening  of  an  ab- 
scess, or  similar  minor  operation,  is  facilitated  by  the  sup- 
pression of  hemorrhage.  The  application  of  sponges  to  a 
bleeding  surface  causes  more  or  less  pain  unless  the  anesthesia 
is  perfect.  If  adrenalin  is  added  to  solutions  for  local  anes- 
thesia there  is  an  immediate  blanching  of  the  skin  and  the 
operation  is  quite  bloodless.  If  one  drop  of  i  to  1000  adre- 
nalin chloride  is  injected  under  the  skin,  a  slight  burning 
sensation  is  felt,  but  there  is  no  anesthesia.  Within  one 
minute  an  area  of  skin  about  two  inches  in  diameter  becomes 
blanched  and  remains  so  for  from  six  to  twelve  hours.  With 
weaker  solutions  proportionately  less  effect  and  of  shorter 
duration  is  produced.  When  local  anesthetics  such  as  cocaine 
or  eucaine  are  associated  with  the  adrenalin,  there  is  the  same 
blanching  of  tissues,  but  there  is  no  interference  with  the 
local  anesthetic  action  of  these  drugs.  It  has  been  the  practice 
of  the  writer  to  add  adrenalin  chloride  in  a  proportion  of  i  to 
5000,  or  I  to  20,000  to  solutions  of  cocaine  for  local  anesthesia. 
Under  such  a  solution  only  the  larger  blood-vessels  bleed 
when  they  are  cut,  and  there  is  very  little  oozing.  In  none 
of  the  cases  was  secondary  hemorrhage  noted. —  C.  A.  Elsberg 
in  American  Medicine. 

ABDOMINAL       ROUTE       FOR       APPROACHING       RECTAL 

TUMOURS. 

Eobert  Abbe,  ^"ew  York,  says  that,  first,  opera- 
tive method  for  cancer  in  different  parts  of  the  rectum 
must  still  be  elective;  there  is  no  one  method  that  applies 
to  all.  The  perineal  route  is  still  the  most  available  for 
very  limited  and  very  low  down  growths.  The  Kraske 
sacral  method  is  available  for  a  moderate  number  of 
growths  which  exhibit  slight  malignancy  as  to  infiltration, 
and  are  not  more  than  a  short  finger  length  within  the 
anus.  But  the  abdominal  method  combined  with  those 
just  mentioned  more  nearly  meets  the  present  attitude  of 
surgery  in  seeking  as  wide  and  thorough  extirpation  as 
possible  for  malignant  growths. 

Second,  the  artificial  inguinal  anus  had  best  always 
be  made  at  the  time  of  operation,  and  need  not  be  done 
beforehand. 

Third,  when  the  section  of  the  rectum  is  made  well  up 
to  the  sigmoid,  the  ends  of  the  severed  gut  should  be  in- 


372  SURGERY. 

verted  by  a  stout  silk  purse-string  suture  for  more  perfect 
cleanliness  and  handling. 

The  question  of  disposing  of  the  upper  stump  is  one 
that  may  well  appeal  for  solution.  Whether  to  put  it  on 
a  severe  stretch  and  attempt  to  bring  it  into  a  perineal 
or  sacral  wound,  or  to  make  at  once  a  lateral  inguinal 
colostomy,  is  a  question-  The  writer's  argument  is  for  the 
latter  for  the  following  reasons  : 

1.  In  the  combined  method  it  settles  at  once  all  un- 
certainty and  delay  by  having  it  brought  out  of  an  inguinal 
cut  before  the  patient  leaves  the  Trendelenburg  position, 
thus  leaving  the  operator  free  to  confine  his  whole  thought 
to  most  thorough  enucleation  of  the  cancerous  rectum. 

2.  It  removes  the  anal  discharges  forever  from  the 
pelvis,  and  thus  takes  away  one  source  of  renewed  irrita- 
tion of  any  remaining  cells  of  disease. 

3.  If  the  base  of  the  bladder  proves  to  be  involved  in 
the  complete  operation  and  a  possible  leakage  occurs,  the 
danger  of  mixed  urinary  and  fecal  contamination  are  ob- 
viated. 

The  results  of  newly  established  artificial  ani  in  peri- 
neum or  sacrum  are  such  that  continence  of  flatus  and 
feces  cannot  usually  be  hoped  for,  even  to  as  great  an  ex- 
tent as  in  an  inguinal  colostomy,  therefore,  inasmuch  as 
a  T  bandage  or  napkin  will  usually  have  to  be  worn,  the 
inguinal  has  no  disadvantage. 

5.  When  then  the  operator  begins  with  the  idea  of 
turning  the  sigmoid  colon  end  up  into  the  groin  perma- 
nently, he  is  much  freer  to  dissect  the  highest  part  of  the 
rectum  and  lower  sigmoid  with  the  hemorrhoidal-  vessels, 
and  then  clean  out  all  infected  lymphatics  from  the  pelvis, 
ab  initio. 

The  operation  as  a  whole  is  thereby  simplified  and 
abbreviated  as  well  as  made  more  thorough. 

6.  The  great  majority  of  cases  with  return  of  disease 
ultimately  require  artificial  anus,  and  it  should  be  anti- 
cipated in  all  by  this  preparation- — Annals  of  Surgery. 

SOME  POINTS  CONNECTED  W^ITH  THROMBOSIS. 

Sir  William  Bennett  cites  two  cases  of  thrombosis  and 
makes  some  interesting  remarks  on  them.  The  first  was 
that  of  a  woman,  aged  49,  who  was  operated  on  for 
femoral  hernia.  There  was  nothing  unusual  noticed  at 
the  operation,  which  was  performed  in  the  ordinary  way. 
The  temperature  rose  slightly  the  next  day,  as  commonly 
happens,  but  did  not  subside,  although  the  wound  healed 
perfectly  by  first  intention.     Ten  days  after  the  operation 


SURGERY.  373 

the  temperature  rose  rapidly  to  103.5  F.,  and  she  com- 
plained of  pain  in  the  left  leg.  Examination  showed  that 
there  was  thrombosis  of  the  saphena  vein,  as  well  as  com- 
mencing thrombosis  in  the  femoral  vein.  She  now  became 
very  seriously  ill;  the  thrombosis  extended  rapidly  up- 
wards, and  as  it  extended  into  the  belly  the  opposite  limb 
became  similarly  atfected.  She  remained  very  ill,  had  one 
or  two  rigours,  and  looked  like  a  person  suffering  from 
septicaemia.  About  four  weeks  after  the  onset  of  the 
thrombus  in  the  lower  limb  she  had  an  attack  of  pulmon- 
ary embolism,  and  nearly  died.  A  large  flowing  mass 
came  away  from  over  the  sacrum,  exposing  the  bone  and 
leaving  a  ^reat  cavity.  She  slowly  recovered,  and  eventu- 
ally left  the  hospital  well. 

The  second  case  was  also  a  woman,  aged  27,.  who  was 
admitted  for  a  severe  attack  of  appendicitis  with  a  high 
temperature,  and  an  operation  was  immediately  performed. 
She  was  intensely  anaemic  at  the  time  of  the  operation. 
She  did  very  well  afterwards,  and  a  week  later  it  was 
found  quite  accidentally  that  one  of  her  lower  limbs  was 
swollen.  She  complained  of  no  pain,  thus  differing  from 
the  case  mentioned  first.  Extensive  thrombosis  of  the 
femoral  and  iliac  veins  was  found,  and  on  the  following 
day  a  sudden  attack  of  pulmonary  embolism  occurred, 
from  which  she  nearly  died.  Here,  then,  was  a  case  of 
thrombosis  occurring  after  an  operation  in  which  the 
patient  was  doing  well  and  free  from  any  suspicion  of 
sepsis,  followed  almost  immediately  by  embolism.  In  the 
other  case  the  embolism  did  not  occur  till  very  much  later, 
until,  in  point  of  fact,  the  thrombus  had  commenced  to 
disappear.  In  the  second  case  the  embolism  occurred 
during  the  process  of  the  growth  of  the  thrombus.  These 
are  two  very  different  conditions,,  and  their  importance  is 
great.  The  thrombus  in  the  first  case  was  the  result  of 
septic  conditions;  in  the  second  the  clotting  was  purely 
passive.  The  second  patient's  blood  clotted  in  the  veins 
because  she,  being  weak  and  intensely  anaemic,  had  been 
called  upon  to  bear  the  shock  of  what  was  to  her  a  serious 
operation,  which  lowered  her  vitality  considerably. 

It  is  well  to  bear  in  mind  that  all  patients  of  the 
anaemic  type  are  very  prone  to  blood  clotting,  and  that  a 
certain  percentage  of  them,  if  placed  in  bed  and  kept  ab- 
solutely quiet  after  an  operation  or  accident,  by  which 
their  already  feeble  physique  is  still  further  reduced,  are 
very  liable  to  jret  thrombosis,  more  especially  in  the  lowei 
extremities,  although  the  clotting  may  occur  in  other 
parts.  There  are  two  other  varieties  of  passive  thrombosis 
to  which  it  is  worth  while  to  direct  attention.     The  first 


374  SURGERY. 

is  that  which  is  proue  to  follow  any  exhausting  disease, 
such,  for  example,  as  enteric  fever,  the  thrombosis  follow- 
ing upon  whicn  is  frequently  passive,  not  septic,  and  the 
second  is  that  which  follows  upon  great  loss  of  blood. 
There  is  a  tendency  in  many  subjects — notably  those  of 
the  anaemic  kind  on  the  one  hand  and  those  of  the 
robust  "gouty"  type  on  the  other — to  the  occurrence 
in  bed,  when  in  a  condition  of  apparent  good  health,  and 
kept  absolutely  quiet  for  a  considerable  period — such  quiet 
as,  for  example,  may  be  necessitated  by  an  operation  on 
the  knee  joint,  severe  abdominal  cases,  or  any  other  cases 
of  severity.  Thrombosis  is  not,  for  an  example,  very  rare 
in  certain  types  of  patients  laid  up  suddenly  with  fracture, 
the  thrombosis  occurring  as  often  as  not  in  a  sound  limb. 
The  practical  bearing  of  this  matter  is  the  following: 
In  all  operations  of  expediency^  such,  for  example,  as  the 
radical  cure  of  hernia,  operations  on  varicose  veins,  etc., 
when  performed  upon  patients  in  sound  general  health, 
who  up  to  the  time  of  coming  under  treatment  have  been 
following  their  ordinary  callings  or  amusements,  it  is  wise, 
and  in  many  cases  necessary,  that  the  patients  should  be 
kept  in  bed  for  some  days  prior  to  the  operation,  so  that 
the  absolute  rest  entailed  by  the  operation  comes  less 
abruptly  upon  them — a  period  of  modified  rest  in  the  flat 
position  intervening  between  the  ordinary  habits  of  life 
and  the  total  rest  which  should  follow  upon  the  operation. 
In  all  cases  of  thrombosis,  whether  septic  or  aseptic  {i.e., 
passive),  no  matter  what  the  cause  may  be,  there  is  a 
certain  period  in  each  variety  at  which  embolism  is  more 
prone  to  occur  than  at  any  other  time.  A  proper  ap- 
preciation of  this  fact  is  of  some  importance,  since  the 
time  at  which  embolism  is  prone  to  occur  is  that  during 
which  absolute  rest  for  the  patient  should  be  most  rigidly 
enforced.  In  the  first  case  (the  septic  one)  embolism  did 
not  occur  until  three  or  four  weeks  after  the  onset  of  the 
thrombosis,  and  no  embolus  became  detached  until  the 
thrombus  had  not  only  ceased  to  grow,  but  had  commenced 
to  disappear;  the  embolism,  in  fact,  occurred  at  the  time 
of  the  softening  of  the  thrombus.  The  importance  of  this 
clinical  point  is  as  follows:  The  period  of  danger  from 
embolism  in  a  septic  ease  of  thrombosis  is  at  the  time  of 
softening,  i.e.,  when  the  patient  is  apparently  on  the  verge 
of  convalescence.  On  the  other  hand,  in  the  second  case, 
in  which  the  thrombus  was  aseptic,  extensive  thrombosis 
occurred  very  soon  after  the  operation,  and  on  the  follow- 
ing day  embolism  occurred  whilst  the  thrombus  was  in- 
creasing in  size — a  clinical  sequence  which  illustrates 
admirably  the  fact  that  in  aseptic  thrombosis  the  danger 


JOTTINGS.  375 

of  embolism  is  greater  during  the  formation  of  the  throm- 
bus, and  not  at  the  period  of  resolution,  the  exact  reverse 
of  the  condition  holding  good  in  septic  thrombosis. 

The  practical  bearings  of  these  facts  upon  treatment 
are  the  following:  In  septic  thrombosis  the  greatest  care 
should  be  taken  to  ensure  absolute  rest  during  the  period 
of  resolution;  in  aseptic  cases  the  greatest  call  for  rest  is 
during  the  period  of  the  formation  of  the  thrombus.  In 
septic  cases  on  no  account  should  patients  be  allowed  to 
move  until  the  thrombus  has  entirely  disappeared;  in 
aseptic  cases,  on  the  other  hand,  there  is  no  objection  to 
a  little  movement  when  the  thrombus  has  ceased  to  grow, 
and  there  is  certainly  no  reason  for  maintaining  complete 
rest  until  it  has  entirely  disappeared;  in  fact,  in  the  latter 
period  some  movement  is  beneficial. 

With  regard  to  the  treatment  of  these  cases  of  passive 
thrombosis  rest  of  course  is  absolutely  necessary  during 
the  progress  of  the  disease.  Medicinally  the  best  treat- 
ment is  what  is  called  the  alkaline  treatment — alkalies 
with  excess  of  ammonia  will  do  more  to  hasten  the  dis- 
appearance of  these  passive  clots  than  anything  else. 
Locally  warm  applications  are  comfortable,  and  perhaps 
to  some  extent  promote  absorption.  When  the  veins  are 
varicose,  if  the  application  has  some  hardening  effect  on 
the  skin  (Lot.  Plumbi,  for  example)  so  much  the  better — 
when  the  veins  themselves  are  normal,  water  fomentations 
effect  every  purpose.  In  the  late  stage  of  aseptic  throm- 
bus, massage,  when  used  with  understanding,  is  of  great 
service;  but  by  those  who  are  without  considerable  ex- 
perience it  should  not  be  used,  as  in  such  hands  it  may  be 
dangerous. — Sir  William  Bennett,  Lond.  Clin.  Jour.  Post 
Grad. 


Jottings. 


Aromatic  sulphuric  acid,  in  doses  of  from  ten  to  twenty 
drops  in  chamomile  tea,  taken  at  bed  time,  arrest  profuse 
perspiration. 

In  the  delirium  of  typhoid  fever,  or  in  acute  delirium 
from  whatever  cause,  dilute  hydrobromic  acid  in  full  doses 
is  almost  a  specific. 


3/6  joi'Ji^GS, 

When  chilly  from  exposure,  breathe  very  deeply 
and  rapidly  and  the  increase  in  bodily  warmth  will  be 
surprising. 

Camphor  should  be  dampened  with  alcohol  when 
it  is  desiied  to  powder  it-  Then  it  can  be  rubbed  into 
an  almost  impalpable  powder. 

When  a  urinary  antiseptic  is  needed  try  lithium 
benzoate.  It  is  eliminated  through  the  kidneys,  increases 
the  flow  of  urine  and  sedates  the  urinary  tract. 

Always  be  on  the  lookout  for  "walking  typhoid" 
If  a  man  comes  to  you  "feeling  sick"  be  sure  and  take  the 
temperature  and  inspect  tongue  and  abdomen. 

If  you  would  act  upon  the  duodenum,  give  calomel  and 
podophyllin;  if  upon  the  illium  or  jejunum,  give  senna  or 
jalap;  if  upon  the  descending  colon  or  rectum,  use  aloes. 

Dr-  Weil  claims  that  vomiting  in  pregnancy  can  be  re- 
lieved by  a  twenty  per  cent,  solution  of  menthol  in  olive 
oil,  ten  drops,  taken  in  sugar  whenever  the  nausea  appears. 

The  use  of  stramonium  is  more  effective  in  spasmodic 
asthma  than  belladonna,  because  it  produces  a  greater 
relaxation  of  the  involuntary  bronchial  muscles. 

In  the  treatment  of  purpura  hemorrhagica,  large 
doses  of  the  tincture  of  the  chloride  of  iron,  as  much  as 
forty  drops  every  two  hours,  are  advised. 

In  neuralgias  about  the  face  or  head  three  minim 
doses  of  the  tincture  of  gelsemium  every  half  hour  will 
often  act  almost  miraculously,  and  leave  no  ill  effects. 

The  injunction  into  the  rectum  of  eight  or  ten  drop,;?  of 
tincture  aconite  will  enable  you  to  pass  a  catheter  into  the 
urethra,  which  before  could  not  be  done. 

For  sciatica  collodion,  tincture  of  iodine,  liquid  am- 
monia, equal  parts.  To  be  applied  widely  over  the  parts 
with  a  camel's  hair  brush. 

In  Europe  smoking  is  growing  so  rapidly  in  favour 
among  the  fair  sex  that  on  some  of  the  Belgian  railroads 
smoking  compartments  are  to  be  provided  exclusively  for 
women. 

Cyanosis  with  a  weak  and  rapid  small  pulse,  low  arte- 
rial tension,  great  feebleness  of  the  heart's  action,  demands 
digitalis.  This  is  especially  true  where  the  lungs  are  in- 
volved in  disease. 


JOTTINGS  377 

Always  direct  that  iodide  of  potassium  be  taken  in 
milk.     Large  doses  are  then  well  borne. 

When  the  grass  is  moved  use  the  damp  grass  for 
the  carpet  in  the  same  way  as  tou  would  employ  tea  leaves. 
The  grass  revives  the  colors  in  a  wonderful  way,  and  re- 
moves all  spots  and  dust. 

Boy  or  Girl— Which  Will  It  Be?— If  the  expectant 
mother  walks  slowly,  flat-footed,  has  sunken  eyes,  and 
craves  oysters,  it  will  be  a  boy.  If  she  walks  quickly, 
with  elastic  gait,  has  full  eyes  and  craves  sweetmeats,  it 
will  be  a  girl. 

Ten  to  twelve  parts  of  water  and  one  part  of  am- 
monia will  preserve  soft  rubber  any  length  of  time.  Keep 
rubber  pipes,  etc.,  in  a  glass  jar  filled  with  the  above  solu- 
tion. Use  for  your  ammonia  bottle  a  rubber  stopper;  it  is 
better  than  a  glass  stopper 

Dr.  L.  D.  Bulkley  says  that  for  some  time  past  he 
has  prescribed  ichthyol  by  the  mouth,  10  to  15  drops,  in 
capsules,  three  times  daily,  and  finds  that  this,  through 
its  action  on  the  liver  and  intestines,  will  cure  nearly  every 
case  of  hemorrhoids.  In  fact,  he  looks  upon  its  internal 
use  as  a  specific. 

When  lime  has  got  into  the  eye  something  must  be 
done  at  once.  Wash  the  eye  thoroughly  with  a  large  quan- 
tity of  warm  water — for  a  little  wateir  but  adds  to  the 
trouble  by  slaking  the  lime — and  then  introduce  a  solution 
of  sugar  and  water.  This  is  superior  to  solutions  of  vin- 
egar or  dilute  acids,  because  sugar  forms  an  insoluble  com- 
pound with  lime 

Dr.  Boskowitz,  of  New  York  City,  asserts  that  lobelia 
will  cure  spasmodic  stricture  "as  if  by  magic,"  and  in  per- 
manent stricture  where  it  is  impossible  to  pass  the  small- 
est sound,  the  diflflculty  will  be  easily  overcome  after  a 
single  application  of  the  drug.  He  drops  into  the  urethra 
about  fifteen  drops  of  fl.  ext.  lobelia,  then  closes  the  meatus, 
and  holds  the  lobelia  in  the  urethra  for  a  few  minutes. 

Several  sufferers  from  writers'  cramp  are  reported 
to  have  obtained  great  relief  by  becoming  enthusiastic 
golfers.  This  game  requires  the  use  of  the  upper  extrem- 
ities just  to  the  degree  adapted  to  people  who  have  lived 
a  sedentary  life.  The  movements  are  necessarily  co- 
ordinate, and  they  are  combined  with  proper  exercise  of 
the  lower  extremities,  and  a  large  amount  of  time  is  passed 
in  the  open  air. 


•■i'JH.Ja 


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Editorial. 


WHAT     SHALL     BE     DONE     WITH     THE     PROFESSIONAL 

MID^VIFE? 

An  article  under  the  above  title  from  the  pen  of  Dr.  Lewi, 
of  New  York,  and  published  in  "  Medicus,"  issued  at  Fre- 
derick, M.D.,  has  given  us  food  for  reflection.  According 
to  the  figures  published  by  the  New  York  City  Board  of 
Health,  it  would  appear  that  during  the  year  1891  there 
was  reported  80,735  births.  Of  this  number,  42,253  were 
reported  by  physicians  and  38,452  by  midwives.  For  the 
previous  year  the  figures  are  very  much  the  same.  It  would 
appear  that  the  medical  profession  of  that  city  shows  an 
undivided  opinion,  that  great  evils  are  wrought  by  reason  of 
the  incapacity  and  negligence  of  these  midwives.  Dr.  Lewi 
states  that  the  hospitals  and  dispensaries  of  that  city  are 
daily  witnesses  to  the  criminality  which  permits  ignorant 
women  to  act  as  medical  guardians  at  the  birth  of  the  child. 
The  concensus  of  opinion  which  holds  this  ignorance  re- 
sponsible for  the  many  cases  of  ophthalmia  neonatorum, 
and  of  ruptured  perineums  and  of  lacerated  ora  uter- 
orum  that  are  met  with  at  the  medical  charities  is  un- 
biased, it  is  gleaned  from  the  actual  experience  of 
the   men   who  lead  in  these  several  specialties.      The  true 


EDITORIAL  379 

cure  would  be  to  prevent  women  to  attend  midwifery  cases 
who  are  not  possessed  of  the  knowledge  essential  to  practice 
medicine  generally.  Such  a  view  is  Utopian — especially 
where  our  cities  are  crowded  with  a  cosmopolitan  population* 
and  even  in  the  country.  It  is  of  the  greatest  importance 
that  women  who  intend  to  act  as  mid  wives  should  be 
educated  to  the  highest  possible  degree  in  their  specialty. 
We  should  judge  from  the  tenor  of  the  article  we  refer  to 
that  practically  there  are  not  any  restrictions  to  the  practice 
of  Midwifery.  We  do  not  wonder,  therefore,  that  the 
medical  profession  of  New  York  is  called  upon  so  constantly 
to  treat  the  results  of  midwifery  neglect.  "  We  know," 
writes  Dr.  Lewi,  "  that  the  asylums  for  the  blind  are  being 
crowded  with  children  rendered  sightless,  because  of  the 
neglect,  criminal  or  otherwise,  of  these  midwives."  In  Canada, 
and  in  this  Province  of  the  Dominion,  matters  are  not  so 
bad  as  they  appear  to  be  in  New  York.  We  make  a  fair 
attempt  at  making  those  women  who  desire  to  become 
midwives  qualify  themselves — and  be  licensed  to  practice. 
We  feel,  however,  that  there  is  much  to  be  done,  and  which 
should  be  done,  to  educate  them  to  a  much  higher  standard. 
The  necessity  for  this  higher  standard  being  reached  would 
eliminate  a  class  of  women,  now  allowed  to  enter,  whose 
natural  intelligence  and  education  is  such  that  it  is  impos- 
sible to  bring  them  to  the  required  level.  The  true  test  of 
this  being  reached  must  be  the  examination.  This  should 
be  conducted  in  a  thoroughly  strict  manner,  and,  if  not 
passed  most  satisfactorily,  the  license  ought  to  be  refused. 
No  special  pleading  should  be  allowed  to  have  weight — 
such  as  "their  living  depended  on  it."  We  have  known 
such  to  have  an  efifect.  Think  of  the  untold  misery  these 
women  can  cause,  not  only  to  the  unfortunate  mother,  but 
to  the  child  just  ushered  into  the  world.  We  fear  that  this 
thought  has  not  sufficiently  fixed  itself  on  the  attention  of 
those  who  have  in  the  past  been  placed  as  guardians  at  the 
portals  where  these  women  seek  admission.  We  have,  how- 
ever, in   many  parishes  in  this  Province  women   who  prac- 


38o  PERSONAL. 

tice  Midwifery,  and  who  have  no  qualification  beyond  the 
fact  that  they  have  attended  many  cases.  Scientific  educa- 
tion they  have  none,  and  they  are  the  bete  noire  of  the 
qualified  physician  possibly  residing  within  a  few  doors  of 
her.  For  a  mere  pittance  they  attend  a  woman  in  labour 
who  very  often  afterwards  carries  with  her  a  condition  the 
result  of  ignorance,  and  which  makes  her  life  a  burden  for 
the  rest  of  her  existence.  Surely  something  might  be  done 
to  remedy  this  evil.  The  interference  of  the  Provincial 
Medical  Board  in  such  cases  should  be  pushed  to  its  fullest 
extent,  not  only  as  a  protection  to  its  legally  qualified 
member,  but  in  the  best  interest  of  the  health  and  comfort 
of  the  mothers  of  our  country. 


Personals. 


Dr.  Von  Eberts  (M.D.,  1897),  who  has  been  Medical 
Superintendent  of  the  Montreal  General  Hospital,  has  re- 
signed, and  his  resignation  took  effect  on  the  31st  August, 

Dr.  Turner  (M.D.,  McGill,  189 1).  who  has  been  one 
of  the  House  Surgeons  of  the  Montreal  General  Hospital 
for  the  past  year,  has  been  appointed  Medical  Superintendent 
of  that  institution  in  succession  to  Dr.  Von  Eberts.  He  took 
up  the  duties  of  his  new  appointment  on  the  ist  September, 

Dr,  R,  F.  Ruttan,  who  for  the  past  eleven  years  has  been 
Registrar  of  the  Faculty  of  Medicine  of  McGill  University, 
has  resigned,  and  has  been  appointed  Professor  of  Chemistry, 
vacant  by  the  resignation  of  Dr.  G.  P.  Girdwood. 

Dr.  Girdwood  has  resigned  the  Chair  of  Chemistry  in 
McGill  University,and  has  been  appointed  Emeritus  Professor. 

Dr.  W.  H,  Drummond  (M.D.,  Bishop's,  1884),  the  well- 
known  dialect  poet  and  author  of  "  The  Habitant  "  and 
"Johnny  Courteau  "  and  other  poems,  received  in  June  last 
the  honourary  degree  of  D.C.L.  from  Toronto  University.  Dr, 
Drummond  is  Professor  of  Medical  Jurisprudence  in  the 
Medical  Faculty  of  Bishop's  University, 

A  statue  to  Pasteur  was  unveiled  on  3rd  August  at  his 
birth  place.  Dole,  Jura.  Tlie  occasion  was  celebrated  with 
laudatory  orations. 


BOOK  REVIEWS.  S^I 

OBITUARY. 

Dr.  Thomas  Christie,  of  Lachute,  Que.,  and  Member  of 
the  Dominion  Parliament  for  Argenteuil,  died  on  the  5th 
of  August  from  an  attack  of  pneumonia.  Dr.  Christie  was 
seventy-eight  years  of.  age,  and  was  born  in  Glasgow,  Scot- 
land. He  came  with  his  parents  to  Canada  when  he  was 
five  years  of  age,  and  with  them  settled  in  the  neighbour- 
hood of  Lachute-  He  graduated  as  Doctor  of  Medicine  in 
1848  from  McGill  University  and  for  fifty-four  years  prac- 
tised his  profession.  Not  only  was  he  the  ideal  Country 
Doctor — but  from  a  comparatively  early  period  of  his  life 
he  took  an  active  interest  in  public  questions,  and  thus 
gradually  stepped  into  political  life.  In  politics  he  was 
a  liberal,  but  he  enjoyed  in  a  remarkable  degree  the 
friendship  of  members  of  both  political  parties.  Such  a 
good  man,  both  in  medicine  and  politics,  will  be  greatly 
missed- 

The  medical  profession  of  Montreal  were  not  only 
grieved  but  startled  on  the  7th  of  August  to  hear  of  the 
death  of  one  of  their  number,  Dr.  J.  A.  S.  Brunelle,  which 
took  place  somewhat  suddenly  the  previous  day  at  Mountain 
View,  N.  Y.,  where  he  had  a  summer  residence-  Although 
of  late  not  in  the  best  of  health,  few  of  his  friends  were 
aware  of  it,  and  his  death  came  to  them  with  unexpected 
suddenness.  By  those  who  knew  him  best,  he  was  greatly 
liked,  for  he  had  a  sunny  smiling  nature.  Dr.  Brunelle 
was  born  at  St.  Hyacinthe  in  1882.  He  graduated  from 
Victoria  College — Montreal  School  of  Medicine  and  Surgery. 


Book   Reviews. 

Grayson's  Laryngology.— A  Treatise  on  the  Diseases  of  the 
Throat,  Nose  and  the  associated  affections  of  the  Ear,  By 
Charles  P.  Grayson,  M.  D.,  Lecturer  on  and  Instructor  in 
Laryngology,  in  the  Medical  Department,  University  of  Penn- 
sylvania. In  one  octavo  volume  of  540  pages,  with  129  en- 
gravings and  5  colored  pla'es.  Cloth,  $3.50  net.  Lea  Brothers 
&  Co.,  Philadelphia  and  New  York,  1902. 

The  many  treatise.*:  frequently  issued  on  this  subject  make  it  a 
very  difficult  matter  for  a  neiv  author  to  furnish  a  late  production 
that  would  justify  its  appearance  and  contain  merit  sufficient  to 
distinguish  it  from  the  many  predecessors.  Dr.  Grayson  has  sought 
to  make  his  work  more  concise  in  treatment  than  most  authors  by 


382  BOOK  REVIEWS. 

giving  under  each  disease  but  one  plan  to  pursue,  and  that  one 
consisting  of  what  he  has  found  to  have  been  most  successful  in 
subduing  symptoms  and  shortening  the  duration  of  disease  through- 
out his  large  clientele.  To  meet  exceptional  cases,  he  has  added  a 
few  modifications  to  this  routine  plan. 

Although  essentially  a  volume  upon  Laryngology,  the  author 
recognizes  the  necessity  for  inclusion  of  Ear  Diseases  in  the  work, 
and  gives  a  modern  and  complete  synopsis  of  what  is  requisite  in 
this  section. 

■  Altogether  the  book  is  a  very  presentable  one,  containing  good 
paper,  clear  type  and  plates,  and  commends  itself  to  both  student 
and  practitioner,  particularly  on  the  basis  mentioned,  as  a  useful 
contribution  in  the  special  field  of  Throat,  Nose  and  Ear  Diseases. 

G.  T.  R. 

Diseases  of  Women. — A  Manual  of  Gynecology  designed 
especially  for  the  use  of  students  pnd  general  practitioners,  by 
F.H.  Davenport,  A.B.,M.D.,  Assistant  Professor  in  Gynecology, 
Harvard  Medical  School.  Fourth  edition,  revised  and  en- 
larged, with  154  illustrations.  Lea  Brothers  &  Co.,  Phila- 
delphia and  New  York,  1902. 

This  is  a  handy  volume  of  a  little  over  four  hundred  pages, 
and  appears  to  be  a  model  of  conciseness  and  clearness.  Its  main 
objects  are  to  give  the  student  clearly,  but  with  considerable  detail, 
the  methods  of  examination  and  the  simple  form  of  treatment  of 
the  most  common  disease  of  the  pelvic  organs,  and  in  the  second 
place  to  help  the  busy  general  practitioner  to  understand  and  treat 
the  gynecological  cases  which  he  meets  in  his  everyday  practice. 
Special  attention  has  been  paid  to  the  description  and  explanation 
of  many  minor  though  important  points  which  are  ordinarily  omitted 
in  text  books,  but.which  are  nevertheless  of  great  value.  The  book 
aims  to  be  practical,  and  is  therefore  devoted  principally  to  diag- 
nosis and  treatment,  to  the  exclusion  of  unsettled  theories.  There 
are  so  many  good  points  in  the  book  that  we  cannot  mention  all  of 
them,  but  we  are  pleased  to  see  that  the  author  prefers  a  basin  of 
warm  water  and  castile  soap  for  lubricating  the  finger  instead  of 
using  oil  or  grease,  because  the  latter  adheres  both  to  the  finger 
and  to  the  dish.  Another  good  point  is  the  advantage  of  training 
the  left  hand  for  digital  examinations  so  as  to  keep  the  stronger 
right  hand  for  depressing  the  abdominal  wall  and  holding  instru- 
ments. The  author  gives  some  good  advice  when  he  says  that  a 
satisfactory  examination  cannot  be  made  on  a  soft  bed  ;  the  patient 
should  always  be  examined  on  a  table;  but  the  table  must  be  cov- 
ered with  a  soft  quilt  ov  blanket  and  covered  with  a  sheet  so  as  to 
take  away  from  the  patient  the  idea  that  she  is  on  a  table.  We 
cannot  emphasize  too  strongly  another  advice  given  by  the  author, 
namely — no  matter  how  busy  you  are,  take  the  time  to  write  a  brief 


BOOK  REVIEWS.  3^3 

but  clear  statement  of  each  case  when  she  comes  for  the  first  time 
to  your  office;  give  every  one  a  fresh  page  and  number  and  index 
it.  and  you  will  find  such  a  book  of  the  greatest  value,  increasing 
with  each  year.  The  reviewer  advises  a  book  of  at  least  one  thou- 
sand pages  of  foolscap  which  will  last  many  years.  For  patients 
seen  for  the  first  time  at  their  houses,  take  down  some  bedside  notes 
and  transcribe  them  into  the  case  book  the  same  day.  In  making 
pelvic  examinations,  he  says,  have  the  patient  remove  the  corsets 
and  empty  the  bladder  first  beforehand,  as  the  nervous  condition 
causes  the  bladder  to  fill  quickly  and  thus  renders  the  examination 
impossible  or  useless.  These  are  only  a  few  points,  but  they  may 
suffice  to  illustrate  the  exceedingly  practical  nature  of  the  work. 

A.  L.  S. 

The  Practical  Medical  Lines  of  Year  Books,  under  the 
general  editorial  charge  of  Gustavus  P.  Head,  M.D.,  Profes- 
sor of  Laryngology  and  Rhinology,  Chicago,  Post  Graduate 
School,  Vol.  vii,  Iviateria  Medica  and  Therapeutics,  Preventa- 
tive Medicine,  Climatology,  Forensic  Medicine.  Edited  by 
George  F.  Butler,  Ph.  G.,  M.D.,  Henry  B.  Favill,  A.B.,  M.D., 
Norman  Budge,  A.M.,  M.D.,  Harold  N.  Mayer,  M.D.,  June, 
1902,  Chicago.  The  Year  Book,  Publishers,  40  Dearborn 
Street. 

Sharp,  terse  and  concise  is  the  manner  in  which  the  various  sub- 
jects enit)raced  in  this  small  volume  are  treated.  It  is  up  to  date  in 
every  way. 

F.  W.  C. 

The  Neuroses  of  the  Genito-Urinary  System  in  the 
Male,  with  Sterility  and   Impotence.      By  Dr.  R, 

Ultzmann,  Professor  of  Genito-Urinary  Diseases  in  the  Uni- 
versity of  Vienna.  Second  Edition.  Revised,  with  notes  and 
a  supplementary  article  on  Nervous  Impotence,  by  the  trans- 
lator, Gardner  W.  Alien,  M.D.,  Surgeon  in  the  Genito- 
Urinary  Department  of  the  Boston  Dispensary  ;  Instructor  in 
Genito-Urinary  Surgery  in  Tuft's  Medical  College.  Illus- 
trated. Pages,  198.  i2mo.  Price,  extra  cloth,  $1.00,  net, 
delivered.  Philadelphia  :  F.  A.  Davis  Company,  Publishers, 
1 9 1 4-  -  6  Ch  erry  Street. 

A  most  worthy  little  book,  on  a  very  interesting  and  import- 
ant subject.  The  paper  used  has  no  gloss,  and  all  details  are  a 
well-known  standard  of  the  F.  A.  Davis  Company.  Very  little 
charge  has  been  noted  in  the  revised  portion,  which  shows  what  a 
master  was  Professor  Ultzaiann.  The  supplementary  article  on 
nervous  impotence  is  most  interesting,  and  does  credit  to  the  trans- 
lator, Gardner  W.  Allen,  M.D. 

G.  F. 


PUBIvISHKRS  DKPARnrMKNTL^ 

SANMETTO  IN  IRRITABLE  AND  ATONIC  CONDITIONS  OF  THE 
GENITO-URINARY  ORGANS. 

I  have  used  Sanmetto  quite  extensively  in  my  practice  for  a  number  of 
years,  and  have  learned  from  the  universally  good  results  obtained  from  its  use 
to  pin  my  faith  to  it  in  all  irritable  or  atonic  conditions  of  the  genito-urinary 
organ?.  I  find  it  the  true  aphrodisiac  in  both  male  and  female  patients.  Since 
I  have  used  Sanmetto  prostatitis  has  lost  much  of  its  terrors  and  cystitis  has 
ceased  to  be  the  grave  disease  it  was  before  its  use.  I  shall  continue  to  pre- 
scribe Sanmetto. 

F.  A.  CROMLEY,  M.D. 
Gallipolis,   Ohio. 

SANMETTO  IN  GENITO-URINARY    IRRITATIONS  AND    ATONIC 
SEXUAL  CONDITIO }JS. 

I  have  used  Sanmetto  very  extensively  in  my  practice  for  years,  and  am 
daily  more  and  more  convinced  of  its  intrinsic  merit  in  all  genito-urinary  irrita- 
tions and  atonic  sexual  conditions.  It  is  my  sheet  anchor  in  urethritis,  cystitis 
and  chronic  prostatitis.  I  shall  continue  its  use  in  cases  where  it  is  indicated, 
and  also  enlarge  upon  the  field  of  its  exhibition  as  circumstances  may  suggest. 
Sanmetto  is  all  right. 

FLAVIUS  J.  KNIGHT,  M.D. 
Charlotte,  Mich. 


TREATMENT  OF  PRE-SEKILITY. 

Ferguson  details  a  case  of  impotence  following  a  prolonged  attack  of 
gonorrhea.  It  was  bis  third  attack,  and  his  virile  power  was  almost  lost  and  he 
suffered  from  frequent  micturition .  He  had  in  addition  orchitis  on  both  sides.  The 
case  was  peculiarly  obstinate  and  many  remedies  had  been  used  to  no  purpose. 
He  had  already  exh  usted  the  resources  of  several  quacks.  Sanmetto  was  pre- 
scribed in  teaspoonful  doses  three  times  a  day  and  improvement  and  recovery 
followed. 

MEDICAL  NEWS. 
New  York  and  Philadelphia. 


C  A.N  AD  A 

MEDICAL  RECORD 

SEPTEMBER.      1902. 

Original  Communications, 

CANADIAN  MEDICAL  ASSOCIATION. 

The  Thirty-Fifth  Annual  Meeting  of  the  Canadian  Medi- 
cal Association  was  held  in  the  City  of  Montreal  on  the 
16th,  17th  and  18th  of  September,  under  the  presidency 
of  Dr.  Francis  J.  Shepherd. 

As  an  evidence  of  the  great  success  which  attended 
this  meeting,  the  fact  that  more  physicians  registered  on 
the  first  day  than  on  any  other  previous  first  day  speaks 
volumes. 

At  the  Morning  General  Session  of  the  first  day  a  resolu- 
tion of  regret  at  the  recent  death  of  Professor  Virchow, 
which  was  at  the  same  time  one  of  appreciation  for  the 
great  work  of  this  eminent  pathologist,  was  proposed  by 
Professor  Adami;  seconded  by  Dr.  Gardner,  Montreal, 
and  carried  unanimously. 

The  meeting  divided  into  sections,  Dr.  McPhedran, 
Toronto,  taking  the  chair  at  the  Medical  Session ,  while  Dr. 
O.  M.  Jones,  Victoria,  B.  C,  looked  after  the  Surgical  Sec- 
tion. 

MEDICAL  SECTION. 

The  Forenoon  of  First  Day. 

LIVING   CASE,   SPLENIC  ANAEMIA. 

Dr.  H.  A.  Lafleur,  Montreal,  presented  patient,  a  man 
in  middle  life.  There  was  a  tumour,  a  movable  mass,  about 
midway  between  the  lower  ribs  on  the  left  side  and  the 
crest  of  the  ilium,  with  pulsation,  but  not  expansile,  over 
the  tumour.  The  first  blood  count,  made  in  March,  showed 
75  per  cent,  haemoglobin,  the  red  corpuscles  5,000,000;  the 


386  CANADIAN    MEDICAL    ASSOCIATION. 

white  0,400.     A    blood  count  was  made  again  on  the  15th 
September,  1902;  b^bowed  4,000,000  and  5,800,  respectively. 

The  tumour  chan^o-ed  according  to  degree  and  distension 
of  the  stomach.     There   .was  absence  of  mobility. 

Dr.  Osier  referred  to  thc^  difficulty  and  the  lack  of  com- 
plete mobility  in  diagnosing  liIJs  case  and  of  enlarged 
spleen  being  often  clinically  mistal^^en  for  something  else. 
This  was  just  one  of  these  cases  in  wh4ch  the  diagnosis  was 
more  surgical  than  clinical- 

SOME  FURTHER  RESULTS  IN  THE  TREATMENT  OF.\  TUBERCULOSIS. 

Dr.  J.  H.  Elliott,  of  the  Gravenhurst  Sanit^orium,  con- 
tributed this  paper:  ^ 

At  a  meeting  of  this  Association  in  Toronto  rn  1899, 
a  report  was  made  upon  155  cases  of  pulmonary  tu^bercu- 
losis  under  sanitorium  treatment.  This  paper  is  a  fii  rther 
contribution  covering  some  400  additional  cases  tretated 
during  the  past  three  years.  The  nomenclature  used  in  ^I'+he 
classification  of  discharged  patients  is  that  adopted  b^y 
Trudeau:  '^Apparently  Cured,"  '^Disease  Arrested,"  ''Much 
Improved,"  "Stationary"  and  "Failed." 

Five  years'  experience  has  shown  that  almost  all  of  the 
patients  discharged  "apparently  cured"  remain  perfectly 
well;  of  those  with  "disease  arrested"  many  have  progress- 
ed to  good  health  at  home  by  following  the  rules  of  life 
learned  at  the  Sanitorium;  renewed  activity  of  the  disease, 
when  occurring,  having  been  as  a  rule  due  to  unfavourable 
surroundings,  or  the  necessity  of  again  taking  up  unsuit- 
able work. 

Not  the  least  important  part  of  the  work  of  a  Sani- 
torium is  its  educative  influence.  Each  patient  who  returns 
home  is  a  teacher  of  the  value  and  importance  of  a  hy- 
gienic life,  to  those  who  wish  to  retain  their  health  as 
well  as  those  who  are  not  strong. 

Experience  is  demonstrating  the  immense  amount  of 
influence  for  good  which  results  from  a  properly  equipped 
and  conducted  Sanitorium.  It  is  unfortunate  that  there  are 
not  more  of  them.  It  is  hoped  that  the  attention  of  our 
philanthropists  will  be  drawn  to  the  crying  need  of  such 
institutions,  and  that  ere  long  we  shall  have  a  number  of 
them  in  the  various  provinces  of  Canada. 


CANADIAN    MEDICAL    ASSOCIATION.  387 

Dr.  Osier  congratulated  Dr.  Elliott  on  the  promising 
results  which  he  has  obtained.  Two  important  points 
should  be  kept  well  in  mind:  First,  early  diagnosis,  and, 
second,  getting  patient  as  soon  as  possible  under  proper 
professional  control. 

Dr.  T.  D.  Walker,  St.  John,  N-  B.,  referred  to  the  con- 
trol the  physician  in  the  Sanitorium  had  over  the  patient. 

Dr.  John  Ferguson,  Toronto,  spoke  of  the  positive  ad- 
vances that  have  been  made  along  the  line  of  the  curability 
of  pulmonary  tuberculosis. 

Dr.  McPhedran,  Toronto,  emphasized  training  patients 
how  to  care  for  themselves  at  home.  He  believes,  too, 
that  it  is  true  that  the  neighbourhoods  of  sanitaria  are 
always  areas  where  tuberculosis  is  always  diminishing. 

PLEURISY  AS  ASSOCIATED  WITH  TUBERCULOSIS. 

Dr.  John  Hunter,  Toronto,  read  this  paper.  He  first 
referred  to  the  manner  in  which  bacilli  reached  the  visceral 
and  parietal  pleural  through  the  sub-pleural,  bronchial  or 
tracheal  lymphatic  glands,  and  from  the  cervical  medias- 
tinal and  peritoneal  lymphatics;  also  from  the  tonsils.  In 
arriving  at  a  diagnosis  of  pleurisy,  a  vigilant  search  should 
be  made  for  a  possible  tuberculosis  origin.  One  should  not 
always  consider  the  outlook  gloomy,  as,  with  properly  car- 
ried out  treatment,  the  progress  is  much  more  favourable 
than  in  pulmonary  tuberculosis.  In  at  least  two-thirds  of 
tubercular  pleurisy  it  is  a  curable  affection.  The  rapidity 
of  the  filling  of  the  pleural  cavity  is  especially  charac- 
teristic of  tubercular  cases. 

Dwelling  upon  treatment  during  convalescence,  deep 
breathing  should  be  practiced  very  assiduously,  and  infla- 
tioji  with  rubber  bags  is  a  valuable-  exercise.  Then  change 
to  a  suitable  climate  should  be  insisted  on  if  the  progress 
towards  recovery  be  retarded. 

CLINICAL  NOTES  ON  BLOOD  PRESSURE  IN  DISEASED  CONDITIONS 

BY 
DR.    A.    E.    ORR,    MONTREAL. 

A.  Gaertner's  Tonometer  was  shown  and  the  manner 
of  its  use  demonstrated.  Four  hundred  patients  at  the  Royal 


$88  CANADIAN    MEDICAL    ASSOCIATION. 

Victoria  Hospital,  Montreal,  were  experimented  on.  The 
normal  pressure  was  found  to  be  110  to  120.  Seventy  cases 
of  typhoid  fever  were  recorded  in  different  stages,  showing 
an  average  blood  pressure  of  104.5  m.m.  It  was  highest, 
but  still  subnormal,  in  the  first  week.  There  was  only 
one  death  which  took  place  in  a  man  of  35  years,  when 
pressure  was  105  on  tenth  day,  110  on  twenty-first  day; 
then  three  hemorrhages,  and  on  the  twenty-fourth  day  a 
fatal  hemorrhage. 

A  large  proportion  of  these  had  cold  baths  or  cold 
sponging.  Nineteen  cases  of  chronic  nephritis  were  re- 
corded. Of  this  group  the  highest  was  260;  average  208.5. 
Of  acute  nephritis  there  were  seven  cases;  only  three  of 
these  showed  high  pressure.  ■  Of  arteriosclerosis,  37  cases 
were  recorded;  highest  110,  16  being  150  and  over;  4  from 
130  to  145;  3  from  110  to  125;  4  subnormal.  The  highest 
was  in  a  man  of  72;  glycosuria,  no  albumen. 

Valvular  diseases  of  heart,  48  cases,  including  11  cases 
of  mitral  regurgitation.  In  mitral  stenosis,  8  cases  were 
recorded,  6  being  mormal.  Mitral  stenosis  with  mitral 
regurgitation,  14  cases.  Eleven  had  practically  normal 
tension.  Aortic  insufficiency,  3  cases.  Myocarditis,  4 
cases,  one  man  aged  60  having  pressure  of  80.  Hyper- 
trophy and  dilatation  of  heart  of  unknown  causation,  2 
cases  120  and  110  respectively.  There  were  18  cases  with 
acute  lobar  pneumonia,  with  an  average  for  the  series  of 
92.7;  only  one  death.  Pleurisy,  16  cases.  Neurasthenia, 
18  cases,  thirteen  having  normal  pressure:  3  from  135  to 
140;  one  of  160.  In  malignant  disease,  cancer  of  viscera, 
there  were  no  high  readings.  Anaemia  6  cases,  all  being 
normal.  Addison's  disease,  both  in  early  stage,  both  nor- 
mal. Purpura  haemorrh^gica,  one  case,  normal.  Puer- 
peral septicaemia,  one  prolonged  case,  ending  in  recovery, 
had  extremely  low  blood  count,  930,000;  above  normal.  One 
gall  bladder  case  with  suppuration,  a  blood  pressure  of  only 
50,  ten  days  before  death. 

One  lead  poisoning,  3  of  jaundice,  one  of  tubercular 
meningitis,  two  of  diabetes,  two  of  exophthalmic  goitre, 
8  of  acute  articular  rheumatism,  heart  not  affected;  chronic 
articular  rheumatism,  4  cases,  all  normal;  gonorrhoeal  rheu- 


CANADIAN    MEDICAL    ASSOCIATION.  389 

matism,  8  cases,  6  normal;  rheumatoid  arthritis,  16  cases, 
6  normal;  gout,  4  cases. 

There  was  one  case  of  hemiplegia  and  14  of  tabes 
dorsalis,  11  normal  pressure;  cerebral  tumor,  8  cases;  gen- 
eral paralysis  of  insane,  one  case;  Friedreich's  Ataxia,  one 
with  albumenuria,  140 ;  one  acute  ascending  paralysis,  140 ; 
2  cases  tie  doloreux,  one  130  during  the  attack.  There  was 
one  case  of  epidemic  influenza  and  36  miscellaneous  .cases. 

In  discussing  this  paper.  Dr.  Osier  considered  it  to  be 
the  best  contributed  article  on  the  subject. 

On  the  technique  of  recording  the  venus  pulse,  Dr-  W. 
S.  Morrow,  Montreal,  gave  a  practical  demonstration  on  the 
blackboard  and  presented  a  living  subject  on  this  topic. 

SURGICAL  SECTION. 
First  Day — Morning  Session. 

AMPUTATION  OF  THE  UPPER  EXTREMITY  FOR  SARCOMA  OF  THE 

SHOULDER  JOINT LIVING  CASE 

BY 
DR.  J.  ALEX.  HUTCHISON,  MONTREAL. 

The  patient,  a  young  woman,  presented  bj'  Dr. 
Hutchison,  gave  a  histors'  of  previous  injury  to  the  shoulder 
followed  by  the  development  of  a  growth  in  the  head  of 
the  humerus,  ac<iompanied  by  intense  pain.  An  X-ray 
of  the  parts  revealed  the  presence  of  a  large  growth  which 
invaded  the  point,  and  involved  the  scapula.  The  patient 
was  in  an  extremely  unsatisfactory  .condition  for  operation, 
and  presented  evidences  of  marked  cardiac  disease.  The 
incision  extended  from  the  middle  of  the  clavicle  in 
front  down  over  the  pectoral  regions  to  the  lower 
part  of  the  axilla,  and  behind,  passed  over  the  scapula 
down  to  meet  the  anterior  incision. 

After  severing  the  middle  of  the  clavicle,  the  great 
vessels  were  ligated,  the  brachial  nerves  divided  high  up, 
the  muscles  divided  and  the  scapula  freed  from  its  attach- 
ments. There  was  little  hemorrhage,  and  the  wound  heal- 
ed readily.  Microscopic  examination  of  the  growth  showed 
it  to  be  a  mixed  spindle,  and  round,  celled  myeloid  sarcoma. 


390  CANADIAN    MEDICAL    ASSOCIATION. 

A   FATAL  CASE   OP   SECONDARY  HEMORRHAGE   FOUR  DAYS 
FOLLOWING        THE        REMOVAL        OF        ADENOIDS 

BY 
DR.   PERCY   G.   GOLDSMITH,   BELLEVILLE,   ONTARIO. 

This  paper  deals  with  the  case  of  a  child  operated  on 
by  Dr.  Goldsmith  for  obstructive  deafness,  due  to  enlarged 
faucial  tonsils.  The  operation  was  not  unusual,  and  the 
condition  of  the  patient,  on  the  second  and  third  day  after 
the  operation,  was  apparently  satisfactory;  on  the  fourth 
day,  however,  repeated  and  alarming  attacks  of  hemorrhage 
set  in,  resulting  fatally  in  a  few  hours.  There  was  no 
history  of  hemophilia.  The  patient  was  under  the  care 
of  the  family  physician  at  the  time  of  death,  and  as  no 
post-mortem  could  be  obtained,  the  cause  of  the  hemor- 
rhage remained  unknown. 

OCCLUSION    OF    POSTERIOR   NARIS 

BY 
DR.  H.  D.  HAMILTON,  MONTREAL. 

The  patient  was  a  young  man  aged  17,  who  complained 
of  constant  discharge  from  right  naris,  with  complete  ob- 
struction of  the  same  side.  Duration  of  the  condition, 
about  12  months- 

On  examination  the  patient  presented  a  complete  bony 
partition  occluding  the  right  choana. 

Family  and  personal  history  was  negative.  Treat- 
ment :  The  bony  wall  was  perforated,  and  the  opening 
further  enlarged  by  graduated  bougies. 

ON   THE   USE   OF   THE    SUBCUTANEOUS   INJECTIONS   OF   PARAFFIN 

FOR  CORRECTING  DEFORMITIES   OF  THE  NOSE. 

BY 

DR.  G.  GRIMMER,  MONTREAL. 

Dr.  Grimmer  spoke  briefly  of  various  other  deformities 
which  had  been  corrected  in  this  manner.  In  the  prepara- 
tion of  the  paraflfin,  it  is  first  sterilized  by  subjecting  it  to 
high  temperature.  It  is  injected  by  means  of  a  ster- 
ilized syringe.  In  the  case  of  the  nose,  the  inner  canthi 
of  the  eyes  should  be  protected  from  the  spreading  of  the 


CANADIAN    MEDICAL    ASSOCIATION.  39 1 

paraffin,  by  firm  pressure  applied  to  the  sides  of  the  nose 
by  an  assistant's  fingers-  After  injection  the  parts  are 
molded  by  the  operator  as  required. 

After  treatment:  Collodion  is  to  be  applied  to  the 
needle  puncture,  and  cold  compresses,  to  control  oedema 
of  the  nose  and  eyelids. 

Some  possible  dangers  from  the  treatment  are,  paraffin 
embolism,  and  necrosis  of  the  skin  over  the  parts. 

Dr.  Grimmer  exhibited  two  patients  successfully 
treated  in  this  manner;  also  two  rabbits  which  had  been 
subjected  to  similar  injections. 

THE    TELEPHONIC    PROPERTIES    OF    THE    INFLAMED    ABDOMEN; 

A   SIGN   NOT   HITHERTO   DESCRIBED   DUE   TO   PARALYSIS 

OF  THE  BOWEL  IN  PERITONITIS 

BY 
DR.   GEO.   A.   PETERS,  TORONTO. 

In  auscultating  the  abdomen  with  a  view  to  ascertain- 
ing whether  there  was  paralysis  of  the  bowel  in  cases  of 
appendicitis,  typhoid  perforations,  traumatism,  and  other 
conditons  which  stand  in  a  causative  relation  to  peritonitis, 
Dr.  Peters  has  observed  that  where  the  gurgling  sounds 
due  to  the  passage  of  gas  and  liquid  in  the  bowel  are  ab- 
sent from  paralysis,  the  heart  sounds  are  invariably  very 
plainly  present  over  the  whole  abdomen. ,  In  intense  cases, 
particularly  in  children,  both  inspiratory  and  expiratory 
breath  sounds  may  be  heard.  Dr.  Peters'  explanation  of 
the  phenomena  is;  unlike  the  healthy  bowel,  where  the  gas 
is  retained  in  certain  well-defined  and  circumscribed  com- 
partments, each  constituting  a  complete  retainer  in  itself, 
with  vital  walls  possessing  a  muscular  tonicity  under 
nervous  control,  the  paralysed  bowel,  hj  reason  of  its 
flaccid  and  atonic  condition,  permits  an  entire  change  in 
the  disposition  of  the  contained  gas;  the  entire  distended  - 
abdomen  becomes  practically  and  accoustically  considered, 
a  continuous  column  of  air  or  gas,  of  the  precise  principle 
of  the  stethoscope.  The  effect  of  this  is  further  heightened 
by  the  rigid  abdominal  wall,  which  acts  as  a  sounding 
board.  The  prognostic  significance  would  seem  to  indicate 
an  unfavourable  termination  in  those  cases  where  the  sign 
is  very  well  marked  in  cases  of  septic  origin. 


392  CANADIAN    MEDICAL    ASSOCIATION. 

A      CASE      OF      FILARIASIS      IN      MAN      CURED      BY      OPERATION 

BY 
DR.   A.   PRIMROSE,   TORONTO. 

A  man  from  the  West  Indies  suffering  from  lymph 
scrotum  presented  himself  for  treatment  and  gave  a  history 
of  attacks  of  fever  which  suggested  the  presence  of  fllaria. 
On  examination  of  the  blood  one  found  the  embryos  present 
in  large  numbers.  The  embryo  fllariae  were  found  in  large 
numbers  at  night,  but  disappeared  from  the  blood  during 
the  day.  An  operation  was  performed  and  a  large  portion 
of  the  scrotum  removed.  The  excised  tissue  was  care- 
fully examined  by  teasing  it  in  salt  solution,  and  a  parent 
worm  was  discovered  and  removed  alive-  This  proved  to 
be  a  female,  and  it  was  subsequently  fixed  and  mounted 
in  a  suitable  manner  for  microscopic  examination.  Sub- 
sequent to  the  operation  the  filaria  embryos  entirely  dis- 
appeared from  the  blood,  and  the  inference  was  that  the 
parent  producing  the  embryos  had  been  removed  by  opera- 
tion. 

The  parent  worm  was  afterwards  carefully  studied 
by  Dr.  J.  H.  Elliott,  M.  D.,  Toronto  (late  of  the  Malaria 
expedition  to  Nigeria  from  Liverpool  school  of  Tropical 
Medicine),  and  a  report  of  his  investigations  with  drawings 
of  the  worm  formed  a  part  of  the  paper  as  communicated 
by  Br.  Elliott. 

GENERAL  SESSION. 

First  Day — Afternoon. 

ADDRESS  IN  SURGERY THE  CONTRIBUTION  OF  PATHOLOGY 

TO  SURGERY 

BY 

DR.   JOHN   STEWART,   HALIFAX,   N.   S. 

Owing  to  the  unavoidable  absence  of  Dr.  Stewart,  this 
paper  was  read  by  Dr.  J.  W.  Stirling,  Montreal.  In  this 
able  address,  Dr.  Stewart,  in  commencing,  compared  the 
struggles  of  the  early  surgeons  for  a  scientific  knowledge 
of  their  craft  to  the  daring  exploits  of  the  early  navigators 
of  Ihe  fifteenth  and  sixteenth  centuries.     A  parallel  not 


CANADIAN    MEDICAL    ASSOCIATION.  393 

altogether  faDciful  iiiiglit  be  drawn  between  those  pioneers 
of  ocean  travel  and  the  early  masters  of  our  craft.  They 
worked  on  two  lines,  the  long,  weary,  and  often  fallacious 
ti-ack  of  Empiricism,  and  the  ample,  but  often  disconnected 
road  constructed  by  those  whose  chief  aim  was,  in  the 
words  of  him  who  led  the  vanguard,  to  "study  and  search 
out  the  secrets  of  nature." 

The  first  advance  came  with  the  Anatomist,  Vesalius, 
"and  fay  Tawned  with  William  Harvey,  the  Columbus  of 
modern  n  cdicine,"  w^hen  he  instituted  the  application  of 
exptrimental  methods  to  biological  questions. 

Finally  came  John  Hunter,  "The  Father  of  Scientific 
Surgery",  of  whom  Billroth  says:  "From  the  time  of 
Hunter  to  the  present,  English  surgery  has  had  something 
of  grandeur  and  style  about  it." 

But  a  great  advance  came  from  the  study  of  plant 
life,  and  the  researches  of  Schwann  and  Schleiden  paved 
the  way  for  the  cellular  pathology  of  Virchow,  the  basis 
of  our  present  system  of  pathology.  "And",  said  Dr. 
Stewart,  "a  shadow  falts  upon  us  gathered  here,  as  we 
.realise  that  the  veteran  master,  the  undisputed  leader  of 
pathological  thought  and  progress  for  over  fifty  years,  has 
fallen,  and  we  unite  in  the  desire  to  lay  our  spray  of  cypress 
on  the  tomb  of  him  whom  we  all  considered  the  greatest 
German  of  our  time." 

While  with  all  these  new  acquisitions  the  pathologist 
went  on  his  way  rejoicing,  the  surgeon  still  lingered  with 
anxious  mind  and  heavy  heart,  for  the  question  of  questions 
to  him  was  still  unanswered,  the  healing  of  wounds  was 
the  enigma  of  surgery. 

By  the  close  of  the  eighteenth  centuiy,  many  scien- 
tific workers  were  satisfied  the  solution  of  this  problem 
lay  in  the  existence  of  pathogenic  microbes,  but  it  was 
reserved  for  Schonlein  to  prove  in  1839  that  Finea  was  due 
to  the  growth  of  a  fungus.  Later  came  Davaine  and 
Chaveau,  with  their  demonstration  of  the  bacillus  of 
anthrax. 

And  finally  came  Lister,  "and,"  said  Dr.  Stewart,  "the 
dark  hemisphere  rolled  in  one  grand  movement  from  its 
age — long     penumbra     into     noonday.     Surgerj',    Modern 


394 


CANADIAN    MEDICAL    ASSOCIATION. 


Purgei'}^  was  boi'ii.     In  the  chronology  of  our  craft,  time 
is  divided  into:  Before  and  After  Lister." 

Lister,  like  Hunter,  united  in  himself  the  jjathologist 
and  the  surgeon,  and,  like  him,  worked  on  the  lines  of 
experimental  pathology. 

president's  address. 

On  the  evening  of  the  first  day,  in  the  Arts'  Museum, 
Dr.  Francis  J.  vShepherd,  of  Montreal,  delivered  the  Annual 
Presidential  Address.  After  welcoming  the  members, 
Dr.  Shepherd  spoke  of  the  Dominion  Registration  Bill 
which  has  been  so  ably  pushed  through,  in  the  face  of  many 
obstacles,  by  Dr.  T.  G.  Roddick,  and  expressed  the  hope 
that  no  one  Province  would  decline  to  act  in  accord  with 
the  almost  universal  desire  to  see  the  Bill  finally  made  law- 
After  a  brief  r(^sum(^  of  medical  progress  the  speaker  en- 
tered a  protest  against  the  freedom  with  which  syphilitica 
are  allowed  to  mingJe  with  the  community  at  large,  often 
causing  the  innocent  to  suffer  more  than  the  guilty.  "It  is 
time,"  said  Dr.  Shepherd,  "that  the  profession  took  this 
subject  up  and  educated  the  public  to  a  better  knowledge 
of  sanitary  laws."  Passing  on  to  the  subject  of  modern 
laboratory  teaching,  the  president  said,  after  referring  to 
the  large  sums  of  money  that  had  been  spent  on  the  erec- 
tion and  endowment  of  laboratories  for  the  encouragement 
of  research  work,  "One  danger  of  this  great  multiplication 
of  laboratories  is  that  it  induces  men  to  •pursue  original 
investigation  who  have  not  the  true  scientific  spirit,  and 
who  are  utterly  unfit  for  such  work.  They  frequently 
collect  and  publish  a  mass  of  useless  and  undigested  ma- 
terial, and  therefrom  draw  inaccurate  conclusions.  All 
this  will  not  redound  to  the  credit  of  medical  science;  "but" 
continued  Dr.  Shepherd,  "I  do  not  wish  it  to  be  inferred 
that  I  am  opposed  to  the  addition  of  modern  laboratories 
to  our  medical  schools;  they  are  all  necessary,  but  they 
must  not  supplant  other  work,  quite  as  important  to  a  man 
who  wishes  to  become  a  practicing  physician  or  surgeon. 
Again,  we  must  remember  that  the  Millenium  will  not 
be  brought  about  by  laboratories,  nor  will  all  scientific 
problems  be  solved    by  them.     There    is  one    laboratory 


CANADIAN    MEDICAL    ASSOCIATION.  395 

which  is  not  so  much  frequented  now  as  when  I  was  a 
student.  I  refer  to  the  hospital  wards.  Students,  while 
perhaps  more  scientific,  I  say  scientific  because  nowa- 
days every  one  who  spends  much  of  his  time  in  a  labora- 
tory learning  the  use  of  all  kinds  of  modern  apparatus, 
including  our  old  friend  the  microscope,  is  regarded  as 
having  a  scientific  training— I  may  say  that  students, 
while  perhaps  more  scientific  (microscopical  and  mechani- 
cal), have  not  the  intimate  personal  knowledge  of  disease 
which  continued  observation  at  the  bedside  gives  them, 
so  that,  when  started  in  some  out-of-the-way  place  without 
their  scientific  machinery,  they  are  like  fish  out  of  water. 
It  may  soon  be  that  they  will,  not  be  able  to  diagnose  a 
fracture  without  the  X-rays,  tuberculosis  without  getting 
bacilli  in  the  sputum,  and  so  on  without  end.  Students 
are  not  taught  to  observe  so  accurately  the  evident  symp- 
toms of  disease, '  and,  as  I  say,  are  becoming  mere  me- 
chanics who  need  an  armamentarium,  which  only  a  great 
hospital  or  university  can  possess,  to  make  an  accurate 
diagnosis  of  am  ordinary  disease;  the  higher  and  more  in- 
tellectual means  of  drawing  conclusions  by  inductive 
reasoning  are  almost  neglected.  Mind  you,  I  do  not  wish 
to  disparage  laboratory  teaching — it  is  essential — but  we 
can  have  too  much  of  a  good  thiag,  and  laboratories  now- 
adays take  up  too  much  of  the  student's  time  in  the  latter 
years  of  his  curriculum.  The  ordinary  student  should 
have  a  good  working  knowledge  of  laboratory  methods, 
and  this  should  be  obtained  chiefly  during  his  first  two 
years,  but  the  refinements  if  insisted  upon  will  be  required 
at  the  expense  of  some  more  useful  and  practical  informa- 
tion, for  the  average  student  can  only  hold  so  much  know- 
ledge— it  is  hopeless  to  attempt  to  put  a  quart  measure  into 
a  pint  pot." 

Speaking  of  specialism.  Dr.  Shepherd  held  up  the 
ideal  of  all-round  knowledge.  He  thought  all  doctors  should 
acquire  a  good  working  knowledge  of  all  specialties,  but  an 
excess  of  time  should  not  be  devoted  to  any  one.  A  year 
or  two  of  hospital  work,  followed  by  some  experience  in 
general  practice,  should  be  managed  by  any  one  who 
wishes   to   become   a   broad-minded   specialist.     Referring 


396  CANADIAN    MEDICAL    ASSOCIATION. 

to  modern  quackery  and  the  inadequate  ideas  of  many 
superficially  educated  practitioners,  Dr.  Shepherd  said: 
''Many  of  the  doctors  who  write  to  papers  like  'The  Alka- 
line Clinic,'  the  'Medical  Short-Cut/  and  others  of  such  a 
character,  have  a  most  misty  idea  of  their  profession,  and 
apparently  are  ignorant  enough  to  deceive  themselves  as 
well  as  the  public.  I  fancy  they  practice  all  the  pathies- 
One  man  from  Texas  asks  the  editor  if  he  had  anything 
that  was  a  'dead-shot'  cure  for  eczema;  another  asks 
what  is  the  'most  up-to-date  scientific  caper'  for  goitre, 
and  so  on." 

At  the  close  of  his  most  interesting  address.  Dr. 
Shepherd  paid  a  high  tribute  to  the  late  Dr.  Wyatt  G. 
Johnston,  Dr.  Wm.  S.  Muir,  of  Truro,  and  Dr.  Brunelle,  of 
the  Hotel  Dieu,  Montreal. 

Second  Day — Forenoon. 

A  General  Meeting  of  the  Association  opened  with  a 
discussion  on  Diseases  of  the  Gall  Bladder  and  Bile 
Ducts.  Dr.  Alex.  MacPhedran,  Toronto,  introduced 
the  Medical  Diagnosis  in  this  discussion.  He  mentioned 
the  fact  that  the  gall  ducts  are  narrower  at  their  entrance 
to  the  bowel  than  in  other  parts  of  their  lumen,  and  as 
they  lie  nearly  horizontally,  the  outflow  of  bile  is  easily 
retarded  or  obstructed.  The  ducts  are  much  exposed  to 
infectiom  from  the  intestinal  tract.  Of  the  cardinal  symp- 
toms in  these  cases  Dr.  McPhedran  considered  jaundice 
the  most  common,  while  pain  varies,  but  is  generally  in- 
tense. The  attendant  fever  is  generally  due  to  toxic  ab- 
sorption. The  main  diseases  to  be  considered  in  differen- 
tial diagnosis  are:  catharrhal  and  suppurative  cholangitis 
and  acute  yellow  atrophy.  Most  catharrhal  conditions  are 
infective,  but  the  chills  and  fever  may  occur  without  pus 
formation.  The  most  common  germ  present  is  the  common 
colon  bacillus.  In  the  gangrenous  cases  the  symptoms 
are  often  ill  defined.  A  most  characteristic  sign  of  gall 
stones  is  the  recurrence  of  the  attack. 

Dr.  A.  D.  Blackader,  of  Montreal,  in  discussing  the 
Treatment  of  gall  bladder  affections,  said  he  would  confine 
himself  principally  to  the  catarrhal  forms  of  the  disease. 


CANADIAN    MEDICAL    ASSOCIATION.  397 

He  considers  the  condition  more  commonly  due  to  altered 
secretion  of  the  bile  ducts,  the  altered  mucus  causing  in- 
spissation  of  the  bile.  Infection  of  bile  he  thought  takes 
place  in  two  ways,  through  the  bile  ducts  and  through  the 
portal  circulation.  In  the  matter  of  treatment  he  con- 
siders that  no  drugs  stimulate  the  flow  of  bile  to  the  same 
extent  as  the  bile  salts.  The  flow  is  increased  by  exercise 
and  deep  breathing.  Diet  should  be  carefully  considered, 
should  be  simple,  and  as  far  as  possible  should  contain 
a  large  amount  of  fat.  Such  patients  should  drink 
plenty  of  pure  or  mineral  water.  The  patient  should  also 
have  due  regard  to  a  proper  method  of  dress ;  no  corsets  or 
constricting  clothing  should  be  worn. 

Surgical  Diagnosis  was  introduced  by  Dr.  James  Bell, 
of  Montreal.  He  said  it  was  common  to  flnd  early  vague 
signs  of  gastrointestinal  indigestion,  which  were  often 
found  to  be  present  for  a  long  time  before  an  acute  attack 
was  precipitated.  He  spoke  of  the  colon  and  typhoid 
bacilli  as  common  causes  of  infective  conditions. 

The  subject  of  Surgical  Treatment  was  introduced  by 
Dr.  J.  F.  W.  Ross,  of  Toronto.  In  commencing  his  paper 
Dr.  Ross  expressed  a  certain  lack  of  faith  in  the  so-called 
medical  treatment  of  gall  stones.  Speaking  of  some  de- 
tails of  gall  stone  operations,  Dr.  Ross  advocated  drain- 
age through  Morrison's  pouch.  He  laid  great  stress  on 
the  free  use  of  gau^e  packing  to  prevent  leakage  into  the 
peritoneal  cavity.  In  gangrene  and  empyema  of  the  gall 
bladder  he  does  not  advise  removal  of  the  gall  bladder,  but 
prefers  opening,  flushing  and  draining.  In  many  cases 
of  cystic  enlargement  of  the  gall  bladder,  however,  he 
advised  entire  removal  of  the  viscus.  It  is  well  to  remember, 
after  removal  of  the  gall  bladder,  that  gall  stones  may 
form  in  the  liver  and  may  pass  out  into  the  intestines. 
He  considers  mucous  flstulae,  which  occasionally  follow 
operation,  as  the  most  troublesome,  and  said  the  evil  should 
as  far  as  possible  be  prevented  by  the  usd  of  a  small  drain- 
age tube.  He  also  drew  attention  to  the  importance  of 
being  sure  that  the  drainage  tubes  did  not  become  blocked. 

The  discussion  of  the  surgical  treatment  was  led  by 
Dr.   G.  E.  Armstrong,  Montreal,  who  recognizes  and  re- 


398  CANADIAN    MEDICAL    ASSOCIATION. 

commends  the  employment  of  medicinal  treatment  first 
in  gall  stones,  etc.  He  does  not  advise  removal  of  the 
gall  bladder  for  stone  in  the  cystic  duct.  He  recommends 
lavage  of  the  stomach  before  operating  on  all  gall  bladder 
cases,  and,  as  it  is  difficult  to  know  what  the  surgeon  may 
encounter  on  opening  the  abdomen,  he  advises  the  admin- 
istration of  calcium  chloride  before  and  after  operation 
to  prevent  possible  haemorrhage. 

Dr.  Dudley  Allan,  of  Cleveland,  Ohio,  next  spoke 
"On  the  Importance  of  Early  Operation  on  the  Gall  Bladder." 
He  considers,  in  view  of  the  fact  that  an  accurate  diagnosis 
is  often  impossible,  an  exploratory  incision  at  least  should 
generally  be  made  early,  when,  he  claims,  it  is  often  found 
that  many  obscure  cases  are  quite  amenable  to  surgical 
treatment,  and,  in  fact,  would  fail  to  recover  if  we  were 
to  temporize.  He  recited  a  number  of  cases  where  the 
diagnosis  was  uncertain,  where  he  had  made  an  exploratory 
incision,  and  had  often  been  gratified  with  the  results. 

The  subject  was  further  discussed  by  Sir  William 
Kingston,  of  Montreal,  and  Dr.  Alex.  H.  Ferguson,  of 
Chicago. 

ON    FOREIGN    BODIES    IN    THE    VERMIFORM    APPENDIX 

BY 
DR.   JAMES  BELL,   OF   MO'StTREAL. 

In  this  paper  the  writer  expresses  his  opinion  that 
appendicitis  never  depends  on  the  presence  of  foreign 
bodies  in  the  lumen  of  the  appendix.  There  is  little  doubt, 
however,  that  when  foreign  bodies  gain  entrance  accident- 
ally into  the  appendix,  they  aggravate  an  otherwise  septic 
infection.  Among  the  foreign  bodies  which  he  has  found 
in  the  appendix  are,  in  two  cases  pins,  in  two  cases  seeds, 
in  one  case  wood  fibre,  in  one  case  gall  stones  and  in  an- 
other case  a  fish  bone. 

Dr.  Bell's  paper  was  further  discussed  by  Mr.  Irving 
Cameron,  of  Toronto. 


CANADIAN    MEDICAL    ASSOCIATION.  399 

MEDICAL  SECTION. 
Second  Day — Afternoon. 

KERNIG'S     sign — THE     FREQUENCY     OF     OCCURRENCE,     CAUSA- 
TION   AND    CLINICAL    SIGNIFICANCE 
BY 
DR.  T.   D.  RUDOLF,  TORONTO. 

This  paper  contained  the  results  of  an  inyestigation 
carried  out  in  the  different  hospitals  of  Toronto.  A  large 
number  of  patients  of  all  ages  were  examined,  suffering 
from  diverse  troubles,  and  the  angles  at  the  hip  and  knee 
accurately  measured  in  over  200  of  them.  In  162  Kernig's 
sign  was  present  in  97,  that  is,  in  over  60  per  cent.  It  was 
always  absent  in  perfectly  healthy  children.  Dr.  Rudolf  con- 
siders that  a  more  convenient  plan  is  to  extend  the  knee  and 
then  flex  the  hip  as  far  as  possible.  Sometimes  there  is 
more  than  the  usual  degree  of  stretching  of  the  ham 
strings  possible,  and  this  extra  flexion  can,  by  the  writer's 
method,  be  exactly .  measured  when  Kernig's  sign  could 
not  show  it.  Out  of  the  97  cases  in  which  Kernig's  sign  was 
present,  in  59  an  angle  of  less  than  165°  at  the  knee  could 
only  be  obtained,  and  of  these  in  10  cases  the  angle  was 
135°  or  less,  showing  a  very  marked  degree  of  the  sign. 
These  59  eases  were  of  all  kinds,  and  only  one  of  them  was 
meningitis.  Dr.  Rudolf  then  went  on  to  state  that  none 
of  the  theories  of  explanation  of  Kernig's  sign  were  satis- 
factory as  to  its  occurrence  in  meningitis. 

MULTIPLE  SARCOMA REPORT  OF  A  CASE 

BY 
DRS.  F.  N.  G.  STARR  AND  J.  J.  MACKENZIE,  OF  TORONTO. 

Dr.  MacKenzie  read  the  notes  on  the  case.  No  au- 
topsy could  be  made.  The  patient  was  a  female  38  years 
of  age,  a  seamstress.  The  personal  or  family  history  had 
no  bearing  on  the  case.  For  a  number  of  years  before  1901, 
the  patient  had  a  goitre,  which,  under  treatment,  almost 
disappeared  in  the  winter  of  1901.  In  April  of  this  year 
a  lump  about  the  size  of  a  pea  was  noticed  slightly  to  the 
left  of  the  middle  line  of  the  adbomen  near  the  symphysis 


400  CANADIAN    MEDICAL    ASSOCIATION. 

pubis,  hard,  but  painless  and  subcutaneous.  In  May  two 
or  three  appeared  in  the  middle  line,  an  inch  above  the 
umbilicus,  then  two  or  three  were  discovered  in  the  back. 
In  June  two  others  appeared  to  the  right  of  the  middle 
line  of  the  abdomen.  In  July  several  additional  lumps 
were  discovered  in  the  right  breast,  in  size  from  a  pea  to 
a  bean.  Loss  of  weight  occurred.  In  August  the  liver 
was  noticed  to  be  enlarging.  Commenced  taking  arsenic 
in  September.  In  October  a  large  tumour  appeared  in  the 
left  breast,  and  a  small  one  was  also  noticed  in  the  left 
thigh.  Patient  began  to  suffer  from  rheumatic  pains.  In 
November  and  December  the  tumours  appeared  in  enormous 
numbers  over  the  chest  and  back,  abdomen,  thighs,  and 
arms  above  elbows,  neck  and  over  back,  sides  and  top  of 
head.  In  January,  1902,  chains  of  tumours,  bean-sized, 
were  noticed  in  the  cervical  region,  submaxillary  and  sub- 
occipital regions.  By  March  the  8th  she  had  thousands 
of  tumours,  most  quite  hard.  Excisions  were  made  and 
microscopic  examination  revealed  a  type  of  spindle-celled 
sarcoma,  in  which  the  prevailing  cell  was  very  long.  As 
regards  treatment,  the  patient  took  arsenic  with  no  in- 
fluence on  the  condition.  Thyroid  extract  produced  slight 
diminution  in  the  size  of  the  tumours.  The  patient  died. 
Without  autopsy  one  cannot  say  where  the  primary  seat 
of  the  disease  was,  although  from  the  great  involvement 
of  the  liver,  that  might  be  the  source  of  the  disease. 

ON  SOME  POINTS  IN  CEREBRAL  LOCALIZATION. 

ILLUSTRATED    BY    A    SERIES    OF    MORBID    SPECIMENS    AND    SOME 

LIVING   CASES. 

At  an  early  morning  session  held  at  the  Royal  Victoria 
Hospital,  Dr.  James  Stewart  conducted  this  clinic. 

ON    THE    ASYLUM^    THE    HOSPITAL    FOR    THE    INSANE,    AND    THE 
STUDY   OF   PSYCHIATRY. 

Dr.  Stuart  Paton,  Baltimore,  Md.,  advocated  hospitals 
or  wards  in  insane  asylums,  for  proper  treatment  of  acute 
cases.  He  also  pointed  out  the  benefits  to  be  derived 
from  having  medical  men  to  form  a  consulting  staff  to  an 
asylum. 


CANADIAN    MEDICAL    ASSOCIATION.  4OI 

ANAESTHETIC  LEPROSY. 

Two  very  interesting  patients,  father  and  son,  were 
presented  by  Dr.  C.  N.  Valin,  Montreal,  according  to  whom 
they  proved  to  a  certainty  the  contagiousjaess  of  this  dis- 
ease. From  the  way  they  had  progressed  under  treat- 
ment. Dr.  Valin  considered  the  cases  hopeful. 

SUKGICAL  SECTION. 

Second  Day — Afternoon. 

REPORT     OF    THREE    CASES    OF    CONGENITAL    DISLOCATION 

OF  THE  HIP 

BY 

DR.  A.  E.  GARROW,  MONTREAL. 

The  etiology  of  this  condition  is  not  well  established, 
but  heredity  seems  to  play  a  part.  Dr.  Garrow  speaks  of 
two  methods  of  reduction,  (a)  bloodless  method,  (b) 
through  an  incision.  The  chief  obstacle  to  reduction  is 
generally  due  to  fibrous  stricture  of  the  lower- part  of  the 
capsule.  Dr.  Garrow's  experience  has  been  mainly  by  the 
open  method.  This  paper  was  further  discussed  by  Dr. 
Shepherd,  of  Montreal. 

THE  OPERATIVE  TREATMENT   OF  GOITRE  WITH  A   REPORT 

OF  CASES 

BY 

DR.   INGERSOL  OLMSTEAD,  HAMILTON'  ONT. 

As  the  medical  treatment  of  goitre  is  very  unsatis- 
factory', an  operation  is  recommended  in  the  following 
conditions: — 1st,  as  soon  as  a  goitre  becomes  dangerous, 
that  is,  when  attacks  of  dyspnoea  occur,  or  inflammatory 
changes  occur,  or  there  is  the  slightest  suspicion  of  a 
malignant  degeneration.  2nd,  all  enlarged  thyroids  hav- 
ing a  tendency  to  grow  towards  the  aperture  of  the  thorax, 
even  if  they  are  moveable.  3rd,  goitres  that  have  reached 
considerable  development  from  the  formation  of  single 
large  colloid  nodes.  4th,  when  with  a  moderate  goitre 
symptoms  like  those  of  Basedow's  disease  appear,  accom- 
panied with  an  increased  development  of  the  goitre.     The 


402  CANADIAN    MEDICAL    ASSOCIATION. 

operation  advised  is  the  one  usually  performed  by  Kocher 
and  is  done  under  cocaine  anaesthesia.  It  consists  of  a 
transverse  symmetrically  bowed  incision,  with  its  convex- 
ity downwards,  from  the  outer  surface  of  one  sterno- 
mastoid  muscle  to  the  other,  higher  or  lower  according  to 
the  position  of  the  goitre.  The  skin,  underlying  platysma 
and  fascia  of  the  sternohyoid  and  sternothyroid  muscles 
are  reflected  upwards.  The  fascia  joined  the  muscles  in 
the  median  line  of  the  neck  is  then  divided,  as  well  as  the 
outer  fibrous  capsule  of  the  gland.  The  half  of  the  gland 
which  is  most  involved  is  then  shelled  out  of  its  capsule, 
the  superior  and  inferior  thyroid  arteVies  tied  and  the 
isthmus  cut  with  goitre  clamp  and  ligated.  The  remain- 
ing attachments  are  then  ligated  and  portion  removed. 
The  wound  is  closed  with  a  subcuticular  wire  suture  with- 
out drainage. 

Twelve  cases  operated  on  during  the  past  year  were 
reported.  The  average  stay  in  the  hospital  was  seven  days. 
The  resulting  scar  was  very  slight,  and  little  or  no  pain  was 
complained  of  during  the  operation. 

THE     PATHOLOGIC     PROSTATE     AND     ITS     REMOVAL     THROUGH 

THE    PERINEUM 

BY 

DR.    ALEX.    H.    FERGUSON,   CHICAGO,   ILLS. 

In  the  opening  of  its  paper.  Dr.  Ferguson  said  he  pro- 
posed to  discuss  more  particularly  hypertrophy  of  the  pro- 
state. Some  of  the  microscopic  changes  in  the  hyper- 
trophied  prostate  are,  1st,  increased  weight — may  be  up 
to  eight  or  nine  ounces, — 2nd,  greater  size;  3rd,  any  part 
or  the  whole  of  the  gland  may  be  involved.  Shape  varies 
very  much.  Microscopically,  Dr.  Ferguson  found  all 
hypertrophied  prostates  were  benign  in  character.  He 
also  found  frequent  evidences  of  inflammatory  changes. 
The  effects  produced  may  be  stated  as,  1st,  the  prostatic 
urethra  is  contracted  and  elongated;  2nd,  the  vesical 
meatus  is  often  rendered  patulous  and  sometimes  oblit- 
erated; 3rd,  the  ejectulatory  ducts  are  also  often  patulous, 
allowing  regurgitation  of  the  semen  into  the  bladder,  and 
thev  are  also  often  obstructed.     The  effects  of  obstruction 


CANADIAN    MEDICAL    ASSOCIATION.  4O3 

on  the  kidneys  and  bladder  are  too  well  known  to  require 
discussion.  Treatment:  Dr.  Ferguson's  method  of  removal 
is  by  the  perineal  route.  He  uses  a  prostatic  depressor 
introduced  into  the  urethra,  then  elevated  in  such  a  manner 
as  to  press  the  prostate  down  in  the  perineum.  The  fingers 
of  the  left  hand  are  passed  into  the  rectum  as  a  guide,  and 
then  he  makes  one  bold  incision  through  the  perineum 
down  to  the  prostatic  capsule.  Dr.  Ferguson  exhibited 
some  special  instruments  devised  and  used  by  himself  in 
this  operation, 

THE  SURGICAL  TREATMENT  OP  ENLARGED  PROSTATE 

BY 
DR.  G.  E.  ARMSTRONG,  MONTREAL. 

Dr.  Armstrong  exhibited  a  specially  constructed  sup- 
rapubic vesical  speculum,  devised  by  himself,  with  a  lateral 
opening  which  allows  the  prostate  alone  to  come  well  in 
view  in  the  speculum.  The  speculum  can  be  packed  around 
with  gauze  to  protect  the  parts  from  possible  burning,  the 
offensive  lobe  or  lobes  are  then  cauterized  with  the  thermo- 
cautery. Dr.  Armstrong  reported  seven  cases  successfully 
operated  upon.  One  point  of  advantage  in  this  operation 
lies  in  the  fact  that  the  cauterizecf  surface  does  not  admit 
of  septic  absorption.  He  urges  this  method  in  the  early 
stages  of  prostatic  hypertrophy. 

The  paper  by  Dr.  Ferguson,  and  also  that  of  Dr.  Arm- 
strong, was  discussed  by  Dr.  James  Bell,  Montreal,  Sir 
William  Hingston,  Montreal,  Mr.  Irving  Cameron,  Toronto, 
and  Dr.  Elder,  Montreal. 

At  the  evening  session  of  the  second  day  the  Address 
IN  Medicine  was  delivered  by  Dr.  William  Osier,  Baltimore, 
Maryland. 

In  opening  his  splendid  address  Dr.  Osier  spoke  of  the 
noble  ancestry  of  our  profession.  The  broad  foundations 
of  our  professional  dignity  were  laid  on  the  Hippocratic 
oath.  The  solidarity  of  the  medical  confraternity  is  pre- 
eminent. Our  profession  is  distinguished  from  all  others 
by  its  beneficence — witness:  Anaesthesia,  Sanitation,  et  al. 
There  is  no  limit  to  the  science  of  medicine.  The  outlook 
for  the  profession  was  never  brighter  than  to-day.     Many 


404  CANADIAN    MEDICAL    ASSOCIATION. 

of  the  diseases  of  our  grandfathers  are  vanishing.  Dr. 
Osier  then  put  forward  a  strong  plea  for  the  unity  of  the 
profession.  A  sense  of  self-satisfaction  is  all  too  common 
in  the  medical  ranks  as  in  other  walks  of  life.  Chauvin- 
ism is  an  enemy  to  progress.  Dr.  Osier  mentioned  four 
forma  of  Chauvinism,  namely,  national  provincial,  paro- 
chial and  individual.  Nationalism  is  apt  to  become  a 
widespread  vice;  in  go  far  as  this  concerns  the  medical 
profession,  however,  international  medical  congresses  have 
done  much  to  dispel  this  spirit.  Dr.  Osier  strongly  advised 
young  men  to  go  abroad  for  post-graduate  study,  especially 
those  who  aspired  to  teach.  If  this  were  not  possible,  he 
strongly  recommended  the  study  of  foreign  medical  lit- 
erature. ''It  helps  a  man"  said  Dr.  Osier,  ''to  be  a  bit  of 
a  hero^ worshipper."  Continuing,  he  said:  "There  is  a  re- 
markable homogeneity  of  the  profession  on  this  Continent; 
still,  there  is  no  little  provincialism  among  the  profession; 
— witness:  the  various  provincial  medical  councils  in  Canada 
and  the  various  state  boards  in  the  United  States."  He 
considers  it  an  outrage  that  a  graduate  of  Ontario  cannot 
practice  in  Quebec,  or  a  graduate  of  Quebec  in  Manitoba. 
It  is  democracy  run  riot;  it  is  provincialism.  The  solu- 
tion of  the  problem  rests  with  the  general  practitioner. 
Dr.  Osier  here  paid  a  high  tribute  to  Dr.  Roddick  for  his 
indefatigable  energy  in  pushing  through  the  Dominion 
Medical  Bill.  Passing  on  to  speak  of  parochial  Chauvin- 
ism, Dr.  Osier  considered  we  are  all  tainted  with  it  to  some 
extent.  A  good  method  of  counteracting  this  is  to  encour- 
age professorial  interchanges.  "Chauvinism  in  the  unit, 
however,  is  of  much  more  interest  and  importance.  The 
consultants  do  the  writing  and  the  talking,  and  take  the 
fees"  said  Dr.  Osier;  "the  backbone,  however,  of  the  med- 
ical profession  is  the  general  practitioner.  But  he  should 
preserve  his  mental  independence  and  keep  up  with  the 
times  in  literature  and  applicances.  Diagnosis,  not  drug- 
ging, is  our  chief  weapon  of  offence"  said  Dr.  Osier;  "lack 
of  systematic  personal  training  in  the  methods  of  the  re- 
cognition of  disease  leads  to  the  misapplication  of  reme- 
dies, to  long  courses  of  treatment,  when  treatment  is  useless. 


CANADIAN     MEDICAL    ASSOCIATION.  4O5 

aiid  SO  directly  to  that  lack  of  confidence  in  oui*  methods 
which  is  apt  to  place  us  in  the  eyes  of  the  public  on  a  level 
with  empirics  and  quacks.  One  should  not  degenerate 
into  a  mere  dispenser  of  quack  nostrums  like  the  drug 
clerk,  who  has  a  specific  for  everything  from  the  pip  to 
the  ■  pox.  Beware  of  the  huge  manufacturing  chemical 
concerns  and  of  the  'drummer'  of  the  drughouse."  Pass- 
ing on  Dr.  Osier  said  that  "learning  alone  is  not  sufficient; 
culture  is  the  bichloride  to  keep  him  from  intellectual  de- 
terioration, and  lastly  charity  among  the  profession.  To 
make  the  Golden  Rule  our  code  oi  ethics,  adopt  the  motto  of 
St.  Ambroise: — ''If  you  cannot  speak  well  of  your  brother, 
keep  silence.''  The  word  of  action  is  stronger  than  the 
word  of  speech. 

THE  X-RAY  AS  A  THERAPEUTIC  AGENT 
BY 

DR.   C.   R.   DICKSON,  OF  TORONTO. 

Dr.  Dickson  said,  the  explanation  of  the  rational  of  the 
X-Ray  is  at  best  as  yet  but  a  hypothesis.  Fortunately 
we  have  a  practical  proof  of  its  utility  as  a  therapeutic 
agent  in  many  conditions.  Dr.  Dickson  has  used  it  suc- 
cessfully in  the  following  cases: — Naevus,  lupus  vulgatis, 
tubercular  joints,  scleroderma,  subacute  articular  rheuma- 
tism (it  relieved  pain  in  many  cases),  neurasthenia,  car- 
cinoma of  the  stomach  (this  patient  gained  weight),  and  in 
carcinoma  of  the  rectum,  which  case  is  also  improving. 

Dr.  G.  r.  GirdwooJ,  of  ^lontreal,  read  a  paper  on  the 
X-Raifs.  DiiUfnostic  and  Therapeutic,  and  exhibited  a  number 
of  photographs. 

The  X-Ray  in  Cancer  was  the  title  of  a  paper  by  Dr. 
A.  R.  Robinson,  of  New  York.  A  strong  plea  is  that  the 
X-Ray  largely  does  away  with  the  knife,  and  leaves  little 
scar.  It  is  probable  that  all  superficial  cancers  can  be 
removed  by  the  X-Ray  if  seen  early.  In  a  delicate  locality, 
such  as  the  eyelid,  the  rays  should  always  be  used  as  paste, 
or  the  knife  will  do  more  harm.  When  malignant  growths 
have  spread  deeply,  the  X-ray  may  be  considered  our  best 
treatment. 


406  CANADIAN    MEDICAL    ASSOCIATION. 

SURGICAL  SECTION. 


Third  Day — Forenoon. 

The  first  paper  was  Remarks  on  the  Sympathetic 
Ophthalmia,  by  Dr.  G.  Herbert  Burnham,  Toronto,  followed 
by  a  paper  on  the  Occular  Manifestatioti  of  Systemic 
Gonorrhoea,  by  Dr.  W.  Gordon  M.  Byers,  Montreal. 

A  paper  on  Excision  of  the  Caecum  was  read  by  Dr.  O. 
M.  Jones,  Victoria,  B.  C.  Dr.  Jones  cited  four  cases  operated 
on.  The  first  lived  two  years  after.  A  post-mortem  prov- 
ed that  the  cancerous  growth  had  not  recurred  at  the 
point  of  the  original  operation.  Symptoms  in  all  cases 
were,  griping  pains  in  the  abdomen,  loss  of  weight  and 
irregular  action  of  the  bowels,  together  with  the  presence 
of  a  mass  in  the  region  of  the  caecum. 

ON    THREE    CASES    OF    PERFORATING    TYPHOID    ULCER 
SUCCESSFULLY  OPERATED  ON. 

Dr.  F.  J.  Shepherd,  Montreal,  reported  these  cases. 
First,  as  to  technique:  Dr.  Shepherd  has  always  made  use 
of  the  lateral  incision  and  has  usually  found  the  perfora- 
tion near  the  ileo-caecal  valve.  By  this  incision  the  site 
of  the  perforation  is  more  easily  found  than  by  the  median. 
He  has  always  closed  the  incision  by  turning  in  the  bowel 
and  making  use  of  a  continuous  Lembert  suture,  employ- 
ing fine  silk.  Other  ulcerations  in  the  neighbourhood  are 
treated  in  the  same  way.  Rubber  drainage  is  employed. 
There  is  always  suppuration  in  these  cases  and  usually  a 
hernia  as  a  result.  General  anaesthesia  is  always  used  in 
these  cases.  Early  and  rapid  operation,  seeing  that  there 
are  no  others  likely  to  perforate,  are  important  points. 
The  first  case  was  a  woman  of  30  with  ambulatory  form; 
the  second  was  a  woman  of  28  admitted  on  the  8th  day. 
It  is  of  interest  in  this  case  that  although  perforation  had 
taken  place  there  was  no  leucocytosis.  The  third  was  a 
male,  aet.  30,  in  the  third  week,  seized  with  severe  pain,  and 
one  hour  after  there  was  obliteration  of  liver  dulness  and 
marked  leucocytosis.  All  are  quite  well  with  the  excep- 
tion of  hernias. 


CANADIAN    MEDICAL   ASSOCIATION.  407 

Dr.  Lapthorn  Smith,  of  Montreal,  presented  a  paper  on 
A  Case  of  Total  Extirpation  of  the  Urinary  Bladder  for  Cancer. 
General  considerations:  Evolution  of  the  operation  in 
Europe  amd  America;  methods  employed;  results  in  100 
reported  cases.  In  the  author's  case  there  had  been  pre- 
vious removal  of  fibroid  by  myomectomj'.  This  was  follow- 
ed by  cystitis,  which  was  treated,  first  by  medicine,  then 
by  injection  and  afterwards  by  drainage  by  permanent 
catheter,  and  then  by  button-hole  operation  when  the 
cancer  was  detected  by  the  finger.  Extra-peritoneal  re- 
moval of  bladder  and  affected  part  of  ureter  and  pelvic 
glands.  Kecovery  from  operation,  but  death  on  the  7th 
day  from  exhaustion. 

THIRD  DAY. 

General  Morning  Session. 

Election  of  Officers:  Dr.  T.  G.  Roddick,  M.  P.,  Chair- 
man of  Nominating  Committee,  presented  the  Report  of 
this  Committee.  London,  Ontario,  was  selected  as  the 
next  place  of  meeting. 

President:     Dr.  W.  H.  MotJrhouse,  London,  Ontario. 

y ice-Presidents:  Prince  Edward  Island — James  War- 
burton,  Charlottetown;  Nova  Scotia — John  Stewart,  Ha- 
lifax; New  Brunswick — W.  C,  Crokett,  Fredericton;  Quebec 
— Dr.  Mercier,  Montreal;  Ontario — W.  P.  Caven,  Toronto; 
Manitoba — Dr.  McConnell,  Morden ;  Northwest  Territories — 
J.  D.  Lafferty,  Calgary;  British  Columbia — C.  J.  Fagan, 
Victoria. 

Local  Secretaries:  Prince  Edward  Island — C.  A.  Mac- 
Phail,  Summerside;  Nova  Scotia — Dr.  Morse,  Digby;  New 
Brunswick — J.  R.  Macintosh,  St.  John;  Quebec — R.  Tait 
MacKenzie,  Montreal  ;  Ontario — Hadley  D.  Williams, 
London;  Manitoba — J.  T.  Lament,  Trehern;  Northwest 
Territories — D.  Low,  Regina;  British  Columbia — L.  H. 
MacKechnie. 

General  Secretary:  George  Elliott,  129  John  Street, 
Toronto,  Ontario. 

Treasurer  :     T.  B.  Small,  Ottawa ,  Ontario, 

Executive  Council:  Drs.  Moore,  Eccles  and  Wishart, 
London,  Ontario. 


408  CANADIAN    MEDICAL    ASSOCIATION. 

DOMINION  HEALTH  BUREAU. 

Dr.  E.  P.  Lachapelle,  Secretary  of  the  Board  of  Health 
of  the  Province  of  Quebec,  moved  the  following  resolu- 
tion, seconded  by  Dr.  J.  M.  Jones,  Winnipeg,  which  was 
carried  unanimously: — 

"Whereas,  public  health,  with  all  that  is  comprised  in 
the  term,  sanitary  science,  has  acquired  great  prominence 
in  all  civilized  countries,  and 

"Whereas  enormously  practical  results  have  been  se- 
cured to  the  commutnity  at  large,  by  the  creation  of  health 
departments  under  Governmeintal  supervision  and  control, 
and 

''Whereas,  greater  authority  and  usefulness  are  given  to 
health  regulations  and  suggestions  when  they  emanate 
from  ain  acknowledged  Government  Department; 

"Therefore,  be  it  resolved,  that  in  the  opinion  of  the 
Canadian  INIedical  Association,  now  in  session,  the  time  is 
opportune  for  the  Dominion  Government  to  earnestly  coin- 
sider  the  expendiency  of  creating  a  separate  department 
of  public  health,  under  one  of  the  existing  ministers,  so 
that  regulations,  suggestions  and  correspondence  on  such 
health  matters  as  fall  within  the  jurisdiction  of  the  Fed- 
eral Government,  may  be  issued  witji  the  authority  of  a 
department  of  public  health 

"That  copies  of  this  resolution  be  sent  by  the  General 
Secretary  to  the  Governor-General  in  Council  and  to  the 
Honourable  the  Miniver  of  Agriculture." 

Treasurer's  Report:  Dr.  H.  B!  Small  presented  his 
report.  317  members  had  been  in  attendance,  nearly  100 
larger  than  any  other  previous  meeting.  All  outstanding 
indebtedness  had  been  paid  and  there  was  in  the  treasury 
1325.00  to  the  good  of  the  Association. 

Votes  of  thanks  were  passed  to  Mr.  and  Mrs.  James 
Ross,  of  Montreal,  in  w^hose  handsome  grounds  had  been 
tendered  a  garden  party  on  the  afternoon  of  the  first  day; 
to  the  Local  Committee  and  Trainsportation  Committee, 
s])ecial  reference  being  made  to  Drs.  C.  F.  Martin  and  J. 
Alex.  Huchison  for  their  indefatigable  efforts  for  the 
success  of  the  meeting;  to  the  Treasurer;  to  the  President 
and  the  profession  generally  for  their  hospitality. 


MEDICINE  AND  NEUROLOGY.  409 

Thus  was  closed  the  greatest  meeting  of  the  35  years 
of  the  Association,  and  it  is  to  be  hoped  that  the  profession 
throughout  Canada  will  still  further  take  an  active  interest 
in  this  national  organization. 


Pros-ress  of  Medical  Science, 


MBDICINE    AND     NEUROLOGV 


IN   CHARGE  OF 

J.  BRADFORD  McCONNELL.  M.D. 


Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medjclne 
University  of  Bishop's  College;  Physician  Western  Hospital . 


THE    DIAZO-REACTION    AS    A    METHOD     OF    DIAGNOSIS 
IN  CLINICAL  MEDICINE. 

The  actual  value  of  a  clinical  test  depends  upon  its 
applicability  to  everyday  work.  Should  it  prove  to  be  a 
method  which  can  be  easily  employed  in  routine  practice, 
and  if  it  be  granted  that  the  results  obtained  are  reliable, 
then  there  can  be  no  doubt  that  the  test  has  come  to  stay. 

Much  has  been  written  of  late  upon  the  value  of  the 
diazo-reaction  as  a  test  for  enteric  fever,  but  it  still  seems 
that  opinions  are  by  no  means  unanimous  as  to  the  worth 
of  the  test  in  the  diagnosis  of  this  disease;  and  it  has  cer- 
tainly been  proved  that  the  reaction  occurs  in  maladies 
other  than  entertic  fever,  of  which  disease  tuberculosis 
is  the  most  important.  Acting  on  the  above  principles, 
I  have  examined  the  urine  in  125  cases  of  all  kinds  and  de- 
scriptions for  the  diazo-reaction.  The  cases  have  not  been 
selected  in  any  way,  but  the  process  has  been  applied  in 
the  outpatient  room  and  the  result  noted. 

On  these  125  cases  in  which  the  urine  was  examined,  5 
only  gave  a  positive  reaction.  In  120  instances  no  result 
whatever  was  obtained.  Amongst  those  patients  whose 
urine  gave  a  negative  result  were  instances  of  diseases  of 
the  lung  of  various  kinds — phthisis,  heart  disease,  gastric 
ulcer,  bronchitis,  etc. 

The  5  cases  were  classified  as  follows  :  One  was  a 
case  of  acute  tonsilitis;  another  of  lobular  pneumonia;  two 
were  cases  of  enteric  fever  in  an  early  stage,  and  one  wag 
suffering  from  acute  tuberculosis.     The  last  patient  wai 


410  PROGRESS  UF  MEDICAL  SCIENCE. 

thought  at  first  to  have  enteric  fever,  and  this  from  a  gene- 
ral consideration  of  history  and  symptoms.  The  occurence 
of  a  positive  reaction  with  the  color  test  not  unnaturally 
tended  to  strongly  strengthen  this  view  of  nature  of  the 
case. 

Nevertheless,  the  event  proved  that  the  diagnosis  was 
incorrect  Thus  the  diazo-reaction  broke  down  just  at  the 
very  point  when  it  would  be  of  the  greatest  possible  use. 
The  extreme  difSculty,  even  the  impossibility,  of  differen- 
tiating typhoid  fever  from  tuberculosis  is  generally  ad- 
mitted, and  it  is  unfortunate  that  this  test,  so  promising 
in  many  ways,  should  fail  us  in  making  a  very  important 
and  difficult  diagnosis. 

Three  other  cases  of  enteric  fever  were  carefully  test- 
ed, but  they  all  gave  negative  results.  These  cases  were 
all  in  a  more  or  less  advanced  stage  of  convalescence, 
which  does  not,  however,  render  the  occurrence  of  the  reac- 
tion in  any  degree  unlikely,  for  many  cases  are  recorded 
in  which  the  result  was  positive,  months  after  the  attack 
of  enteric  fever  had  been  recovered  from. 

I  have  also,  subsequent  to  the  above  observations, 
made  many  examinations  of  the  urine  of  patients  suffering 
from  typhoid  fever,  for  the  purpose  of  finding  the  diazo- 
reaction.  Speaking  generally,  I  have  found  that  at  some 
period  of  the  fever  the  result  was  nearly  always  positive, 
and  this  usually  at  an  advanced  stage  of' the  malady— that 
is  to  say,  at  the  end  of  the  second  or  early  in  the  third 
week.  Positive  results  were  always  most  freely  obtained 
when  the  temperature  was  high  and  the  symptoms  severe; 
in  other  words,  they  w^ere  always  most  obvious  in  well- 
marked  and  anxious  cases. 

The  result  of  my  observations,  so  far  as  regards  enteric 
fever,  is  that  the  clia^^o-reaction  is  of  little  or  no  use  in  a  prac- 
tical sense.  And  this  because  it  does  not  occur  at  a  stage 
of  the  malady  at  which  alone  difficulties  can  really  arise— 
the  early  stage.  Further,  the  liability  of  a  positive  reac- 
tion to  recur  in  cases  of  tuberculosis  is  a  most  serious 
drawback,  and  one  which  alone  would  tend  to  render  the 
test  valueless. 

As  regards  the  125  cases,  there  was  not  once  a  positive 
reaction  in  the  very  numerous  instances  of  gout  and  ane- 
mip.  Pud  the  eame  ar»nlies  to  diabetes. 

It  has  been  stated  that  in  phthisis  the  reaction  shows 
itself  only  in  those  patients  in  whom  the  malady  is  for 
advanced,  and  that,  therefore,  the  fact  of  its  occurrence 
should  be  regarded  as  a  danger  signal. 


MEDICINE   AND    NEUROLOGY.  4II 

My  experience  of  the  diazo-reaction  in  phthisis  is  not 
large,  but  I  have  had  the  opportunity  of  applying  the  test 
in  very  advanced  cases  of  the  disease.  My  results  do  not 
in  any  way  agree  with  those  which  would  mark  the  diazo- 
reaction  either  as  of  usual  occurrence  in  the  later  phases 
of  the  malady  or,  when  it  does  occur,  as  being  of  any 
special  significance.  In  ordinary  cases  of  this  description 
the  result  was  negative,  and  when  the  reaction  was  posi- 
tive there  was  no  reason  whatever  to  suppose  that  the  case 
offered  any  special  feature  of  gravity  beyond  that  which 
is  usual  at  the  stage  at  which  the  affection  has  arrived- 

It  is  worthy  of  note,  too,  in  this  connection,  that  the 
case  referred  to  above  of  acute  tuberculosis,  which  was 
at  first  thought  to  be  one  of  enteric  fever,  although  show- 
ing a  well-marked  positive  reaction,  yet  some  months  later 
was  in  no  worse  condition,  the  disease  not  having  made 
rapid  progress. 

My  experience,  then,  of  the  diazo-reaction  is  that  from 
a  strictly  practical  point  of  view  it  is  of  very  little  value. 
When  the  result  is  positive  in  enteric  fever  the  malady  is 
so  far  advanced  that  there  can  be  no  possibility  of  error 
as  regards  the  diagnosis.  In  the  very  early  stage,  when 
alone  there  may  be  some  little  difficulty  in  determining 
the  nature  of  the  malady,  the  test  usually  gives  negative 
results,  and  even  if  this  is  not  the  case  the  positive  reac- 
tion by  no  means  excludes  the  possibility  of  the  case  being 
one  of  tuberculosis. 

In  my  judgment,  far  too  much  importance  is  at  the  pre- 
sent time  attached  to  laboratory  tests  in  clinical  medicine. 
A  reversion  to  the  old-fashioned  but  sound,  though  la- 
borious, manner  of  acquiring  a  knowledge  of  the  svmptoms 
and  physical  signs  of  disease  is  greatly  to  be  wished,  for 
it  is  by  the  cultivation  of  the  senses  at  the  bedside  and 
111  the  dead-house,  and  in  this  way  only,  that  a  real  and 
satisfactory  knowledge  of  medicine  can  be  obtained  — 
Post-Graduate.— By  Dr.  Syers  (Brit.  Med.  Journ  Mav 
24,  1902.)  ' 

A  SPECIFIC  TEST  FOR  HUMAN  BLOOD. 

For  many  years  it  has  been  the  dream  of  medico-le^al 
.«;tudents  that  some  day  human  blood  could  be  positively 
identified.  It  was  not  hoped  that  severe  temperatures,  a^e 
or  contamination  would  be  overcome;  even  the  absolute 
identification  of  the  fresh  specimen  seemed  impossible.  Now, 
the  wildest  hopes  are  realized  ;  not  only  may  human  blood 
be  identified  beyond  fear  of  contradiction,    but  acre,  tern- 


4  I  2-  PROGRESS  OF  MEDICAL  SCIENCE.     , 

perature,  filth,  contamination  and  menstrual  detritus,  etc., 
have  no  efifect  on  the  reaction.  Many  innocent  men  have 
been  executed,  and  many  guilty  criminals  have  escaped 
justice  because  the  medical  profession  were  not  equal  to  the 
task  of  absolutely  identifying  human  blood, 

DaCosta,  in  Clinical  Hematology,  quite  recently  issued 
by  B.  Blakiston's  Son  &  Co. ,  of  Philadelphia,  gives  full 
instructions  for  the  performance  of  the  test  of  Bordet  : 
"  The  blood  serum  of  an  animal  subcutaneously  injected 
with  the  blood  of  another  animal  of  a  different  species  rapid- 
ly develops  the  property  of  agglutinating  and  dissolving  the 
erythroc)'tes  similar  to  those  injected,  but  has  no  effect  upon 
blood  derived  from  any  other  source.  The  blood  of  a  rabbit 
thus  anti-serumized  against  human  blood  is  diluted  lOO-fold 
with  distilled  water  or  normal  salt  solution,  and  o.  5  cubic 
centimeter  employed.  When  the  human  blood  is  added  at 
ordinary  room  temperature  a  distinct  cloudy  precipitate  is 
formed,  which  is  increased  in  turbidity  by  exposure  to  a  tem- 
perature of  37''C.  No  change  occurs  on  adding  the  serum 
to  the  blood  of  other  animals;  twenty  three  specimens  having 
been' tested,  with  the  single  exception  of  the  monkey,  and 
in  this  instance  the  reaction  was  delayed  and  incomplete, 
and  in  no  way  comparable  to  the  cloudiness  produced  by 
the  mixture  of  human  blood  with  its  anti-serum.  Old,  dried, 
and  even  putrefied  blood,  diluted  i  to  100  with  normal  salt 
solution,  reacts  typically,  and  characteristically  positive 
results  have  been  obtained  with  human  blood  mixed  with 
equal  volumes  of  diluted  blood  of  sheep,  oxen,  horses  and 
dogs.  Specimens  were  frozen  io°C.  below  zero  for  two 
weeks  without  in  any  way  affecting  the  reaction.  Llood 
n>ixed  with  menstrual  urine,  or  such  contaminating  fluids  as 
soapy  water,  responded   promptly  and  typically." 

Such  a  discovery  is  particularly  gratifying,  since  neither 
the  laity  nor  the  legal  profession  could  ever  appreciate  why 
we  could  not  be  ready  to  identify  human  blood.  The  com- 
plicated spectral  test,  which  was  only  employed  by  experts 
possessing  expensive  equipments  of  instruments,  is  relegated 
to  medical  history.  This  distinguished  and  authoritative 
author  has  declared  the  test  a  specific  test  any  physician 
may  preform  it,  but  we  wonder  if  the  general  practitioner 
will  get  vouchers  from  the  court  for  expert  testimony  }  We 
rejoice  in  the  advance  of  science,  but  we  could  hope  that  the 
labours  of  noble  medical  men  might  be  made  more  remu- 
nerative to  themselv  es  andthe  profession. 


MEDICINE  AND  NEUROLOGY.  413 

Let  every  reader  test  this  reaction  and  report.  It  has 
now  the  sanction  and  approval  of  good  authority,  but  can 
the  country  doctor  perform  the  test  as  we  are  told  he  can  ? 
We  believe  firmly  in  his  efficiency,  but  we  want  to  hear  from 
him  after  he  has  tried  a  few  experiments. — Medical  Summary. 

ORAIi   CLEANLINESS. 

Many  people,  otherwise  fastidious,  go  about  with  filthy 
mouths.  Those  using  false  teeth  are  ordinarily  the  worst 
offenders,  but  those  whose  teeth  are  good  are  also  common 
offenders.  Every  physician  knows  that  a  filthy  mouth  is 
frequently  the  cause  of  foul  breath  and  indigestion.  It  is 
regrettable  that  the  "  disciple  of  health"  should  offend  the 
sick  by  a  foul  breath  ;  yet,  the  breath  of  many  physicians  is 
almost  unbearable,  especially  to  ladies.  A  few  physicians 
use  liquor,  and  many  use  tobacco,  and  few  cleanse  their 
teeth  systematically  and  regularly.  It  is  "  our  plain  duty  " 
to  instill  into  the  mind  of  the  laity  the  necessity  of  personally 
performed  oral  ablutions  after  the  age  of  four  or  five  years, 
but  how  can  we  do  this  with  reeking  breaths  .-•  Every  child 
should  be  taught  to  cleanse  its  mouth  after  every  meal,  and 
before  retiring,  as  soon  as  able  to  handle  a  tooth-brush. 
Plain  soap  and  water  and  a  good  brush  are  all  the  essentials, 
but  some  of  the  modern  non-poisonous  antiseptics  are  desir- 
able and  palatable  additions  to  the  oral  toilet.  A  saturated 
solution  of  boracic  acid  is  better  than  none.  The  physi- 
cian who  tastes  beer,  wine,  whisky  or  tobacco  would  do 
well  to  disinfect  his  mouth  before  visiting  patients.  The 
physician  who  does  not  scrub  his  teeth — natural  or  false — 
four  times  daily  neglects  one  of  the  fundamental  principles 
of  hygiene,  and  is  hardly  to  be  styled  a  "  teacher  "  of  the 
laity  on  matters  of  hygiene.  As  to  oral  hygiene,  those  with 
reasonably  good  natural  teeth  may  do  well  to  scrub  them 
thoroughly  with  soap  and  water,  or  with  salt  and  water,  or 
with  some  antiseptic,  four  times  a  day.  Those  having  false 
teeth  should  scrub  the  plates  and  the  mouth  in  like  manner, 
and  at  such  times,  and  keep  the  plates  in  a  saturated  boracic 
acid  solution  every  night.  Any  one  doing  so  may  keep  na- 
tural or  false  teeth  sweet  and  clean,  and  free  from  germs  ;  those 
who  do  not,  can  not.  Since  it  is  now  known  that  many 
infections  maybe,  and  are,  transmitted  by  the  breath,  it  is 
the  plain  duty  of  the  physician  to  keep  his  own  mouth  clean, 
and  teach  his  clientele   to  do  likewise. — Medical  Summary. 


414  PROGRESS  OF  MEDICAL  SCIENCE. 

COMPLICATED   ANAEMIA. 

BY   T.  J.  BIGGS,  M.  D. 

Ruth  K ,  af^e   14,  American,  admitted  November 

14.     Diagnosis :     Essential    anaemia. 

Th^  patient  had  been  sent  to  me  by  Dr.  B •,  who 

said  that,    in    spite    of  all    treatments    employed,    his   little 
patient  had  grown  steadily  worse,  and  the   parents  were  well- 
nigh  discouraged.     Her  condition  was  associated  with  men- 
strual  disorders  ;   a  year  previous  she  said  her  disposition 
seemed    to    change.     She    found   she  was  becoming  morose 
and    despondent  ;    at    times  hysterical,   and   suffering    very 
much   from   melancholy.     Her   menstrual   order   was  of  the 
menorrhagic    form,    her    complexion    was  pallid,  waxy,  skin 
pufTy  without  oedema ;  she  was  easily  fatigued  upon  the  least 
exertion  ;  the  heart    was    irritable ;  there  was  shortness   of 
breath,    pulse   full,    but   soft,    and  at  times  pulsations  in  the 
peripheral   veins.     There    was    a  disgust  for  food,  imperfect 
indigestion    and    occasional    attacks    of   gastralgia.     In  the 
right   apex    there    was    a   suspicious   dullness,    indicating   a 
possible  incipient    phthisis.     Examination    of  blood  showed 
a  relative  decrease  in  quality  and  quantity  of  the  haemoglo- 
bin,   resulting    in   the  blood  being  paler  than  normal.     The 
red  corpuscles   were  lighter   in  color   and  showed  less  tent 
dency  to  form   rouleaux;  their    character  was  changed,    no 
being   of  uniform    size,    some    normal,    others    small    (mi- 
crocytes),  others  usually  large  (macrocytes),  others  irregular- 
ly shaped   (poikilocytes).     The  number  of  corpuscles  to    a 
cubic  millimetre  was  about  2,500,500.     The  white  corpuscles 
were  considerably    increased   in  number.     A    few   granular 
bodies  were  present,  indicating    degeneration    of   the  white 
corpuscles. 

The  patient  was  put  to  bed,  secretions  regulated,  and 
a  half  teaspoonful  of  bovinine  was  ordered  every  hour  in 
peptonized  milk. 

On  November  i8th  the  bovinine  was  increased  to  a 
tablespoonful  every   two  hours. 

November  30th,  the  bovinine  was  increased  to  a  wine- 
glassful  every  two  hours,  given  in  peptonized  milk,  alternat- 
ing with  old  port  wine.  The  patient  at  this  time  showed 
some  improvement,  felt  stronger,  slept  better,  digestion  seem 
ed  excellent,  bowels  regular,  and  she  slept  throughout  the 
night  quietly. 

December  foth,  microscopic  examination  of  the  blood 
showed  increased  quantity  and  quality  of  haemoglobin,  and 
red  blood  cells  3,000,000  to  the  cubic  millimetre. 


MEDICINE   AND    NEUROLOGV.  415 

December  i8th,  the  patient  had  gained  seven  pounds 
in  weight,  color  good,  puffiness  of  the  skin  disappeared,  and 
she  was  taking  daily  exercise  in  the  open  air  without  suf- 
fering fatigue. 

December  24,  microscopic  examination  of  the  blood 
showed  haemoglobin  almost  normal,  the  red  blood  cells 
about  4,500,000  to  the  cubic  millimeter,  general  condition 
splendid. 

On  December  26   patient   was    discharged,    cured. 

The  complete,  thorough  and  rapid  cure  in  this  case  was 
undoubtedly  due  to  the  blood  treatment,  for  all  through  her 
course  of  treatment,  outside  of  cathartics  and  some  mild 
heart  stimulant,  she  took  absolutely  nothing  but  bovinine. 
Bovinine  acts  in  anaemia  in  all  its  forms  by  first  stimulating 
the  blood  cells  to  a  healthy  proliferation,  and,  secondly,  by 
properly  and  thoroughly  supplying  perfect  nutrition,  carries 
them  on  to  a  full  and  healthy  maturity.  Iron  in  all  its  forms, 
while  at  first  undoubtedly  beneficial,  can  only  go  halfway, 
for  it  simply  stimulates  the  proliferation  of  the  blood  cells 
and  supplies  only  partial  nutrition,  the  result  being  that  in 
the  majority  of  cases  where  it  is  employed  alone,  many  of 
the  newly  born  cells,  for  lack  of  proper  nutrition,  atrophy, 
or  become  granular  bodies. 

A    CURE    FOR    TONSILLITIS. 

Dr.  J.  A.  Henning  claims  to  be  able  to  cure  every  case 
of  tonsillitis  which  comes  to  him  before  the  third  day.  The 
patient  is  confined  to  a  room  of  uniform  temperature,  given 
a  mild  cathartic  and  kept  on  a  liquid  nutritious  diet.  Exter- 
nally a  volatile  liniment  is  applied  over  the  tonsils  and 
throat,  and  the  following  mixture  taken  internally: 

R  Tinct.  guaiac  ammon §  ss 

"        aconite gtt.  xl 

*'        Phytolacca gtt.  xx 

"        baptisia 3  ss 

Aqua —  q.  s.  ad.     3  iv 

M.  Sig. — Give  from  fifteen  to  sixty  drops,  according 
to  the  age,  every  half  hour  or  hour  for  six  hours,  then  less 
often  as  the  patient  improves  ;  this  course  will  be  continued 
until  the  patient  is  cured. 

The  medicine  must  be  taken  as  it  is,  without  any  water 
in  it  or  even  afterward;  a  part  ot  the  medicine  will  remain 
in  the  throat  and  exercise  a  local  influence. —  Chicago  Med. 
Times. 


4l6  PROGRESS  OF  MEDICAL  SCIEN'CE. 

TO   PREVENT    PITTING   IN    SMALLPOX. 

Dr.  T.  C.  Gibson,  in  American  Medicine,  says  that  the 
following  is  the  best  prescription  he  has  ever  tried  to  prevent 
pitting  in    smallpox: 

R.  Ichthyol 3  i j 

Guaiacol 5  ij 

Glycerin f.  1  ss 

M.      ^pply  locally  with  a  feather  three  times  a  day. 
The  earlier  it  is  commenced,  the  better  the  effect.'  The 
face  should  be  bathed  before  each  application  with  lukewarm 
water  and  soap. 

THE  TREATMENT  OF  EARACHE. 

Dr.  Geo.  L.  Richards  in  a  paper  read  at  the  last  meet- 
ing of  the  American  Medical  Association,  and  reported  by 
Pediatrics  advocates  the  use  of  a  glycerole  gelatin  bougie  in 
the   acute  earaches    of  children.    Its  formula  is  as  follows    : 

R,    Carbolic  acid njj  vij 

Fl.  ext.  opium itjj    vj 

Cocaine gr.    iij 

Atropine  sulph gr.    iij 

Aqua rrij    Iij 

Gelatin gr.  xviij 

Glycerin — '  gr-  clviij 

M.  This  makes  47  bougies.  They  should  be  kept  in 
lycopodium  or  wrapped  in  tinfoil.  Before  using,  the  bougie 
should  be  dipped  in  water,  then  it  will  readily  slip  into  the 
external  ear,  and  dissolving,  set  free  the  anodyne. 

ADAMKIEWICZ'S      SERUM      TREATMENT      OF      CANCER. 

Two  recent  publications  {^Berliner  Klinische  Wochen- 
schrift,  June  16,  1902)  call  for  renewed  interest  in  cancroin, 
the  serum  proposed  by  Adamkiewicz  for  the  treatment  of 
cancer.  Prof.  Kugel,  of  Bukarcst,  gives  the  minutest  details  of 
an  apparently  hopeless  case  cured  by  the  use  of  this  agent. 

The  patient  was  a  woman  fifty-three  years  old,  who 
some  years  before  had  a  small  mass  removed  from  the  left 
breast.  During  the  next  six  years  recurrences  near  the  cica- 
trix were  extirpated  three  times,  and  later  the  entire  breast 
was  removed.  Microscopic  examination  made  by  both  Babes 
and  Albert  showed  the  growth  to  be  one  of  carcinoma. 
After  this  evidences  of  the  progress  of  the  diseases  were 
found  below  the  clavicle,  in  the  cartilage  of  fourth  rib,  in  the 
right  breast  ;  there  was  pain  and  edema  of  the  left  upper 
extremity,  and  the  usual  symptoms  appearing  in  the  develop- 
ment   of    1    cancer  Gfoing'  towards  a  fatal  issue. 


MEDICINE   AND  NEUROLOGY.  417 

As  no  relief  could  have  been  afforded  by  operation  the 
cancroin  was  used.  In  October,  1900,  the  first  injection  was 
made.  Almost  immediately  after  this  the  edema  and  pain 
in  the  upper  extremity  decreased,  and,  after  a  few  injections, 
entirely  disappeared.  The  patient  began  to  increase  in 
weight,  and  other  features  of  the  case  either  improved  or 
remained  stationary.  All  this  was  reported  in  the  Therapeii- 
tische  Monatshefte,  August,   1901. 

During  the  past  year  the  improvement  in  the  patient 
has  been  still  more  marked,  and  the  cancerous  infiltration 
has  gradually  disappeared,  so  that  at  the  present  time  only  a 
small  red  spot  indicates  the  position  of  the  affected  portion 
of  the  rib  cartilage,  while  the  enlarged  cervical  glands  are  no 
longer  present. 

To  this  case,  so  graphically  described  by  Kugel,  must  be 
added  a  number  which  Adamkiewicz  himself  describes  in 
the  same  journal.  They  comprise  a  considerable  variety, 
cancer  of  the  tongue,  of  the  larynx,  esophagus,  stomach  and 
breast. 

In  all  of  the  cases  the  use  of  the  cancroin  was  followed 
by  favourable  results,  without  any  untoward  signs.  What 
makes  the  matter  more  interesting  is  the  quick  response  of 
the  symptoms  to  the  cancroin  injections  shown,  for  instance 
in  the  decided  reduction  of  swelling  in  a  cancerous  tongue, 
after  the  second  injection.  In  the  cancer  of  the  esophagus 
one  week's  treatment  was  followed  by  remarkable  improve- 
ment. The  pains  decreased,  the  dyspnea  disappeared,  the 
vomited  masses  lost  their  fetid  character,  the  diarrhea  was 
replaced  by  normal  evacuations  and  stenosis  of  the  esophagus 
was  relieved.  Two  months  after  treatment  the  patient  was 
permitted  to  go  home,  improved  in  all  symptoms  and  able 
to  take  food  per  os.  She  was  gaining  weight  at  the  rate  of  a 
half  kilogram  a  week. 

The  evidence  presented  in  these  reports  are  exceeding- 
ly encouraging,  especially  in  view  of  the  almost  complete 
absence  of  any  disposition  of  cancer  to  improve  under  the 
administration  of  any  remedy.  Unlike  in  tuberculosis,  hope 
cannot  come  to  the  aid  of  agent  and  cause  an  improvement 
for  a  time.  Cold  facts  predominate  in  the  treatment  of  can- 
cer, and,  alas,  the  progress  is  always  in  one  direction. 

The  nev/  agent  deserves  trial,  not  because  it  is  a  new 
remedy,  but  because  it  is  announced  with  evidence  of  value 
in  cases  which,    to  say  the  least,  cannot  be  questioned  as  to 


4l8  PROGRESS  OF  MEDICAL  SCIENCE. 

diagnosis,  though  some  other  explanation   may  be  ventured 

of  the  improvement   coincident    with    its    use. Si.    Louis 

Medical  Review. 

DEODORIZATION  OF  £XCR£TA  MOSS  MANURE. 

The  first  public  mention  of  the  usefulness  of  moss  litter 
as  a  deodorizer  and  absorbent  seems  to  have  been  made  by 
Dr.  Ludwig  Happe,  in  Braunschweig,    in  December,  1880, 
since  which  time  its  application  for  the  purpose  has  gradually 
increased  until  now,  when  the  system  has  been  introduced 
into  several  towns  in  Germany,  and  is  also  practiced  in  Con- 
gleton,    Cheshire,     England,     In  Canada    this    method    of 
deodorizing  human  refuse  had  been  in  use  for  years  at  Cale- 
donia Springs.      It,  of  course,  at  once  recalls  the  dry  earth 
system  regarding  which  great  expectations  were  at  one  time 
entertained.     The  advantages  of  moss  litter  over  dry  earth 
for    the    purposes    in   question  are,  however,  very  decided. 
They  consist  in  the  perfect  inofifensiveness  of  the  moss  litter 
product,  in  the  fact  that  one  part  of  moss  Utter  will  deodorize 
and  dry  at  least  six  parts  of  mixed  excreta,  and  in  the  greater 
afjricultural    values    of    the  resulting     manure.     Dry    earth 
(which   is  required  in  quantity  at  least  equal  to  that  of  the 
excreta),  is    valueless  from  an  agricultural  point    of   view; 
but  this  is  not  the  case  with  moss  litter,  which,  as  its  analyses 
show,  often  contains  as  much  nitrogen  as  ordinary  barn -yard 
manure.     Numerous  analyses  have  been  made  of  moss  litter 
manure  as  produced  in  Germany,  and  its  average  contents 
rom  seven  different    towns  may  here  be  stated: 

Per  cent.  Lbs.  per  ton.  Value  per  ton. 

Nitrogen....; 0.664  13.28  at  13c.  $1.72 

Phosphoric  acid 0-35o  7.00  5  0-35 

Potash 0.285  5-7°  SX  0-30 

Water 83.00  $2.37 

Numerous  trials  have  been  made  on  various  crops  with 
this  manure,  and  very  satisfactory  results  are  always  reported. 
In  all  cases  it  is  stated  to  excel  barn-yard  manure  even 
when  the  latter  is  used  in  much  greater  quantity. 

Canada  possesses  in  its  bogs  and  swamps  inexhaustible 
quantities  of  moss  litter  which  is  frequently  found  in  beds, 
several  feet  in  thickness,  lying  above  the  peat. 

The  manufacture  of  moss  litter  has  been  attempted  at 
Musquash,  in  New  Brunswick,  and  also  in  Welland  County, 
Ontario.     From  the  latter  locality  the  writer  was  supplied 


MEDICINE   AND    NEUROLOGY.  419 

with  several  bales  of  the  moss  litter  for  experimental  pur- 
poses, and  Dr.  Laberge,  M.  O.  H.  Montreal,  undertook  to 
superintend  the  carrying  out  of  an  experiment  to  determine, 
its  deodorizing  and  absorbent  qualities.  He  reported  that 
100  pounds  of  moss  litter  were  sufficient  for  drying  800 
pounds  of  ordinary  excreta  from  privy  pits  in  Montreal,  arid 
rendering  it  entirely  inoffensive.  A  sample  of  the  product 
remained  for  days  in  the  writer's  office  without  attracting 
notice,  and  indeed  it  was  quite  devoid  of  odour.  Its  analysis 
gave  the  following  results  : — 

Per  cent.  Lbs.  per  ton.  Value  per  ton. 

Nitrogen 1.31  26.2  at  13c.  $3.41 

Phosphoric  acid 0.90  18.0  at  5  0.90 

Potash 0.14  2.8  at  5X  L^S 

Water 63.47  $4.46 

The  valuation  of  ordinary  fresh  barn-yard  manure  with 
75  per  cent,  of  water  is  about  $2  per  ton  ;  with  6^  per  cent 
water,  as  in  the  case  of  the  average  given  above  by  Dr.  Goess- 
mann,  the  value  is  nearly  $2.15.  Therefore,  much  better  re- 
sults might  be  expected  agriculturally  from  a  "  moss  manure' 
of  the  composition  just  described. 

These  facts  are  reported  in  order  to  show  that  Canada 
possesses  in  her  waste  lands  abundance  of  material  which 
might  be  used  in  our  towns  and  villages  for  the  production 
of  a  very  valuable  manure,  with  the  simultaneous  introduction 
of  very  many  sanitary  advantages.  It  is  not  to  be  expected 
that  cities  or  towns  which  are  advantageously  situated  for  the 
water  carriage  system,  or  which  have  already  adopted  it,  will 
make  any  changes,  but  there  are  many  towns  and  villages 
in  the  Dominion  where  the  application  of  the  moss  litter  sys- 
tem would  be  very  suitable,  and  the  authorities  of  which,  by 
selling  the  product  or  giving  it  gratis  to  the  farmers  of  the 
neighbourhood,  might  confer  a  great  agricultural  advantage. 
— Bulletin  Laboratory  Inland  Revenue,   Canada. 

THE  PROPHYIiACTIC  USE  OF  DIPHTHERIA  ANTITOXIN. 

Dr.  Sevestre,  the  well-known  French  authority  upon 
diphtheria,  has  recently  reviewed  the  subject  of  the  prophylaxis 
of  diphtheria  by  preventive  injections  of  antidiphtheria  se- 
rum. After  giving  many  details,  he  states  that  preventive 
injectionsof  antitoxin  produce  immunity  in  children  exposed 
to  diphtheria.  Serious  accidents  have  never  followed  the  use 
of  well  prepared  serum,  though  an  eruption  or  some  joint 
pains  may  result.     But  this  immunity  only  lasts  three  or  four 


420  PROGRESS   OF  MEDICAL  SCIENCE. 

weeks  at  most.  Should  diphtheria  develop  after  the  in- 
jections, it  is  very  mild  in  character.  Preventive  injections 
are  especially  indicated  in  a  family,  school  or  hospital  in 
which  a  case  of  diphtheria  has  appeared.  They  are  often 
of  value  in  a  ward  containing  patients  with  measles  or 
scarlet  fever.  Large  doses,  often  repeated,  are  needed  in 
measles.  It  should  not  be  forgotten  that,  even  though  these 
injections  be  given,  disinfection  and  isolation  are,  neverthe- 
less, necessary.  The  prophylactic  use  of  serum  is  recommend- 
ed  by  the  Pediatric  Society  and  the  Academy  of  Medicine 
of  Paris. — {Bulletin  Medical,  March,  1902.) 

EFFICACY    OF    DIPHTHERIA    ANTITOXIIT. 

The  use  of  Prof.  Behring's  diphtheria  serum  has  result- 
ed, according  to  statistics  just  published,  in  the  lowest  death- 
rate  ever  recorded  from  diphtheria  in  Berlin,  in  1901.  The 
deaths  from  diphtheria  were  then  469,  Prior  to  the  intro- 
duction of  Prof.  Behring's  serum,  the  deaths  from  this  disease 
ranged  from  1,300  to  2,600  a  year.  In  all  but  one  of  the 
Berlin  hospitals  the  serum  treatment  is  in  use.  In  these  the 
mortality  is  from  12  per  cent,  to  13  per  cent.,  whereas  in 
the  one  hospital  where  it  is  not  used  the  mortality  is  64.7 
per  cent. —  Vermont  Health  Bulletin. 

DIAGNOSIS      AND      TREATMENT      OF      TUBERCULAR 
CYSTITIS. 

J.  B.  Bissel,  New  York  —  As  to  the  characteristic 
signs  : — The  most  frequent  symptom  is  hematuria.  Often  the 
hemorrhage  is  very  slight  and  with  little  or  no  pain ;  frequently 
it  is  not  constant.  Usually  it  comes  at  the  end  of  urination, 
varying  in  amount  from  a  couple  of  drops  to  a  teaspoonful. 
It  is  probably  the  earliest  symptom  of  the  disease — so  early 
at  times  that  it  may  be  called  a  prodromal  symptom.  The 
hematuria  which  comes  on  later,  after  the  chronic  inflam- 
matory conditions  are  present,  indicating  the  ulcerating 
stages  of  the  tubercular  deposit,  is  a  different  hemorrhage. 
It  lasts  longer,  comes  earlier  in  the  act  of  urination  and  the 
pain  which  accompanies  it  is  often  severe. 

Pain  is  a  pretty  constant  symptom.  It  comes  on  early, 
continues  through  the  course  of  the  disease  and  at  times  is 
so  severe  as  to  make  one  think  of  calculus  or  of  malignant 
ulceration.  Tenesmus  is  usually  present  with  the  pain.  Fre- 
quency of  urination  is  a  pretty  constant  .'jymptom,  coming 
on  early  in  some  cases. 


MEDICINE   AND    NEUROLOGY.  42 1 

As  the  disease  progresses,  these  signs — pain,  tenesmus, 
frequency  of  urination  and  hemorrhage — increase.  Later 
pus  is  always  found,  either  scattered  through  the  urine,  as 
in  the  early  stages — or  in  shreds,  or  in  the  large  pieces  of 
ulcerated  tissue  which  appears  still  later.  Large  quantities 
of  bladder  epithelium  are  usually  found  with  the  pus  or  before 
it  and  point  to  the  bladder  as  the  seat  of  the  disease.  Be- 
fore other  symptoms,  for  several  weeks  or  more,  repeated 
evacuations  of  clear  limpid  urine  may  attract  the  notice  of 
the  patient. 

The  frequent  voidance  of  clear  urine  without  pain  and 
without  apparent  cause,  with  a  few  drops  of  bright-red  blood 
at  the  end  of  urination,  or,  less  often,  preceding  it,  is  almost 
pathognomic  of  beginning  tubercular  cystitis. 

The  reaction  of  the  urine  is  acid,  although  toward  the 
end  it  may  become  neutral  or  even  ammoniacal. 

At  times  mucus  is  present  in  enormous  amounts.  As 
the  disease  goes  on,  the  urine  may  become  fetid  and  almost 
green  in  colour  and  contain  large  fragments  of  detritus,  with 
blood  scattered  throughout  the  urine,  instead  of  coming  free 
at  the  end  of  urination  as  at  first.  This  is,  of  course,  during 
the  period   of  extensive  tubercular  deposits   and   ulceration. 

The  ulceration  may  be  extensive  enough  to  perforate 
the  bladder-wall  and  occasionally  has  sloughed  through  into 
the  rectum.  Incontinence  maybe  present,  but  is  only  mark- 
ed after  the  tubercular  process  reaches  the  neck  of  the  blad- 
der and  the  latter  has  been  extensively  involved. 

The  cystoscope  is  of  great  advantage  if  used  carefully. 

By  it  the  ulcers  can  be  made  out,  usually  about  the 
ureteral  orifices  or  in  the  trigone. — Phila.  Med.  Jour. — St. 
Louis  Medical  Review. 

PROSTATIC       GONOCOCCAL       AUTO-REINFECTIONS       OF 
THE     URETHRA. 

T.  M.  Townsend,  New  York,  presents  the  following 
summary  of  his  views  on  this  question; — i.  Early  and  vig- 
orous efforts  should  be  made  to  prevent  gonorrheal  prostatitis. 
2.  Once  established,  all  care  should  be  taken  to  prevent  it 
from  becoming  foUicular  and  chronic.  3.  Auto-reinfections 
of  the  urethra  from  chronic  prostatitis  can  be  differentiated 
from  acute  infections.  4.  An  opinion  on  the  probabilities  of 
future  recrudescences  should  be  very  guarded.  5.  Each  pro_ 
static  message  should  be  immediately  followed  by  thorough 


422  TROGRESS  CF  MEDICAL  SCIENCE. 

irrigation   of  both   portions   of  the  urethra,   to  prevent  recur-, 
rent  acute  urethritis.     6.  Omission    of  this  irrigation  is  some- 
times  permissible    for  diagnostic   purposes.     The   frequency 
with  which  prostatic  massage  may  be  done  is  quite  variable. 
Ordiiiariiy,  afrebrile  cases  of  mixed  foUicular  and  parenchyma- 
tpus  types  bear  daily  massage  well.     After  six  or  eight  days, 
the  in  erval  between   massages   may  be  lengiheneJ   one  day 
until  five  or  seven    days   are   reached.      Old   follicular  pro- 
statites do  not  seem  to  tolerate  t  eatment  oftener  than   every 
third  day,  increasing    the  interval    with  the    improvement. 
In  the  prostatic    treatmenr,    the    following    ends    must  be 
attained: — Evacuation  of  the  infecting  focus  or  foci;  effective 
emptying  of  other  diseased  follicles;  restitutio  ad    iniegrum 
of    newly  infected    areas.     The  selection    of    the   irrigating 
fluid  depends  upon  the   miscroscopic  findings,  silver  prepara- 
tions being  preferable  when   gonococci  persist ;  when  goiio- 
cocci  disappear,  other   bacteria  remaining,  solutions  of  cor- 
rosive sublimate  are  indicated;  where  no  bacteria  are  demon- 
strable,   astringents    should    be  used. —  N.    Y.  Medical  Re- 
cord—St. Louis  Medical  Review. 

ARiXGANCS   IN   I.lZSiCiNE. 

The  possession  of  mentality  tends  to  breed  arrogance 
in  its  owner.  The  individual  is  usually  unconscious  of  this, 
but  the  effects  are  equally  mischievous.  It  requires  gen- 
uine humility,  consideration  for  the  rights  and  needs  of 
others,  to  keep  this  arrogance  within  bounds. 

In  medical  writers  and  teachers  we  find  this  natural 
tendency  makes  them  ignore  the  real  needs  of  those  who 
depend  upon  them  for  instruction  in  the  everyday  cases 
which  engage  most  of  their  attention,  and  the  successful 
handling  of  which  means  to  them  advancement  and  repu- 
tation, in  order  to  discourse  exhaustively  about  some 
rara  avis,  which  a  majority  of  physicians  do  not  see  once  in 
a  lifetime- 
Medical  men,  who  have  long  since  mastered  the  treat- 
ment of  minor  functional  ailments,  no  longer  take  an  in- 
terest in  them,  and  are  unwilling  to  linger  over  the  a  b  o 
of  practice,  but  it  is  precisely  here  that  the  medical  novice 
needs  special  drilling,  with  all  the  light  that  long  experi- 
ence and  a  masterful  mind  can  shed. 

^lost  of  the  troubles  which  bring  people  to  the  doctor 
for  help  are  simple  functional  troubles — the  bad  cold,  the 
persistent  headache,  the  acute  indigestion,  the  pelvic  pain 
and  dragging,  the  torpid  liver,  rheumatism,  etc.,  these  are 
the  things  they  want  to  be  relieved  of.     And  nine  times 


MEDICLNli  AND  NEUROLOGY.  423 

out  of  ten,  it  is  the  neglect  or  wrong  treatment  of  these 
ailments  which  result  in  grave  organic  lesions. 

It  is  very  easy  to  believe  that  every  one  knows  the 
fundamentals  of  his  business,  particularly  if  we,  ourselves, 
have  acquired  the  contempt  of  familiarity,  and  want  to 
venture  into  the  region  of  the  unknown,  to  study  intricate 
and  complex  problems,  to  speculate,  theorize  and  exper- 
iment, leaving  those  who  can  follow  us  to  do  so  if  they 
will,  and  those  who  can  not  to  linger  by  the  wayside. 

But  medical  men  who  elect  to  become  teachers  should 
ever  bear  in  mind  that  their  first  duty  is  to  equip  those 
who  depend  upon  them  for  the  knowledge  needed  in  the 
actual  struggle  they  will  have  to  face  as  soon  as  they  hang 
out  their  own  shingles.  We  should  probabl}-  have  better 
diagnosticians  if  medical  students  were  not  carefully,  if 
unintentionally,  trained  to  overlook  the  obvious  in  a  search 
for  some  rare  and  hidden  malady. 

Let  the  teacher  and  the  master  thoroughly  train  pupil 
and  subordinate  how  to  deal  with  simple  everyday  matters. 
The  mastery  of  these  will  lead  naturally  to  the  study  and 
comprehension  of  more  difficult  problems  in  the  proper 
time  and  place. 

The  teacher  who  desires  to  fulfill  his  obligation  to  his 
pupils  will  not  allow  himself  to  feel  or  show  any  disdain 
for  the  commonplace  diseases,  but  patiently  ground  his 
pupils  in  the  working  knoiclcdqe  which  must  constitute  the 
basis  of  success  for  each  of  them. 

It  requires  even  finer  mental  powers  to  resolve,  sim- 
plify and  elucidate  than  to  tackle  hard  problems.  More- 
over, there  are  few  if  any  diseases  about  which  the  final 
word  has  been  said.  Cultivated  faculties  of  observation 
and  discrimination  can  do  their  most  effective  work  on 
familiar  ground — Medical  Brief. 

RULES  FOR   THE   SICK   ROOM. 

Here  are  a  few  rules  of  the  sick  room  that  are  worth 
femembertngf  : — 

Never  take  the  temperature  in  the  armpit  until  you  are 
sure  the  skin  is  dry. 

Never  neglect  to  chart  the  temperature  as  soon  as  you 
have  taken  it. 

Never  allow  a  patient  to  take  the  temperature  himself. 
Many  patients  are  more  knowing  than  nurses  where  there  is 
a  question  of  temperature. 

Never  use  anything  but  a  graduated  measure  for  ad- 
ministering doses  of  medicine,  unless  ordered  to  administer 
the  dose  in  drops. 


424  PROGRESS   OF  MEDICASCIEN.ECL 

Never  put  a  hot  water  bottle  next  the  skin.  Its 
efificiency  and  the  patient's  safety  are  both  enhanced  by 
surrounding  the  bottle  with  flannel. 

Never  complain  that  you  cannot  get  a  feeding  cup  if 
there  is  a  teapot  to  be  had  instead. 

Never  administer  a  quantity  of  food  to  a  patient  until 
you  have  found  out  if  he  can  swallow. 

Never  disregard  a  patient's  intelligent  craving  for 
particular  articles  of  diet. 

Never  use  your  patient  as  a  thermometer  for  estimating 
the  temperature  of  the  bath.  Although  he  turns  red  in  hot 
water  and  blue  in  the  cold,  the  record  is  not  exact,  and  there 
are  other  objections  of  a  more  or  less  obvious  nature. 

Never  allow  a  patient  to  be  wakened  out  of  his  first  sleep 
either  intentionally  or  accidentally. 

Never  imagine  that  a  patient  who  sleeps  during  the  day 
will  not  sleep  during  the  night.  The  more  he  sleeps  the 
better  he  will  be  able  to  sleep. 

Never  hurry  or  hustle. 

Never  stand  and  fidget  when  a  sick  person  is  talking  to 
you.     Sit  down. 

Never  sit  where  your  patient  cannot  see  you. 

Never  require  a  patient  to  repeat  a  message  or  request 
Attend  at  once. 

Never  judge  the  condition  of  your  patient  from  his 
appearance  during  the  conversation.  See  how  he  looks  an 
hour  afterward. 

Never  read  a  story  to  children  if  you  can  tell  it. 

Never  read  fast  to  a  sick  person.  The  way  to  make  a 
story  seem  short  is  to  tell  it  slowly. 

Never  play  the  piano  to  a  sick  person  if  you  can  play  on 
strings  or  sing. 

Never  confine  a  patient  to  one  room  if  you  can  obtain 
the  use  of  two. 

Never  allow  monotcny  in  anything. — Nursing  Section 
of  the  Hospital. 


SURGBRY. 


1  N   CHARGE    OF 

ROLLO  CAMPBELL,  M.D., 

Lecturer  on  Surgery,  University  of  Bishop's  College  ;  Assistant  Surgeon,   Western  Hospital; 

AND 

GEORGE  PISK,  M . D . 
Instructor  in  Surgery,  University  of  Bishop's  College  ;    Assistant  Surgeon,  Weste  rn    Hospital 


DIAGNOSIS      AND      TREATMENT      OF      TUBERCUULR 
ARTHRITIS. 

J.  K.  Young  {Therapeutic  Gazette,  June,  1902)  discusses 
this  important  subject.  There  are  certain  etiological  facts 
connected  with  tubercular  arthritis  in  whatever  joint  which 
are  valuable  in  arriving  at  a  diagnosis.  Eighty  per  cent,  of 
cases  occur  before  adult  life.  Males  are  more  frequently 
affected  than  females.  There  is  undoubtedly  often  a  here- 
ditary tendency.  Some  of  the  signs  which  stand  out  prom- 
inently are  spasm,  pain,  atrophy  and  night  cries.  Too 
little  attention  is  paid  to  early  fixation  of  a  joint  by  muscular 
spasm.  Sooner  or  later  it  is  followed  by  atrophy  of  the  con- 
tracted muscles.  The  pain  which  accompanies  tubercular 
arthritis  is  sometimes  referred  to  the  peripheral  distribution 
of  the  nerves.  Thus  in  spine  disease  the  pain  is  referred  to 
the  anterior  portion  of  the  body,  and  in  hip  disease  to  the 
inner  side  of  the  knee.  The  o,ccurrence  of  night  cries  is 
characteristic  of  the  second  stage  of  tuberculous  disease. 
They  are  significant  of  the  extension  of  the  disease  to  other 
portions  of  the  joint,  especially  ulceration  of  the  cartilage. 

Tubercular  arthritis  must  be  differentiated  from  numer- 
ous other  diseases  of  joints.  The  differential  diagnosis 
between  arthritis,  say  of  the  knee  joint,  and  of  synovitis,  the 
disease  with  which  it  is  most  frequently  confounded,  brings 
out  the  points  given  above. 


NOX-TUBERCULAR 

CHRONIC 

CHRONIC  SYNOVITIS. 

TUBERCULAR  ARTHRITIS. 

1. 

Marked  effusion,  capsule  thickened. 

1. 

No    fluctuation,    capsule    not  thick- 

2. 

Joint    outline   enlarged  and  obliter- 

ened. 

ated. 

2. 

Joint  outline  clear  and  distinct. 

3. 

Motion  nearly  normal. 

3. 

Motion  limited. 

4. 

Reflex  muscular  spasm  absent. 

4. 

Reflex  mascular  spasm  present. 

5. 

No  atrophy. 

5. 

Marked  atrophy. 

6. 

Pain  absent. 

G. 

Pain  acute  on  motion. 

7. 

Limp  absent. 

7. 

Limp  present. 

8. 

Night  cries  absent. 

8. 

Night  cries  present. 

9. 

Relation  of  femur  and  tibia  normal. 

9. 

Tibia  subluxated. 

Tubercular      arthritis    should    be    differentiated     from 
specific  arthritis.    The  symptoms  just  given  of  non-tubercular 


426  JOTTNGS. 

synovitis,  togetiier  with  the  history  and  the  effect  of  con- 
stitutional remedies,  will  make  the  diagnosis  clear.  The 
same  symptoms  will  make  the  differential  diagnosis  between 
articular  rheumatism  and  tubercular  arthritis.  X-ray  pho- 
tography furnishes  an  important  means  of  diagnosis.  By  it 
we  can  distinguish    the  amount   of  bone  destruction  present. 

Treatment  is  constitutional,  mechanical  and  local.  The 
constitutional  treatment  should  be  as  painstakng  as  the  treat- 
ment of  tuberculous  disease  in  other  parts  of  the  body,  and 
along  the  same  lines.  The  mechanical  treatment  may  be 
summed  up  in  one  word — traction.  By  whatever  means 
traction  is  employed  it  should  be  thorough  and  long  con- 
tinued. The  local  treatment  of  tubercular  joints  by  means 
of  iodoform  injections  is  very  valuable  in  the  smaller  joints, 
but  not  so  valuable  in  the  knee  and  hips. 

The  operative  treatment  should  be  thorough  when  it  is 
done  at  all;  and  there  are  two  points  which  should  be 
insisted  on  in  all  operations  on  tuberculous  joints  :  first  the 
preservation  of  the  bodily  heat,  and  second,  rapidity  of 
operation.  There  are  few  operations  in  surgery  in  which  the 
shock  is  more  profound  than  in  excision  of  the  hip. —  The 
Memphis  Medical  Monthly. 

Jottings. 

A   CURB  FOR  WORTS. 

We  have  found  nothing  more  generally  useful  than  the 
repeated  application  of  the  end  of  a  bit  of  wood  (e.  g.,  a 
match)  moistened  with  acid  nitrate  of  mercury,  care  being 
taken  only  to  touch  the  top  of  the  wart,  and  not  to  let  the 
fluid  run  to  the  sound  tissue.  The  wart  gradually  shrivels 
and  finally  falls  off. — ^eiv   York  Med.   and  Surg.   Journal. 

AN  ALLEGED  CURE  FOR  DIABETES. 

The  London  correspondent  of  the  New  York  "  Times  " 
cables  to  his  journal  that  Dr.  A.  C.  Faulds,  of  Glasgow,  has 
discovered  a  remedy  for  diabetes  in  an  infusion  of  dried 
eucalyptus  leaves.  He  uses  this  in  preference  to  the  oil  of 
eucalyptus,  and  says  that  his  experiments  were  prompted  by" 
learning  that  the  remedy  was  used  by  the  natives  of  New 
Zealand.  Of  forty- six  diabetic  patients  treated  with  euca- 
lyptus. Dr.  Faulds  claims  to  have  cured  fifteen,  or  thirty- 
three  per  cent. — Medical  Record 


■TTHK- 


Canada  Medical  Record 


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Editorial. 


CANADIAN  MEDICAL  ASSOCIATION. 

The  Annual  Meeting  of  this  Association,  which  was  held 
in  Montreal,  on  the  15th,  i6th  and  17th  of  September,  was  by 
far  the  most  successful  in  its  history.  The  number  of  mem- 
bers who  registered  was  much  in  excess  of  that  of  any  pre- 
vious meeting.  We,  who  were  present  at  the  inauguration  of 
the  Association  in  1867,  in  the  city  of  Quebec,  and  have  at- 
tended the  majority  of  meetings  since,  could  not  help  being 
struck  with  the  fact  that  the  turning  point  in  its  history  has 
at  last  been  reached.  Many  of  those  who  took  an  active  part 
in  its  early  history  have  passed  over  to  the  great  majority, 
but  not  before  they  had  impressed  many  of  their  younger  breth- 
ern  with  the  idea  that  such  an  .Association  must  live,  and 
that  its  growth  must  keep  pace  with  the  growth  of  confedera- 
tion. There  were  times  when  it  seemed  almost  useless  to 
continue  the  hard  work  necessary  for  its  existence,  but  the 
work  was  done,  and  we  believe  the  present  is  filled  with  pro- 
mises of  a  bright  future.  We  saw  men  at  this  meeting,  who 
have  rarely,  if  ever,  been  absent ;  among  them  Dr.  Harrison 
of  Selkirk,  Man.,  and  Dr.  Sloan,  of  Blythe,  Ontario,  and  their 
meeting  with  fellow  workers  who  have  helped  to  sustain  the 
Association  seemed  to  make  them  young  again.  It  was  a 
source  of  regret  that  Dr.  Stewart,  of  Halifax,  was,  owing  to 
illness  in  his  family,  unable  to  be  present  to  read  his  paper, 
"Surgery."     The  Address  of    Dr.   Shepherd,    the  president, 


428  EDITORIAL. 

was  a  masterly  production,  and  made  points  which  we  hope 
will  impress  many,  and  lead  them  to  ask  whether  the  ultra 
scientific  courses  given  at  most  Medical  Schools  at  present 
is  calculated,  as  some  think,  to  turn  out  good  general  prac- 
titioners. Of  the  Address  in  Medicine  given  by  Dr.  Osier,  of 
the  Johns  Hopkins  Hospital,  Baltimore,  we  can  truly  say  it  im- 
pressed every  one  as  being  a  magnificent  oration.  No  better 
has  ever  been  read  before  any  Medical  Association.  We  Can- 
adians must  ever  be  proud  that  not  only  is  Dr.  Osier  a  Can- 
adian, but  a  Canadian  graduate  (McGill|),  and  that  his  early 
scholastic  medical  life  was  passed  with  his  Alma  Mater  and 
the  early  years  of  his  practice  in  the  city  of  Montreal.  The 
attendance  being  large,  the  two  Sections,  Medical  and  Surgi- 
cal, into  which  the  Association  divided,  were  scenes  of  much 
life.  The  papers  were,  on  the  wnole,  good ;  some  unsually  so. 
Perhaps  those  who  took  part  in  the  discussions  were  not  as 
numerous  as  we  might  have  wished,  but  those  who  did  take 
part  spoke  briefly  and  to  the  point.  A  pleasant  feature  was  the 
fact  that  some  present  spoke  in  the  French  language  and  were 
applauded  on  sitting  down.  This  limited  discussion  is  a  gen- 
eral fault  at  all  Association  Meetings,  and  its  cause  is  somewhat 
difficult  to  fully  understand.  Some  ascribe  i\.  to  diffidence, 
others  to  want  of  practice  in  speaking  before  any  assemblage. 
If  this  latter  is  the  cause,  the  remedy  lies  in  the  formation  of 
local  societies  and  taking  part  in  the  debates. 

The  social  part  of  the  meeting  was  well  looked  after.  A 
reception  in  the  Art  Gallery,  a  railroad  ride,  and  visit  to  the 
Victoria  Jubilee  Bridge,  thence  to  Lachine,  a  sail  of  an  hour 
on  Lake  St.  Louis  on  the  steamer  "Duchess  of  York,"  during 
which  a  splendid  luncheon  was  served,  then  descending  the 
Lachine  Rapids  to  the  city  of  Montreal.  A  garden  party,  given 
by  Mrs.  James  Ross,  the  wife  of  one  of 'our  millionaire  citizens, 
v/as  a  feature  in  the  social  festitives,  and  was  a  thoroughly  en- 
joyable event.  On  Thursday  evening,  a  Smoking  Concert, 
in  the  Vitoria  Rifles  Armory,  which  was  largely  at- 
tended, brought  the  festivities  to  a  close.  A  feature 
of  this  year's  meeting  was  the  special  attention  paid  to  the 
ladies  who  accompanied  the  members.  A  committee  of  the 
local  doctors'  wives  and  daughters  took  them  in  hand.  They 
were  entertained  to  luncheon,   and  on  its  conclusion  electric 


BOOK   REVEWS.  429 

cars  were  in  waiting,  which   took    them  around  the  city  and 
out  to  the  Back  River, 

In  every  way  then  the  meeting  was  a  great  success,  and 
much  credit  is  due  to  the  committees  who  had  the  matter  in 
hand,  and  who,  thanks  to  the  generosity  of  the  Montreal  pro- 
fession, had  money  and  to  spare.  The  next  meeting  will  be  in 
London,  Ontario. 

THE  MEDICAL  FACULTY  OF  BISHOP'S  COLLEGE. 

The  Session  of  the  Medical  Faculty  of  Bishop's  College, 
which  opens  on  the  first  October,  is  the  first  session  where 
the  courses  will  be  of  nine  months'  duration ;  that  is,  the  Pri- 
mary courses ;  the  Final  will  continue  six  months'  courses  for 
this  and  next  session.  Those  only  who  enter  as  Freshmen  this 
year  come  under  the  nine  months'  courses.  The  attendance  of 
students  promises  to  be  excellent. 


Book   Reviews. 

A  Text-Book  of  Surgery.  By  Dr.  Hermann  Tillmann?, 
Professor  in  the  University  of  Leipsic  Translated  from  the 
Seventh  German  Edition  by  Benjamin  P.  Pilton,  M.D., 
Instructor  in  Surgery,  Cornell  University,  and  John  Rogers, 
M.D.,  Instructor  in  Surgery,  Cornell  University.  Edited  by 
Lewis  A.  Stimson,  M.D.,  Professor  of  Surgery,  Cornell  Uni- 
versity. Volume  I.  The  principles  of  Surgery  and  Surgical 
Pathology,  with  516  illustrations.  New  York:  D.  Appleton 
&  Company,  1901. 

This  new  edition  of  a  well-known  and  most  reliable  work  on 
Surgery  hardly  requires  to  be  more  than  brought  to  the  notice  of 
our  readers,  as  the  book  has  for  a  long  time  been  held  in  high 
esteem  by  those  most  quahfied  to  know;  viz.,  teachers  on  the  sub- 
ject with  which  this  volume  deals.  Through  an  oversight,  this 
book,  which  is  the  first  volume  of  the  new  edition,  escaped  the  re- 
viewer's notice,  and  we  must  apologize  for  the  omission,  and  trust 
that,  like  good  wine,  the  subject  now  dealt  with  will  have  improved 
by  the  delay  of  keeping.  The  volume  under  description  is  one  ot 
the  most  complete  in  every  detail,  which  it  has  been  the  reviewer's 
pleasure  to  peruse,  the  text  being  plain  and  concise,  the  print  of 
such  a  size  as  not  to  weary  the  eye,  and,  if  the  remaining  volumes 
keep  up  to  date  as  t'.ey  are  issued,  the  complete  set  will  prove  a 
most  valuable  addition  10  the  library  of  any  medical  man  desiring 
to  keep  abreast  of  the  limes  in  the  ever  attractive  and  constantly 
advancing  subject  of  Surgery. 

R.  C. 


430  BOOK  REVIEWS. 

The  Practical  Medicine  Series  of  Year  Books,  issued 
monthly,  under  the  general  ediiorial  charge  of  G.  P.  Head, 
M.D.,  Professor  of  Laryngology,  Cnicago;  Post- Graduate 
School,  Vol.  VIII.,  Pediatrics  and  Orthopedic  Surgery,  edited 
by  W.  S.  Christopher,  M.D.,  John  Ridlon,  A.M.,  M.D.,  Samuel 
J.  Walker,  A.B.,  M.D.,  July,  1902.  Chicago  :  The  Year  Bo  )k 
Publishers,  40  Dearborn  street. 

The  combination  of  Pediatrics  and  Orthopedics  at  first  sight 
might  seem  a  strange  combination.  It  is  not  so,  however,  for  the 
bulk  of  Orthopedic  work  is  done  on  the  young,  and  really  is 
Surgical  Pediatrics.  The  little  volume  now  before  us  brings  up  to 
date  all  that  is  new  in  these  branches. 

F.  VV.  C. 

Dudley's  Gynecology.  A  Treatise  on  the  Principles  and 
Practice  of  Gynecology.  By  E.  C.  Dudley,  A.M.,  M.D., 
Professor  of  Gynecology  in  the  Northwestern  University 
Medical  School,  Chicago.  New  {3rd)  edition.  Enlarged 
and  thoroughly  revised.  In  one  very  handsome  octavo 
volume  of  756  pages  with  474  engravings,  of  which  60  are  in 
colours  and  22  coloured  plates.  Cloth,  $5  net.  Leather, 
$6  net.  Half  morocco,  $6.50  net.  Lea  Bros.  &  Co.,  Phila- 
delphia and  New  York,  1902. 

This  is  a  work  of  which  both  author  and  publisher  may  well 
be  proud.  Dr.  Dudley  has  furnished  a  complete  and  trustworthy 
exposition  of  modern  gynecology,  than  which  we  could  not  pos- 
sibly imagine  anything  more  up  to  date.  The  second  edition  was 
freqiiently  commended  as  the  best  treatise  on  Gynecology  extant, 
but  the  present  edition  is,  in  many  ways,  superior  to  it.  It  con- 
tains nearly  one  hundred  more  pages  of  printing  and  twenty-five 
new  engravings  and  fourteen  plates.  There  are  two  points  about 
this  work  which  seem  to  us  to  especially  recommend  it  to  the 
student:  First,  the  new  and  more  rational  method  of  arranging 
the  chapters  according  to  their  pathological  and  etiological  sequence 
rather  than  in  the  old  way  of  describing  all  the  diseases  of  a 
special  organ.  The  student  will  have  a  more  rational  and  more 
comprehensive  idea  of  metritis,  for  instance,  by  associating  it 
closely  with  vulvo-vaginitis,  salpingitis,  ovaritis  and  peritonitis  than 
by  regarding  it  as  an  independent  lesion.  In  connection  with  this 
general  plan  of  grouping  the  subjects  on  pathological  lines,  the 
author  has  excluded  whatever  was  not  based  upon  pathology  or 
carefully  observed  experience.  The  other  point  which  commends 
the  book  so  much  is  that  a  large  number  of  minor  manipulations 
and  most  of  the  major  and  minor  operations  have  been  ilkistrated 
with  new  drawings  to  show  the  several  procedures  as  they  take 
place  step  by  step.  For  example,  the  consecutive  steps  in 
hystero-myomectomy  are  shown  in  twelve  drawings  ;  salpingec- 
tomy, in  five  drawings ;  vaginal  hysterectomy,  in  fifteen  draw- 
ings; ovariotomy,  in  eight  drawings;  curettage,   in  five  drawings 


publisher's  department.  431 

After  carefully  looking  over  these  drawings  and  plates,  we 
can  safely  say  that  no  work  un  gynecology  has  tver  been  so 
beautifully  illustrated,  while  the  text  seems  to  have  forgotten 
nothing  even  down  to  the  most  minute  detail.  The  author's  large 
experience  as  a  teacher,  as  a  hospital  surgeon  anxj  as  a  dis- 
tinguished Fellow  of  the  American  Gynecological  Society  has 
qualified  him  for  the  duty  of  writing  a  valuable  treatise,  and  he 
has  availed  himself  of  his  qualifications  to  the  fullest  extent.  We 
will  take  great  pleasure  in  recommending  this  text-book  to  our 
students  in  gynecology. 

A.  L.  S. 


PUBIvISHKRS  DKPARXMENT. 


SANMETTO  IN  CYSTITIS,  GONORRHOEA  AND    IRRITABLE 
PROSTATE. 

I  have  been  an  extensive  user  of  Sanmetto  for  a  number  of  years,  and  can 
truthfully  say  that  when  the  therapy  of  the  pure  santal  and  saw  palmetto  is  in- 
dicated, I  find  Sanmetto  a  remedy  par  excellence.  I  have  used  it  extensively  in 
cystitis,  chronic  gonorrhoea  and  irritable  prostate,  and  it  has  universally  relieved, 
f  not  cured,  my  patients.  As  long  as  it  maintains  its  present  standard  of  purity 
I  shall  use  it,  for  I  deem  it  pure  and  ethical. 

W.  R.  HiLLEGAS,  M.  D. 

Chicago,  111. 

I 

HYPERTROPHIED  PROSTATE  WITH  DIFFICULT  MICTURITION. 

For  an  old  gentleman,  seventy-four  years  of  age,  who  was  suffering  from 
hypertrophied  prostate  with  difficult  micturition,  I  prescribed  Sanmetto.  The 
results  were  favourable,  and  after  taking  two  bottles  of  Sanmetto  he  was  so 
much  improved  as  not  to  require  the  use  of  the  catheter,  which  he  had  been 
compelled  to  use  for  several  months  previous,  at  least  once  in  twenty-four  hours. 
I  have  since  prescribed  Sanmetto  in  five  similar  cases  with  equally  good  results. 

E.    C.   CULBERTSON,  M.  D. 

Keith,  Ohio. 


SANMETTO    IN    CYSTITIS,     URETHRITIS,    PROSTATITIS     AND 

GENERAL  INFLAMMATION  OF  THE  GENITO-URINARY 

TRACT. 

I  am  an  earnest  fiiend  of  Sanmetto.  It  is  a  valuable  and  ethical  prepara- 
tion. From  years  of  experience  in  its  use  I  have  learned  to  rely  upon  it  in 
cases  of  cystitis,  urethritis,  prostatitis  and  general  inflammation  of  the  genito- 
urinary tract.  In  cases  where  its  use  is  indicated  its  curative  properties  are 
most  remarkable.  I  am  satisfied  if  the  profession  will  carefully  discriminate  in 
their  cases  they  will  always  be  well  pleased  with  the  results  obtained  from  the 
exhibition  of  Sanmetto.     I  shall  continue  its  use  where  indicated. 

W.  E.  J.  MiriiELET,  M.  D. 
Chicago,  111. 


432  publisher's  department. 

protected  ethpharmal  medicines. 

I  have  no  use  whatever  for  any  form  of  patented  medicine.  In  the  use  of 
crude  materials  many  vexatious  things  are  encountered  ;  if  these  can  be  elimi- 
nated, much  has  been  accomplished,  and  an  excuse  found  for  the  use  of  protected 
ethpharmal  medicines.  So  far  as  my  experience  goes  it  is  a  real  advantage  to 
the  profession  ;  it  enables  us  to  procure  in  a  certain  fixed  form  certain  drug 
effects,  and  that  is  what  we  want.  I  think  pharmacy  has  reached  so  high  a 
standard  by  our  best  pharmaceutical  chemists  that  the  real  drug  effect  is 
thoroughly  brought  out.  I  procured  about  a  month  ago  an  eight  ounce  vial 
of  Sanmetto.  I  am  perfectly  familiar  and  for  years  have  knovsn  the  drugs  and 
drug  effects  of  the  remedies  said  to  be  contained  in  Sanmetto.  The  announced 
composition,  freely  made  known  to  the  profession,  has  made  amends  for  the 
name  ;  protected  or  not  as  the  case  may  chance  to  be.  I  use  it  for  all  kinds  of 
irritation  of  the  urinary  ti act.  The  sample  is  exactly  what  we  get  in  the  eight 
ounce  bottle  in  our  drug  houses  in  this  place,  and  I  know  it,  so  am  willing  to 
order  a  full  size  bottle,  eight  ounces,  or  any  other  amount. 

L.  G.  Armstrong,  M.  D. 

Boscobel,  Wis. 


Electro-Therapeuiics,  Radiography,  Thermo  and  Hydro-Therapeutics  are 
practically  and  thoroughly  covered  in  the  Journal  of  "Advanced  Therapeutics'' 
(800  pages,  issued  mom hly,  $3  per  year.) 

The  reader  is  invited  to  join  the  "  Founders'"  Club,  and  to  all  who  order 
during  1902  the  price  is  $2,  for  the  first  and  each  succeeding  year.  It  is  only 
requisite  that  you  address  following  order  to  "Advanced  I'herapeutics,"  156 
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he  close  of  the  year. 


CANADA 


MEDICAL  RECORD 


OCTOBER,     I902. 


Original  Communications, 


CASE  OF  PLACENTA  PRAEVIA. 

WITH   THREATENING    UR/EMIC    CONVULSIONS  ;     RAPID 

MANUAL  DILATATION  OF  THE  OS  UTERI  ;    TURNING 

AND   DELIVERY;   RECOVERY.* 

By  A.  Lapthorn  Smith,  M.D.,  Fellow  of  the  American  Gynecological  Society  ;  Professor 

of  Clinical  Gynecology,  Bishop's  College,  IMontreal  and  Professor  of  Gynecology 

in  the  University  of  Vermont,  Burlington  ;  Gynecologist  to  the  Western 

Hospital  ;  Surgeon-in-Chief  of  the  Samaritan  Hospital  ;  Gynecologist 

to  tho  Montreal  Dispensary;  and  Consulting  Gynecologist  to  the 

Women's  Hospital,  Montreal. 

By  permission  of  Dr.  S.  F.  Wilson,  of  this  city,  who  called 
me  in  consultation,  I  am  allowed  to  report  this  case.  Mrs. 
M.,  the  mother  of  three  children,  had  always  been  in  robust 
health  until  her  first  pregnancy,  eight  years  ago,  when  she 
nearly  died  from  puerperal  convulsions.  She  was  only  saved 
then.  Dr.  Wilson  informed  me,  by  accouchement  force  at  seven 
months,  after  having  had  convulsions  every  week  from  the 
fourth  month,  in  spite  of  treatment.  She  became  pregnant 
with  her  fourth  child  about  the  first  of  November,  and  every 
month  after  that  she  had  considerable  hemorrhage  without, 
however,  sending  for  her  doctor  until  about  the  sixth  month, 
when  she  had  such  a  severe  one  that  she  sent  for  Dr.  Wilson, 
who  at  once  diagnosed  placenta  previa  and  packed  and  gave 
ergot  to  stop  the  hemorrhage  until  I  could  be  sent  for. 

On  my  arrival  the  woman  was  in  a  very  serious  condition 
requiring  saline  enemata  and  hypodermics  of  strychnine. 
While  Dr.  Wilson  was  doing  these  things  and  his  partner, 
Dr.  Morrison,  was  administering  the  anaesthetic,  I.  was  pre-* 
paring  my  hands,  and  in  a  few  minutes  with  one  hand  on  the 
abdomen  and  the  other  in  the  uterus  I  had  rapidly  dilated  the 
cervix  and  caught  a  foot  and  brought  it  down  without  rup- 
turing the  bag  of  waters.  This  was  then  done  and  in  less  time 
than  it  takes  to  tell  it  the  six    months    foetus   was   delivered 


Read  before  the  Clinical  Society  of  the  Montreal  Dispensary,  June,  1902. 


434  CASE  OF  PLACENTA  PRAEVIA. 

living,  but  not  viable.     The  placenta  quickly  followed  and  on 
examining  it  fully  one  half  of  it    could  be  seen  to  be  covered 
by  a  dark  firm  clot  corresponding  to  the  surface  which  had 
become  detached  by  the  first  contractions.     The  hemorrhage, 
which  had  been  furious  until  I  introduced  my  hand,  seemed  to 
have  stopped  from  that  moment,  and  there   was  no  bleeding 
after  the  extraction  of  the  child,  the  uterus  having  then  been 
able  to  contract  enough  to  close  the  bleeding  openings.     The 
child  died  in  half  an  hour  and  the  mother,  after  running  the 
gauntlet  of  the  profound  anaemia  as  well  as  the  condition  of 
the  kidneys,  gradually  came  back  to  life.     She  later  developed 
a  temperature   and   has  how  a   pelvic  abcess,  probably  a   pus 
tube,  which  Dr.  Wilson  intends  to  have  me  open  by  the  vagina 
and    drain   in   the  meantime,  to  be  followed  later,  when  her 
strength  will  bear  it,  by  an  abdominal  incision.     This  was  my 
third  case  of  placenta  previa  and  in  view  of  the  present  ten- 
dency to  perform  so  serious  an  operation  as  Caesarian  section 
for  the  relief  of  the  condition,  it  may  be  of  interest  to  refer  to 
the  other  two  cases,  both  of  which  terminated  in  recovery  of 
the  mother.     My  first  case  occurred  twenty-three  years  ago  in 
a  woman  four  months  pregnant.     This  was  just  before  Brax- 
ton Hicks  had  published  his  method ;  so  I  did  the  best  I  could 
with  the  knowledge  we  then  had  at  our  disposal,  which  was  to 
put  the  woman  in  the  kne'e-chest  position  and  tampon  firmly 
the  vagina.     The  result  could  not  have  been  more  satisfactory ; 
she  did  not  lose  a  drop  of  blood  after  that ;  and  in  eight  hours 
I  saw  the  woman  safely  delivered ;  first  the  cylinder  of  tightly 
packed  cotton,  about  four  inches  long,  then  about  two  inches 
of  clot,  then  the  placenta,  which  must  have  been  centrally  im- 
planted, for  it  fitted  on  the  child's  head  like  a  Scotch  bonnet, 
and  then  came  the  child ;  all  of  them  coming  out  in  one  piece, 
so  to  speak.     This  woman  was  up  and  cleaning  offices  in  less 
than  ten  days.     The  next  case  was  a  woman  near  term  who 
was  suddenly  taken  with  a  terrible  hemorrhage.     On  exami- 
nation the  placenta  was  found  to  be  centrally  implanted.     I 
was  very  ill  at  the  time  and  had  to  hand  the  case  over  to  Dr. 
Johnson,  who  summoned  an  expert,  who  immediately  anaes- 
thetized the  patient  and  turned  and  delivered.     There  was  a 
gush  of  blood  which  flew  across  the  room  as  he  mtroduced 
his  hand,  but  the  moment  he  drew  on   the    foot   the   bleeding 
stopped  and  did  not  return.     This  child  was  too  asphyxiated 
by  the   mother's   hemorrhage  to  live,   but  the   mother  made  a 
good  recovery. 

Judging  from  my  knowledge  of  these  three  cases,  I  cannot 
see  how  any  one  could  justify  himself  in  performing  a  Cae- 
sarian section,  far  less  in  completely  removing  the  tubes  and 
ovaries  with  the  uterus,  as  has  recently  been  so  strongly  ad- 
vocated by  several  obstetricians  of  the  first  rank.     The  only 


CASE    OP    PLACENTA    PRAEVIA.  435 

possible  excuse  which  they  could  give  is  that  when  Caesarian 
section  is  performed  betore  the  mother   or  child   have  been 
weakened  by  hemorrhage,  the  chances  of  the  child  should  be 
much  better  than  by  version ;  but  how  are  we  to  discover  cases 
of  placenta  praevia  before  the  hemorrhage  begins  ?    Aloreover, 
it  is  quite  probable  in  my  mind  that  it  the  child  is  viable  it 
would  have  just  as  good  a  chance  of  surviving  if  delivered  by 
version  as  wdien  delivered  by  Caesarian  section.     While  for 
the  majority  of  cases  the  child  does  not  count  for  anything,  for 
the  simple  reason  that  it  is  already  dead  or  that  it  is  not  pos- 
sible for  it  to  live,  no  matter  how  it  is  delivered — while  of 
the  total  removal  of  the  uterus  and  appendages  it  is  no  excuse 
to  say,  as  some  of  these  authorities  do,  that  the  woman  after 
having  the  case  explained  to  her  was  quite  willing  that  she 
might    be    rendered    unable    to    have   another    pregnancy ;    a 
woman  in  that  condition  is  a  very  bad  judge  of  the  advantages 
of  maternity.     To  the   general   practitioner   who  meets   with 
this  appalling  hemorrhage,  I  would  say   "summon  expert  help 
immediately,  and  while  waiting  for  him  to  come,  to  control  the 
hemorrhage   for  a  few  minutes  by  means  of  clean  handker- 
chiefs soaked  in  vinegar  packed  in  the  vagina ;  but  failing  to  ob- 
tain assistance  promptly  I  would  advise  the'  rapid  but  thorough 
sterilizing  of  the  hands  and  a  partial  anaesthetization  of  the 
patient  by  another  doctor,  or  even  by  a  neighbour,  with  the 
A.  C.  E.  mixture  and  then  to    dilate  the  os  with  the  fingers 
formed  into  a  cone,  so  that  they  fill  the  os  pretty  thoroughly. 
As  soon  as  the  hand  can  be  made  to  enter  the  uterus,  grasp  a 
foot  wdth  the  right  hand  and  assist  the  version  by  the  left  hand 
on  the  abdomen ;  there  will,  as  a  rule,  be  no  more  hemorrhage 
after   the  soft   plug   formed  by  the  child's  thigh  and  buttock 
covers  the  bleeding  sinuses."     The  cause  of  all  the  deaths  of 
the  mother,  and  they  are  not  many  under  this  method,  and  of 
many  of  the  deaths  of  the  viable  child,  are  not  due  to  the  me- 
thod, but  to  the  delay  in  employing  it,  and  these  conditions  are 
as  essential  in  Caesarian  section  for  its  success,  both  as  regards 
-the  mother  and  the  child.     Even  in  a  primipara  with  the  os 
closed  it  is  invariably  softened  by  the  pregnant  condition  so 
that  in  twentv  or  thirty  minutes  at  most  first  one  and  then  two 
and  then  three  fingers  can  be  bored  into  the  uterus  until  the 
constricting  muscles  are  tired  out  and  the  whole  hand  can  be 
passed  in.     The  hemorrhage  almost  always  stops  the  moment 
the  foot  is  drawn  down. 

I  would  also  like  to  say  a  few  words  about  the  other  fea- 
ture of  the  first  case  above  renorted.  namely,  the  convulsions. 
I  believe  that  more  women  have  died  from  the  remedies  usual- 
Iv  emploved  than  from  the  disease ;  I  mean  the  prolonged  use 
ot  chloroform  and  chloral.  Bv  the  hypodermic  mjection  of 
half  a  grain  of  morphine  followed  in  ten  minutes  by  the  hypo- 


43^  THE   TREATMENT  OF  HEART  DISEASE. 

dermic  injection  of  twenty- five  minims  of  tincture  of  vera- 
trum  viride,  I  have  in  my  last  three  cases  at  once  brought  the 
pulse  down  from'  i6o  to  50  or  60  and  the  woman  had  no  con- 
vulsion later  than  ten  minutes  after.  My  former  assistant,  Dr. 
De  Cotret,  now  director  of  the  largest  lying-in  hospital  in 
Canada,  who  introduced  the  veratrum  treatment  at  my  request, 
tells  me  that  he  has  had  thirty-eight  cases  of  eclampsia  with- 
out a  death  of  a  mother. 

245  Bishop  St.,  Montreal. 


Selected    Articles. 


THE  STUDY  OF  THE  TREATMENT  OF  VARIOUS  FORMS 
OF  HEART  DISEASE. 

By  G.  R.  Johnson,  M.  D.,  Philadelphia. 

Undoubtedly,  the  most  important  point  in  the  treat- 
ment of  heart  disease  is  rest.  In  the  most  severe  stages 
this  is  absolutely  necessary,  for  in  this  condition  syncope 
is  almost  certain  to  follow  any  attempt  at  work,  or 
even  walking.  The  use  of  physiological  mechanics  is 
all-important  in  the  treatment  of  heart  cases,  for,  while 
much  can  be  done  by  the  use  of  drugs,  yet  nothing  takes 
the  place  of  rest.  In  fact,  there  are  many  cases  in  which 
drugs  appear  to  be  utterly  useless,  and  it  is  possible  to 
obtain  improvement  only  by  the  use  of  long  rest,  lasting  for 
weeks  or  months.  The  reason  for  this  is  very  evident ; 
anything  which  reduces  the  number  of  beats  of  the  heart 
naturally  reduces  its  work,  and  in  a  diseased  organ  this 
becomes  a  matter  of  moment.  To  use  a  disabled  engine  as 
little  as  possible  renders  its  existence  fof  a  longer  period 
possible.  So  it  is  with  the  heart,  which  is  the  machine  from 
which  life,  as  we  know  it,  really  springs. 

Outside  of  the  use  of  rest,  it  is  well  to  consider  the  pos- 
sibility of  reducing  the  quantity  of  blood  that  comes  into 
the  heart  from  the  right  auricle  and  must  be  forced  by  that 
organ  through  the  lungs  and  later  driven  through  the  body 
by  the  left  ventricle.  There  is  an  old-time,  deep-seated 
prejudice  against  the  use  of  venesection,  but  it  is  a  question 
whether  this  prejudice  is  not  unreasoning.  It  is  true  pos- 
sibly that  venesection  may  be  required  only  in  urgent  cases, 
but  in  these  when  the  right  ventricle  is  dammed  with  venous 
blood    so  that  its  contraction  is  imperiled  and  the   stoppage 


THE   TREATMENT  OF  HEART  dISEASE.  437 

of  the  heart  is  threatened,  it  may  he  the  actual  means  of 
preserving  h'le.  Under  these  circumstances  it  seems  to  be 
imperatively  demanded,  and  at  y  old-time  prejudice  against 
its  use  should  not  be  allowed  to  interfere  with  the  doctor's 
decision.  Depletion  can  be  accomplished,  howe\er,  by 
other  means,  such  as  by  increasing  the  evacuation  of  the 
bowels,  the  kidneys  and  the  skin.  For  example,  by  the 
use  of  purgatives,  by  which  the  watery  secretions  of  the 
bowels  are  increased  and  by  the  use  of  real  stimulants,  such 
as  the  acetate  of  potash  and  nitrc'US  ether.  Again,  by  the 
use  of  diaphoretics  the  secretion  from  the  skin  can  be  in- 
creased. 

When  we  come  to  the  actual  drug  treatment  of  cardiac 
cases,  we  find,  first,  the  use  of  the  cardiac  tonics,  of  which  the 
most  common  is  digitalis.  This  drug  is  undoubtedly  very 
trustworthy  and  efficient  in  properly  selected  cases.  It 
requires  a  considerable  caution  in  its  use,  for,  on  the  one 
hand,  it  is  necessary  not  to  overdose  the  patient  ;  and  there 
is  also  the  danger  of  the  accumulative  action  of  digitalis 
bursting,  as  it  were,  with  a  sudden  storm,  through  ihe 
patient's  system.  While,  on  the  other  hand,  if  not  enough 
of  the  medicine  is  given  when  the  symptoms  are  criiical  and 
relief  demanded,  its  administration  is  worse  than  uselr  ss,  ft^r 
it  creates  a  false  confidence.  Undnubtedl)-,  the  tendency  of 
the  profession  is  to  err  on  the  side  of  giving  too  small 
doses  of  digitalis. 

Another  drug  which  has  lately  sprung  into  prominence 
is  strophanthus.  It  is  an  excellent  heart  tonic,  though 
perhaps  not  as  trustworthy  as  digitalis.  A  very  efficient 
way  of  giving  strophanthus  is  to  give  it  in  the  form  of  the 
tincture  in  combination  with  the  tincture  ot  nux  vomica. 
If  these  two  drugs  are  given  in  equal  proportions  they 
produce,  as  a  rule,  an  excellent  effect,  not  only  upon  the 
heart,  but  upon  the  nervous  system  in  general.  The  citrate 
of  caffeine  and  strychnine  are  also  excellent  drugs  in  their 
place,  the  strychnine  being  indicated  rather  where  a  general 
nervous  tonic  is  required. 

To  illustrate  the  use  of  treatment  in  a  case  of  cardiac 
trouble,  permit  me  to  quote  the  following  case,  which  is  that 
of  a  man,  aged  45  years,  who  had  been  under  observation 
for  ten  years.  He  first  came  under  my  care  to  be  ,treated 
for  acute  articular  rheumatism,  and  on  each  occasion  a  pre- 
systolic mitral  murmur  was  heard,  while  later  there  developed 
a  tricuspid  murmur  and  the  phenomenon  of  a  pulsating  liver. 


43^  THE  TREATMENT  OF  HEART  DISEASE. 

For  the  past  few  years  he    has  been  obliged  to  stay  in  bed 
from  time  to  time  on  account  of  his  shortness  of  breath. 

After  each  attack  he  resumed  his  labour,  which  was  severe 
in  character,  but  in  course  of  a  few  weeks  he  would  again  be 
forced  to  return  to  bed.  Recently,  after  exposure  to  severe 
cold,  he  developed  a  cough.  His  legs  began  to  swell.  He 
went  to  bed  and  grew  rapidly  worse.  On  examination  I 
found  that  he  was  suffering  from  extreme  shortness  of  breath. 
His  face  was  cyanosed.  He  had  a  small  rapid  pulse,  rang- 
ing nearly  150  a  minute,  while  his  respirations  were  shallow 
and  rapid.  This  condition  grew  rapidly  worse,  so  that  I 
immediately  bled  him,  10  ozs,  being  taken  from  him,  and  I 
gave  him  a  hypodermic  injection  of  brandy  and  20  drops  of 
digitalis.  This  was  followed  by  speedy  relief,  so  that  within 
four  hours  the  pulse  fell  considerably  in  its  rate  and  his  res- 
piration quieted  down.  He  is  now  in  a  much  better  con- 
dition, although  he  still  presents,  of  course,  the  characteristic 
appearance  of  mitral  stenosis.  His  face  is  congested.  He 
shows  the  characteristic  club  finger  ends  and  has  a  dropsi- 
cal condition  of  the  feet  and  ankles.  His  cardiac  impulse 
is  displaced  outward  and  downward,  and  there  is  also  a 
marked  epigastric  impulse.  On  listening  over  the  cardiac 
area  I  find  a  long  presystolic  murmur  at  the  apex  with  a 
tricuspid  systolic  murmur  over  the  sternum.  Scattered 
throughout  his  chest  are  numerous  sibilant  rales,  while  there 
is  absence  of  breath  sounds  at  the  base  of  both  lungs.  I 
gave  this  man  fifteen  drops  of  the  tincture  of  digitalis  every 
four  hours,  and  on  the  following  day  his  pulse  gradually 
sank  lower  and  lower,  and  two  days  later  it  fell  to  eighty, 
when  I  reduced  the  dose  of  digitalis  to  10  drops  every  two 
hours. 

His  physical  condition  also  improved  so  that  his  ankles 
were  no  longer  dropsical  and  the  dullness  at  the  base  of  the 
lungs  was  not  so  noticeable.  Under  treatment  and  rest  the 
patient  improved  until  the  tricuspid  murmur  was  no  longer 
noticed. 

This  form  of  heart  disease  is  one  of  the  most  frequent 
which  the  general  practitioner  is  called  upon  to  treat.  Mi- 
tral constriction  strains  the  heart  to  its  utmost,  and,  while 
compensation  can  be  maintained  moderately  well  when  the 
patient  remains  at  rest,  it  becomes  a  dangerous  condition 
when  the  patient  is  forced  to  work  ;  for  the  additional  strain 
upon  the  heart  reduces  its  compensation,  backward  pressure 
is  exerted  upon  the  lungs  and  right  ventricle,  as  a  result  of 
of  which   tricuspid    regurgitation    takes  place,  followed    by 


THE   TREATMENT  OF  HEART  DISEASE.  439 

dropsy,  pulsating  liver,  venous  distention  throughout  the 
body  and  albuminous  urine.  The  action  of  the  heart  at  the 
same  time  is  irregular,  rapid  and  feeble  in  impulse,  but 
fortunately  for  the  patient  he  is  able  frequently  to  recover  to 
a  great  extent  from  its  serious  condition.  Undoubtedly, 
many  physicians  have  patients  who  have  been  almost  in  a 
dying  condition  a  number  of  times,  from  which  they  have 
recovered  to  a  comparative  degree  by  careful  treatment. 

In  giving  the  tincture  of  digitalis  it  is  well  to  watch  the 
patient  carefully,  and,  if  the  disease  does  not  produce  ma- 
terial improvement  within  24  or  48  hours,  it  is  well  to  increase 
it.  Many  physicians  never  begin  with  less  than  15  minims 
every  four  hours,  which  makes  a  dram  and  a  half  in  the  24. 
If  improvement  does  not  set  in,  the  dose  can  be  increased  to 
15  minims  every  three  hours,  or  20  every  four  hours  con- 
tinually, but  these  doses  must  be  watched,  for  the  object  is  to 
get  a  speedy  impression  upon  the  heart  and  then  withdraw 
as  much  of  the  drug  as  is  not  necessary.  The  bugaboo  of 
the  accumulative  effect  of  digitalis  still  lingers  around  this 
drug.  This  depended  upon  the  theory  that  the  patient 
might  take  harmless  doses  of  the  drug  for  some  days  or 
weeks  and  then  "suddenly  a  poisonous  effect  would  be  no- 
ticed which  might  end  even  in  sudden  death.  In  the  case  of 
digitalis  this  is  due  to  the  tact  that  it  is  not  eliminated  as  rapid- 
ly as  other  drugs,  so  that  after  a  time,  the  interval  not  being 
long  enough,  the  drug  is  reabsorbed  into  the  system  and  its 
toxic  effect  is  noted.  However,  if  the  drug  is  given  for  a 
long  period  in  the  amount  of  half  a  dram  of  4^  minims  a 
day,  this  effect  as  a  rule  is  not  noticed,  and  in  this  way 
digitalis  may  be  given  for  longer  periods  of  time  without 
producing  any  serious  results.  The  advantage  which  stro" 
phanthus  is  supposed  to  have  over  digitalis  is  that  it  does  not 
increase  arterial  tension.  Five  minims  of  the  tincture  of 
strophanthus  is  equal  in  dose  to  10  or  15  of  the  tincture  of 
digitalis,  for  it  was  found  that,  weight  for  weight,  strophanthus 
is  the  more  powerful  drug,  so  that  its  official  strength  has 
been  reduced  from  one  in  ten  to  one  in  twenty,  while  the 
strength  of  the  tincture  of  digitalis  is  one  in  eight.  The 
other  remedies  in  use  in  cardiac  trouble  are  similar  in  action, 
but  are  not  as  strong  nor  as   powerful  as  these    two   drugs. 

There  are  many  points  in  regard  to  the  use  of  cardiac 
tonics  in  the  various  forms  of  valvular  disease.  For  ex- 
ample :  there  is  a  dispute  as  to  the  action  of  digitalis  in  aortic 
regurgitation.  It  has  been  criticized  by  some  authorities  on 
the  theory  that  in  many  cases  aortic  disease  is  accompanied 


440  THE  TREATMENT  OP  HEART  DISEASE. 

by  hypertrophy  of  the  left  ventricle,  and  that  in  consequence 
digitalis  is  apt  to  increase  the  over-action  of  this  organ. 
Again,  and  what  seems  to  be  a  more  vital  objection,  is  that 
digitalis  lengthens  the  diastolic  interval  and  that  regurgita- 
tion occurs  in  this  time  so  that  the  amount  of  blood  which 
falls  back  from  the  aorta  is  greater  under  the  influence  of 
the  drug.  In  consequence,  there  is  an  increased  tendency  to 
cardiac  dilatation  and  a  greater  probability  of  syncope  re- 
sulting from  the  diminution  of  the  supply  of  blood  sent  to 
the  brain.  In  the  experience  of  many  authorities,  however, 
the  main  objection  to  digitalis  in  this  form  of  heart  disease 
seems  to  be,  not  that  it  does  any  special  harm,  but  that  it 
does  very  little  good.  It  is  in  cases  of  mitral  disease  in 
which  digitalis  seems  to  be  especially  happy.  It  is  the  rapid, 
feeble  and  irregular  action  of  mitral  disease  which  is  pecu- 
liarly benefited.  When  aortic  trouble  is  complicated  by 
mitral  regurgitation,  then  digitalis  is  of  advantage. 

The  best  diuretics  for  use  in  heart  trouble  are  undoubted- 
ly the  acetate  of  potash  and  squills.  The  so-called  diuretic 
mixture,  known  as  the  misturi potassii  acetatis  composcta^  is 
peculiarly  useful  in  this  condition.  It  contains  30  grains  of 
the  spirit  of  nitrous  ether  to  the  dose,  together  with  i  5 
nunims  of  the  tincture  of  squills,  20  grains  of  the  acetate  of 
potash  and  one  dram  of  succus  scoparii.  The  digitalis  can 
be  given  in  this  mixture,  and  it  makes  a  peculiarly  happy 
combination  in  the  majority  of  cases.  When  the  cardiac 
failure  is  imminent  and  a  very  decided  effect  upon  the  heart 
is  desired,  the  digitalis  may  be  combined  with  the  carbonate 
of  ammonia  given  in  5  grain  doses  every  2  or  three  hours. 
The  unfortunate  feature  in  regard  to  this  treatment  is,  that  it 
may  fail  on  account  of  nausea,  or  on  account  of  the  rapid 
fall  of  the  pulse.  It  is  often  well,  however,  to  give  the  digi- 
talis with  water  alone,  considering  only  the  action  upon  the 
heart.  Taylor,  of  Guy's  Hospital,  has  found  that  the  action 
of  digitalis  is  often  improved,  especially  in  cases  where  it 
seemed  to  have  no  efil'ect,  by  the  addition  of  the  tincture  of 
belladonna.  This  idea  occurred  to  him  in  experimentation 
some  years  ago,  and  he  has  reported  a  number  of  cases  in 
which  he  met  with  success. 

It  is  less  difficult  nowadays  to  recognize  such  forms  of 
heart  trouble  as  infective  endocarditis.  As  the  treatment  of 
ordinary  heart  disease  has  grown  to  be  more  scientific,  there 
has  been  still  much  to  learn  in  regard  to  the  pathology  of  in- 
fective endocarditis,  especially  as  to  the  role  played  by  micro- 
organisms.    In  Bramwell's  experiments  the   introduction  of 


THE  TREATMENT  OF  HEART  DISEASE.  44 1 

material  from  ulcerated  aorti  valves  into  the  blood  current 
of  healthy  rabbits  did  not  produce  any  special  result.  Orth 
found  that  if  he  passed  a  fine  probe  down  the  carotid  artery 
of  a  rabbit  and  injured  the  aortic  valves  and  then  injected  in- 
to the  blood  vessels  bacteria  from  pus,  that  he  could  produce 
this  condition  unless  he  previously  injured  the  valve.  As 
a  result  of  these  experiments  we  might  believe  that  a  diseas- 
ed condition  of  the  valves  is  necessary  to  produce  infective 
endocarditis,  and  when  we  come  to  study  these  cases  we  find 
that  there  is  frequently  a  history  of  the  previous  rheumatic 
heart  affection.  In  scarlet  fever  and  diphtheria  we  find  that 
the  majority  of  cases  escape  contamination  even  when  bacilli 
are  found  in  the  blood,  unless  there  exists  an  old  valvular 
lesion.  Rheumatism  may  predispose  to  disease,  but  it  does 
not  itself  produce  it  unless  it  is  associated  with  micro-organ- 
isms. Osier  has  found,  as  the  result  of  his  study  on  the  sub- 
ject, that  1 1  per  cent,  of  his  cases  of  infective  endocarditis 
followed  puerperal  fever.  He  explains  this  by  the  fact  that 
the  already  poisoned  blood  of  pregnancy  becomes  charged 
with  material  absorbed  from  the  uterus,  and  the  tendency  to 
thrombosis  occurs.  It  is  probable  that  all  septic  conditions 
of  the  blood  are  more  or  less  exposed  to  this  shock,  and  in- 
fective endocarditis  can  follow  even  slight  injuries  if  the 
wound  becomes  unhealthy.  There  is  a  peculiar  likelihood  of 
this  occurring  especially  in  pneumonia  at  a  time  when  the 
crisis  is  expected,  or  when  the  inflammatory  exudate  is  clear- 
ing away  and  an  absorption  is  taking  place.  Then,  all  of  a 
sudden,  there  may  develop  a  septic  endocarditis.  Netter 
has  gone  over  this  subject  very  thoroughly  and  has  found 
that  in  endocarditis  following  pneumonia  the  same  kind  of 
microbes  in  the  valves  as  in  inflamed  lungs,  and  taking  the 
microbes  from  the  pneumonic  lesions  and  injecting  them  into 
the  lungs  of  rabbits  whose  carotid  valves  had  been  experi- 
mentally injured,  he  produced  septic  endocarditis.  There 
is  one  great  peculiarity  in  regard  to  infective  endocarditis, 
and  that  is  the  enlargement  of  the  spleen.  Acting  as  a  sort 
of  filter,  this  organ  is  especially  exposed  to  the  poisonous 
products  which  may  develop  in  the  blood.  It  has  been 
found  in  nearly  all  post-mortems  on  infective  endocarditis 
that  the  spleen  was  enlarged  and  diseased.  It  seems  as  if  this 
organ  supplied  the  proper  food  for  the  development  of  these 
microbes. 

The  treatment  of  infective  endocarditis  has  not  been 
very  brilliant.  In  fact,  the  disease  as  a  rule  is  fatal.  Here 
and  there  cases  are  reported    in   which   the  ravages  of  the 


442  THE  TREATMENT  OF  HEART  DISEASE. 

disease  have  stopped  and  the  patients  have  recovered,  but, 
as  a  rule,  a  permanent  cure  is  scarcely  to  be  expected.  As 
infective  endocarditis  is  generally  the  consequence  of  some 
form  of  blood  poisoning,  the  treatment  depends  con- 
siderably on  that  of  septicaemia.  Oliver,  who  has  had  con- 
siderable experience  in  this  class  of  cases,  has  found  the  most 
satisfactory  results  from  the  use  of  sulpho-carbolate  of  sodium 
given  in  half  dram  doses  three  or  four  times  a  day.  He 
also  administered  salol  and  betanaphthol.  Quinine  has  also 
been  recommended,  but  its  results  are  doubtful.  The  ideal 
treatment,  of  course,  in  this  class  of  cases  would  be  the  injec- 
tion of  some  material  possessing  bacteriological  properties, 
but,  unfortunately,  such  preparations  which  are  harmless  for 
the  blood  and  tissues  have  not  yet  been  developed;  possibly 
the  present  decade  will  develop  them. 

The  following  case  is  interesting  as  illustrating  a  case  of 
infective  endocarditis.     The  man  was  a  mechanic  with  good 
family    and    personal    history.       While    at    his    work    some 
months  before,  he  struck  his  chest  in  the  region  of  his  heart, 
but  he  never  was  seriously  ill  until  about  six  months  after  he 
was  injured,  when  he    noticed  that  he  could  not  work  prop- 
erly and  he   suffered  from  shortness  of  breath  and  pain  in 
the  cardiac  region  and  his  legs  began    to  swell.     This  went 
on  until  he  had  reached  such  a  state  that  he  could  not  He 
down  in  bed.     His  movements  became  painful,  and  a  pallid, 
anxious  expression  appeared  upon  his  face.     His  respirations 
became    sallow  and  rapid,  his  tongue   furred,  his  digestion 
wretched    and  there    appeared    also    great  thirst.     But  his 
most  troublesome  symptoms,  he  states,  were  insomnia  and 
shortness  of  breath.     The  physical  examination    exhibited 
the  fact  that  his  apex  beat  was  displaced  downward  and  out- 
ward, but  there  was  a  greater  increase   in  the  deep  area  of 
cardiac  dullness.     A  blowing  systolic  murmur  could  be  heard 
to  the  left  of  the    ensiform    cartilage    and    there    was  also 
jugular  congestion   and  a  pulsating  liver.     His  condition  re- 
mained about  the  same   for  a  number  of  days  after  coming 
under  my  care  until  one  afternoon  he  had  a  chill  followed  by 
extreme  shortness  of  breath.     His  pulse  became  very  irregu- 
lar in  a  minute  and    finally  he  died. 

The  physical  signs  pointed  to  the  probability  of  the 
disease  being  due  to  insufficiency  of  the  tricuspid  valves. 
The  fact  that  the  patient  had  profuse  perspirations  and  inter- 
mittent fever  pointed  to  the  fact  that  he  was  subject  to  infec- 
tive endocarditis.  As  to  the  relation  between  the  injury  to 
his  chest  and  the  infective  endocarditis,  there  is  probably  no 


THE   CAUSE   OP   DIABETIC   COMA.  443 

doubt  that  the  injury  produced  the  heart  lesion  and  that 
vegetations  appeared  and  the  disease  later  assumed  an  infec- 
tive condition. 

On  examination  of  his  heart  after  death  it  was  found 
that  there  was  no  special  disease  in  either  the  left  ventricle 
or  the  right  ventricle,  while  there  was  a  dilatation  of  the 
right  auricle,  and  at  the  base  of  the  tricuspid  valve 
there  was  a  vegetation  which  projected  into  the  cavity  for 
nearly  an  inch.  On  making  cultures  from  this  granulation 
the  presence  of  staphylococci  was  demonstrated.  Undoubted- 
ly, there  were  three  currents  produced  in  the  heart  action;  (i) 
a  tricuspid  direct  current ;  (2)  a  tricuspid  regurgitant  current, 
and  (3j  a  current  from  the  left  side  of  the  heart  into  the 
right  side  through  a  perforation  which  was  found.  This 
cardiac  condition  undoubtedly  explains  his  symptoms,  the 
insomnia  being  due  to  the  disturbance  of  circulation  in  his 
brain — The  Medicus. 


THE  CAUSE  OF  DIABETIC  COMA. 

It  may  now  be  accepted  that  oxybutyric  acid  is  the 
cause  of  diabetic  coma.  Series  of  laboratory  investiga- 
tions and  clinical  observations  have  fairly  well  determin- 
ed this  point.  For  several  years  chemists  have  been 
working  along  this  line  and  have  finally  reached  rather 
definite  conclusions  in  the  matter. 

This  acid,  which  is  a  product  of  the  fermentation  of 
starch,  sugar,  milk  and  of  various  other  substances,  has 
been  shown  to  be  present  in  the  blood  and  urine  in  very 
large  quantities  in  cases  of  diabetic  coma.  Treatment 
intended  to  neutralize  this  acid  in  the  blood  has  given 
results  which  tend  to  confirm  the  above-mentioned  conclu- 
sions. Besides  this,  coma,  similar  in  all  respects  to  diabe- 
tic coma,  has  been  caused  in  monkeys  and  in  other  animals 
by  poisoning  them  with  oxybutyric  acid. 

From  the  decomposition  of  this  acid,  acetone  and  dia- 
cetic  acid  arise,  so  that  tests  for  these  latter  substances 
serve  to  show  the  presence  of  oxybutyric  acid  in  any  liquid. 
The  chloroform-like  odor  of  acetone  is  to  be  noticed  in  the 
breath  of  patients  with  diabetic  coma,  and  may  also  be 
detected  in  the  urine.  Indeed  acetonaemia  was  the  term 
proposed  only  last  year  for  this  condition  of  diabetic  toxae- 
mia. But  now  we  learn  that  beta-oxybutyric  acid  and  not 
acetone  is  the  true  poison. 

It  is  surprising  how  much  of  this  acid  is  found  in  the 
urine  of  such  cases.     It  mav  amount  to  as  much  as  from 


444  THE   CAUSE    OF   DIABETIC   COMA. 

one  to  four  onces  daily.  Half  an  ounce  daily  is  frequently 
found  in  cases  of  diabetes  when  there  is  no  evidence  of 
coma. 

Recently  it  is  suggested  that  a  determinatioin  of  the 
amount  of  ammonia  in  the  urine  may  be  used  as  affording 
an  estimate  of  the  quantity  of  oxybutyric  acid  present, 
since  this  acid  constantly  appears  in  the  urine  in  combina- 
tion with  ammonia.  Testing  for  excess  of  ammonia  is 
simpler  than  testing  for  the  acid.  We  have  seen  no  precise 
manner  of  testing  suggested,  but  it  is  well  known  that  add- 
ing K  O  H  solution  and  boiling  will  set  free  the  combined 
ammonia  in  any  mixture.  The  escaping  gas  may  be  dried, 
collected  and  measured  in  several  different  ways. 

Indeed  the  steps  which  led  up  to  this  discovery  of 
oxybutyric  acid  in  the  urine  began  with  the  fact  that  am- 
monia was  found  to  be  in  excess  in  diabetic  urine.  Ordin- 
arily in  health  the  combined  ammonia  secreted  by  the 
kidneys  in  twenty-four  hours  is  12  to  15  grains  or  about 
eight-tenths  of  a  gram.  It  was  first  noted  that  in  diabetes 
the  amount  of  ammonia  in  the  urine  was  considerably 
increased.  As  this  ammonia  was  combined,  the  necessary 
inference  was  that  there  was  an  increase  in  some  acid  ex- 
creted by  the  kidneys.  This  was  then  shown  to  be  an 
organic  acid,  and,  at  the  same  time,  the  similarity  between 
acid  poisoning  in  rabbits  and  the  coma  of  diabetes  was 
pointed  out.  Upon  this  evidence  was  instituted  the  alkali 
treatment  of  diabetic  coma.  This  organic  acid  was  finally 
shown  to  be  oxybutyric  acid;  and  it  was  further  shown 
that  decomposition  of  this  acid  gives  rise  to  acetone  and 
diacetic  acid,  substances  which  had  already  been  observed 
in  urine. 

Large  doses  of  some  alkali,  as  for  instance  two  or 
three  drams  of  sod.  bicarb.,  may  be  given  thrice  daily  to 
combat  the  condition  of  threatening  coma.  Alkaline  solu- 
tions, isotonic  with  the  blood,  may  be  used  subcutaneously 
when  a  fatal  issue  is  impending. 

The  question  of  diet  has  also  received  a  ray  of  light 
from  these  discoveries.  The  profession  has  been  suspecting 
that  too  exclusive  a  diet  does  more  harm  than  good  in  diabe- 
tes. Now  it  has  been  observed  that  acetone  appeared  in  the 
urine  of  a  healthy  person  when  deprived  of  food  for  a  period 
of  time.  The  same  thing  was  found  to  be  true  in  most  dis- 
eases in  which  nutrition  falls  much  below  par.  And  recent 
experiments  have  shown  that  when  a  healthy  person  is  kept 
for  some  time  upon  a  diet  very  poor  in  carbohj'^drates,  oxy- 
butyric appears  in  the  urine.  Add  to  these  observations  the 
clinical  fact  that  some  diabetes, When  put  upon  too  rigid  diet 
promptly  die  of  coma,  and  the  conclusion  follows  that  a 


MEDICINE  AND   NEUROLOGY.  445 

moderate  amount  of  carbohydrates  allowed  to  diabetics 
together  with  sufficient  alkali  when  needed  is  better  than 
a  diet  which  excludes  all  starches  and  sugars. 

This  discovery  has  opened  up  a  new  field  of  investiga- 
tion, and  it  is  probable  that  it  is  not  yet  fully  worked  over. 
Already  much  light  has  been  thrown  upon  the  questions 
of  the  causation,  the  general  management  and  the  treat- 
ment of  diabetes,  and  we  may  expect  other  discoveries  of 
value  along  the  same  line  to  be  made  by  our  learned 
friends  and  allies,  the  physiological  chemists. — Medicus. 


Progress  ot  Medical  Science. 

MKDICINK    AND     NEUROI^OGY 

IN   CHARGE   OF 

J.  BRADFORD  McOONNELL.  M.D. 

Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College  ;  Physician  Western  Hospital . 


PLEURAL  EFFUSION   OF  ENLARGED  LIVER. 

To  distinguish  between  a  small  pleural  effusion  and  an 
enlarged  liver  or  subdiaphragmatic  abscess,  Henry  Jack- 
son {Boston  Medical  and  Surgical  Journal)  determines  by 
percussion  the  upper  line  of  dullness  on  the  chest  wall  and 
then  has  the  patient  breathe  in  deeply  and  hold  the  breath. 
The  upper  area  of  dullness  will  now  be  found  at  a  lower 
level  if  the  liver  and  not  the  pleura  is  involved. — Denver 
Medical  Times. 

THE    DIFFERENTIAL    DIAGNOSIS    OF    SMALLPOX    AND 
CHICKENPOX. 

In  a  letter  addressed  to  a  contemporary,  Dr.  G.  S. 
Perkins  calls  attention  to  a  simple  means  of  distinguishing 
chickenpox  from  smallpox,  which  deserves  to  be  more 
widely  known.  He  points  out  that  the  vesicles  in  chicken- 
pox  are  unilocular,  whilst  in  smallpox  they  are  multilocular. 
The  practical  result  of  this  pathological  fact  is  that  if  a 
chickenpox  vesicle  be  pricked  with  a  needle,  its  contents  can 
be  completely  evacuated  and  the  cell  will  collapse,  whereas 
in  smallpox  if  one  makes  twenty  pricks  with  a  needle  the 
vesicle  will  not  collapse,  because,  being  multilocular,  it  is 


44^  PROGRESS    OP    MEDICAL    SCIENCE. 

impossible  to  empty  it.  There  are,  of  course,  mamy  other 
points  of  difference  "between  the  two;  indeed,  smallpox  is 
only  likely  to  be  mistaken  for  the  less  serious  malady  when 
the  practitioner  is  not  alive  to  the  possibility  of  a  mistake 
in  the  diagnosis.  In  smallpox,  even  in  its  modified  form, 
varioloid,  the  initial  constitutional  symptoms  are  early 
and  well  marked,  with  a  considerable  rise  of  temperature 
and  cerebral  disturbance.  In  smallpox  the  eruption  is 
most  abundant  on  the  face  and  limbs,  whereas  in  chicken- 
pox  it  is  most  abundant  oiu  the  trunk  and  its  distribution 
is  more  discrete  and  general.  Moreover,  in  chickenpox 
the  eruption-  appears  in  crops  and  not,  as  in  smallpox,  with- 
in a  few  hours  of  the  first  appearance  of  papules.  Then, 
too,  there  is  the  characteristic  fall  of  temperature  on  the 
appearance  of  the  vesicles.  An  absolutely  characteristic 
feature  of  chickenpox  is  the  appearance  on  the  body  of 
vesicles  of  different  degrees  of  evolution,  some  being  fully 
matured  while  others  have  just  made  their  appearance. 
In  spite  of  these  usually  very  distinctive  features,  cases 
now  and  then  occur  in  which  even  the  most  experienced 
may  hesitate  to  formulate  a  definite  opinion.  In  such 
cases  twenty-four  hours'  observation  will  almost  invariably 
clear  up  the  mystery  and  allow  of  a  correct  diagnosis. — 
Medical  Press  and  Circular. 

CONCERNINX3^  SYPHILIS  OF  THE  LIVER 

Although  syphilis  of  the  liver  is  not  an  infrequent  oc- 
currence, comparatively  little  has  been  written  on  the  clin- 
ical aspects  of  the  subject.  The  author  gives  a  short  re- 
sum(5  of  the  history  of  this  affection  and  some  of  the  liter- 
ature dealing  with  it. 

He  divides  syphilis  of  the  liver  clinically  into  three 
groups : 

1.  Gummata  of  the  liver. 

2.  Syphilitic  cirrhosis  of  the  liver. 

3.  Syphilitic  affections  of  the  liver  (including  groups 
one  and  two),  with  icterus. 

The  latter  can  be  either  acute  or  chronic. 

Of  the  first  class  the  author  reports  four  cases.  In 
all  these  there  was  marked  enlargement  of  the  liver  char- 
acterized by  nodules  of  various  sizes.  Antiluetic  treat- 
ment brought  about  complete  cures,  anatomical  and  clin- 
ical. 

Of  the  third  class  ten  cases  are  presented  with  the 
same  satisfactory  results  following  anti-syphilitic  treat- 
ment. 

The  symptoms  of  syphilis  of  the  liver  are  pain  in  the 


MEDICINE   AND   NEUROLOGY.  44/ 

right  hypocliondrium,  sometimes  constant,  sometimes  par- 
oxysmal. If  paroxysmal,  the  attacks  may  resemble  gall- 
stone colics.  In  nearly  every  case  there  are  digestive  dis- 
turbances, such  as  loss  of  appetite,  eructation,  constipation, 
etc.  There  is  loss  of  weight,  though  not  usually  so  rapid 
or  so  marked  as  in  cases  of  malignant  growths  of  this 
organ.  Icterus  may  be  acute  or  chronic,  and  in  the  latter 
cases  are  nearly  always  due  to  pressure  on  the  common 
duct.  The  liver  itself  is  always  more  or  less  enlarged;  if 
due  to  gummata  the  surface  is  very  uneven;  if  due  to 
cirrhosis  the  organ  is  simply  enlarged.  Enlargement  of 
the  spleen  is  not  constant.  Ascites  occurs  in  the  later 
stages. 

It  is  not  possible  to  differentiate  between  malignant 
tumours  of  the  liver  and  gummata  by  the  consistence.  If 
the  disease  has  continued  for  a  year  or  two  without  great 
loss  of  weight,  and  if  there  is  any  history  of  lues,  the  resis- 
tance may  be  attributed  to  this  cause. 

An  increase  of  the  eosinophyle  cell  speaks  for  syphilis. 
Care  must  be  taken  not  to  confound  the  diffuse  syphilitic 
enlargement  of  the  liver  with  the  hypertrophic  cirrhosis 
due  to  alcoholism.  In  the  former,  there  is  usually  a  his- 
tory of  syphilis  and  luetic  manifestations  on  the  body.  The 
anti-luetic  treatment  acts  promptly. 

The  chief  point  in  treatment  is  the  free,  use  of  the 
iodides,  gradually  increased  from  two  to  five  grammes,  for 
a  period  of  several  months. — Einhorn  {Archil'  fuer  Ver- 
dauungskrankheiten,  vol.  viii,  part  3). — Interstate  Medical 
Journal. 

THE  CLASSIFICATION  OF  CHRONIC  NEPHRITIS. 

No  serious  attempt  has  ever  been  made  to  classify 
cases  of  chronic  nephritis  from  the  standpoint  of  etiology. 
Morbid  anatomists  and  pathologists  are  far  from  unanimous 
in  their  descriptions  of  the  various  types  or  groups  of  this 
disease.  And  physicians  are  not  always  able  to  make  a 
differentiation  that  is  satisfactory  from  the  clinical  point 
of  view,  or  that  holds  good  in  the  light  of  post-mortem 
revelations.  Yet  it  is  important  that  we  ha^-e  some  work- 
ing classification,  even  though  it  be  somewhat  faulty  and 
largely  artificial. 

The  classification  that  seems  the  best  is  practically 
that  of  Senator.  It  is  one  that  appeals  to  the  clinician  as 
well  as  to  the  morbid  anatomist.  The  term  ''parenchyma- 
tous" can  be  used  in  place  of  ''diffuse  without  induration," 
because,  though  not  literally  expressive  of  the  true  condi- 
tion, which  is  more  or  less  diffuse,  it  recognizes  what  is 


448  SURGERY. 

true,  that  in  this  form  the  parenchymal  changes  predomi- 
nate; they  are  quantitatively  greater  than  in  the  second 
variety,  where  the  process,  while  diffuse,  produces  chiefly 
interstitial  or  stromal  changes  with  resulting  induration. 
The  classification  would  be  as  follows: 

1.  Chronic  parenchymatous  nephritis.  (Chronic  dif- 
fuse nephritis  without  induration). 

2.  Chronic  interstitial  nephritis.  (Chronic  diffuse 
nephritis  with  induration). 

(a)  Primary  chronic  interstitial  nephritis. 
(6)  Secondary  chronic  interstitial  inephritis. 
(c)  Arterio-sclerotic  kidney.       (Arteriosclerotic  inter- 
stitial nephritis). 

3.  Mixed  type — i.  e.,  a  combination  of  1  and  2. — James 
B.  Herrick  (Jour,  of  Am.  Med.  Ass.,  October  4,  1902). — In- 
iterstate  Medical  Journal. 


SURGERY. 

IN   CHARGE    OF 

ROLL.O  CAMPBELL,  M.D., 

Lecturer  on  Surgery,  University  of  Bishop's  College  ;  Assistant  Surgeon,  W  ;stern  Hospital ; 

AND 

GEORGE  FISK,  M.D. 
Instructor  in  Surgery,  University  of  Bishop's  College  ;  Assistant  Surgeon,  Western  Hospital 


ON    THE    AVOIDANCE    OF    SHOCK    IN    MAJOR    AMPUTA- 
TIONS BY  COCAINIZATION  OF  LARGE  NERVE  TRUNKS 
PRELIMINARY   TO    THEIR    DIVISION. 

The  diminution  of  arterial  tension  is  the  characteristic 
feature  of  shock,  and  while  slight  injuries  to  am  extremity 
cause  an  increase  in  said  tension,  very  severe  ones  cause 
a  decrease  of  the  same.  When  a  certain  amount  of  shock 
already  exists,  there  is  especial  danger  in  the  division  of 
sensory  nerve  trunks.  Cocaine  injection,  by  blocking  the 
centripetal  influences,  effectually  keeps  down  shock  from 
this  source.  In  one  case  described  by  the  author  the 
pulse  jumped  from  110  to  150  upon  the  division  of  the 
brachial  plexus,  no  cocaine  being  used.  In  a  second,  where 
the  same  thing  was  done  after  the  drug  had  been  intro- 
duced, there  was  absolutely  no  shock.  When  peripheral 
mixed  nerves  are  put  on  a  stretch  there  is  an  acceleration 
of  cardiac  rhythm,  indicative  of  a  reflex  pressor  effect. 
However,  this"  may  be  followed  by  lowering  of  pressure  if 


SURGERY.  449 

the  trauma  be  too  extensive.  In  extensive  traumata  to 
extremities  the  author  advises  other  and  early  operation 
(with  cocaine  as  above)  to  rid  the  patient  of  the  influences 
which  tend  to  increase  the  already  existing  shock.  Arte- 
rial tension  cannot  be  judged  by  the  finger  on  the  pulse, 
but  an  instrument  has  been  devised  for  the  purpose.  There 
are  appended  several  charts  which  show  the  variance  of 
the  blood  pressure  during  operations. — Cushing  (Annals 
of  Surgery,  September,  1902). 


CASES    IN    HAEMATHERAPY    FROM    SOUND    VIEW 
HOSPITAL. 

By  T.  J.  Biggs,  M.  1).,  Stamford,  Coxn. 


CASE    I.    SKIN-GRAFTING    WITH    CALLUS    SHAVINGS     IN    BLOOD. 

Mary  M.,  age  60  years,  Irish.  Diagnosis,  ulcer  of 
leg.  Patient  admitted 'to  Hospital  March  3,  1002.  She 
had  a  large  varicose  ulcer  situated  over  the  tibia,  about 
31  by  2  inches.  This  condition  had  existed  for  nine  years. 
and  during  that  time  in  spite  of  all  treatment  employed 
had  never  entirely  healed.  It  had  been  skin-grafted  in  the 
old  way,  three  times  unsuccessfully.  At  the  time  of  enter- 
ing the  hospital  the  patient  suffered  so  severely  from  pain 
that  at  times  she  would  cry  out.  She  was  put  to  bed, 
secretions  regulated,  the  ulcer  cleaned  up  by  means  of  a 
dermal  curette,  and  dressed  for  the  first  twenty-four  hours 
with  a  Thiersch  pack.  On  the  morning  of  March  5,  after 
the  surface  had  been  thoroughly  cleaned  up,  a  bovinine 
pure  pack  was  applied  and  kept  wet  with  the  bovinine  for 
twenty-four  hours. 

On  the  morning  of  the  7th  I  determined  to  employ 
grafts  secured  from  a  callus  on  the  small  toe,  in  order  to 
demonstrate  the  technique  of  this  mode  of  skin-grafting 
to  five  visiting  physicians.  The  mode  of  procedure  was 
as  follows:  The  callus  was  thoroughly  scrubbed  up,  and 
the  external  layers  scraped  off.  Then  thin  sections  of  the 
layers  next  to  the  true  skin  were  obtained  by  means  of  a 
very  keen  razor.  Nine  of  these  were  deposited  on  the 
ulcerous  surface.  Over  these  were  laid  strips  of  perfor- 
ated rubber  tissue,  then  strips  of  plain  bi-sterilized  gauze 
saturated  in  bovinine,  and  a  bandage  applied.  The  nurse 
was  instructed  to  keep  the  dressings  wet  with  bovinine- 
pure.  This  dressing  was  removed  on  the  14th.  and  it  was 
found,  much  to  the  delight  and  astonishment  of  the  visit- 
ing physicians,  that  out  of  the  nine  grafts  employed  eight 


450  SURGERY. 

were  firmly  adherent  aud  in  a  healthy  growing  condition. 
The  ninth  had  become  displaced  and  was  removed.  The 
wound  was  now  dressed  with  bovinine  pure;  the  dressings 
being  kept  wet,  and  changed  once  in  twenty-four  hours. 
Coincident  with  the  local  dressings,  from  the  outset  the 
patient  had  been  given  a  wineglassful  of  bovinine  in  milk 
alternating  with  wine  and  beer  every  three  hours.  On 
March  24  she  was  discharged  cured,  the  entire  surface 
having  become  covered  with  new  healthy  skin. 

This  experiment  has  been  employed  frequently  enough 
by  me  to  demonstrate  that  where  the  technique  is  carefully 
followed  it  will  in  the  majority  of  cases  yield  the  most 
gratifying  results.  A  point  of  interest  in  this  case  and 
a  usual  one,  is  that  from  the  day  of  the  fir«t  dressing  of 
the  bovinine  up  to  the  time  the  patient  was  discharged, 
she  was  relieved  of  all  pain, 

CASE   II.    SKIN-GRAFTING   WITH   SKIN-SCRAPINGS     IN  BLOOD. 

Anna  H.,  age  12  years,  American,  Diagnosis,  burn  of 
right  hand.  Patient  was  admitted  to  hospital  March  8, 
1902.  As  a  result  of  the  burn  she  had  on  the  back  of  her 
hand  am  ulcerous  surface  2  by  If  inches,  very  painful,  and 
in  spite  of  three  months'  treatment  had  refused  to  heal. 
It  was  impossible  in  this  case  to  secure  skin -grafts,  and 
as  I  wished  to  demonstrate  to  the  visiting  physicians  who 
were  present  the  efficacy  of  skin-scrapings  as  a  means  of 
bringing  about  a  rapid  healing  of  small  surfaces  where 
grafts  could  inot  be  obtained,  with  an  ordinary  vaccinating 
comb  I  secured  skin  scrapings  from  the  little  patient's 
arms,  legs  and  back.  These  were  deposited  within  the 
periphery  and  dressed  as  in  the  other  case.  Vhe  dressing 
was  kept  wet  with  bovinine  pure  until  the  morning  of  the 
16th,  at  which  time  it  was  removed,  aind  to  the  delight  of 
the  visiting  physicians  as  before,  the  surface  was  fouind 
to  be  almost  entirely  healed,  there  remaining  unhealed 
only  a  small  space  about  the  size  of  a  ten  cent  piece,  in  the 
center.  The  wound  was  now  dressed  with  bovinine  pure 
and  the  nurse  ordered  to  change  it  every  24  hours.  Inter- 
nally the  patient  has  been  getting  a  teaspoonful  of  bovi- 
nine every  two  hours  in  peptonized  milk.  March  24  she 
was  discharged  cured. 

.CASE    III.    SKIN    GRAFTS    HEALED    IN    6    DAYS      WITH    BLOOD. 

Arnold  L.,  age  24  years,  German.  Diagnosis,  wound 
of  the  left  cheek,  the  result  of  being  thrown  from  a  street 
car.     Patient  admitted  to  hospital  March  10,  1902.     The 


SURGERY.  451 

wound  was  filled  with  gravel  and  dirt,  and  involved  almost 
the  entire  side  of  the  face.  A  space  in  the  center  of  the 
cheek,  2  by  1^  inches^  was  completely  denuded  of  skin. 
In  this  case,  it  being  desirable  to  have  the  wound  heal  rapid- 
ly and  with  no  evidence  of  scar,  I  determined  to  use 
grafts  of  normal  skin  sufficiently  large  to  entirely  cover 
the  denuded  surface.  These  grafts  were  secured  from  the 
patient's  arms.  The  wound  was  dressed  as  in  the  other 
cases,  the  dressing  being  kept  wet  with  bovinine.  March 
17  the  dressing  was  removed,  and  the  wound  was  en- 
tirely healed,  leaving  no  evidence  of  a  scar  whatever;  but 
around  the  periphery  there  was  some  decided  redness. 
This  is  probably  the  most  rapid  case  of  healing  of  this 
class  on  record. 

CASE    V.    GREAT    12-YEAR    OLD    ULCER    HEALED    WITH    APPLIED 
BLOOD,    WITHOUT    SKIN-GRAFTING. 

Mike  L.,  age  57,  Irish.  Diagnosis,  ulcer  of  left  leg. 
Admitted  to  hospital  March  3,  1902.  This  condition  was 
of  about  12  3'ears'  standing,  aind  during  that  time  had 
never  entirely  healed.  He  had  been  treated  at  various 
hospitals  and  at  various  clinics  and  by  private  physicians, 
but  said  that  he  got  no  special  relief.  The  ulcer  was  a 
large  one  situated  on  the  calf  of  the  leg,  being  4  by  3| 
inches.  It  was  covered  with  unhealthy  granulations  which 
exuded  a  foul-smelling  purulent  discharge.  The  surface 
of  the  ulcer  was  thoroughly  cleaned  up  with  a  dermal 
curette,  and  dressed  with  a  wet  Thiersch  pack.  This  was 
kept  wet  and  not  changed  in  24  hours.  At  the  end  of  the 
24  hours  this  dressing  was  removed,  the  wound  thoroughly 
cleansed  with  bovinine  and  hydrozone  reaction,  followed 
by  Thiersch  irrigation,  and  dressed  with  bovinine  pure. 
The  bovinine  dressings  w^ere  changed  twice  in  24  hours, 
and  the  patient  got  a  wineglassful  of  bovinine  internally, 
every  three  hours.  March  23  the  ulcer  had  healed  with 
the  exception  of  a  small  space  at  the  upper  periphery. 
This  was  touched  up  with  a  25  per  cent,  solution  of  pyro- 
zone.  and  dressed  with  bovinine-pure,  the  dressings  being 
renewed  twice  in  24  hours.  March  30  the  patient  was 
discharged  cured,  the  ulcer  having  become  covered  with 
healthy  skin,  mad  no  scar  tissue,  it  being  almost  impossible 
to  tell  it  from  the  surrounding  skin,  the  only  difference 
being  that  it  was  a  little  redder. 

CASE    VI.    VIOLENT    ENDOMETRITIS    CURED    BY    APPLIED    BLOOD, 
WITHOUT    CURETTAGE. 

Florence  B.,  age  30  years;  American.  Diagnosis,  en- 
dometritis.    Patient  admitted  to  hospital  March  2,  1902. 


452  SURGERY. 

She  was  greatly  anaemic  and  emaciated.  Was  so  weak 
that  she  had  to  be  carried  from  the  carriage  to  her  bed. 
Discharge  was  so  profuse  that  unless  proper  appliances 
were  used  it  would  run  from  her  almost  constantly. 

This  condition  had  existed  for  four  years,  and  during 
that  period  she  had  been  twice  curetted,  but  no  result  or 
relief  obtained.  Examination  revealed  the  uterus  to  be  in 
a  highly  diseased  condition.  So  much  so  that  I  advo- 
cated a  vaginal  hysterectomy,  or  at  least  a  thorough 
curettement.  To  these  propositions  both  the  patient  and 
her  friends  absolutely  declined  to  agree,  and  begged  that 
I  employ  some  other  treatment.  I,  therefore,  without  any 
promise  of  result,  determined  to  employ  bovinine  injec- 
tions and  applications.  On  the  3rd  March,  after  the 
patient's  secretions  had  been  regulated,  I  commenced  treat- 
ment by  washing  out  the  uterus  and  injecting  the  solution 
of  bovinine  and  salt  water,  two-thirds  bovinine  and  one- 
third  salt  water,  and  tamponing  the  vagina  with  bovinine- 
pure.  Internally  she  was  gi^-en  two  teaspoonsful  of  bovinine 
every  hour  in  peptonized  milk  and  a  little  water.  The 
vaginal  injections  and  tamponing  were  employed  twice  in 
24  hours,  up  to  March  14.  At  this  time  the  discharge 
had  entirely  ceased  and  the  uterus  was  becoming  smaller. 
The  uterine  washings  now  were  employed  once  in  24  hours 
aind,  instead  of  bovinine  tamponings,  vaginal  injections  of 
the  bovinine  pure.  Internally,  the  bovinine  was  increased 
to  a  wineglassful  every  two  hours.  March  18  the  pa- 
tient was  up,  and  went  for  a  short  walk,  and  returned  in 
splendid  conditioin.  Had  gained  4f  pounds  in  weight.  On 
March  23,  the  uterine  injections  were  discontinued,  and 
the  vaginal  injections  employed  once  in  24  hours.  At  this 
time  the  uterus  had  assumed  its  normal  size,  and  all  evi- 
dence of  inflammation  had  disappeared.  The  patient  was 
looking  and  feeling  splendidly,  therefore  local  treatment 
was  discontinued.  April  1  she  was  discharged  cured, 
but  instructed  to  return  at  intervals  for  examination  and 
continue  the  bovinine  internally  indefinitely. 

This  case  was  certainly  an  extreme  one  and  by  all 
gynaeclogists  an  operation  would  have  been  deemed,  I 
think,  an  absolute  necessity. 

GONORRHEAI.  ARTHRITIS. 

Jacobson  gives  a  clinical  lecture  on  this  subject.  The 
chief  points  in  diagnosis  are  classified:  (1)  Age.  Gonor- 
rheal arthritis  is  chiefly  met  with  between  twenty  and 
forty.  It  may  occur  in  infants  with  gonorrheal  conjunc- 
tivitis.    (2)  Sex.  It  is  more  common  in  males.     This  is  prob- 


SURGERY.  455 

ably  explained  by  the  numerous  glandular  recesses  of  the 
male  urethra,  which  are  reached  by  the  gonococci.  The 
disease  is,  however,  not  uncommon  in  women.  (3)  Time 
of  Onset.  Arthritis  may  sometimes  occur  early  in  the 
disease,  but  usually  not  for  several  weeks.  The  late  ap- 
pearance may  be  explained  by  the  gonococci  having  had 
time  to  reach  the  posterior  urethra  and  its  annexes. 
Lorimer,  from  an  examination  of  250  cases,  found  the  aver- 
age interval  in  men  six  weeks,  in  women  three  months. 
(4:)  Joints  attacked.  These  are  usually  the  knee,  ankle, 
elbow,  wrist  amd  shoulder.  Arthritis  with  effusion  gene- 
rally attacks  the  knee,  ankle  and  shoulder,  the  phlegmo- 
nous and  peri-articular  form  the  wrist  and  elbow.  But  any 
joint  may  be  attacked,  some  of  them  out-of-the-way  ones, 
such  as  the  tempero-mandibular,  sacro-iliac,  etc.  An  anky- 
U  sed  joint  and  wasted  muscles  of  unexplained  origin  sug- 
gests a  past  gonorrheal  arthritis.  The  arthritis  is  usually 
monarticular.  When  polyarticular,  symmetrical  joints  are 
usually  attacked.  If  several  joints  appear  to  be  acutely 
attacked  the  disease  soon  settles  in  one  and  the  rest  clear 
up.  (5)  Fever,  Pain  and  Inflammation.  There  are  three 
types — the  acute,  subacute  and  chronic.  The  latter  are 
more  common.  As  a  rule,  the  symptoms  are  less  intense 
than  in  rheumatic  fever.  Swelling,  redness  and  edema 
vary  with  the  variety  of  the  arthritis,  swelling  being  great- 
est in  hydrarthrosis,  and  redness  and  edema  when  the 
disease  is  mainly  capsular  and  peri-capsular.  (6)  The 
Discharge.  In  many  cases  it  is  difficult  to  determine  the 
existence  of  a  discharge,  especially  in  women.  In  men 
the  arthritis  usually  occurs  with  a  gleety  discharge.  The 
long  vitality  and  latency  of  gonococci  must  be  borne  in 
mind.  Neisser  found  them  present  in  80  cases  of  chronic 
gonorrhea;  in  18  they  had  lasted  over  a  year,  and  in  10 
cases  over  two  years.  The  cocci  may  easily  be  excited  into 
activity  by  alcohol,  excess  of  coitus,  menstruation,  preg- 
nancy and  curetting  the  uterus.  In  cases  of  discharge, 
due  to  other  causes  than  the  gonococci,  joint  complications 
do  not  occur,  except  in  case  pyemia  occurs. 

Diagnosis. — (1)  Acute  Bheumatism.  In  this  there  is 
more  pain  and  fever  than  in  gonorrheal  arthritis.  In  gonor- 
rheal arthritis  the  disease  usually  settles  in  one  joint,  and 
never  becomes  general  as  in  rheumatism.  Salicylates  do 
not  act  in  gonorrheal  arthritis.  In  the  latter  there  is  no 
peculiar  odour  in  the  sweat,  and  cardiac  complications  are 
rare.  (2)  Cellulitis.  The  phlegmonous  and  peri-capsular 
frrms  may  be  mistaken  for  cellulitis,  but  the  former  begins 
about  a  joint,  usually  the  elbow  or  wrist,  and  the  severity 


454  SURGERY. 

is  less  marked.  (3)  Gout.  The  joints  attacked  are  usually 
different.  A  urethral  discharge  may  occur  in  gout,  but  is 
rare. 

Prognosis. — This  depends  to  a  great  extent  orn  the 
patient.  Any  lighting  up  of  the  discharge  is  likely  to  be 
followed  b.y  fresh  joint  troubles,  and  these  are  likely  to 
be  worse  than  the  first.  The  vitality  of  the  patient  is  im- 
portant. A  patient  out  of  work,  compelled  to  get  about 
with  his  ankles  and  plantar  fascia  attacked,  is  a  bad  case 
to  cure.  The  duration  of  the  arthritis  is  an  important 
factor. 

Treatment. — The  main  points  are:  (1)  Cure  the  dis- 
charge; (2)  use  fixation  and  supporting  pressure  to  the 
joint  by  putting  up  in  plaster  of  Paris.  In  acute  cases  it 
may  be  necessary  to  treat  with  fomentations  or  ice  for  a 
few  days.  When  there  is  much  effusion  the  joint  should 
be  aspirated  before  applying  the  plaster.  In  two  or  three 
days'  time,  when  the  pain  has  gone,  the  plaster  should  be 
reapplied  or  an  india-rubber  bandage  applied  over  cotton- 
wool. If  the  feet  are  chiefly  affected,  it  is  important  for 
the  patient  to  get  about  a  little,  and  a  Martin's  bandage  is 
best  used.  When  the  plantar  fascia  is  attacked,  it  is  liable 
to  soften  and  cause  flat-foot.  In  such  cases  rest  off  the 
feet  is  necessary.  After  a  week  or  ten  days  the  joint  should 
be  ready  for  passive  movements,  friction,  douches,  massage 
and  the  Tallerman  hot-air  treatment,  in  order  to  prevent 
ankylosis.  The  liability  to  this  is  increased  by  prolonged 
fixation.  The  general  health  should  be  improved  and  a 
nutritious  diet  given.  Salicylates  and  iodides  are,  in  the 
author's  opinion,  useless,  but  iron  and  cod  liver  oil  may  be 
given. — Dr.  Jacobson  in  Guy's  Hospital  Gaz.,  Ref.,  London 
Treatment. 

THE  TREATMENT  OF  VENERAL    DISEASES 
IN   DISPENSARY   PRACTICE. 

The  writer  gives  a  brief  statistical  study  of  the 
venereal  diseases  taken  from  the  case-books  of  the  genito- 
urinary dispensary  of  the  University  Hospital  of  Pennsyl- 
vania. In  all,  these  include  a  study  of  6,587  cases  of 
genitourinary  disorders.  Of  this  number  4,890  belong  to 
the  class  of  venereal  diseases,  of  which  there  were: 
gonorrhoea,  1,240;  chronic  anterix)r  urethritis,  449; 
chronic  posterior  urethritis,  253;  stricture,  420;  chancroid, 
452;  chancre,  440;  secondary  syphilis,  479;  tertiary 
syphilis,  157. 

Gonorrhoea  is  more  scientifically  treated  than- 
formerly,  the  patients  being  thereby  saved  considerable 


SURGERY.  V  455 

discomfort.  The  shortening  of  the  disease,  the  aim  of 
most  of  the  newer  methods  of  treatment,  has  not  been  ac- 
complished. An  investigation  of  the  case-books  shows 
that  in  the  majority  of  instances  gonorrhoea  in  dispensary 
practice  is  quite  as  protracted  now  as  it  was  ten  years  ago. 

In  the  treatment  of  gonorrhoea,  about  all  the  newer 
methods  of  the  last  ten  years  have  been  tried  in  the  dis- 
pensary, but  it  has  finally  settled  down  to  the  following 
simple  plan:  During  the  first  ten  days  or  two  weeks  the 
patient  is  given  two  solutions  for  injection.  The  first  is' 
composed  of  permanganate  of  potassium,  one-half  grain  to 
eight  ounces  of  water.  With  this  the  patient  is  directed 
to  flush  the  urethra  with  an  ordinary  hand  springe,  which 
is  filled  six  times,  the  procedure  to  be  employed  thrice 
daily.  This  is  followed  by  a  solution  of  protargol,  ten 
grains  to  four  ounces,  which  is  injected  into  the  urethra 
and  retained  for  ten  minutes.  At  the  end  of  four  days 
the  permanganate  is  increased  to  a  strength  of  l-to-4,000, 
and  the  protargol  to  20  grains  to  4  ounces.  After  the 
second  and  third  week   a  favourite  prescription  is: 

R    Zinc  sulphate 10  grains 

Bismuth  subcarbonate 2  grammes 

Solution  of  hydrastis  (colourless) .  .    .  .  1-2  ounce 

Water  to  make. 4  ounces 

At  the  same  time  copaiba  and  oil  of  sandalwood  are  al- 
ways given.  Under  this  routine  treatment  the  majority  of 
acute  cases  get  well  in  from  six  to  seven  weeks. 

In  cases  of  chronic  urethritis  where  the  disease  de- 
pends upon  stricture  or  granular  patches,  sounds  are 
passed  three  times  a  week,  followed  by  an  irrigation  of 
silver  nitrate,  beginning  with  a  solution  of  l-to-8,000, 
which  is  gradually  increased  to  l-to-1,000.  In  cases  of 
chronic  folliculitis,  involving  the  glands  along  the  urethra, 
a  sound  is  introduced,  covered  with  an  ointment  contain- 
ing iodine  and  iodide  of  potassium.  Chronic  posterior 
urethritis  is  treated  by  massage  of  the  prostate  and  irrigar 
tions  of  the  urethra,  with  deep  instillations  of  protargol. 
Three  per  cent,  sulphate  of  copper  and  one  and  two  per 
cent,  nitrate  of  silver  are  of  value  in  chronic  disorders  of 
the  deep  urethra. 

Chancroids,  wiiere  there  is  no  question  as  to  the  diag- 
nosis, are  cauterized  with  nitric  acid.  The  patient  uses 
a  dusting  powder  of  iodoform  two  parts  and  acetanilid  one 
part.  As  a  substitute  for  iodoform,  bismuth  formic  iodidef 
powder  has  been  used.  Powdered  chloretone  is  useful 
where  there  is  pain. 

The  initial  lesion  of  syphilis  is  kept  clean,  and  as  free 
from  irritation  as  possible.     It  is  washed  with  a  50  per 


45^  SURGERY. 

cent,  solution  of  peroxide  of  hydrogen  twice  daily, 
followed  by  a  dusting  powder  of  acetanilid  and  iodine  in 
equal  parts.  No  constitutional  treatment  is  instituted  un- 
til secondary  acute  manifestations  occur. 

Constitutional  syphilis  is  divided  for  treatment  into 
two  classes,  the  benign  cases  and  the  more  severe  form- 
To  the  former  is  given  proto-iodide,  one-third  grain  in  pill 
form,  three  to  four  times  a  day.  This  treatment  is  con- 
tinued for  eighteen  months.  In  the  more  severe  cases  in- 
creasing doses  are  given,  until  the  gums  are  inflamed,  or 
there  is  decided  fetor  of  the  breath.  The  number  of  pills 
requisite  to  bring  about  this  condition  is  divided  by  two, 
the  result  being  the  dose  which  is  to  be  administered  to 
that  patient.  When  mercury  by  the  mouth  is  not  assimil- 
ated, inunctions  of  mercury  are  employed.  In  tertiary 
syphilis  mercury  is  always  employed  in  conjunction  with 
potassium  iodide. — H.  M.  Christian  in  Therap.  Gaz.  Med. 

OPERATION    FOR    SIMPLE    DEPRESSED     FRACTURE    OF 
SKULL,  'WITH  COMA  IN  A  CHILD. 

Mr.  Battle,  St.  Thomas'  Hospital,  London,  operated 
on  a  child,  aet.  2  years  3  months,  who  had  been  admitted  a 
few  days  before  after  a  fall  of  20  ft., from  a  window  on  to  the 
pavement.  The  child  had  not  recovered  consciousness 
since  the  injury;  her  eyes  were  constantly  rotated  down- 
wards and  to  the  right;  she  moved  the  left  arm  and  leg, 
but  the  right  arm  and  the  leg  did  not  respond  to  stimulus, 
and  were  rigid.  A  depressed  fracture  could  be  felt  over 
and  behind  the  left  motor  area.  As  the  coma  appeared 
to  be  deepening,  it  was  considered  best  to  trephine  in  the 
hopes  that  some  clot  might  be  found,  the  removal  of  which 
would  relieve  pressure  on  the  cerebral  substance.  A  semi- 
circular flap  was  raised  and  the  skull  trephined;  the  frac- 
ture was  rather  irregular,  and  there  was  not  much  depres- 
sion. After  the  application  of  the  trephiine.  a  small  quan- 
tity of  clot  was  exposed  on  the  surface  of  the  dura  mater, 
but  it  was  insufficient  to  account  for  the  symptoms.  The 
opening  in  the  skull  was  considerably  enlarged  by  means 
of  bone  forceps,  then  an  incision  was  made  through  the 
dura  mater;  there  was  no  blood  clot  on  the  surface  of  the 
brain,  nor  did  the  cerebral  substance  look  bruised;  there 
was,  however,  an  immediate  and  rapid  flow  of  cerebro- 
spinal fluid.  It  was  not  considered  advisable  to  explore 
the  brain,  the  symptoms  being  insufficiently  localized  to 
point  to  any  one  centre  or  connected  group  of  centres. 
The  flap  was  replaced,  no  attempt  being  made  to  restore 
the  bone.     A  drainage  tube  was  left  in  the  wound  in  order 


SURGERY.  457 

that  if  any  cerebrospinal  fluid  continued  to  escape  it 
might  come  away  easily.  Mr.  Battle  said  that  this  was 
evidently  a  case  in  which  there  was  probably  contusion 
and  laceration  on  the  surface  of  the  brain,  in  which  the 
continued  condition  of  coma  was  associated  with  excessive 
secretion  of  cerebrospinal  fluid,  and,  possibly,  a  progressive 
oedema  of  the  brain  in  the  neighbourhood  of  the  injured 
portion.  The  depression  of  the  skull  was  not  regarded  as 
a  sufficient  cause  for  the  symtoms,  the  bone  was  not  much 
depressed,  and  it  extended  over  a  fairly  large  area. 

The  result  of  the  operation  was  very  satisfactory,  the 
patient  being  able  to  sit  up  in  bed  and  take  a  penny  with 
either  hand  within  a  week.  For  two  days  there  was  a 
discharge  of  cerebrospinal  fluid,  and  for  some  days  the 
head  was  kept  somewhat  raised,  and  the  child  lying  on  her 
right  side  so  as  to  gradually  diminish  the  tendency  to 
overflow  from  the  wound.  Mr.  Battle  said  he  considered 
the  whole  case  interesting  from  the  duratio^n  of  the  coma 
and  from  the  rapidity  of  improvement  after  the  operation. 
Bearing  on  the  question  of  rapidity  of  recovery  he  men- 
tioned a  case  that  had  been  under  his  care  some  years 
ago:— 

A  boy  who  had  been  operated  on  for  compound  com- 
minuted fracture  of  his  frontal  bone  suddenly  developed 
coma  with  left  hemiplegia  about  eight  days  afterwards. 
The  patient  was  taken  to  the  operating  theatre,  and  with- 
out need  for  an  anaesthetic  the  right  side  of  the  brain  w^as 
explored  in  all  directions  with  a  trocar  and  cannula,  but 
no  abnormal  condition  w^as  discovered.  It  was  thought 
that  his  state  was  a  hopeless  one,  but  next  day  he  had  re- 
covered consciousness  and  spirits,  and  when  the  house  sur- 
geon went  round  in  the  morning  the  patient  insisted  on  sit- 
ting up  in  bed  and  shaking  hands  with  him,  and  there  was 
no  trace  of  paralysis  left,  and  he  left  the  hospital  a  short 
time  afterwards  perfectly  well. — Dublin  Medical  Press. 

THE    INJURY    TO    THE    YOUNG    CELLS    CAUSED    BY   THE 
COMMON  SURGICAL  DRESSINGS. 

Robert  T.  Morris  says  that  absorbent  cotton  is  perhaps 
the  most  injurious  of  the  dressing  materials  that  are  placed 
near  the  wound.  Absorbent  gauze  and  gutta  percha  tissue 
are  harmful,  and  the  various  antiseptics  used,  while  they 
may  destroy  pus,  have  also  the  power  of  destroying  new 
epithelium  and  new  connective  tissue  formations.  Skilful 
neglect  of  wounds  requires  much  experience.  Lister's  pro- 
tective oil  silk  is  one  of  the  best  dressings  to  lie  next  to 
the  wound;  an  innocuous  and  valuable  dressing  for  the 


458  SURGERY, 

wound  surface  can  be  made  by  pouring  collodion  upon 
glass  and  peeling  it  ott'  in  a  thin  film  after  evaporation  of 
the  volatile  part.  Silver  foil  is  becoming  popular  as  a  pro- 
tective dressing,  A  dressing  presented  by  the  author  is 
known  as  the  Cargile  membrane,  first  suggested  by  Dr. 
Oargile,  of  Arkansas,  for  the  purpose  of  preventing  the 
formation  of  peritoneal  adhesions.  The  material,  de- 
scribed in  a  recent  issue  of  the  Medical  Record,  is  a  very 
thin  gold-beaters'  skin,  made  from  the  peritoneum  of  the 
ox.  It  is  pervious  to  moisture,  and  at  the  same  time  it 
does  not  entangle  new  cells.  Its  presence,  as  in  animal 
membrane,  seems  particularly  grateful  to  the  tissues,  and 
the  author  has  not  yet  found  a  dressing  that  has  been 
found  so  satisfactory  as  this  material  to  lie  next  the  wound. 
^'Sulphite  laps"  is  the  best  and  cheapest  absorbent  dress- 
ing to  be  found,  but  as  yet  is  not  obtainable  in  the  market. 
The  combination  of  Cargile  membrane  and  sulphite  laps 
ought  to  become  a  popular  one. — Mobile  Medical  and  Sur- 
gical Journal. 

PREVENTION    OF   STITCH  ABSCESS. 

Maylard  (Annals  of  Surgery,  January,  1902)  holds  that 
in  the  practice  of  modern  operative  surgery  there  are  two, 
and  probably  only  two,  precautions  where  doubt  must 
always  exist  as  to  the  certainty  on  which  a  perfectly  asep- 
tic result  may  be  expected.  These  two  precautions  deal 
with  (1)  the  condition  of  the  surgeon's  hands,  and  (2)  the 
condition  of  the  parts  to  be  operated  upon,  or,  in  other 
words,  the  state  of  the  skin  and  deeper  tissue.  Convinced 
by  the  results  of  experiments  that  infective  micro-organ- 
sims  are  derived  from  the  sudoriferous  and  sebaceous 
glands  of  the  surgeon's  hands,  the  author  advocates  a  pre- 
caution founded  on  the  physiological  basis  of  exciting 
these  glands  of  the  skin  to  act  freely  before  the  commence- 
ment of  the  operation.  In  the  method  described  in  this 
paper  the  hands  are  submerged  for  from  five  to  ten  min- 
utes in  hot  water  as  hot  as  can  be  conveniently  borne. 
The  soddened  surface  epithelium  having  been  removed  by 
massage  of  the  hands  under  water  and  the  use  of  ordinary 
soap  the  hands  are  finally  rinsed  in  warm  carbolic 
lotioin  (1  to  40).  In  the  preparation  of  the  operator's  hands, 
"soaking,"  it  is  tersely  asserted,  "is  better  than  soap- 
ing." The  author's  method  of  sterilizing  the  skin  and 
deeper  tissues  of  the  patient  is  based  on  the  fact  that  it  is 
possible  to  salivate  a  patient  by  the  inunction  of  the  sur- 
face of  the  abdomen  with  mercurial  ointment.  Such  a 
result  proves  that  the  agent  applied  is  carried  by  ^natural 


SURGERY.         .  459 

channels — certainly  the  lymphatics — so  as  to  produce  an 
effect  upon  a  comparatively  distant  region  elsewhere.  So 
long  as  the  agent  is  kept  in  contact  with  the  skin  so  long 
will  these  channels  be  engaged  in  transmitting  it  to  other 
parts.  It  is  inferred  that  when  an  operation  is  performed 
on  parts  whose  lymphatics  contain  such  a  potent  bac- 
tericidal agent  as  mercury,  this  should  not  only  prove  de- 
structive to  any  micro  organisms  with  which  it  might  come 
into  direct  contact,  but  its  presence  should  still  further 
render  the  normal  tissue  unfit  for  the  multiplication  and 
development  of  these  bodies.  The  author  describes  only 
his  method  of  prolonged  application  of  lanoline-oleate  of 
mercury  ointment  to  the  skin  over  the  seat  of  operation, 
and  states  that  according  to  the  results  of  careful  scientific 
and  clinical  investigation,  whilst  chemical  examination 
failed  to  afford  any  positive  information,  bacteriological 
investigation  proved  a  material  diminution  in  the  number 
of  micro-organisms,  and  the  records  of  actual  practice 
afforded  incontestable  proof  of  the  value  of  the  method. — 
Indian  Lancet. 

SEVERE  EXTRINSIC   TRAUMATISMS   OF   THE   SPINE. 

BY  THOMAS  H.   MANLEY,   M.   D.,   NEW  YORK,   N.   Y. 

Severe  spinal  injuries  reduced  to  an  anatomical  basis 
may  be  divided  into  two  classes: 

1.  Those  which  involve  the  rachidian  structures  alone, 
the  osseous,  ligamentous,  muscular  and  vascular. 

2.  Those  in  which  the  effects  of  violence  fall  with  great- 
est force  on  the  central  organ,  the  cord,  its  meningeal  in- 
vestments, its  ganglia  or  medullary  substa.nce. 

The  former,  or  extrinsic  injuries,  are  much  the  more 
common,  and  though  not  so  serious  to  life  or  function, 
may,  by  extension  of  pathological  processes,  involve  the 
deeper  or  more  vital  parts;  but  in  most  cases  they  are  re- 
covered from,  however,  sometimes  leaving  deformity  or 
impaired  function. 

The  osseous  structures  of  the  vertebral  column  consist 
essentially  of  two  parts: 

1.  A  segmented  whole,  made  up  of  the  vertebral  bodies, 
with  an  intervertebral  substance,  and  an  enveloping  sheath 
of  a  tough,  fibroug  structure. 

This,  properly  speaking,  is  the  triple  curved  backbone, 
which  supports  the  head  and  carries  the  whole  trunk.  This 
is  a  flexible  structure  which,  within  various  limits,  may 
be  bowed  or  twisted  with  remarkable  impunity. 

2.  The  posterior  stage  work  of  the  spinal  column.     The 


460  SURGERY. 

vertebral  apophyses,  which  serve  chiefly  the  double  pur- 
pose of  providing  a  hollow  tube  for  the  cord  and  attach- 
ments for  ligaments,  muscles  and  tendons. 

All  the  structures  external  to  the  theca  spinalis  are 
provided  with  an  abundant  circulation,  while  the  cord  it- 
self and  its  membranes  are  but  very  sparsely  supplied  with 
vessels. 

The  primary  extrinsic  lesions  of  the  spine  are: 

1.  Contusions,  blows  or  falls. 

2.  Sprains,  hyperflexion  or  torsion. 

3.  Hemorrhage,  intra  or  extrarachidian. 

4.  Fractures — simple  and  open. 

5.  Diastases — fracture  and  luxations. 

6.  Visceral  complications. 

Contusions,  blows  or  falls  on  the  back  seldom  involve 
danger  to  the  spinal  structures,  except  when  the  volume 
of  force  is  great  and  concentrated  on  a  limited  area.  The 
spinal  defenses  provide  frequent  immunity  by  sudden 
sinking  of  the  head,  the  projecting  shoulders  and  ribs,  the 
iliac  crests,  the  ponderous  lumbar  development  and  gluteal 
projections.  A  sudden  violent  blow  over  the  neck  is  the 
most  serious,  because  of  the  large  sympathetic  ganglia 
here  located  and  its  contiguity  with  the  bulb  at  the  base 
of  the  brain. 

The  pneumatic,  thoracic  areas  are  well  calculated  to 
resist  shock,  and  lower  down,  afford  protection  to  many 
of  the  solid,  floating  organs  of  the  abdomen. 

The  spinal  cord  ends  at  the  last  dorsal  vertebra,  and 
hence,  concussive  force  on  the  lumbar  or  sacral  regions 
can  only  affect  the  terminal  nerve  ganglia  and  cords  con- 
tained therein. 

The  effect  of  a  blow  on  the  lumbar  or  sacral  region  is 
from  direct  concussion  and  contre-coup  effects,  transmitted 
shock. 

Sprain  of  the  spine  implies  the  effects  of  a  complex 
force,  with  consecutive  conplex  pathological  conditions, 
entorse  and  arrachement;  torsion  with  over-stretching  or 
sundering  of  ligaments  are  invariably  essential  factors. 

The  neck,  the  most  mobile  segment,  suffers  most  fre- 
quently, and  grave  sprains  there  are  most  commonly  pro- 
duced by  the  body  being  projected  against  the  occiput, 
as  in  diving,  or  falls  on  the  side  of  the  head.  The  costal 
bases,  which  laterally  support  the  thoracic  spine,  safeguard 
this  segment  against  torsion  injury.  The  lumbar  region 
frequently  suffers  from  sprains  after  great  effort  in  various 
exercises,  or  in  making  h^eavy  lifts  with  the  spine  in  a  later- 
allv  inclined  attitude. 


SURGERY. 


46 1 


A  severe  sprain  of  a  joint  is  always  a  serious  accident; 
of  the  spine  more  so,  because  of  vital  and  delicate  organs 
which  it  e.ncases.  Spinal  sprains  may  involve  a  diastasis 
of  the  vertebral  segments,  though  generally  the  apophyseal 
articulations  alone  are  engaged.  In  lumbar  sprains  the 
tendons  may  suffer  rupture  or  luxation.  Spinal  hemor- 
hage  may  be  broadly  divided  into  two  varieties,  viz.,  that 
which  occupies  the  cord  and  that  which  occurs  external  to 
the  theca  in  any  of  the  overlying  structures.  The  former 
can  never  occur,  as  a  primary,  uncomplicated  lesion;  the 
latter,  the  extrinsic  variety,  occurs  frequently  in  nearly 
e\-ery  type  of  severe  spinal  injury;  it  is  usually  venous,  it 
may  take  place  in  the  vertebral  hollow,  along  side  the  cord, 
or  into  the  subcutaneous  inter-muscular  spaces,  porterior 
to  the  apophyses. 

The  most  confused  ideas  prevail  in  relation  to  ''spinal 
hemorrhage,"  the  prevailing  impression  being  that  the 
blood  escapes  into  the  meninges  or  the  medullary  elements 
of  the  cord  (hematomeni.ngea),  while  quite  invariably  the 
blood  leak  is  into  the  spinal  canal  (hematorachis).  The 
latter  is  of  itself  rarely  a  cause  for  serious  apprehension, 
but  when  complicated  it  becomes  an  aggraving  factor  in 
provoking  pathological  changes,  tending  to  meningitis,  or 
myelitis,  ascending  or  descending.  The  gravity  of  this 
hemorrhage  depends  on  its  site,  volume  and  complica- 
tions. 

Fracture  of  the  spine  should  always  be  considered  in  a 
category  separate  to  itself.  This  fracture  may  exist — a 
broken  back — without  any  definite  symptoms  at  all.  Diag- 
nosis of  it,  by  any  means  known  to  art,  may  at  times  be 
absolutely  impossible.  When  the  spinal  cord  escapes  im- 
pingement, as  it  does  in  the  greater  number  of  cases, 
restitutio  ad  inter/rum  may  speedily  follow,  or  the  fragments 
may  unite,  leaving  an  anchylosis  or  a  deviation,  most  com- 
monly a  kyphos.  This  involves  a  deformity  with  impair- 
ment of  function  in  the  mechanical  action  of  the  column, 
in  its  oscillatory  movements  and  its  strength,  but  in  no 
manner  impairing  the  function  of  the  cord. 

Fracture  of  the  spine  is  seldom  attended  with  palpable 
displacement,  the  ligamentous  attachments  being  so  nu- 
merous and  firm  that  the  fragments  are  usually  sprung 
into  position  automatically.  This  fracture  only  assumes 
a  serious  aspect  when  the  cord  is  divided. 

Diastasis,  or  fracture-luxation:  A  genuine,  complete 
luxation  of  the  spine,  without  simultaneous  destruction  of 
the  cord,  can  be  only  imagined,  it  can  never  occur. 

A  displaced  vertebral  body  is  a  diastasis  and  not  a 


462  SURGERY. 

dislocation,  because  the  intervertebral  junctions  are  not 
true  joints,  and  luxation  of  the  apophyses  can  only  occur 
with  coexistent  fracture  of  an  arch  or  pedicle,  except  in 
the  cervical  region.  It  is  very  frequently  impossible  to 
distinguish  an  apophyseal  luxation  from  a  fracture,  except, 
possibly,  in  the  neck,  and  even  here  a  luxation  of  the  ver- 
tebrae has  often  been  suspected,  when  on  autopsy  none 
was  found,  but  a  fracture  of  the  base  of  the  skull  was  dis- 
covered. Again,  I  have  known  of  an  exploratory  operation 
for  luxation — fracture  when  none  was  discerned  through 
the  incision,  but  it  was  later  known  that  one  existed,  three 
vertebrae  further  down. 

Visceral  complications,  coexistent  or  consecutive  to 
violent  spinal  injuries,  are  not  infrequent.  The  thoracic 
and  abdominal  organs  most  frequently  suffer.  Mediastinal, 
pleural  or  pulmonary  hemorrhage  may  occur  after  a  frac- 
ture through  the  vertebral  blocks  or  a  diastasis  through 
the  intervertebral  substance,  in  consequence  of  a  lacera- 
tion of  the  ainterior  ligaments  and  intra-rachidian  plexus 
of  vessels.  The  heart  or  great  vessels  may  suffer  from 
the  effects  of  violent  commotion  of  the  thorax. 

In  the  abdomen  the  kidney  may  suffer  displacement, 
contusion  or  laceration;  the  spleen,  pancreas  or  liver  are 
liable  to  similar  lesions;  a  distended  gall  or  urinary  blad- 
der, or  stomach  may  suffer  rupture  and  leakage;  the  preg- 
nant uterus  in  any  stage  may  sustain  shock,  with  the  pre- 
mature expulsion  of  its  contents. 

In  many  severe  extrinsic  rachidian  injuries,  through 
the  spinal  cord  may  previously  escape  such  damage  as  will 
induce  paralysis,  yet  later  symptoms  may  follow,  sug- 
gestive of  meningeal  changes,  or  disturbances  of  nutrition, 
and  pronounced  disturbance  of  the  ganglionic  connections 
with  the  sympathetic  involved. 

In  all  this  class  of  traumatisms  it  will  be  well  to  be 
reserved  in  prognosis  until  at  least  the  primary  effects  have 
been  recovered  from  and  function  is  fully  regained.— (7m- 
cinnati  Lancet-Clinic. 

RADICAL  CURE  OF  HYDROCELE. 

From  a  ^arge  experience  of  the  value  of  two  or  three- 
drop  inieotions  of  pure  phenol  into  an  emptied  tunica 
vjTofinaiis  te'^tis.  Drs.  Toley  and  Patterwhnite  have  been  so 
plpf^'^ofi  with  thA  results  they  obtained  thnt  thev  recom- 
tupttI  +he  nse  of  nlip,nol  in  small  doses  for  the  radical  cure 
of  liA^drocele.  Their  procedure  consists  in  thp  use  of  a 
double  trorpr  pnd  cnnnnla.  the  inner  trcrnr  t'rhtlv  fitting 


JOTTINGS.  463 

and  projecting  slightly  beyond  the  outer  and  bearing  a 
thread  at  its  proximal  end,  so  that  it  can  be  attached  to 
any  ordinary  hypodermic  syringe.  The  inner  cannula,  being 
attached  to  the  syringe,  is  first  filled  with  liquid  phenol, 
and  two  or  three  drops  injected.  Such  a  small  quantity 
of  phenol  could  not  affect  the  whole  of  the  surface  of  even 
a  moderate-sized  sac,  but  the  sac  of  a  hydrocele  is  never 
completely  emptied  by  tapping,  and  the  remaining  fluid  is 
quite  sufficient,  with  the  added  phenol,  to  excite  the  necess- 
ary adhesive  inflammation  over  the  lining  membrane  of  the 
tunic.  The  use  of  pure  phenol  in  this  disease  is  not  new, 
but  in  the  past  it  fell  into  disrepute  from  the  untoward 
results  that  followed  from  its  use  in  excessive  quantities. 
But  to  the  authors  we  are  indebted  for  demonstrating  its 
utility  and  safety  in  small  doses. — Med.  Press  and  Circular. 

GUNSHOT  AVOUNDS. 

In  gunshot  wounds,  when  a  round  ball,  or  a  conical 
one  with  small  velocity,  penetrates  a  fascia,  the  fibres  of 
the  latter  may  be  so  disturbed  and  crowded  aside  as  to 
interfere  much  with  probing  and  with  drainage.  Thus  a 
probe  may  impinge  upon  a  fascia  so  that  no  further  ad- 
va.nce  can  be  made,  and  errors  as  to  the  actual  presence 
or  the  direction  of  the  bullet  may  easily  occur. — Inter- 
national Jonrnal  of  Surgery. 


Jottings, 


A  hot  bath  at  bed  time  will  relieve  many  cases  of  in- 
somnia. 

Remember  that  kerosene  oil  and  vinegar  are  good  house- 
hold remedies  for  the  removal  of  pedicuH  and   their  eggs. 

Iodoform  odour  may  be  removed  from  the  hands  by 
thorough  washing  in  vinegar  after  the  use  of  soap  and  water. 

A  single  drop  ofthe  wine  of  ipecac  repeated  every  fifteen 
or  twenty  minutes,  will  often  produce  the  most  marked  relief 
both  from  vomiting  and  diarrhoea. 

Five  to  ten  drops  ofthe  tincture  of  gelsemium  Qvery  four 
hours  will  almost  invariably  relieve  that  painful  condition 
or  backache  commonly  called  lumbago. 

Freckled  people  will  rejoice  to  know  that  freckles  may 
be  removed  by  the  use  of  corrosive  sublimate ;  two  to 
five  grains  to  the  ounce  of  lotion  or  ointment. 


'1464  OBSTETRICS. 

A  single  djsi  of  fro  >n  ten  to  fifteen  grains  of  salicylate 
of  sodium  will  often  care  acute  supra-orbital  pain.  It  is  safe 
to  give  it  in  every  case  where  blooi  poisoning  is  suspected. 

Dr.  H.  B.  iStaney  says  . — "Never  try  to  introduce  a  ca- 
theter into  the  bladder  where  the  prostate  gland  is  enlarged 
without  having  the  finger  in  the  rectum  to  spread  the  lateral 
lobes  apart  and  lift  the  point  of  the  instrument  above  the 
sinus  pocularis." 

Perforation  of  the  intestine  frequently  threatens  toward 
the  end  of  an  attack  of  typhoid  lever,  and  great  caution 
needs  to  be  observed  in  all  .wing  a  return  to  indigestible  food 
during  early  convalescence.  A  disregard  of  this  caution 
may  lead  to  a  fatal  issue  on  the  very  threshold  of  recovery. 


OBSTKTRICS. 

IN  CHARGE   OF 


H.  L.  REDDY,  M.D..  L.  R.  C.  P.;  London. 

Professor  of  Obstetrics,  Universiiy  of  Bishop's  College  ;   Physician  Accoucheur  Women's 
Hospital  ;   Consulting  Phycisian  to  the  Western  Hospital. 


SUPRARENAL     GLAND     IN    PRURITUS     OF    THE    VULVA. 

Two  cases  of  pudendal  irritation  witli  marked  pruritus 
are  described.  One,  a  young  woman  18  jears  of  age,  ten 
days  before  coming  under  observation,  was  seized  witli  a 
violent  itching  of  tlie  vulva  and  anus.  Notwithstanding 
aj)proved  treatment  there  was  no  relief,  and,  in  the  mean- 
time, the  condition  had  become  so  severe  that  she  was  un- 
able to  leave  the  house.  A  local  examination  showed  an 
intensely  congested  conditon  of  the  vulva  and  the  lower 
part  of  the  vagina,  with  increased  secretion.  A  strong  solu- 
tion of  suprarenal  was  applied  to  the  part,  which  was 
followed  by  a  rapid  blanching  of  the  mucous  membrane. 
Momentarily  the  itching  was  increased,  and  then  gave  way 
to  a  slight  burning  sensation,  which  passed  off  in  a  few 
minutes.  The  effects  of  this  application  lasted  for  fourteen 
hours,  wlien  the  itching  recurred.  A  second  application 
gave  permanent  relief. — F.  S.  Meara. 

LACERATION   OF  THE   CERVIX  A  CAUSE   OF  ABORTION. 

The  experience  of  the  writer  confirms  him  in  the  belief 
that  lacerations  of  the  cervix  particularly  those  which 
are  of  some  depth,  are  a  frequent  cause  of  abortion.  A 
primipara  can  usually  give  some  cause  for  an  abortion, 
such  as  a  misstep  or  a  fall,  but  in  those  who  have  pre- 
viously borne  children,  where  there  is  a  fissure  extending 


OBSTETRICS.  465 

as  high  as  the  internal  os  that  will  admit  the  tip  of  the 
index-finger,  or  the  integrity  of  the  lower  uterine  segments 
is  lost,  there  is  a  predisposition  to  abortion. — R.  W.  Rogers. 

USE   OF   THE   X-RAY   DURING   PREGNANCY. 

Bouehacourt  has  found  the  X-ray  thoroughly  un- 
satisfactory in  its  application  to  the  study  of  the  fetus 
in  utero.  He  finds  by  his  experiments  that  the  factors 
which  interfere  with  vision  of  the  fetus  include  liquor 
amnii,  membranes,  uterine  wall,  respiratory  and  voluntary 
movements  of  the  mother,  movements  of  the  fetus,  opacity 
of  the  maternal  pelvic  and  vertebral  bones,  inequality  of 
distance  of  different  portions  of  the  uterus  from  the  plate, 
and  unequal  thickness  of  different  portions  of  the  tissues 
traversed  by  the  X-ray. 

TREATMENT  OF  RETENTION  OF  PLACENTA. 

S.  Grosjean  favours  tamponing  the  uterus  as  the  sim- 
plest and  safest  method  of  obtaining  the  expulsion  of  a 
retained  placenta,  unless  one  has  had  sufficient  experience 
in  digital  curettage.  By  the  means  which  he  advocates, 
Grosjean  has  succeeded  in  emptying  the  uterus  in  twelve 
of  thirteen  cases.  It  also  arrested  the  hemorrhage  which 
accompanied  six  of  the  cases.  The  placenta  was  expelled, 
on  an  average,  at  the  end  of  fifteen  hours.  In  four  cases 
renewal  of  the  tampon  once  or  twice  after  twenty-four 
hours  was  necessary.  In  one  of  these  the  method  failed 
entirely,  although  the  packing  was  inserted  four  times. 

APPENDICITIS  AND  PREGNANCY. 

A.  Herrgott  reports  two  cases  of  appendicitis  during 
pregnancy  which  terminated  fatally  in  spite  of  operative 
interference.  He  holds  that  operation  is  demanded  not 
oinly  for  all  cases  of  appendicitis  during  pregnancy,  but 
also  upon  all  women  having  appendicitis  who  are  suscep- 
tible of  becoming  pregnant.  During  labour  the  adhesions 
limiting  the  process  are  broken,  infection  becomes  general, 
and  the  condition  for  treatment  becomes  very  unfavour- 
able. 

NAUSEA  AND  VOMITING  OF  PREGNANCY. 

J.  M.  Batten,  after  trying  all  the  different  drugs  re- 
commended for  this  trouble,  has  come  to  the  conclusion 
that  they  are  of  no  value.  He  has  found  that  over  feedinr^ 
generally  gives  relief.  Before  rising  the  patient  should 
have  a  hearty  breakfast,  and  three  other  full  meals  during 


46^  OBSTETRICS. 

the  day.  She  should  also  have  food  near  her  bed  at  night,  so 
that  she  may  have  something  to  eat  if  hungry.  Fasting 
during  the  night  is  conducive  to  sickness  in  the  morning, 
and  possibly  during  the  ensuing  day. 

MOIiECUI-AR  CONCENTRATION  OF  THE  BLOOD  IN 
ECLAMPSIA. 

The  examination  of  the  blood  of  six  cases  of  eclampsia 
leads  A.  Szili  to  the  conclusion  that  the  freezing  point  of 
eclamptic  blood  is  practically  the  same  as  that  of  normal 
blood,  a  point  which  is  almost  constant.  This  he  takes  as 
showing  that  the  permeability  of  the  kidneys  is  not  altered 
in  the  same  way  in  eclampsia  as  in  most  uremic  processes. 
He  accordingly  deduces  the  hypothesis  that  the  supposed 
toxic  substance  which  is  the  etiological  factor  of  eclampsia 
is  a  complex  molecule,  perhaps  an  intermediate  product  of 
katabolic  changes  in  the  albumin  molecule. 

POINTS  IN  OBSTETRICS. 

Hammamelis  is  valuable  in  the  varicose  veins  and 
hemmorrhoids  of  pregnancy.  Use  locally  and  internally 
to  full  limit. 

In  threatened  mastitis,  use  every  effort  to  abort  the 
abscess,  both  for  cosmetic  reasons  and  because  a  breast 
is  never  again  so  good  a  milk  producer  after  it  has  once 
healed.  Internally:  give  calcium  sulfid,  saline  laxatives, 
and  belladonna.  Locally:  apply  belladonna,  tincture  of 
opium  and  lead  water,  and  alternate  this  with  tincture  of 
opium,  one  ounce  to  ^  point  of  sweet  oil,  applied  hot  and 
I'ubbed  in  well  with  gentle  massage.  Keep  the  breast 
under  firm  pressure  at  all  times  except  when  making  ap- 
plications. If  pus  form,  evacuate  promptly  at  lower  part 
of  gland;  use  an  anesthetic  so  that  all  pus  pockets  may 
be  searched  out  and  thoroughly  drained. 

Never  rupture  the  membranes  in  a  primapara;  and 
never  rupture  them  in  multipara  till  the  second  stage  is 
well  advanced. 

Hirst  prefers  ether  to  chloroform  in  labour  except  in 
the  presence  of  eclamptic  symptoms. 

Fifteen  grains  of  chloral  by  the  rectum,  repeated  once 
or  twice,  will  mollify  the  early  stages  of  labour. 

It  is  good  practice  to  give  a  dram  of  fluid  extract  of 
^rgot  as  soon  as  the  child  is  delivered.  Before  the  ergot 
has  had  time  to  act  the  placenta  will  have  been  expelled 
"r  delivered,  and  danger  of  postpartum  hemorrhage  is 
averted. 

While  oxalic  acid  is  one  of  the  best  emenagogs,  one 


OBSTETRICS.  46/ 

must  beware  of  using  it  in  pregnancy,  since  it  is  a  powerful 
oxytoxic  and  may  easily  induce  abortion. 

Never  use  the  forceps  in  a  normal  labour  till  the  head 
has  been  stationary  for  two  hours.  Never  use  them  for  no 
better  excuse  than  to  hasten  the  labour. 

If  the  fetal  vessels  cease  to  beat  for  10  minutes  pre- 
vious to  delivery,  it  may  be  certain  that  the  child  is  dead. 

If  a  woman  dies  suddenly  in  full  term  labour,  extract 
the  child  immediately  by  version  or  Caeian  section. 

Scale  pepsin  added  to  quinine  will  fjrevent  vomiting, 
when  given  during  labour  in  the  enormous  doses  necessary 
to  get  the  effecft  on  the  uterus. — Medical  World. 

AN    EXPERIMENTAL    STUDY    OF    THE    URINARY 
ANTISEPTICS. 

The  writer  has  made  a  comparative  study  of  the  dif- 
ferent antiseptics  which  are  given  internally  for  the  pur- 
pose of  rendering  the  urinary  tract  sterile.  Some  of  these 
experiments  were  directed  to  ascertain  the  effect  of  the 
different  substances  upon  urine  which  contained  bacteria, 
or  when  the  bacteria  were  added  to  urine  which  was  asep- 
tic. Of  all  the  urinary  antiseptics,  urotropin  was  found 
to  be  the  most  efficient.  In  doses  of  sixty  grains  daily,  the 
urine  had  a  distinct  antiseptic  action  upon  micro-organism, 
whether  contained  in  the  bladder  or  added  to  the  urine. 
Next  to  urotropin,  salicylic  acid  was  the  most  efficient. 
Sandalwood  oil,  methylene  blue,  salol,  balsam  of  copaiba, 
had  a  distinct  antiseptic  action.  Chloride  of  potassium, 
boric  acid,  and  uva  ursi  had  no  appreciable  action. — O. 
Sachs. — TFiener  Klin  Wochen. 

TREATMENT    OF    PHI^EGMASIA    ALBA    DOLENS. 

M.  T.  Brennan  claims  to  have  obtained  excellent  re- 
sults from  the  application  of  solutions  of  picric  acid.  He 
believes  that  this  relieves  the  pain  and  swelling  more 
rapidly  than  any  other  agent.  He  employs  a  saturated 
alcoholic  solution  and  renews  the  dressings  two  or  three 
times  a  day.  An  aqueous  solution  is  used  if  the  skin  is 
injured  or  tender. 

PRECOCIOUS  MATERNITY. 

Dr.  Allen  reports  the  pregnancy  and  parturition  of  a 
coloured  girl  aged  eleven  years,  eight  months,  in  the  Mary- 
land Medical  Journal.  Menstruation  began  at  ten  years, 
three  months.  Her  child,  of  normal  size,  was  born  at  term 
without  complications.  ,Both  mother  and  child  are  now 
perfectly  well. 


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COLI.EGE    OF    PHYSICIANS    AND    SURGEONS,    PROVINCE 

OF  QUEBEC. 

The  half-yearly  meeting  of  the  above  body,  which  is 
ithe  Provincial  Licensing  Board  of  this  Province,  was  held 
in  the  City  of  Quebec  on  the  24th  of  September.  Two  re- 
solutions which  were  passed  have  given  rise  to  consider- 
able discussion  in  the  daily  papers  of  Montreal,  and,  to  a 
certain  extent,  in  those  of  Quebec.  The  first  was  a  resolu- 
tion, the  result  of  a  report  presented  by  the  Educational 
Committee — which  report  we  know  had  received  but  little 
if  any  consideration  from  the  English-speaking  members  of 
the  Committee.  This  Committee  met  only  a  few  minutes 
before  the  hour  named  for  the  opening  of  the  College,  and 
on  the  subject  being  brought  before  it,  in  the  shape  of  a 
resolution,  it  was  vigorously  opposed  by  the  two  English 
members,  Drs.  Craik  and  McConnell.  Time  pressing,  it  was 
decided  to  bring  the  matter  before  the  College  and  further 
discuss  it  there.  This  resolution  declared  that  in  future 
all  who  desired  to  present  themselves  for  the  Preliminary 
Examination  of  the  College  must  produce  evidence  of 
having  taken  a  cours  complet.     A  vigorous  protest  against 


EDITORIAL. 


469 


it  was  made  by  all  the  English-speaking  members — Dr. 
Craik    said   that   such   a   resolution    would   act   most   in- 
juriously on  candidates  of  English  origin,  as  the  Protestant 
community  had  no  such  institutions,  as  had  their  Eoman 
Catholic  confreres — scattered  all  over  the   Province,   and 
where  education  was  received  at  a  yearly  cost  of  about 
one  hundred  and  thirty  dollars.     For  Protestants  to  take 
a  somewhat  similar  course  would  cost  from  three  to  four 
hundred  dollars  a  year,  and,  practically,  meant  the  candidate 
taking  the  degree  of  B.  A.    While  such  a  degree  was  desir- 
able  for  these  entering  the  Medical  profession,  the  country, 
lie  felt  sure,  was  as  yet  not  prepared  for  it.  Dr.  F.W.Gampbell 
took  broader  ground  and  opposed  the  resolution,  because, 
while   the   College  had  every  right  to  specify  what  examina- 
tions a  candidate  must  pass,  it  had  no  right  to  specify  by 
what  means  he  must  get  the  required  education.     Those 
who  favoured  the  resolution   said  the  object  desired  to  be 
obtained  by  it  was  to  have  the  candidates  well  grounded  in 
the  various  subjects  of  the  examination,  and  not  permit 
them  to  cram  for  it  by  a  tutor.     Dr.  Campbell  met  this  by 
stating  that  during  the  twelve  years  he  was  secretary  of 
the  College,  he  knew  that  nearly  every  one  who  had  taken 
a  cours  complet   had  found  it  necessary  to  employ  a  tutor 
before  going  up  for  the  Medical  Preliminary.     This  fact, 
and  the  additional  fact  that  the  number  of  rejections  was, 
in  his  opinion,  far  beyond  what  they  should  have  been,  led 
him  to  try  and  find  out,  if  possible,  the  cause.     With  this 
end  in  view  he  succeeded  in  getting  a  meeting  of  a  large 
number  of  the  heads  of  Roman  Catholic  and  Protestant 
educational  institutions  in  this  Province.     It  took  place  in 
the  City  of  Montreal,  and  the  matter  was  freely  and  fully 
discussed. 

The  decision  arrived  at  was  that  there  was  not  a  single 
institution  in  Quebec  which  gave  an  education  which  pre- 
pared a  young  man  for  the  entrance  examination  in  med- 
icine. Dr.  Campbell  declared  that,  under  such  circum- 
stances, to  pass  such  a  resolution  was  unfair  to  Roman 


47^  EDITORIAL. 

Catholics,  and  most  unjust  to  Protestants.  On  the  part 
of  those  of  the  Educatioinal  Committee,  who  passed  the 
resolution,  it  is  but  fair  to  state  that  they  avowed  no  desire 
to  act  unjustly  toward  the  English-speaking  community, 
and  expressed  a  perfect  willingness  to  accept  as  equivalent 
to  a  cours  complet,  the  certificate  of  any  College,  High  School 
or  Academy,  which  gave  a  classical  education,  and  was 
recommended  by  the  English-speaking  members  of  the 
College.  Dr.  Campbell  still  pressed  his  objection,  affirm- 
ing that  several  men  occupying  excellent  professional  posi- 
tions, had,  to  his  knowledge,  been  self-taught.  Notwith- 
standing the  earnest  objection  of  the  English-speaking 
members,  the  resolution  was  passed  by  a  strictly  national 
vote.  This  is,  of  course,  not  final,  as  the  subject  must  come 
before  the  Legislature  for  adoption,  when  we  know  it  will 
be  strenuously  opposed.  In  this  connection  we  may  say  that 
many  eminent  men  in  the  profession  to-day  oppose  a  class- 
ical education  as  being  necessary  for  a  medical  man.  Sir 
John  Williams  of  the  University  College  of  South  Wales 
is  one  of  these,  and  the  Dublin  Medical  Press  in  noticing 
his  utterance  says:  "We  are  pleased  that  one  occupying  so 
conspicuous  a  place  in  the  profession  should  have  raised 
his  voice  against  an  indefensible  adherence  to  an  ana- 
chronistic system  of  education." 

The  next  serious  question  which  came  before  the 
College  was  the  consideration  of  the  Roddick  Bill.  A. 
resolution  in  favour  of  it  was  negatived  by  a  vote  of  21  to 
11.  The  minority  would  have  stood  at  13  if  Drs.  Lafleur  and 
McConnell  had  not  left  for  Montreal  before  the  vote  was 
taken.  A  second  resolution  opposing  the  Bill  and  directing 
the  College  to  oppose  any  attempt  to  introduce  into  the 
Legislature  the  necessary  measure  for  its  adoption  was 
carried  by  the  same  vote:  21  to  11.  Several  of  the  French- 
speaking  members  spoke  in  favour  of  it,  but  the  great  ma- 
jority were  fiercely  opposed.  In  our  opinion  they  failed  to 
bring  forward  a  single  sound  argument  against  it.  We  notice 
that  since  the  meeting,  the  President  of  the  College,  accord- 


EDITORIAL.  471 

ing  to  one  or  more  of  the  Montreal  papers,  affirms  that  when 
the  Governors  of  the  College  have  had  time  to  give  the  Bill 
full  consideration,  they  most  likely  will  give  it  their  sup- 
port.    This,  in  our  opinion,  is  begging  the  question.     The 
College  is  presumed  to  be  a  body  of  intelligent  physicians, 
and  to   say  they   require   more  time  for  consideration   is 
absurd.     It  is  six  years  since  Dr.  Roddick  first  introduced 
his  Bill  before  the  Dominion  Parliament,  and  six  months 
since  it  Was  passed.     It  has  been  discussed  by  every  medical 
journal  in,  and  by  mcst  of  the  newspaper  press,  of  Canada. 
,  Nearly  every  member  of  the  profession  in  the  Dominion 
has  received  a  copy  of  the  Bill.     Ample  time  for  its  con- 
sideration has  been  given,  and  the  vote  in  the  College  of . 
Physicians  and  Surgeons   was  the  result  of  that  considera- 
tion.    We  are  informed  that  notwithstanding  this  adverse 
vote,  it  is  Dr.  Roddick's  intention  to  proceed,  as  soon  as  the 
Quebec    Legislature    opens,    with   the   necessary   measure, 
to  put  his  Act  in  operation.     Moreover,  we  believe  that  he 
will  succeed,  for  promises  of  support  have  been  given  him 
from  very  strong  quarters.   Possibly,  the  Quebec  College  of 
Physicians  and  Surgeons    may  learn  that  it  were  better 
if  its  members  were  more  modern  and  up  to  date  in  their 
views.     In   many  ways   we  feel  that  they  have  much  to 
learn,  and  if  they  are  wise  they  will  commence  the  necess- 
ary education  forthwith. 


AN    OBJECT    LESSON    IN    SANITATION. 

We  have,  at  least  once  before,  written  on  the  wonder-- 
ful  results  of  sanitation,  which  have  taken  place  in  Ha- 
vana, since  its  occupation  by  American  troops,  and  which 
still  continues  under  the  same  direction  although  the  great 
bulk  of  the  troops  have  been  withdraMn  and  Cuba  star- 
ted on  its  own  lines  as  a  republic.  (^Vrtainly  the  trans- 
formation has  been  marvellous  and  should  be  an  object 
lesson  to  the  whole  world. 

One  of  the  greatest  achievements  is  the  very  marked 
reduction   in  the  mortality  of  the  island,  and   especially 


472  EDITORIAL. 

in  the  city  of  Havana.  Fir^st  in  importance  in  this  con- 
nection is  Ihe  almost  absolute  eradication  of  yellow  fever, 
which  formeily  played  no  important  a  part  in  malving 
Cuba's  cities  places  to  which  capital  and  peojjle  feared 
to  go.  Investigations  leading  to  the  discovery  of  the  part 
played  by  the  mosquifo  in  the  transmission  of  yellow  fever, 
were  made  with  the  Cuban  funds,  under  the  direction  of 
the  military  government,  on  the  lines  indicated  by  it.  As 
a  result  of  these  investigations,  Cuba  has  been  practically 
free  from  yellow  fever  during  the  past  year.  The  few 
cass  which  ot-curred  were  readily  <  ontroUed,  and  the  dis- 
ease did  not  spread.  A  systematic  vaccination  of  the  en- 
tire people  is  being  carried  on  from  month  to  month,  while 
a  cami)aign  against  glanders,  which  has  been  very  jjrev- 
alent  throughout  the  island,  has  been  brought  to  a  success- 
ful conclusion,  the  government  reimbursing  the  owners 
of  altlicted  animals  to  the  extent  of  50  per  cent,  of  the 
estimated  value.  This  plan  elicited  the  hearty  co-opera- 
tioin  of  the  people  with  the  government,  thereby  making 
possible  the  results  accomplished.  The  medical  authorities 
are  now  devoting  themselves  to  the  control  of  tuberculosis, 
and  are  preparing  a  sanatorium  near  Havana  for  that  pur- 
pose. All  hospitals  are  fitted  with  wards  for  the  treat- 
ment of  tuberculous  patients,  and  the  campaign  against 
this  disease  is  being  carried  on  in  a  thoroughly  effective 
manner.  The  result  of  this  work  has  demonstrated  that 
the  island  is  a  healthy  and  safe  residence  for  Anglo- 
Saxons.  A  large  part  of  the  credit  for  this  sanitary  re- 
formation is  due  to  Major  W.  C.  Gorges.  Surgeon  United 
States  Army,  who  is  the  (.'hief  Sanitary  Officer  of  Havana. 
In  a  private  Jetter  to  Major  Ronald  Ross  (quoted  by  the 
British  Medical  JouniaT),  Major  Gorges  says:  "The  work 
here  has  been  much  more  successful  than  I  had  hoped 
when  we  started.  There  seemed  to  me  very  little  prospect 
for  accomplishing  much  when  we  commenced  in  February 
of  11)01,  but  as  you  will  see  from  our  reports,  our  results 
have  been  most  positive.  For  the  first  time  since  the 
English  occupation,  1762,  we  have  had  an  October  free 
from  yellow  fever,  and  malaria  decreased  more  than  one- 
half.     Mr.  Le  Prince,  directly  in  charge  of  mosquito  work, 


EDITOKIAL.  473 

estimates  that  mosquitoes  have  been  decreased  90  per  cent, 
by  the  work,  as  compared  with  this  time  last  year.  Of 
course  this  is  a  difficult  statement  to  substantiate;  it  is 
a  matter  so  much  of  individual  opinion.  But  I  have  con- 
vinced myself  that  they  have  been  greatly  decreased.  My 
own  quarters  on  the  bay  front,  where  they  have  always 
been  very  bad,  have  had  none  practically  for  the  last  six 
months;  and  I  know  many  other  localities  where  similar 
positive  statements  can  be  made.  But  this  is  certain,  that 
last  October  we  had  seventy-four  deaths  from  yellow  fever; 
this  year  no  deaths  and  no  cases;  and  from  malarial  fever, 
last  year  twenty-five  deaths;  this  year  nineteen.  This,  I  am 
convinced,  is  entirely  due  to  the  mosquito  work.  The 
disappearance  of  yellow  fever,  however,  I  think  is  almost 
altogetehr  due  to  the  killing  of  infected  mosquitoes  at  the 
infected  point.  We  do  this  by  burning  pyrethrum  powder 
in  the  infected  house  and  all  the  neighbouring  houses.  It 
is  ex.tremely  gratifying  to  see  how  promptly  the  focus 
of  infection  is  stamped  out  in  this  way;  and  it  has  been 
likewise  surprising  to  me.  I  knew  that  some  mosquitoes 
must  escape  from  the  most  careful  mosquito  hunt,  but  we 
have  apparently  entirely  controlled  the  disease  this  year 
by  this  method,  when  the  conditions  were  exceedingly 
favourable  for  its  spread.  It  must  be  that  there  are  only  a 
few  infected  mosquitoes  in  each  individual  case,  and  that 
they  remain  pretty  close  to  the  point  of  infection.  And 
this  probably  is  rendered  greater,  if  we  consider  that  it 
takes  a  mosquito  fifteen  or  twenty  days  after  biting  before 
he  himself  is  able  to  transmit  the  disease.  If  fifty  mos- 
quitoes bite  a  yellow  fever  patient,  it  seems  to  me  quite 
probable  from  natural  causes  that  only  four  or  five  would 
survive  the  eighteen  or  nineteen  days  required  to  render 
them  dangerous.  This  sanitation  was  started  and  con- 
tinued under  the  direction  of  General  Wood,  who  was 
originally  a  medical  office  of  the  United  States  Army  and 
was  named  Governor  of  Cuba.  Now  that  his  office  has 
ceased  to  exist,  it  will,  in  all  probability,  be  continued  by 
his  chief  sanitary  officer.  Dr.  Gorges.  We  feel  that  both 
of  these  gentlemen  have  earned,  not  only  renown,  but  the 
gratitude  of  the  civilized  world. 


474  EDITORIAL. 

THE  TREATMENT  OF  TYPHOID  FEVER. 

The  Dublin    Medical  Press   of  July    KJth    last   says: — 
There  are  certain    diseases   that  seem    ever  to   be    in   the 
experimeintal  stage  of  treatment.     And  evidence,  not  alone 
of  the  restless  nature  of  the  physician  of  to-day,  but  also 
of   the   progress   of   scientific   knowledge.     Of   this    latter 
class  is  tj^phoid  fever,  a  disease  which  exemplifies  in  a  pecu- 
liar manner  the  prevalent  theories  of  disease.     To-day  we 
recognize  that  it  is  due  to  a  toxin  that  shows  a  marked 
predilection  for  the  adenoid  tissues  of  the  small  intestines, 
as  strychnine  and  other  such  poisons  do  for  the  muscle 
tissue.     In  typhoid  the  toxic  products  of  Eberth's  bacillus 
are  as  clearly  recognized  by  their  effects  as  are  effects  of 
eloterium  or  pilocarpine.     But  how  does  the  toxin  produc- 
ing bacillus  gain  entrance  to  the  body.     In  the  pre-bac- 
teriological    days  the    text-books    told    of    the    poisonous 
vapours   of   decomposing   products   absorbed  through   the 
pulmonary  air-cells.     We  then  found  the  ground  shifted 
and   adapted   to   meet   what  was  considered   the  require- 
ments of  the  discovery  of  the  bacillus.     The  alimentary 
canal  was  discovered  to  be  the  site  of  infection,  and  the 
introduction  of  the  bacillus  was  accounted  for  by  want  of 
proper  cleanliness — the  soik^d  apparatus  and  stained  linen 
not  having  been  removed  prior  to  their  being  dried  up,  and, 
as  such,  becoming  sources  of  infection.  Withal,  some  physi- 
cians were  not  satisfied  with  all  this  explanation,  and  a 
diligent  search  commenced  for  the  primary  colony  of  the 
germ  of  the  disease,  and  naturally  enough  an  endeavour 
to   attenuate   or  destroy   it.     From   these   researches   Dr. 
Wasdin  concludes  that  the  primary  germ  colony  of  disease 
cannot  be  considered  as  occuring  in  the  intestinal  canal, 
but   to   be   normally   located   in   the   respiratory   tract — a 
theory  which  recalls  that  of  the  past,  and  one  which  in 
part  accounts  for  the  rare  case  of  typhoid  in  which  the 
clinical  symptoms  without  the  normal  pathological  condi- 
tions are  not  present.     According   to  Dr.  Wasdin's  report, 
the  bacillus  toxin  from  the  blood  current  gives  rise  to  all 
the  well-known  terminal  expressions:  infection  of  the  in- 
testinal  canal,  the  serous  membranes,  the  bone  marrow, 
and  so  forth.     To  reach  the  affected  area  in  the  lung  an 


EDITORIAL,  475 

atomised  solution  of  acetozone  is  used,  and  the  same  drug 
is  given  in  casuples  three  times  a  day.  When  the  temper- 
ature threatens  to  be  dangerously  high,  cold  sponging  is 
recommended.  The  good  effect  of  the  treament  is  stated 
to  be  marked  from  the  first  by  an  increased  secretion  by 
the  kidneys,  a  decided  lessening  of  the  malodorous  char-' 
acter  of  the  stools,  which  become  sterile.  By  the  combined 
action  of  the  oral  administration  of  the  drug,  and  its  in- 
halation as  an  atomised  or  cloud  fluid,  the  advocates  of 
the  therapy  claim  that  they  reduce  the  possibility  of 
gaseous  fermentation  and  its  concomitants,  haemorrhage 
and  perforation,  and  at  the  same  time  the  destruction  of 
the  secondary  infection  of  the  canal  by  the  typhoid  organ- 
ism, thereby  averting  further  toxaemia  by  absorption  from 
the  alimentary  canal.  The  germicide  is,  therefore,  to  be 
directed  against  both  the  primary  colony  in  the  respiratory 
tract,  and  the  secondary  expression  in  the  alimentary 
canal.  The  benzoyl-acetyl-peroxide,  which  has  long  been 
known  as  benzozone,  the  antiseptic  used  by  Dr.  Wasdin, 
is  a  nonpoisonous  product  of  the  aromatic  series,  prepared 
from  benzoleic  acid.  The  antiseptic  and  non-poisonous 
properties  of  the  chemical  are  well  known,  and  its  use  in 
toxaemias  can  be  tentatively  recommehded.  The  treat- 
ment attacks  the  disease  on  an  entirely  new  principle,  the 
theory  of  which  has  much  to  commend  it,  not  the  least  of 
which  is  the  innocuous  character  o^  the  therapeutic  agent 
employed. 


THE  EXERCISE  VALUE  OF  DANCING. 

The  Dublin  Medical  Press  of  the  9th  of  July,  last  says: 
— Daiucing  is  a  pastime  proper  to  the  seasons  unfavour- 
able to  outdoor  sports,  and  apart  from  its  social  advan- 
tages, it  is  entitled  to  regard,  if  only  by  reason  of  the  mus- 
cular exercise  which  it  entails,  since  this  is  indispensable 
to  health.  A  correspondent,  also  an  amateur  statistician, 
has  taken  the  trouble  to  calculate  the  distance  covered  by 
dancers  in  their  gyrations.  He  finds  that  a  valse  of  aver- 
age duration  represents  approximately  a  run  of  a  thou- 


4/6  EDITOEIAL. 

sand  yards.  This  is  the  longest  dance,  with  the  excep- 
tioai  of  the  quadrille,  which,  with  its  four  figures,  covers 
nearly  1,800  yards.  The  mazurka  is  only  equivalent  to 
about  900  yards,  and  the  polka  to  800,  while  the  lazy  pas 
(le  quatre  is  barely  700  yards.  Carrying  his  statistical  in- 
genuity still  further,  he  estimates  that  the  usual  series  of 
dances  at  an  ordinary  ball,  beginning  at  10  p.  m.  and  finish- 
ing at  5  a.  m.,  represents  no  less  than  50,000  steps,  equiva- 
lent to  nearly  25  miles  on  level  ground.  Admitting  that 
the  dancers  are  few  in  these  degenerate  days  who  go  con- 
scientiously through  the  entire  list  of  dances  provided  for 
their  entertainment,  the  fact  remains  that  each  man  (and 
woman)  who  does  his  (or  her)  duty  accomplishes  a  very 
respectable  amount  of  exhilarating  exercise.  The  value 
of  exercise  from  a  physiological  point  of  view  is  greatly 
enhanced  by  its  exhilarating  effects,  and  this  is  one  reason 
why  the  daily  ''constitutional"  fails  to  yield  the  health- 
giving  effects  of  cycling,  golf  or  dancing,  the  only  draw- 
back to  the  last  named  being  the  lack  of  fresh  air  and  sun- 
light, which  add  so  materially  to  the  enjoyment  and  salu- 
tary effects  of  all  forms  of  outdoor  exercise. 


SO-CALLED    'CHRISTIAN    SCIENCE."    . 

While  it  is  totally  incomprehensible  to  the  practical, 
hard-headed  common-sense  individual,  that  any  one  should 
pursue  such  an  intangible  chimera  as  "Christian  Science" 
with  such  sublime  faith  as  to  depend  upon  it  in  the  pres- 
ence of  serious  bodily  illness,  certain  it  is  that  the  dis- 
ciples of  this  vicious  religious  monomania  are  increasing 
in  number  and  temporal  power,  and  that  it  is  no  longer 
safe  to  entirely  ignore  it  as  a  menace  to  the  health  and 
well-being  of  the  community.  Both  the  medical  and  sec- 
ular press  have  devoted  considerable  attention  to  the  sub- 
ject, largely  in  the  way  of  ridicule,  but  the  most  powerful, 
logical  aind  altogether  unansw^erable  argument  we  have  yet 
seen  is  comprised  in  a  series  of  short  lectures  bv  Rev. 


EDITORIAL.  477 

Andrew  F.  Underbill,  of  St.  John's  Episcopal  Church, 
Yonkers,  N.  Y.,  entitled  "Valid  Objections  to  So-Called 
Christian  Science."  Kealizing  that  their  interests  are 
identical  with  those  of  the  medical  profession,  and  that 
the  enemy  of  one  is  the  enemy  of  both,  the  Arlington  Chem- 
ical Company  is  anxious  to  do  its  part  in  relegating  this 
absurd  cult  to  the  limbo  of  oblivion  where  it  may  rest 
peacefully  side  by  side  with  the  many  foolish  fads  that 
have  preceded  it. 

Appreciating  the  force  of  the  argument  referred  to, 
and  being  convinced  that  it  will  place  in  the  hands  of  the 
physician  a  well-forged  weapon  wherewith  to  combat  such 
a  subtle  and  dangerous  enemy,  the  Arlington  Chemical 
Company  has  obtained  the  permission  of  the  author  to  re- 
print these  lectures  in  booklet  form  and  distribute  them 
to  physicians.  If  any  of  our  readers  have  been  overlooked 
in  the  mailing,  a  request  to  the  above  company  will  bring 
a  copy. 


Dr.  Osier  relates  an  anecdote  of  Dr.  Benjamin  Win- 
slow  Dudley,  of  Lexington,  Ky.,  who  was  one  of  the  most 
famous  lithotomists  of  his  day.  No  surgeon  in  the  South 
or  West  had  such  a  reputation,  and  he  more  tha.n  any  one 
else  built  up  the  fame  of  the  Transylvaiuia  school.  In  1837, 
a  poor  lad  with  stone  was  brought  to  him  from  one  of  the 
distant  settlements.  The  operation  was  successful  and 
when  the  parents  asked  Dr.  Dudley  for  his  fee,  knowing 
their  circumstances,  he  refused  to  take  anything.  The 
young  lad  was  deeply  impressed  by  the  generosity  of  the 
great  surgeon  and  made  a  resolve  that  if  ever  he  became 
rich  the  fee  should  be  paid.  About  two  years  ago  one 
of  the  heirs  of  Dr.  Dudley  had  a  letter  from  W.  G.  Saun- 
ders, of  Iowa,  stating  that  he  was  anxious  to  make  arrang- 
ments  to  pay  a  long-standing  indebtedness  and  asked  if 
a  fee  of  |500  would  be  suitable  for  the  operation  of  litho- 
tomy performed  on  him  by  Dr.  Dudley  in  1837.  Last  year 
the  executors  of  Mr.  Saunders  wrote  that  in  a  codicil  of  his 


47^  BOOK   REVIEWS. 

will  directions  were  given  to  pay  the  fee  with  interest  and 
they  had  much  pleasure  in  handing  over  the  sum  of  |2,390. 


Dr.  McHull,  of  Atlanta,  Ga.,  writes  to  American  Med- 
icine, that  he  had  occasion  recently  to  look  through  the 
death  certificates  in  the  office  of  the  Board  of  Health.  The 
following  were  assigned  as  causes  of  death  in  certain  cases : 
''Broken  thye,"  ''bad  blood,"  "hemmorrhage  from  nable," 
"mesals,"  "heart  dropse,"  ''bilious  liver,"  "grastritis," 
"angina  becgrois,"  "ptesis."  "Parlices"  caused  death  in 
one,  while  "perrallisis"*was  the  cause  in  another.  Multi- 
tudes died  of  "colery  infantum;"  a  few  of  "colarah  mor- 
bus;" one  physician  was  inot  sure  whether  it  was  "dirhea" 
or  "disentary;"  another,  however,  was  quite  sure  that 
"dyorhear"  was  the  cause  of  the  death  of  his  patient.  One 
infant  succumbed  to  "choaking  croup:"  another  patient 
passed  away  for  "want  of  proper  treatment." 


Book   Reviews, 


Progressive  Medicine.  A  quarterly  digest  of  advances,  dis- 
coveries and  improvements  in  the  medical  and  surgical 
sciences.  Edited  by  Hobart  Amory  Hare,  M.  D.,  Professor 
of  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical 
College  of  Philadelphia,  assisted  by  H.  R.  M.  Landis,  M.  D., 
Assistant  Physician  to  the  out-patient  department  of  Jefferson 
Medical  College.  Vol.  HI.,  September,  1902.  Lea  Brothers 
&  Co.,  Philadelphia  and  New  York,  1902. 

The  present  volume  embraces  diseases  of  ihe  thorax  and  its 
viscera,  including  the  heart,  lungs  and  blood  vessels  ;  dermatology 
and  syphilis  ;  diseases  of  the  nervous  system  and  obstetrics.  As 
an  epitome  of  the  literature  of  these  subjects  for  the  last  three 
months  is  given,  it  will  readily  be  understood  that  it  is  quite  impos- 
sible to  critically  examine  and  comraeni  upon  such  a  mass  as  is 
included  in  this  volume  of  four  hundred  pages.  We  have,  however, 
passed  several  hours  in  reading  the  most  important  of  its  contents, 
and  have  been  struck  with  the  practical  character  of  the  majority. 


BOOK  REVIEWS.  479 

The  chapter  on  Diseases  of  the  Lungs,  by  William  Ewart,  of  Lon- 
don, while  emphasizing  the  fact  thai  one  disease,  pneumonia,  has 
not  made  much  progr^^ss  for  many  years  towards  successful  treat- 
ment, yet  intimates  that  its  future  seems  decidedly  bright.  We  note, 
and  with  pleasure,  that  the  "  lost  art,"  bleeding,  is  once  more  being 
recommended  for  employment  "  in  the  early  stages  in  strong  mid- 
dle-aged subjects  with  difficult  respiration  and  heaving  pulse."  We 
have,  in  the  early  years  of  our  practice,  seen  such  immense  relief 
follow  its  employment  in  several  such  cases, that  we  have  never  ceased 
to  wonder  at  its  not  being  used.  The  employment  of  the  anti- 
pneumococcus  serum  has  been  tried  by  many,  but  not  one  seems  to 
write  of  even  average  success.  We  find  perhaps  the  most  satisfac- 
tory part  cf  the  treatment  of  this  disease,  as  recorded  in  this 
volume,  is  that  by  the  carbonate  of  creosote  (creosotal),  a  paper 
on  which  we  published  a  few  months  ago.  The  success,  as  recorded 
by  more  than  one  wri-.er,  has  heen  phenomenal.  The  portion  de- 
voted to  Pulmonary  Tuberculosis  brings  up  to  date  a  subject  which, 
as  the  whole  profession  is  aware,  is  to-day  the  burning  question  of  the 
hour.  We  have  been  particularly  struck  with  the  recommendation 
of  Robinson  [British  Medical  Journal,  Feb.  22,  1902),  which 
we  fully  endorse,  that  wards  should  be  set  apart  in  all  general 
hospitals  for  the  treatment  of  phthisis,  both  as  a  humanitarian  duty, 
and  also  for  the  important  object  of  medical  education.  At  present 
it  is  doubtful  if  many  graduates  of  the  present  time  are  able  to  fol- 
low a  single  case  of  phthisis  from  commencement  to  the  end.  In 
that  part  devoted  10  diseases  of  the  brain  some  interesting  cases  of 
brain  tumour  successfully  removed  are  recorded. 

The  fourth  and  last,  but  not  least,  article  in  the  volume  is  pre- 
pared by  Richard  C.  Norris,  of  the  University  of  Pennsylvania. 
That  it  is  well  done  goes  without  saying,  as  is  all  thai  appears  from 
Dr.  Norris'  facile  pen.  The  entire  ground  of  obstetrics,  covering 
pregnancy,  the  management  of  labour,  obstetrical  surgery,  tu- 
mours complicating  pregnancy,  labour  obstructed  by  pelvic  de- 
formity, placenta  previa,  post  partum  hemorrhage,  the  management 
of  puerperium  and  the  care  of  the  newborn  infant  have  been  gone 
over  in  a  painstaking  way  that  insures  the  reader  of  Progressive 
Medicine  a  complete  r^jz/w^  of  all  that  is  new  in  these  important 
branches  of  the  subject. 

In  short,  this  volume  will  be  found  to  contain  all  that  is  new 
on  the  subjects  which  it  covers. 

In  medical  literature  so  vast  is  the  number  of  volumes  and 
periodical  articles  which  annually  appear  that  no  practitioner  can 
hope,  without  such  an  aid  as  Progressive  Medicine,  to  keep 
abreast  of  the  rapid  advances  that  lake  place,  and  no  one  who 
attempts  to  do  his  duty  by  his  patients  can  afford  to  be  without 
these  volumes,  and  there  is  no  one,  however  well  he  may  be  posted, 
but  can  find  ample  material  well  worthy  of  fiis  careful  investigation 
and  study. 

F.  W.  C. 


480  BOOK   REVIEWS. 

Reynolds'  &  Newell's  Practical  Midwifery.  A  Manual 
of  Obstetrics  for  Students  and  Physicians,  by  Edward  Rey- 
nolds, M.  D.,  Assistant  in  Obstetrics,  etc.,  and  Franklin  S. 
Newell,  M.  D.,  Assistant  in  Obstetrics  and  Gynecology  in 
Harvard  University  Medical  School,  Boston.  In  one  octavo 
volume  of  531  pages,  with  253  engravings,  and  3  full  page 
coloured  plates.  Cloth,  $3.75,  net.-  Lea  Brothers  &  Co., 
publisher?,  Philadelphia  and  New  York,  1902. 

The  authors  in  the  preface  state  that  this  work  is  written  in  a 
dogmatic  style  so  as  to  be  more  useful  to  students  and  for  teaching 
purposes.  There  would  only  be  one  ground  possible  for  writing  a 
work  like  this  in  such  a  manner  and  we  feel  that  they  have  thoroughly 
justified  their  assertion — "  Of  all  the  books  on  the  subject  lately 
printed  we  have  come  across  no  book  so  well  calculated  to  teach 
the  student  modern  obstetrics."  It  must  be  highly  commended. 
All  who  desire  to  learn  obstetrics  should  have  a  co|)y  of  it. 

H.  L.  R. 

Disease  of  the  Anus,  Rectum  and  Pelvic  Colon.    By 

James  P.  Tuttle,  A.  M.,  M.  D.,  Professor  of  Rectal  Surgery  in 
the  New  York  Polyclinic  Medical  School  and  Hospital,  Visit- 
ing Surgeon  to  the  almshouse  and  workhouse  hospitals.  D. 
Appleion  &i  Co.,  New  York,  1902. 

The  volume  is  of  convenient  size,  printed  on  good  paper,  with 
eight  coloured  plates  and  three  hundred  and  thirty-eight  illustra- 
tions. Credit  is  due  the  publishers.  The  subjects  treated  have 
been  dealt  with  in  a  thorough  and  systematic  manner.  The  author 
has  had  a  wide  experience  in  rectal  diseases  and  has  set  forth  his 
views  and  methods  in  such  a  way  as  to  be  both  pleasant  reading 
and  of  real  value  to  the  general  practitioner  when  he  is  called  upon 
to  treat  diseased  conditions  in  this  field  of  surgery.  The  book 
shows  that  many  advances  have  been  made  within  the  past  few 
years  in  this  field  of  surgery.  Both  improved  methods  of  examina- 
tions and  treatment  have  been  clearly  presented.  Chapter  i  deals 
with  embryology,  anatomy  and  physiology.  Chapter  2  discusses 
malformations  of  the  anus  and  rectum.  Chapter  3  is  devoted  to 
methods  of  examination  and  diagnosis.  We  were  interested  in 
reading  the  article  on  hemorrhoids  and  glad  to  find  the  clamp  and 
cautery  advocated  as  the  operation  of  choice  in  the  radical  cure. 
It  is  claimed  that  where  the  operation  is  properly  performed  hemor- 
rhage is  practically  never  met  with.  This  has  been  our  own  ex- 
perience. Stricture,  too,  may  be  said  to  never  occur.  Throughout 
the  book  treatment  of  the  various  diseased  conditions  has  been 
gone  into  in  detail,  a  character  of  the  work  which  is  sure  to  be 
appreciated. 

F.  R.  E. 


CANADA 


MEDICAL  RECORD 


NOVl£MB£R.     1902. 


Original    Communications. 


SEPTICEMIA  AND  THE  CURETTE. 

BY  H.  PLYMPTON,  M.  D.,  BROOKLYN,  N.  Y. 

To  attempt  to  break  up  an  old  established  custom  in 
any  line  of  life  is  at  best  a  thankless  job,  and  one  likely 
to  call  down  harsh  criticism  upon  the  head  of  the  daring 
iconoclast. 

To  attempt  to  uproot  old  prejudices  existing  in  favour 
of  a  certain  line  of  practice  in  surgery,  and  diametrically 
oppose  such  practice,  is  to  invite  from  some,  adverse  criti- 
cism of  the  harshest  kind.  The  only  recompense  for  this 
is  a  logical  refutation  of,  or  concurrence  in  the  argument 
advanced,  on  the  part  of  other  members  of  the  profession. 

This  latter  is  what  I  hope  for,  and  if  I  provoke  a  dis- 
cussion, or  start  a  line  of  thought  in  the  minds  of  half  of 
the  readers  of  this  article,  I  shall  have  achieved  all  I  start- 
ed out  to  do. 

Curetting  the  uterus  to  remove  fragments  of  after- 
birth or  other  debris  has  been  taught  in  our  Medical 
Schools  from  time  immemorial,  and  it  is  firmly  fixed  in  the 
receptive  and  retentive  mind  of  every  Medical  student  that 
the  first  move  following  any  such  abnormal  uterine  condi- 
tion  is  to  cleanse  the  uterus  by  means  of  the  curette. 

That  the  organ  should  be  thoroughly  and  aseptically 
cleansed  admits  of  no  argument,  but  that  the  work  should 
be  done  with  the  currette  I  deny  most  emphatically. 


482  SEPTICEMIA  AND  THE  CURETTE. 

The  majority  of  cases  of  death  following  the  decom- 
position of  foetus  or  placenta  in  utero    are  caused  by  the 
use  of  the  curette,  and  I  hold  that  septicemia  may  be  avoid-' 
ed  if  a  more  rational  procedure  be  resorted  to. 

The  condition  of  the  uterus  containing  septic  matter 
is  one  of  great  congestion,  the  thickened  walls  being  coated 
internally  and  over  the  os  with  a  thick,  brown,  tenacious 
mucus. 

The  congestion  is  active,  and  therefore  the  more  dan- 
gerous in  the  event  of  the  admission  of  septic  matter  into 
the  circulation. 

If  the  curette  is  used,  denuding  the  walls  of  their  pro- 
tective covering,  an  immediate  vaccination  takes  place 
with  a  septic  virus,  septicemia  following  in  an  incredibly 
short  space  of  time  (chemical  metamorphosis  is  marvellous- 
ly rapid  in  the  circulatory  system),  and  death  quickly 
ensues. 

If,  without  using  the  curette,  we  can  remove  the  septic 
matter  from  the  uterus  without  disturbing  the  mucus 
covering,  and  enable  the  uterus  of  itself  to  expel  the  coat- 
ing, we  shall  have  taken  a  long  step  forward  in  the  treat- 
ment of  this  class  of  uterine  cases. 

The  uterus  by  reason  of  its  congestion  may  be  inade 
to  perform  a  self-cleansing  act  by  exciting  the  exudation 
of  the  serum  of  the  blood  into  its  cavity,  thereby  washing 
itself  out,  and  expelling  all  septic  matter  instead  of  absorb- 
ing it. 

This  process  of  ex:osmosis  is  induced  by  a  properly 
combined  alkaline  solution  at  a  temperature .  above  100° 
and  a  strict  avoidance  of  bi-chloride,  carbolic  acid,  formal- 
dehyde, or  any  antiseptic  of  an  acid  reaction  or  astringent 
nature,  which  would  coagulate  the  fibrine  and  albumen  of 
the  blood. 

My  method  of  procedure  is  as  follows: 

First,  the  gentle  removal  of  whatever  fragments  are 
lying  in  the  uterine  cavity,  by  means  of  forceps,  care  being 
taken  not  to  tear  from  the  walls  any  adherent  piece. 


SEPTICEMIA  AND  THE  CURETTE.  483 

Second,  the  gentle  flushing  of  the  uterine  cavity  with 
the  alkaline  solution  (110°),  the  reservoir  containing  the 
fluid  being  not  more  than  two  feet  above  the  level  of  the 
hips. 

If  the  flushing  could  be  continuously  administered  for 
a  few  hours  (say  two  or  three),  the  conditions  would  be 
more  speedily  reduced  to  normal,  but  the  discomfort  of  the 
position  of  the  patient  (on  a  douche  pan),  prevents  this, 
and  a  flushing  once  every  two  hours  with  one  quart  of  solu- 
tion is  about  the  limit  of  treatment. 

For  flushing  the  uterus,  I  use  a  small  dilating  uterine 
douche,  and  as  there  is  plenty  of  room  for  the  escape  of 
fluid  and  fragments,  there  is  no  danger  of  fallopian  colic 
or  salpingitis. 

The  first  flushing  is  frequently  followed  by  contractile 
pains  and  expulsion  of  any  previously  adherent  pieces, 
together  with  much  of  the  mucus. 

A  tablet  of  Ext.  Cannabis  Indica,  gr.  %. 
"  Ext.  Ergotin,  "       gr.  ¥2. 

every  hour  till  desired  effect  is  produced  will  contract  ut- 
erus and  alleviate  pain. 

The  bowels  should  be  moved  freely,  both  by  enema 
and  catharsis. 

During  the  interval  between  douches,  the  patient 
should  be  kept  on  her  back  with  the  hips  sufficiently  raised 
to  permit  the  retention  in  the  vagina  of  as  much  of  the 
alkaline  solution  as  it  will  hold. 

The  rapidity  with  which  this  treatment  will  reduce 
temperature,  relieve  pain,  stop  vomiting  and  remove  offen- 
sive odor  is  marvellous  to  one  who  has  not  tried  it.  Some- 
times two  flushings  are  sufficient  to  cleanse  the  uterus 
thoroughly,  vaginal  douches  being  all  that  are  needed  sub- 
sequently to  complete  the  work. 

Uterine  congestion  is  speedily  relieved,  and  the  uter- 
ine discharge  changes  from  brown,  thick,  bad  smelling 
mucus  to  a  thin  transparent  one,  accompanied  or  followed 
by  more  or  less  of  a  flow  of  blood. 


484  PROCEDURE   IN   POST-MORTEM 

A  reduction  in  the  frequency  of  the  flushings  is  desir- 
able as  soon  as  a  tendency  to  return  to  normal  conditions 
begins  to  be  observed,  as  it  frequently  will  within  twenty- 
four  hours.  Then  simple  vaginal  douches  every  three 
hours  with  an  occasional  uterine  flushing  if  symptoms  in- 
dicate it. 

The  action  of  exosmosis  (and  endosmosis,  for  there  is 
every  reason  to  believe  in  the  absorption  of  some  of  the 
fluid)  is  what  is  desired  to  relieve  the  existing  congestion, 
as  in  bronchitis,  pneumonia,  congestion  of  kidney,  con- 
gestion of  any  mucous  membrane,  etc.,  and  is  the  most 
rational  means  of  restoring  to  normal  condition, 

I  do  not  wish  to  be  understood  as  decrying  the  use  of 
that  most  valuable  instrument,  the  curette,  but  only  the 
abuse  of  it,  to  wit:  its  employment  under  such  conditions 
as  make  it  practically  a  sharp  weapon  loaded  with  septic 
matter,  dangerous  beyond  the  poisoned  arrow  of  the  Malay, 
or  the  fang  of  cobra,  and  utterly  opposed  to  our  modern 
ideas  of  antisepsis. 


PROCEl>TrRE    IN    POST-MORTEM    MEDICO-LEGAIi 
EXAMINATIONS. 

BY   CHARLES   A.    HEBBERT,    M.R.C.P.,    London, 
Professor  of  Anatomy,  Bishop's  College,  Montreal. 

Case  7. 
This  case  is  published  for  the  purpose  of  bringing 
forward  several  points  in  the  cases  of  presumed  infanticide 
and  to  draw  attention  to  the  law  on  the  subject,  and  further, 
to  demonstrate  some  ill-defined  or  imperfectly  understood 
conditions  which  a  medical  jurist  may  have  to  determine 
or  elucidate,  and  probably  lead  by  such  methods  to  some 
clearance  of  the  difficulties  he  may  have  to  contend  with. 
It  may  be  stated  that  the  inquiry  was  as  to  the  death 
of  an  illegitimate  child  born  in  secrecy,  the  mother  being 
alone  and  seated  on  the  water  closet  at  the  time  of 
birth. 


MEDICO-LEGAL    EXAMINATIONS.  485 

External  Appearances. 

The  body  was  that  of  a  male  infant,  19  inches  in  length, 
weight  8  lbs.,  the  testicles  were  in  the  scrotum,  the  finger 
nails  projected  beyond  the  finger  ends  and  the  toe-nails 
were  at  the  level  of  the  toe  ends.  The  umbilical  cord  was 
attached.  The  whole  length  of  the  cord  was  3^  inches,  of 
which  I  inch  showed  an  irregular  obliquely  torn  margin* 
There  was  no  sign  .of  ecchymosis  in  this  margin.  There  was 
an  ecchymosis  over  the  glabellum,  and  the  upper  lip  was 
swollen  and  showed  some  marks  of  bruising.  The  lower  lip 
and  chin  were  free  from  bruising.  The  tongue  was  clenched 
between  the  gums.  The  surface  of  the  body  was  pallid  and 
rigor  mortis  was  present. 

Internal  Examination. 

Head. — No  fracture  of  skull.  Brain  normal.  The 
tongue,  with  larynx,  pharynx,  trachea,  oesophagus,  lungs,  heart 
and  thymus  gland,  were  removed  en  masse.  The  lungs  floated 
in  water  and  had  been  fully  aerated.  There  were  no  ecchy- 
moses  visible  on  the  pericardium  or  pleura.  The  larynxi 
trachea  and  bronchi  down  to  the  third  and  fourth  division 
appeared  healthy,  and  there  was  no  reddening  or  softening 
of  the  mucous  membrane  in  any  part  of  the  tract. 

The  Heart. — The  right  side  was  engorged  with  black 
fluid  blood. 

Abdomen. — The  stomach  was  empty.  The  mucous 
membrane  pale  and  no  ecchymoses  noticeable.  Small  in- 
testines empty.     Large  intestine  contained  some  meconium. 

The  liver  and  kidneys  were  apparently  normal  in  struc- 
ture, but  somewhat  dark  in  colour,  and  congested.  The 
spleen  was  normal.  Bladder  empty.  The  verdict  returned 
was  that  the  child  had  been  born  alive  at  full  term  and  that 
the  cause  of  death  was  probably  due  to  asphyxia. 

Comment. 

The  first  point  of  importance  in  this  case  was  how  far 
the  mother  was  responsible  for  the  death  of  the  child,  and 


486  PROCEDURE   IN   POST-MORTEM 

whether  or  not  a  charge  of  homicide  should  be  brought 
against  her  ?  The  child  was  expelled  in  the  pan  of  a  water- 
closet,  the  mother  bong  alone  and  unattended  ;  the  child 
was  born  alive,  but  died  before  severance  from  the  mother* 
as  shewn  by  the  absence  of  ecchymosis  in  the  fcetal  end  of 
the  cord.  The  placenta  was  removed  from  the  mother  some 
hours  later  with  some  difficulty  on  account  of  firm  adherence 
to  the  womb.  This  fact  with  the  ragged  appearance  of  the 
foetal  end  of  the  cord  would  indicate  a  forcible  tearing 
of  the  structure,  as  might  occur  on  a  woman  suddenly 
arising  from  the  seat  of  a  closet,  the  weight  of  the  child  on 
the  one  hand  and  the  firm  union  of  the  placenta  to  the 
womb  on  the  other  hand  causing  a  sudden  fracture  of  the 
cord  at  the  point  of  least  resistance. 

The  bruising  of  the  glabellum  and  the  upper  lip,  the 
two  most  prominent  parts  of  an  extended  head  in  delivery, 
would  suggest  the  impact  of  those  parts  at  the  time  of 
expulsion  on  the  hard  floor  of  the  basin  and  the  fact  that 
the  basin  must  have  contained  various  fluids  would  account 
for  the  cause  of  death,  partly  from  asphyxia,  partly  from 
shock,  and  it  may  be  added  from  the  fragility  of  a  newborn 
child's  life.  Every  practitioner  knows  how  hard  sometimes 
it  is  to  preserve  a  child's  existence  on  birth  even  under  the 
most  favourable  surroundings,  and  how  much  harder  it  must 
be  for  a  child  to  survive  under  the  circumstances  of  non- 
attention,  the  complete  ignorance  of  the  situation  and  the 
terrified  state  of  the  suffering  woman  at  such  a  time. 

The  verdict  that  the  mother  should  not  be  incriminated 
was  obviously  just. 

Now,  the  next  point  of  importance  is  the  law  on  the 
subject. 

The  law  humanely  assumes  that  the  child  has  been  born 
dead  until  the  contrary  is  proved,  and  in  this  accepted  proof 
the  question  is  involved  as  to  when  does  a  child  become  a 
human  being. 

The  Criminal  Code,  1892,  55-56  Vict.,  c.  29,  criminal 
offences.  Part  xvii.,  section  219,  defines  : — 

A  child   becomes  a  human  being  within   the  meaning 


MEDICO-LEGAL    EXAMINATIONS.  487 

of  the  Act  when  it  has  completely  proceeded  in  a  living 
state  from  the  body  of  its  mother,  whether  it  has  breathed 
or  not,  whether  it  has  an  independent  circulation  or  not,  and 
whether  the  navel  string  has  been  severed  or  not.  The 
killing  of  such  a  child  is  homicide  when  it  dies  in  conse- 
quence of  injuries  received  before,  during  or  after  birth. 

Sect.  271 — Killing  Unborn  Children. 

I.  Every  one  is  guilty  of  an  indictable  offence  and 
liable  to  imprisonment  for  life  who  causes  the  death  of  any 
child  which  has  not  become  a  human  being,  in  such  a 
manner  that  she  would  have  been  found  guilty  if  such  child 
had  been  born. 

Now,  in  this  case  it  was  clear  that  the  child  had  legally 
become  a  human  being,  because  it  had  fully  breathed,  but, 
at  the  same  time,  had  died  before  it  had  an  independent 
circulation  from  the  mother,  as  shewn  by  the  evidences  of  the 
umbilical  cord. 

The  question  is,  under  which  section  the  woman  could 
be  indicted  ?  It  was  clear  that  the  cause  of  death  was  not 
the  result  of  either  wilful  neglect  or  criminal  interference, 
but  rather  due  to  the  fright  and  lack  of  attention  attending 
such  a  situation,  and  it  w:uld  have  been  a  grave  mistake  to 
have  prosecuted  the  woman  on  the  more  serious  charge. 
On  the  other  hand,  she  could  not  be  liable  to  the  minor 
charge,  as  the  child  had  been  pronounced  a  human  being. 
Separate  existence  ought  to  be  more  clearly  defined.  Should 
a  child  which  has  breathed,  but  has  not  had  a  separate 
circulation,  be  considered  as  the  victim  of  homicide .''  The 
law  says  yes,  but  the  foregoing  is  a  case  which  might  suggest 
some  emendation  of  that  clause. 

I  have  thought  this  subject  worth  airing  and  consider- 
ing, for  the  issues  may  be  very  important,  involving  the 
liberty  or  even  the  life  of  a  person. 

In  the  first  section  of  the  code  quoted,  a  child  is 
accepted  as  a  human  being  if  it  has  breathed,  without  a 
separate  circulation,  or  has  had  a  separate  circulation  with- 
out having  breathed)  or  either  the  first  or  second  condition 


488  DIAGNOSIS  OF  PLEURITIC  EFFUSIONS. 

whether  the  cord  is  severed  or  not,  and  the  charge  is  homi- 
cide if  this  being  dies  by  interference.  It  might  be  reason- 
ably argued  that,  biologically,  a  being  is  not  a  being  until 
the  functions  of  life,  breathing,  circulation  separate  from  the 
mother  have  been  completely  established  and  the  being  is 
organically  capable  of  maintaining  its  own  existence. 

This,  then,  is  the  dilemma ;  legally,  a  human  child  is  a 
human  being  with  a  possible  imperfect  separate  existence. 
Biologically,  it  is  not  until  the  separate  life  of  the  organism 
is  complete  and  self-maintaining. 

I  have  consulted  several  eminent  lawyers  on  these 
points,  and  they  fully  appreciate  the  legal  difficulties  which 
may  arise.  I  have  brought  forward  this  case  as  suggestive, 
and  to  invite  some  comment  and  argument  on  the  subject. 


Selected  Articles. 


THE  DIFFERENTIAL   DIAGNOSIS   OF  PLEURITIC 
EFFUSIONS. 

BY    DR.    ALEX.    VOX    KORAXYI,    PROFESSOR   AT    THE    FACULTY   OF 
MEDICINE    AT    BUDAPEST. 

It  is  well  known  to  clinicians  that  many  cases  of  pleu- 
ritic effusioin  are  diflftcult,  if  not  impossible,  to  delimit  by 
percussion  owing  to  one  or  more  of  the  solid  organs,  such 
as  the  liver,  lying  in  the  immediate  neighbourhood  of  the 
effused  liquid.  These  cases,  rare  though  they  be,  are  suf- 
ficient to  prove  the  existence  of  certain  defects  in  our 
means  of  clinical  investigation.  The  importance  of 
Traube's  space  in  the  diagnosis  of  left-sided  effusion  is 
also  a  factor  in  the  diagnosis  of  all  such  cases,  one,  too, 
that  should  not  be  overlooked  in  the  delimitation  of  the 
chest.  This  is  a  space  w^hich  is  often  filled  by  increase  in 
size  of  the  liver,  the  heart,  or  the  spleen,  and  these  condi- 
tions require  to  be  differentiated  from  pleuritic  effusion. 
The  space  is  in  the  lower  part  of  the  thorax  lying  between 
the  liver  and  spleen.  This,  the  so-called  Traube  space,  is 
often  the  most  difficult  to  percuss  owing  to  the  frequency 
of  its  being  filled  with  fluid,  while  above  it  may  be  found 
the  consolidated  lung,  fluids  always  gravitating  to  the  low- 


DIAGNOSIS  OF  PLEURITIC  EFFUSIONS.  489 

est  leveL  In  this  case  the  crescentic  outline  of  the  lung 
will  still  be  observed  whether  the  dulness  be  present  or 
not.  The  same  diflSculty  prevails  posteriorly  in  defining 
the  limits  of  the  lung  and  spinal  column.  It  is  with  this 
object  in  view,  and  to  elucidate  the  utility  of  transsonant 
percussion,  that  the  author  has  approached  the  subject. 

If  the  stethoscope  be  placed  over  a  solid  organ  of  the 
body  at  a  point  where  it  approaches  the  parietes,  and  the 
part  percussed  at  the  same  time,  a  peculiar  sound  of  a 
shrill  ringing  character  will  be  heard.  This  sound  con- 
tinues as  long  as  the  percussion  is  within  the  parietal  con- 
tact limits  of  the  auscultated  organ,  but  ceases  imme- 
diately the  limit  is  passed.  By  this  means  the  surface 
contact  of  a  parietal  organ  can  be  accurately  delineated 
on  the  surface  of  the  body.  The  author  has 'marked  out 
the  boundaries  in  many  obscure  cases  by  this  topograph- 
ical percussion,  which  could  not  have  otherwise  been  ac- 
complished. The  author  uses  a  simple  binaural  stetho- 
scope with  two  india-rubber  tubes  fitted  with  olive-shaped 
vulcanite  ends  for  the  ears.  The  point  of  the  left  index 
finger  is  pressed  well  down  .into  the  surface  of  the  body 
and  then  struck  with  the  firmly  extended  finger  of  the 
right  hand.  This  form  of  percussion  is  a  slight  modifica- 
tion of  Reichmann's,  who  employed  a  rod  to  press  into  the 
surface,  which  he  struck  with  the  finger  in  percussing. 
Either  method  may  be  employed  in  this  form  of  ausculta- 
tion, and  the  results  obtained  will  be  in  proportion  to  the  " 
operator's  experience  of  the  particular  method,  as  the  prin- 
ciple is  the  same,  though  reduced  to  its  simplest  form  in 
the  striking  of  the  finger. 

The  method  adopted  by  the  author  is  to  press  the  point 
of  the  left  index  finger  well  into  the  thorax,  and  then 
strike  it  with  a  finger  of  the  right  hand;  either  method 
gives  a  similar  tone  by  the  stethoscope.  Long  and  careful 
observation  is  absolutely  necessary  to  prevent  mistakes. 
One  point  might  be  noted  for  the  benefit  of  those  who  have 
not  practiced  this  form  of  auscultation,  viz.,  that  the  dis- 
tance between  the  finger  and  the  stethoscope  must  not  be 
too  great,  or  the  sound  may  be.  so  altered  as  to  lead  to 
error;  it  is  therefore  necessary  that  the  finger  should  slow- 
ly and  methodically  .follow  the  stethoscope  in  percussing 
the  organ.  Again,  the  ribs  are  good  conductors  of  sound, 
and  mav  lead  to  error  if  the  finger  be  not  well  pressed 
down  between  them,  more  particularly  in  the  neighbourhood 
of  the  sternum.  In  the  event  of  one's  not  being  able  to  get 
between  the  ribs,  an  assistant  may  be  directed  to  place  his 
hands  on  the  chest  on  either  side  of  the  point  which  is 
under  examination ;  for  instance,  one  on  the  sternum  and 


490  DIAGNOSIS  OF  PLEURITIC   EFFUSIONS. 

the  other  on  the  lateral  wall  of  the  thorax.  By  th\s  device 
the  author  has  been  able  to  percuss  the  most  complicated 
cases  with  excellent  results. 

This  form  of  auscultatory  percussion  enables  one  to 
analyse  the  dulness  of  a  number  of  organs  lying  in  very 
close  proximity  to  each  other,  which  can  be  done  with 
perfect  accuracy  and  ease,  when  the  heart,  liver,  and  stom- 
ach are  clearly  defined. 

This  method  of  diagnosis  is  particularly  valuable  in 
left-sided  pleuritic  effusion.  If  the  stethoscope  be  placed 
on  the  outside  of  the  cardiac  area  it  will  be  found  to  have 
extended  far  into  the  effusion  if  followed  to  its  outer 
border.  In  percussing  the  exudation  itself  it  must  be 
borne  in  mind  that  the  upper  part  of  the  dulness  does  not 
accurately  define  the  limit  of  the  effusion,  as  more  accur- 
acy will  be  required  to  define  the  line  of  demarcation  be- 
tween the  compressed  lung  and  the  fluid.  If  the  thorax  be 
percussed  behind,  it  will  be  difficult  to  limit  the  effusion 
externally,  as  the  lung  will  gradually  sink;  but  if  per- 
cussed towards  the  spinal  column  it  will  be  found  to  go 
across  the  medial  line,  towards  the  right  or  healthy  side. 

The  lower  margin  of  the  fluid  is  another  important 
feature  in  the  diagnosis,  which  practically  should  extend 
from  the  twelfth  rib  posteriorly  along  the  margin  of  the 
thorax  to  the  front,  but  in  practice  it  will  be  found  to  be 
far  below  the  marginal  vault  of  the  thorax,  as  the  exuda- 
tion by  its  own  weight  tends  to  push  the  diaphragm  down, 
and  thus  distend  the  pleural  sac  in  that  direction.  On 
the  other  hand,  the  empty  lung  will  be  found,  not  in  the 
complementary  space  made  by  this  depression  of  fluid,  but 
highly  placed  in  the  posterior  part  of  the  thorax  about  on 
.'I  level  with  the  ninth  rib  in  the  scapular  region.  It  will 
be  seen  that  the  defining  of  an  effusion  is  a  long  and  te- 
dious process,  and  entails  what  in  many  cases  is  unneces- 
sarv  labour;  but  questions  do  sometimes  arise  that  tax  our, 
ingenuity  to  the  utmost  to  delimitate  effusions  from  some 
other  morbid  change  that  may  lead  us  astray  in  operating 
— for  instance,  if  it  be  doubtful  whether  the  case  is  pleural 
effusion  or  pneumonia  or  whether  there  is  effusion 
with  pneumonia.  This  can  easily  be  differentiated" 
by  placing  the  stethoscope  within  the  scapular  line  and 
slowly  percussing  outwardly.  If  a  pleural  effusion  exist 
the  dulness  will  follow  the  costal  curve,  but  if  it  be  pneu- 
monia without  effusion  the  alteration  in  sound  will  be  two 
inches  higher  than  the  curve.  By  the  same  process  of  ex- 
amination both  sides  may  be  high  and  reveal  double  pneu- 
monia, while  an  effusion  in  both  sides  would  be  two  inches 
lower  thain  the  normal. 


THE  EMPLOYMENT  OF  DIGITALIS.  49 1 

The  author  urges  that  no  one  should  be  without  this 
knowledge  in  the  diagnosis  of  disease,  which  can  only  be 
made  practical  by  long  experience  and  careful  observation. 
Its  value  is  not  confined  to  the  delimination  of  Traube's 
space,  as  he  has  already  shown,  but  may  be  extended  to 
many  obscure  cases  constantly  presenting  themselves  to 
the  clinician. 

In  conclusion,  it  should  be  noted  that  the  thick  mus- 
cular masses  on  both  sides  of  the  spinal  column  are  good 
conductors  of  sound,  and  may  lead  to  an  erroneous  con- 
clusion when  percussed  by  the  resonant  method;  but  if 
the  scapular  line  be  taken  as  a  guide  there  is  less  risk  of 
error. — Dtihlin  Medical  Press. 


THE   EMPLOYMENT    OF   DIGITALIS   AND   ACONITE 
IN   THE  TREATMENT    OF   CARDIAC   DISEASE. 

By  H.  A.  Hare,  M.  D.,  Professor  of   Therapeutics  In  the  Jefferson  Medical  College, 

of  Philadelphia. 


Among  all  the  difficulties  which  have  beset  the  subject 
of  the  proper  use  of  drugs  in  disease,  and  there  have  been 
many,  as  we  all  know,  it  cannot  be  doubted  that  the  factor 
of  greatest  importance  has  been  the  employment  of  remedies 
by  physicians  without  their  having  a  correct  conception, 
and  sometimes  no  conception  at  all,  of  the  pathological  pro- 
cess underlying  the  condition  which  is  to  be  relieved.  This 
depends  upon  the  fact  that  many  practitioners  lack  prelim- 
inary training,  not  only  in  morbid  anatomy  and  morbid 
physiology  or  pathology,  but  also  fail  to  study  the  possible 
effect  of  well-known  drugs  in  abnormal  states.  The  employ- 
ment of  certain  remedies  in  disease  has  cast  discredit  upon 
therapeutics  by  their  abuse,  while  many  physicians  who  have 
carefully  studied  diseased  organs  become  so  saturated,  so  to 
speak,  with  the  seriousness  of  the  lesions  which  they  find, 
that  they  scoff  at  the  thought  that  drugs  can  be  of  service, 
forgetting  that  the  vital  powers  are  eliminated  at  the  autopsy, 
and  that  the  conditions  present  represent  a  state  so  grave 
that  death  has  taken  place — that  is,  the  worst  possible  state 
of  affairs  is  seen.  I  have  made  these  opening  remarks 
because  I  do  not  wish  to  be  considered  a  therapeutic 
optimist  or  nihilist,  and  because  I  so  often  emphasize  the 
fault  of  using  drugs  when  they  cannot  do  good  that  I  fear  I 
may  be  called  a  therapeutic  unbeliever.     In  no  class  of  cases 


492 


THE  EMPLOYMENT  OF  DIGITALIS. 


does  what  I  have  said  hold  true  with  greater  force  than  in 
those  of  cardiac  disease.  Some  physicians  are  content  to 
diagnose  valvular  disease,  prescribe  digitalis,  and  ignore  the 
state  of  the  heart  muscle,  the  state  of  the  blood  vessels  and 
that  of  the  kidneys,  liver,  and  even  the  dose  of  the  drug,  so 
long  as  it  is  within  bounds  not  poisonous. 

It  has  always  seemed  to  me  that  it  is  the  duty  of  the 
physician  to  study  the  condition  of  the  heart  muscle,  and 
almost  entirely  exclude  any  suppositions  as  to  the  condition 
of  the  valves  of  the  heart.  While  this  may  be  an  exaggerat- 
ed way  of  making  the  statement  which  I  wish  to  emphasize, 
it  is  resorted  to  because  in  the  majority  of  instances  we  are 
apt  to  endeavour  to  decide  which  segment  is  diseased  without 
a  correspondingly  careful  study  of  the  condition  of  the 
ventricular  wall. 

Again,  it  is  by  no  means  an  uncommon  practice  of 
physicians,  after  determining  more  or  less  carefully  the  con- 
dition of  the  heart,  to  fail  to  make  a  careful  study  of  arterial 
tension,  pulse  force,  and,  equally  important,  to  attempt  to 
discover  whether  there  is  arteriocapillary  fibrosis.  Upon  the 
condition  of  the  heart  muscle,  and  upon  the  development  of 
arteriocapillary  fibrosis,  much  more  depends  in  the  diagnosis, 
prognosis  and  treatment  of  a  case  of  so-called  cardiac  disease 
than  is  usually  thought.  It  is  also  not  permissible  to  reach 
correct  conclusions  in  regard  to  these  important  factors  in 
the  case  unless  at  the  same  time  the  renal  condition  is 
adequately  investigated.  And,  again,  it  is  not  sufificient  in 
many  of  these  cases  to  be  content  with  one  or  two  examina- 
tions of  the  urine,  which  may  fail  to  reveal  albumin,  unless 
at  the  same  time  estimations  of  urea  are  also  made,  and  a 
careful  record  of  the  quantity  of  urine  and  of  its  specific 
gravity  is  kept.  Not  only  do  these  renal  conditions  aid  us 
in  getting  information  concerning  the  probable  conditions  of 
the  heart  muscle  and  of  the  blood  vessels,  but  they  also  give 
us  an  insight  into  the  ability  of  the  kidneys  to  eliminate 
poisonous  materials  and  the  drugs  themselves,  both  of  which, 
if  retained  to  an  abnormal  degree,  produce  results  which  are 
disadvantageous. 

I  have  within  the  last  few  years  devoted  a  great  deal  of 
attention,  not  only  to  these  factors  in  these  cases,  but  as 
to  the  question  of  the  proper  administration  of  the  various 
cardiac  stimulants,  and,  equally  important,  as  to  the  dose 
which  each  individual  patient  needs  from  day  to  day. 

Digitalis,  like  iron,  has  proved  itself  so  valuable,  doing 
good  in  so  many  instances  which  seemed  grave,  that  we  are 


THE  EMPLOYMENT  OF  DIGITALIS.  493 

wont  to  forget  that,  like  most  things  which  do  good,  it  can 
also  do  harm,  and  judging  from  my  previous  habit,  and  from 
the  habit  of  other  practitioners,  I  am  convinced  that  in  the 
great  majority  of  instances  digitalis  is  administered  in  doses 
which  are  much  too  large,  and  often  continued  over  a  period 
which  is  far  too  long.  It  is  by  no  means  an  uncommon 
thing  to  find  physicians  administering  as  much  as  lO  or  even 
20  minims  of  tincture  of  digitalis  three  or  four  times  a  day 
in  cases  of  marked  rupture  of  compensation.  There  can  be 
no  doubt  that  in  some  cases  such  doses  are  necessary  at  the 
beginning  of  the  treatment  to  meet  the  crisis  which  exists, 
and  in  much  the  same  way  that  we  are  wont  to  give  large 
doses  of  mercury  in  early  syphilis,  afterward  cutting  the 
doses  down  one  half,  so  it  may  be  necessary  at  times  to  give 
massive  doses  of  digitalis  which,  after  a  period,  should  be 
rapidly  and  considerably  diminished.  I  have  been  surprised 
to  find  what  excellent  results  I  could  produce  by  the  use  of 
such  small  amounts  as  one  or  two  minims  of  an  active, 
physiologically  tested  tincture  of  digitalis  given  three  or  four 
times  a  day,  the  patient  being,  of  course,  required  to  rest  and 
so  give  his  heart  that  most  needed  therapeutic  aid  when  its 
compensation  is  ruptured. 

Apropos  of  this,  I  may  add  that  in  my  belief  we  often 
fail  to  get  results  from  doses  and  from  drugs  upon  which  we 
rely,  more  because  we  are  careless  as  to  the  physiological 
activity  of  the  product  than  because  we  have  made  an  error 
in  judgment  as  to  the  remedy  which  is  needed,  or  the  dose 
which  is  required.  With  the  important  subject  of  the  employ- 
ment of  drugs  closely  related  to  digitalis  in  the  treatment  of 
various  cardiac  conditions,  there  is  not  space  to  deal  in  this 
paper.  In  deciding  what  cardiac  stimulant  is  required  in  a 
given  case,  we  must  not  only  consider  the  condition  of  the 
valves  and  the  myocardium  as  already  indicated,  but  we 
must,  if  possible,  reach  some  conclusion  in  regard  to  the 
state  of  the  coronary  arteries.  Digitalis,  which  improves  the 
nutrition  of  the  heart,  largely  by  improving  the  circulation  in 
these  arteries,  can  manifestly  do  more  harm  than  good,  if 
these  nutritive  vessels  are  so  nearly  closed  that  it  is  impossible 
for  the  heart  to  pump  blood  through  them  in  increased 
quantity.  And  again,  the  myocardium  miy  have  undergone 
such  advanced  degeneration  that  it  is  impossible  for  the 
digitalis  to  improve  the  nutrition  of  the  heart,  although  at 
the  same  time  it  may  be  driving  the  remaining  healthy  fibers 
to  an  endeavour  far  in  excess  of  their  ability. 


494 


THE  EMrLOYMENT  OF  DIGITALIS. 


I  am  also  quite  sure  that  in  a  certain  number  of  cases  of 
valvular  disease  the  patient  does  not  require  digitalis  or  any 
other  cardiac  stimulant  for  the  relief  of  his  cardiac  symptoms  ; 
but,  on  the  other  hand,  in  addition  to  rest,  will  often  be 
greatly  benefited  by  the  administration  of  aconite,  which  has 
the  same  steadying  effect  upon  the  heart  through  its  influence 
on  the  vagi  as  has  digitalis,  while  by  its  sedative  influence  on 
the  heart  muscle  in  cases  of  excessive  compensation,  and  by 
its  relaxing  effect  upon  the  blood  vessels,  it  diminishes  the 
overaction  of  hypertrophy  which  is  sometimes  confused  with 
the  tumultuous  overaction  of  ruptured  compensation.  It  is 
much  easier  for  us  to  conclude,  in  the  case  of  valvular  disease, 
with  dyspnea  and  disturbed  heart  action,  that  these  symptoms 
are  due  to  a  failing  heart  than  that  they  are  due  to  a 
hypertrophy  and  an  excessive  activity.  Such  cases  I  have 
frequently  seen  in  men  who  are  well  developed,  in  the 
muscular  sense,  and  whose  occupation  has  caused  them  to  do 
heavy  manual  work,  or  to  take  part  actively  in  some  of  the 
severe  athletic  games.  And  not  infrequently  have  I  seen 
other  cases  in  which  the  useot  well-balanced  doses  of  aconite 
and  digitalis  have  produced  results  which  neither  drug  could 
produce  by  itself,  although  at  first  glance  they  are  physiologi- 
cal antagonists. 

Finally,  the  utter  uselessness  of  expecting  good  results 
from  either  of  these  drugs  in  the  treatment  of  certain  cases 
of  myocardium  disease  which  persistently  take  severe  exer- 
cise "  for  their  health"  needs  to  be  emphasized.  I  have 
repeatedly  seen  cases  of  men  of  advanced  years  with  some- 
what fibroid  blood  vessels  who  have  mistaken  the  heaviness 
of  advancing  years  for  the  heaviness  of  lack  of  exercise,  and 
who  on  the  golf  field,  on  the  bicycle,  or  by  rowing  or  walk- 
ing, have  tried  to  drive  away  the  symptoms  from  which  they 
suffer,  with  a  result  that  sooner  or  later  the  condition  from 
which  they  are  suffering  becomes  greatly  aggravated,  and 
they  become  more  or  less  invalids  if  they  are  so  fortunate  as 
to  escape  sudden  or  nearly  immediate  death  from  their  ill- 
judged  efforts.  It  seems  to  me,  too,  that  when  we  are 
attempting  to  treat  such  cases,  and  are  endeavouring  to 
administer  doses  and  remedies  as  accurately  as  possible,  we 
should  insist  upon  quiet  and  a  careful  mode  of  life  until  we 
are  able  to  determine  that  the  remedies  suit  the  case,  for 
otherwise  the  change  of  exercise  or  change  in  diet  may  not 
only  prevent  the  remedies  from  doing  good,  but  also  warp 
our  judgment  as  to  our,  own  plan  of  treatment,  and 
prevent    us   from  instituting  it  in    another    case,    when  in 


MEDICINE   AND   NEUROLOGY.  495 

reality,  had  proper  precautions  of  this  kind  been  tacen,  we 
would  have  increased  confidence  and  been  able  to  do  much 
good  to  a  lar^e  class  of  patients,  for  it  is  not  to  be  forgotten 
that  every  one  in  this  room  sooner  or  later,  according  to  his 
years,  his  inheritance,  and  his  mode  of  life,  develops  more 
or  less  arteriocapillary  fibrosis,  degeneration  of  his  myocard- 
ium, and  sclerotic  changes  in  his  kidneys. 

I  may  close  by  saying  that  curiously  enough  a  very 
large  proportion  of  the  patients  to  which  I  have  recently 
referred  are  physicians  who,  after  a  long  life  of  intense 
nervous  strain,  not  infrequently  find  themselves  at  a  com- 
paratively early  age  suffering  from  disorders  of  the  heart, 
which  they  fail  to  recognize,  either  because  on  examining 
this  organ  they  fail  to  discover  murmurs,  or  because  they  do 
not  recognize  the  fact  that  a  physician's  life  seems  to  be 
peculiarly  apt,  as  is  that  of  the  banker  and  large  business 
manager,  to  develop  degenerative  cardiac  change.  The 
employment  of  strychnine,  belladonna  and  other  drugs, 
in  connection  with  digitalis  and  aconite,  might  be  discussed 
if  time  permitted,  but  they  are  not  included  in  the  title  of 
this  paper,  and,  therefore  cannot  be  considered.  —  The 
Therapeutic   Gazette. 


Progress  of  Medical  Science. 


MEDICINK    AND     NBUROI^OQY 

IN   CHARGE   OF 

J.  BRADFORD  McCONNBLL.  M.D. 

Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College;  Physician  Western  Hospital. 


TREATMENT    OF    ECLAMPSIA. 

In  the  Therapciitische  Monatshefte  for  April,  1902,  Veit 
asserts  that  we  do  not  yet  possess  a  rational  treatment  of 
eclampsia,  because  the  exact  nature  of  the  disease  is  still 
unknown.  The  treatment,  therefore,  must  be  such  as  is  found 
to  be  the  best  from  experience.  The  main  object  is  to 
check  the  attacks  and  obtain  the  spontaneous  labour.  Some 
say  that  expectant  therapy  is  the  best,  and  as  soon  as  the 
child  is  born  spontaneously  the  disease  is  at  an  end  ;  others, 


49^  PROGRESS    OF    MEDICAL    SCIENCE. 

on  the  contrary,  say  that  we  must  terminate  the  pregnancy, 
for  only  then  will  the  attacks  cease.  In  Veit's  opinion  both 
are  wrong.  Neither  is  a  good  treatment.  Morphia  is 
advised  by  G.  V.  Veit,  and  Caesarian  section  is  advised  by 
Halbertsma.  None  of  these  means  can  be  applied  to  every 
case  of  eclampsia. 

In  treating  any  given  case,  first  of  all  the  strictest  anti- 
septic rules  must  be  observed  during  labour,  because  eclamptic 
patients  are  particularly  predisposed  to  puerperal  infection. 
Secondly,  the  quantity  of  food  and  remedies  per  os  must  be 
Hmited,  as  the  somnolent  patients  are  threatened  with 
aspiration  pneumonia.  Thirdly,  each  vaginal  exploration 
should  be  made  under  narcosis  in  order  to  avoid  irritation. 
These  are  the  prophylactic  measures  which  the  author 
usually  follows.  The  treatment  itself  depends  upon  the 
general  and  local  conditions  of  the  patient,  and  especially 
upon  the  dilatation  of  the  cervix.  When  the  os  is  totally 
dilated  and  the  presenting  part  of  the  fetus  is  high  up  in  the 
pelvis,  in  spite  ot  the  good  general  condition  of  the  patient 
at  the  onset  of  the  first  attack  of  eclampsia,  the  extraction 
of  the  child  should  be  done  under  narcosis.  When  the 
external  os  is  not  completely  dilated,  our  conduct  will 
depend  upon  the  state  of  the  cervical  canal.  If  the  last  is 
totally  soft  above  the  external  orifice  there  is  no  danger  in 
dilating  the  cervix  ;  this  can  be  done  with  two  fingers  or 
with  a  slight  cut  in  the  sharp  pendulated  border  of  the 
cervix.  At  the  first  eclamptic  attack  delivery  should  be 
done  at  once.  When  the  cervix  lets  in  only  one  finger  and 
the  canal  is  yet  intact,  our  conduct  should  depend  upon  the 
patient's  condition. 

At  the  beginning  of  eclampsia  every  effort  should  be 
made  to  tear  the  membranes  in  order  to  diminish  the 
tension  of  the  uterus  and  allow  the  pain  to  become  stronger. 
If  in  spite  of  these  measures  more  attacks  follow,  it  is  recom- 
mended to  apply  a  dilator.  As  soon  as  the  canal  is  dilated, 
extraction  should  be  made  at  the  first  convulsion.  In  this 
case  administration  of  morphine  is  indicated,  not  with  the 
expectation  of  complete  removal  of  the  attacks,  but  to  render 
them  less  severe.  Some  obstetrician  reported  aggravations 
of  symptoms  after  injections  of  morphine.  Although  it  is 
difficult  to  form  a  definite  opinion,  it  is,  nevertheless,  certain 
that  it  renders  the  attacks  less  severe ;  it  is,  therefore,  only  a 
symptomatic  remedy.  If  we  have  recourse  to  it  occasionally, 
it  should  be  used  as  early  as  possible.     Among  other  nar- 


MEDICINE  AND  NEUROLOGY.  497 

cotics  we  may  mention  chloral  hydrate  (per  rectum),  which 
can  be  administered  in  15-grain  doses  repeatedly.  Little 
benefit  can  be  obtained  from  the  bromides,  veratrum  viride, 
or  amyl  nitrite.  Venesection  has  been  recently  recom- 
mended. A  rapid  cure  cannot  be  promised,  but  ameliora- 
tion of  symptoms,  and  especially  lessening  of  cyanosis,  can 
thus  be  readily  obtained.  Some  follow  up  the  venesection 
by  saline  infusions,  as  the  disease  is  supposed  to  be  of  toxic 
nature.  The  practical  importance  of  this  treatment  is  still 
slight.  Next  to  this  treatment  are  hot  baths,  which  gained 
the  utmost  confidence;  their  effect  is  produced  by  dia- 
phoresis. If  hot  baths  cannot  be  employed,  Jacket  advises 
the  use  of  wet  sheets. 

In  spite  of  their  favourable  influence.the  means  mentioned 
cannot  cure  eclampsia,  no  matter  how  correct  the  theoretical 
considerations  are  ;  the  complete  practical  result  has  not  been 
obtained  of  any  of  them.  Caesarian  section  and  accoiichment 
force  are  advised  by  some,  but  in  the  author's  opinion  they 
cannot  be  applied  to  uncomplicated  cases  of  eclampsia.  For 
the  last  eleven  years,  among  1 1,000  confinements,  he  observed 
fourteen  cases  of  eclampsia,  and  only  one  died;  it  makes  a 
percentage  of  15.8.  Among  operated  cases  the  mortality  is 
very  high.  However,  in  the  hands  of  skilful  operators 
Caesarian  section  and  accouchment  force  are  not  always  fatal. 

The  conditions  are  different  when  with  a  narrow  cervical 
canal  the  convulsions  increase  in  intensity  and  frequency, 
the  labour  does  not  advance,  and  the  patient's  condition  be- 
comes aggravated.  The  choice  of  the  method  will  depend 
upon  the  patient's  surroundings.  The  author  was  called  to 
the  country  to  see  a  patient ;  Caesarian  section  would  imperil 
her  life  because  of  surroundings  unfavourable  to  an  operation. 
With  one  finger  in  the  cervix  he  took  hold  of  one  foot  and 
extracted  the  child.  Combined  version  in  such  cases  is 
recommended.  Diihrssen  obtained  good  results  with  cervical 
incisions  and  vaginal  Caesarian  section ;  others,  on  the 
contrary,  obtained  less  favourable  results.  In  case  the  cervix 
is  entirely  closed,  a  question  arises  whether  eclampsia  has 
anything  to  do  with  the  pregnancy.  Narcotics  should  be 
given  then  and  patients  kept  under  observation.  Should 
the  attacks  repeat  themselves  in  a  threatening  manner  and 
the  patient's  condition  become  aggravated,  while  the 
cervix  is  still  closed,  pregnancy  is  at  fault.  Then  the 
classical  Caesarian  section  is  indicated  in  preference  to 
the  vaginal  route.     Here  Caesarian  section  is  easier  and  les^. 


498  PROGRESS    OF    MEDICAL    SCIENCE. 

complicated    than  a  confinement  through  the  vagina  with  a 
closed  cervix. 

These  various  ways  of  treatment  are  in  accord  with  the 
most  modern  views  on  the  subject.  It  certainly  does  not 
follow  that  they  are  perfect  and  complete.  Our  efforts 
should  be  directed  toward  the  pathogenesis  of  the  affection, 
as  well  as  to  a  better  study  of  the  normal  anatomy  and 
physiology  of  pregnancy.  The  method  of  study  of  cytotoxins 
is  particularly  worth  mentioning,  because  we  find  in  normal 
pregnancy,  and  especially  in  eclampsia,  certain  cells  in  the 
circulation  of  the  mother,  under  the  influence  of  which  anti- 
toxins are  formed.  From  researches  the  author  made  in 
conjunction  with  R.  Sholten,  they  were  astonished  to  find 
albumin  in  the  urine  after  the  placenta  was  transplanted  in 
the  abdomen.  When  it  will  be  possible  to  show  that  the 
albuminuria  of  pregnancy  is  analogous  to  the  cytotoxic  albu- 
minuria produced  experimentally,  we  will  have  in  our  power 
the  foundation  for  a  new  therapy  which  may  lead  to  a  proper 
understanding  of  the  affection ;  but,  unfortunately,  the  time 
has  not  yet  arrived  for  a  definite  opinion  on  the  subject. — 
Therapeutic  Gazette. 

DTSMBNORBHEA. 

The  British  Medical  Jotirnal  of  May  17,  1902,  contains 
an  article  by  Herman,  in  which  he  gives  the  following  ad- 
vice : — 

Spasmodic  dysmenorrhea  has  no  tendency  to  spon- 
taneous cure.  A  patient  has  been  known  to  suffer  from  it 
throughout  the  whole  of  her  menstrual  life.  In  cases  of 
exceptional  severity  it  may  grow  worse.  About  twenty-five 
years  ago  the  writer  saw  a  patient,  then  aged  about  forty- 
five,  who  had  suffered  ever  since  her  catamenia  began  from 
pain  every  month  so  severe  as  to  make  her  vomit.  In  her 
early  youth  she  consulted  Sir  James  Clarke,  who  was  at  that 
time  physician  to  the  Queen,  and  was  by  him  advised  not 
to  have  any  local  treatment.  As  she  got  older  the  monthly 
attack  of  vomiting  came  to  last  longer  and  longer,  till  at 
length  she  was  almost  continuously  sick.  In  some  cases  in 
which  pain  has  lasted  long  and  been  severe  it  has  seemed 
that  the  body  of  the  uterus  was  larger  than  in  most  nulli- 
parae, as  if  some  hypertrophy  had  taken  place.  But  it  is  so 
difficult  to  be  sure  of  a  slight  increase  in  size  that  this  is  only 
a  conjecture. 

The  natural  cure  of    spasmodic   dysmenorrhea    is 


MEDICINE  AND   NEUROLOGY.  499 

pregnancy.  But  the  disease  is  often  accompanied  by  sterility, 
which  may  be  cured  by  the  dilatation.  In  about  one-third 
of  the  writer's  patients  who  were  married  and  sterile,  the 
cure  of  the  dysmenorrhea  v/as  followed  by  pregnancy. 

The  best  drugs  for  the  relief  of  uterine  colic  are  anti- 
pyrin  and  phenacetine.  In  slight  cases  these  give  adequate 
relief,  and  as  we  know,  not  of  any  harmful  results  from  their 
occasional  use,  if  these  drugs  relieve  there  is  no  need  for 
further  treatment.  If  these  drugs  fail,  powerful  narcotics, 
such  as  morphine  or  chloroform,  will,  if  given  in  sufficient 
doses,  quiet  the  pain,  and  cases  have  been  known  so  bad 
that  the  pain  could  not  be  otherwise  controlled.  But  it  is  a 
bad  thing  for  a  young  woman  to  use  these  drugs  every  month, 
and,  if  this  is  necessary,  local  treatment  which  will  remove 
the  pain  is  preferable. 

In  a  few  cases  the  writer  has  found  that  guaiacum  re- 
moved the  pain.  He  gives  ten  grains  of  guaiacum  resin  in  a 
tablespoonful  of  malt  extract,  twice  or  three  times  a  day, 
beginning  a  week  before  menstruation  is  expected.  He  does, 
not  know  how  this  drug  acts,  nor  how  to  pick  out  the  cases 
that  it  will  cure ;  but  he  knows  that  it  sometimes  will  cure. 

The  local  treatment  of  spasmodic  dysmenorrhea  is  to 
dilate  the  cervix.  This  is  best  done  by  the  passage  of  bou- 
gies. In  most  cases  the  cervical  canal  will  admit  a  No.  6 
bougie  easily.  A  little  resistance  is  usually  met  with  when 
about  No.  9  is  reached.  When  a  bougie  has  been  passed 
which  entered  with  difficulty  and  fits  tightly,  after  it  has 
remained  two  or  three  minutes  in  the  canal,  it  will  be 
loosely  held  and  a  size  larger  can  be  passed.  The  writer  has 
generally  continued  the  dilatation  until  the  bougie  met 
with  considerable  resistance.  This  usually  begins  with 
the  passage  of  No.  12  or  thereabouts.  He  knows  not 
what  is  the  minimum  dilatation  that  is  sufficient  to  cure. 
He  has  known  the  passage  of  a  No.  8  bougie,  in  a  case  of 
spasmodic  dysmenorrhea  and  sterility,  to  be  followed  by 
pregnancy.  Before  the  introduction  of  dilatation  as  a  means 
of  treatment  it  was  known  that  occasionally  menstruation 
could  be  prevented  from  being  painful  by  the  passage  of  the 
uterine  sound  shortly  before  its  occurrence.  Hence  exten- 
sive dilatation  is  not  always  necessary.  The  enlargement 
of  the  canal  that  dilatation  produces  lasts  for  some  months, 
and  one  would  suppose  that  the  larger  the  dilatation  the 
longer  will  the  effect  last,  but  the  author  has  few  facts  with 
which  to  support  this  opinion. 

The  cervix  does  not  always  yield  to  the  dilating  agent 


5Q0  PROGRESS    OF    MEDICAL    SCIENCE. 

with  the  same  readiness.  In  about  one-sixth  of  his  cases 
the  author  has  it  recorded  that  unusual  resistance  was  met 
with.  The  fact  of  such  unusual  resistance  does  not  in  his 
experience  modify  the    prognosis. 

Dilatation  does  not  invariably  cure.       The  author  has 
gone  through  some  records  of  cases  to  find  out  what  pro- 
portion of  cases  are  cured.       He  found  that  in  at  least  two- 
thirds  of  cases  benefit  follows.  That  no  relief  followed  in  one- 
third  of  the  cases  dilated  does  not  imply  that  one-third  of 
cases  of  spasmodic  dysmenorrhea  are  incurable  ;  it  is  partly 
accounted   for  by  some  cases  having  been  dilated  in  which 
the  dysmenorrhea  was  not  of  the  spasmodic  kind.     In  some 
of  these  cases  the  patients'  statements  may  have  been  mis- 
leading ;  in  others,  diagnosis  was  known  to    be    doubtful, 
and  the   dilatation  was   done  either   because  nothing   else 
oflfered  any  prospect  of  benefit,    or  for  some  reason  other 
than  the  cure  of  the  dysmenorrhea.     But  allowing  for  the 
inclusion   of  these    cases,  it    must  be    admitted    that  some 
cases  of  spasmodic  dysmenorrhea  are  not  cured  by  dilatation. 
Some  cases  are  not  cured  even  by  pregnancy.      The  author 
believes  that  he  is  within  the  truth  when  he  states  that  cure 
follows    in  three-fourths  of  the  cases.       Among  his  cases  in 
which  the  disease  was    primary  (that  is,  dated  from  the  be- 
ginning of  menstruation),  the  proportion  of  cures  was  larger 
than  among  those  in  which    the  pain   began  to  be  felt  at  a 
later  age.     How  long  does  the  benefit  last.?     It   is   so  diffi- 
cult, for  reasons  that  need   not  be  gone   into,  to    keep  such 
patients   in  communication  with  their  physician,  that   noth- 
ing very  exact  can  be  said  about  this.       The  cure  may  last 
throughout  the  patient's  whole  menstrual  life.     One  patient, 
whose  cervix  the  author  dilated  in  1878,  she  then  being  aged 
twenty-seven,  he  saw  in   1900.       She  had  menstruated  with 
little  or  no  pain  ever  since  the  dilatation,  and    the  irregular- 
ity of  the  menopause  had  begun.      This  justifies  the   asser- 
tion made.     In  some  cases  the  cure  is  temporary  only  ;  the 
pain  returns,  and  is  again    removed  by  further  dilatation. — 
Therapeutic  Gazette, 

VARIETIES  OF  ENEMATA  AND  METHODS  OF  PREPARING 

SAME. 

Of  much  practical  value  is  a  knowledge  of  not  only  the 
indications  for  the  employment  of  rectal  injections,  but  the 
diflferent  varieties  thereof  and  their  immediate  method  of  pre- 
paration.    A  physician's  resources  are  oftentimes  abundantly 


MEDICINE  AND  NEUROLOGY.  5OI 

enlarged  by  a  practical  adjustment  to  circumstances  in  this 
direction.  For  instance,  purgative  enemas  may  be  necessary 
in  patients  who  cannot  well  bear,  or  who  respond  feebly  to 
cathartics  by  the  mouth.  After  abdominal  operations  a  pur- 
gative enema  may  be  called  for,  and  also  in  cases  of  intestinal 
obstruction  and  in  many  varieties  of  abdominal  pain.  Then, 
again,  to  supplement  aperients  given  by  the  mouth  cathartic 
enemata  may  be  resorted  to,  likewise  in  almost  all  cases  pre- 
ceding operative  work  in  the  abdomen.  An  aperient  enema 
should  also  be  given  before  rectal  and  vaginal  examinations, 
and  before  the  administration    of  an  anesthetic. 

The  simplest  form  of  an  enema  for  unloading  the  bowels 
is  a  mixture  of  soft  soap  and  warm  water,  the  activity  of 
which  may  be  increased  by  adding  about  half  an  ounce  of 
turpentine,  a  handful  of  salt  or  a  little  molasses.  In  lieu  of 
a  watery  enema  (sometimes  objectionable  on  account  of  the 
quantity  necessary — one  to  three  pints),  four  to  six  ounces  of 
warm  olive  oil,  two  to  four  ounces  of  castor  oil,  or  one  ounce 
of  glycerine,  may  be  used,  A  little  turpentine  will  aid  any 
of  these.  Turpentine  has  always  seemed  especially  valuable 
when  there  is  much  intestinal  flatus. 

Nutrient  enemata  become  highly  valuable  in  quite  a 
number  of  conditions,  among  which  may  be  mentioned 
persistent  vomiting  of  pregnancy,  gastric  neuroses  of  other 
types,  gastric  ulcer,  and  other  gastric  diseased  states,  various 
intestinal  conditions  and  operations  upon  the  stomach  and 
bowels,  and  sometimes  in  diseased  conditions  of  the  mouth, 
throat  and  esophagus.  Nutrient  enema  usually  are  made  up 
with  peptonized  milk,  to  which  is  added  beef  tea  or  extract, 
beaten  eggs,  various  gruels  and  brandy  as  may  be  desired. 

A  cleansing  enema  should  always  precede  one  contain- 
ing nourishment.  A  disregard  of  this  rule  has  caused  many 
a  failure. 

Normal  salt  solution,  consisting  of  one  dram  of  salt  to 
one  pint  of  water  at  a  temperature  of  loo^  F.,  is  now  very 
commonly  employed  to  overcome  collapse  after  operations 
and  general  shock  from  hemorrhage    or  other  cause. 

In  cases  of  heart  failure,  opium  poisoning  and  other 
forms  of  depression,  stimulating  enemata  are  many  times  of 
value.  These  may  consist  of  brandy  and  hot  water,  strong 
hot  coffee,  aromatic  spirits  of  ammonia  with  hot  water. 
While  the  water  should  be  hot,  care  should  be  exercised 
that  it  is  not  at  such  temperature  as  to  damage  the  mucous 
lining  of  the  bowel. 


502  PROGRESS    OF    MEDICAL    SCIENCE. 

Medicines  may  sometimes  require  administrations  per 
rectum.  Chloral,  the  bromides,  strychnia,  opiates,  etc.,  in 
proper  solutions  and  dilution  undoubtedly  can  be  made  effect- 
ual in  this  manner.  In  order  to  be  certain  of  the  use  of  the  full 
portion  of  the  drug,  when  used  in  this  way,  it  is  best  to  make 
a  separate  and  smaller  mixture  of  the  medicament  which 
may  be  injected  and  followed  by  such  quantity  of  diluent  as 
can  readily  be  retained.  In  this  manner  one  can  be  certain 
of  the  administration  of  all  of  the  drug  intended. 

The  old  "  starch  and  laudanum"  enema,  so  often  men- 
tioned in  text-books  in  relation  to  the  treatment  of  diarrhea, 
has  frequently  been  misapplied  or  not  used  at  all  because  of 
ignorance  in  its  preparation,  and  thus  a  means  almost  always 
readily  at  hand  is  lost.  The  starch  and  opium  enema  is 
made  up  as  follows  :  a  tablespoonful  of  ordinary  starch  is 
rubbed  up  first  with  cold  water,  a  thin  paste  resulting. 
Boiling  water  is  then  added  to  the  consistency  of  thick  gruel. 
When  the  preparation  is  cool,  such  quantity  of  the  tincture 
of  opium  as  desired  is  thoroughly  incorporated.  A  high 
injection    with    a  soft  tube  is  always  best. 

If  a  patient  can  for  a  time  maintain  the  knee-chest 
position  after  an  enema,  so  much  the  better ;  but  if  not,  it  is 
more  desirable  to  lie  prone  upon  the  abdomen  or  upon  the 
left  side. 

Only  gentle  force  should  be  exerted  in  giving  a  rectal 
injection. 

In  the  experience  of  some,  cold  solutions  for  purgative 
effects  have  appeared  better,  and  not  without  reason  is  it 
argued  that  cold  enemata,  and  not  warm,  are  indicated  in 
those  conditions  where  they  are  employed  almost  constantly. 
—  The  Clinical  Review. 

EUCALYPTUS  IN  THE    TREATMENT   OF   DIABETES. 

In  the  Glasgow  Medical  Journal  for  May,  1902,  Faulds 
details  his  investigations  as  to  the  value  of  eucalyptus  in  dia- 
betes mellitus. 

What  seems  very  interesting  is  the  fact  that,  when  the 
patient  gets  a  fresh  warm  infusion,  the  sugar  at  once  drops  in 
quantity,  and  in  some  cases  from  60  grains  to  half  a  grain 
per  ounce.  It  is  evident,  then,  that  there  is  not  any  one  of 
the  substances  contained  in  this  infusion  that  arrests  the 
excretion  of  sugar,  but,  evidently,  a  combination  of  them 
have  this  effect — i.e.,  there  seems  no  alkaloid  in  it  which, 
when  given  alone,  has  the  power  of  influencing  the  amount 


MEDICINE  AND   NEUROLOGY.  503 

of  glucose  in  diabetic  urine.  Then  how  and  why  does  the 
fresh  infusion  act  so  promptly?  The  writer  thinks  that, 
just  as  a  newly  infused  cup  of  tea  is  an  enjoyable  beverage, 
not  on  account  of  the  action  of  its  alkaloid  theine  alone,  but 
because  it  contains,  in  addition,  a  mixture  oi  a  volatile  oil  and 
tannin,  so  does  tea  from  eucalyptus  (which  we  know  has 
antiseptic  properties)  act  in  checking  tissue  metamorphosis, 
which  is  so  active  in  this  disease. 

The  causation  of  glycosuria  is  still  wrapped  in  mystery, 
but  it  is  probably  produced  by  a  variety  of  causes,  such  as 
gout,  cold,  nervous  exhaustion  and  over-indulgence  in  food 
and  drink.  In  fact,  any  condition  that  tends  to  limit  or 
prevent  the  appropriation  of  sugar  must  lead  to  an  excess  of. 
sugar  in  the  blood,  and  thus  to  glycosuria.  In  these  cases 
it  seems  that  in  the  earlier  stage  the  eucalyptus  treatment 
will'prove  beneficial ;  but  where  the  disease  has  been  inherited, 
or  where  the  patient's  antecedents  or  immediate  relatives  are 
neurotic  (in  which  case  the  probable  cause  is  a  progressive 
degeneration  of  the  vasomotor  centers  of  system  which  will 
disturb  the  equilibrium  of  the  blood-supply  to  the  hepatic 
cells),  this  treatment,  like  others,  will  be  of  no  avail.  And 
such  has  been  the  author's  experience  ;  for,  in  forty-one  cases 
treated  with  eucalyptus,  eleven  came  from  talented  families, 
or  were  neurotics  ;  seven  were  hard  brain- workers,  and  four 
inherited  the  actual  disease.  In  these  twenty -two  the  eucalyp- 
tus treatment  had  no  effect.  Add  to  these  four  cases  in 
which  the  disease  had  gone  to  the  stage  of  approaching 
coma  before  this  treatment  had  been  commenced,  and  we 
get  the  total  number  of  unsuccessful  cases.  The  remaining 
fifteen  showed  a  total  disappearance  of  the  disease,  and  so 
far  as  can  be  judged  are  completely  cured. —  Therapeutic 
Gazette. 

NIGHT  SWEATS  IN  PHTHISIS. 

All  physicians  know  the  difficulty  of  keeping  the  night 
sweat  of  phthisis  in  control.  Almost  every  known  remedy 
has  been  tried  since  the  Greeks  used  agaricin  down  to  the 
present.  Graves  and  Stokes  used  Dover's  powder,  which 
in  time  gave  place  to  mineral  acids,  zinc  and  belladonna, 
atropine,  and  a  host  of  other  specifics.  To  the  long  list 
Nolda  adds  tannoform,  the  external  use  of  which  he  recom- 
mends. In  seven  out  of  eight  cases  in  which  he  had  the 
front  and  back  of  the  thorax  dusted  with  powdered  tanno- 
form, it  checked  the  sweating  {Berl.   Klin.    Woch.^.     This 


504  PROGRESS    OF    MEDICAL    SCIENCE. 

method  of  treating  the  symptom  has  the  advantage  of  not 
interfering  with  the  digestive  function,  which  is  usually  so 
imperfectly  performed  in  such  cases ;  neither  does  it  in  any 
way  preclude  the  use  of  any  of  the  other  antisudorifics. 
The  powder  of  itself  should  prove  an  agreeable  application 
to  the  skin,  and  promote  the  comfort  which  is  such  an 
essential  factor  in  producing  sleep  in  such  cases. — Dublin 
Medical  Press  and  Circular. 


HOW  TO  SLXSEIP  SOUNDLY. 

The  "sure  cures"  for  insomnia  are  almost  innumerable. 
One  of  the  latest  is  that  of  a  German,  Prof.  Fischer  {Doctor  s 
Magazine)^  who  claims  ihat  it  will  not  only  bring  about 
profound  and  refreshing  sleep,  but  also  increased  mental 
strength.  The  discovery  consists  essentially  in  putting  the 
pillow  or  pillows  under  the  feet  instead  of  the  head.  The 
advantages  claimed  for  the  innovation  are  that  the  venous 
circulation  is  favoured  and  the  heart  needs  to  work  less 
during  sleep,  hence  the  tired  feeling  on  waking  is  prevented. 
The  professor  claims  to  be  in  rccei'pt  of  a  great  many 
communications  from  ladies  all  over  the  German  Empire 
who  are  profuse  in  their  praises  of  his  epochal  discovery. — 
Denver  Medical  Times. 

LEUCOCYTES  AND  DIAGNOSIS. 

The  importance  of  a  microscopic  examination  of  the 
blood  in  the  estimation  of  both  red  corpuscles  and  white  is 
coming  to  be  more  and  more  recognized,  not  only  in  dis- 
eases of  the  blood,  but  in  those  of  a  general  nature.  In 
many  undefined  cases  it  is  found  that  the  point  of  diag- 
nosis is  immediately  cleared  by  a  blood  examination.  Thus, 
in  typhoid  fever  lymphocytosis  is  the  rule,  while  leucocy- 
tosis  is  stated  never  to  occur  unless  there  is  some  complica- 
tion. As  the  latter  is  the  rule  in  most  infectious  diseases 
and  inflammatory  conditions,  the  value  of  the  distinction 
is  obvious,  more  especially  as  the  lymphocytosis  in  typhoid 
occurs  early,  along  with  a  leucopenia,  some  time  before  the 
Widal  reaclio  1  is  established.  An  examination  of  the  blood 
is  .stated  to  distinguish  at  once  a  case  of  early  typhoid  from 
one  of  pneumonia  or  influenza.  Again,  a  marked  leucocy- 
tosis  occurs  in    such  conditions  as    appendicitis,  pyosalpinx 


MEDICINE  AND   NEUROLOGY.  5^5 

and  suppurating  ovarian  cysts,  thereby  distinguishing  them, 
not  only  from  typhoid,  but  from  malaria,  in  which  leucope- 
nia  is  the  rule.  And  not  only  in  the  early  stages  of  disease  is 
the  condition  of  the  leucocytes  of  assistance,  but  during  its 
progress  any  marked  increase  or  diminution  in  their  num- 
ber points  to  some  change  of  importance  in  the  patient's 
system.  Thus,  a  sudden  leucocytosis  in  typhoid  very  fre- 
quently points  to  a  perforation.  The  whole  subject  is  very 
well  summarized  in  a  recent  paper  by  Dr.  Brown  of  Baltimore 
{^Medical  Navs,  July  26),  who  quotes  two  cases  in  which 
a  sudden  increase  in  the  number  of  leucocytes  from  about 
seventeen  to  thirty-four  thousand  per  cmm.  synchronised 
with  a  perforation  of  the  appendix.     The  Medical  Press. 

THE  MEDICINAL  TREATMENT  OF  TUBERCULOSIS. 

While  not  denying  the  importance  of  the  hygienic 
treatment  of  tuberculosis,  expecially  as  conducted  in  sana- 
toria, the  writer  believes  that  the  medicinal  treatment 
should  not  be  neglected. 

The  writer  has  used  ichthyol  in  his  clinic  in  great  va- 
riety of  cases,  many  of  them  advanced.  The  most  notice- 
able and  most  constant  effect  was  the  diminution  of  the 
bronchial  catarrh.  This  diminution  show^ed  itself  in  the 
lessened  amount  of  sputum  and  the  partial  disappearance 
of  the  rales.  Secondarily,  an  increase  of  weight  and  an 
improvement  in  the  general  condition  was  noted.  One 
advantage  of  ichthyol  is  the  fact  that  it  can  be  used  for 
long  periods  of  time  without  unpleasant  secondary  effects. 
It  may  be  used  with  advantage  in  cases  of  actual  or  threat- 
ening hemoptysis,  on  account  of  its  vaso-constrictor  effects. 
In  short,  the  writer  believes  that  it  should  be  given  a  trial 
in  all  cases  not  too  far  advanced. 

If  we  expect  to  derive  benefit  from  ichthyol  it  must  be 
given  in  large  doses  and  for  long  periods  of  time.  The 
following  formula  is  convenient: 

R     Ichthyol 10 

Aq.  menth.  pip 80 

8yr.  simpl 20 

Mix. 

During  the  first  week  one  teaspoonful  in  a  glass  of 
water  is  given  daily,  half  being  drunk  in  the  morning,  half 
in  the  ev^ening.  During  the  second  week  two  teaspoonfuls 
in  two  glasses  of  water  are  given  daily,  to  be  taken  at 


506  PROGRESS    OF    MEDICAL    SCIENCE. 

four  times.  The  dose  is  slowly  increased  in  this  manner 
until  eight  grammes  are  taken  daily.  In  comparatively 
robust  cases  the  dose  may  be  increased  as  above,  but  daily 
instead  of  weekly. 

Ichthoform  is  given  in  powders  of  ten  to  thirty  centi- 
grammes (grs.  iss  to  ivss),  ten  powders  being  given  daily. 
Its  action  resembles  that  of  ichthyol,  but  it  sieems  to  have 
a  particularly  favourable  effect  upon  the  bowel  disturb- 
ances accompa,nying  tuberculosis.  The  meteorism,  colic 
and  diarrhea  are  effectively  combated  and  a  greater  inges- 
tion and  assimilation  of  food  made  possible. 

Sodium  salicylate  was  given  as  an  antipyretic.  With 
few  exceptions  its  use  caused  a  drop  in  the  maximum  tem- 
perature from  102°  or  104°  to  99°,  and  of  the  average  tem- 
perature from  100°  to  98°.  During  the  use  of  this  drug 
tuberculin  injections  produced  little  or  no  rise  of  temper- 
ature, and  cannot  therefore  be  used  as  a  diagnostic  aid. 
Sodium  salicylate  must  be  used  steadily  for  months  if  we 
desire  to  cure  the  fever,  as  the  temperature  ju'omptly  re- 
turns to  its  former  height  if  its  administration  is  inter- 
rupted. The  drug  is  best  administered  in  powders  of  one 
gramme  (gr.  xv)  each,  followed  by  a  glass  of  water.  Of 
such  dosies,  four  to  six  are  taken  daily;  when  the  fever  is 
unusually  high,  eight  to  ten.  The  former  number  produce 
no  effect  on  the  blood  pressure,  while  the  latter  do  cause 
a  fall  (10  to  12  mm.  Hg.)  of  the  same. — Interstate  Medical 
Journal. — Errico  of  Kenzi  {Berl.  Klin.  Wochenschr.,  1902, 
No.    18). 

TREATMENT   OF  TUBERCULOUS  PERITONITIS  IN 
CHILDREN. 

Rotch  summarizes  the  treatment  of  tuberculous  perito- 
nitis from  a  study  of  sixty-nine  cases  treated  at  the  Boston 
Children's  Hospital. 

The  most  common  age  of  incidence  in  childhood  is 
one  and  a  half  to  four  years.  In  the  first  year  of  life  it 
is  very  rare  and  almost  universally  fatal,  as  at  this  time 
it  is  almost  invariably  part  of  a  general  tuberculosis. 
Pathologically,  the  cases  may  be  divided  into  primary 
and  secondary  cases.  The  secondary  cases  are  most 
often  those  infected  from  lungs,  intestines  and  mesenteric 
lymph  nodes.  Where  the  lungs  or  the  intestines  are  the 
primary  cause,  the  prognosis  is  that  of  general  tuber- 
culosis, so  that  laparotomy  is  seldom  of  avail.  Where  the 
tuberculosis  is  primary  in  the  mesenteric  lymph  nodes, 
laparotomy  is  often  of  value  and  should  be  tried.     And 


MEDICINE  AND   NEUROLOGY.  5^7 

where  the  tuberculosis  is  primary  in  the  peritoneum,  lapa- 
rotomy is  directly  indicated  and  often  results  in  com- 
plete cure. 

In  the  primary  cases  the  prognosis  is  better  where  the 
tuberculosis  is  represented  by  miliary  tubercles  of  the 
peritoneum  with  ascites  than  in  the  cases  with  thick  adhe- 
sions, without  much  fluid. 

Taking  into  consideration  the  fact  that  in  competent 
hands  exploratory  laparotomy  is  a  safe  procedure  in  com- 
parison with  non-operative  treatment,  and  the  further  fact 
that  spontaneous  recovery  without  laparotomy  occurs  only 
in  a  small  minority  of  the  cases,  the  author  believes  that 
the  laparotomy  should  be  done  whenever  it  is  possible. — 
Archives  of  Pediatrics^  September,  1902. 

EMPYEMA  IN  INFANTS  AND   CHILDREN. 

It  is  not  possible  in  infants  and  children  to  differen- 
tiate the  symptoms  of  pleurisy  with  effusions  from  those 
of  empyema.  In  most  children,  before  the  age  of  five,  the 
effusion  is  likely  to  be  purulent.  In  children  empyema 
follows  some  acute  affection  of  the  lung  in  95  per  cent,  of 
the  cases.  Naturally,  this  affection  is  most  often  a  pneu- 
monia, though  bacteriological  examination  of  the  fluid 
shows  that  a  mixed  infection  is  not  infrequently  present. 
The  tuberculous  forms  of  empyema  are  relatively  infre- 
quent in  childhood.  Empyema  may  follow  the  acute  ex- 
anthemata, also  typhoid,  tonsilitis,  appendicitis,  sepsis  of 
the  newly  born,  etc.  It  sometimes  happens  that  the  effu- 
sion is  at  first  serous,  later  becoming  purulent,  without 
extraneous  infection. 

In  a  few  cases,  not  necessarily  tuberculous,  the  effu- 
sion is  hemorrhagic. 

The  symptoms  are  usually  masked  by  those  of  the 
causal  affection.  The  temperature  is  usually  elevated; 
.  there  is  more  or  less  cough,  pain  and  dyspnea.  Exhaust- 
ing night-sweats  are  common.  The  diagnosis  must  rest 
on  physical  signs  and  exploratory  puncture. 

The  prognosis  in  the  post-pneumonic  form  is  not  bad, 
except  if  there  be  complicating  secondary  broncho-pneu- 
monia, or  where  the  pneumonia  persists.  The  prognosis 
of  the  tuberculous  forms  rest  upon  the  age  of  the  patient 
and  the  extent  of  the  lung  involved  in  the  pleuritic  affec- 
tion; but,  on  the  whole,  it  is  better  even  in  this  class  of 
case  than  it  is  in  adult  life. — Koplik  (Medical  Neics,  Sep- 
tember 13,  1902). 


508                            PROGRESS    OF    MEDICAL    SCIENCE. 
CONSTIPATION ITS   TKEATMENT   WITHOUT  DRUGS. 

First,  correct  all  the  bad  habits.  Nothing  can  take  the 
place  of  this  injunction.  *  *  *  Take  time  for  every  meal, 
or  don't  eat  it.     *     *     * 

Bending  the  body  at  the  middle  backward  and  forward, 
sidewise,  twisting,  gyrating,  stooping,  swinging  and  thrusting 
the  arms  upward,  backward,  forward,  round  and  round, 
reaching,  strikini!^,  pulling  and  pushing — all  these  motions 
are  of  value.  Rapid  walking,  horseback  riding — if  the  horse 
is  not  too  easy  in  gait  ! — kicking,  swinging  the  legs,  squat- 
ting and  rising  rapidly  many  times  repeated.  Any  motions 
or  exercises  that  act  upon  the  abdominal  muscles,  that 
stimulate  the  diaphragm,  accelerate  the  breathing  function 
and  favour  the  perstaltic  movement  of  the  bowels  will  aid 
in  banishing  the  demons  and  hobgoblins  that  dance  and 
devastate  in  the  wake  of  this  national  if  not  cosmopolitan 
malady,  constipation, —  The  Dietetic  and  Hygienic  Gazette. 

AN  IMPROVED   METHOD   OF  PERCUSSION. 

The  limitations  of  percussion  in  thoracic  and  ab- 
dominal disease  are  quite  well  understood.  In  the  majority 
of  instances,  percussion  is  carried  out  by  tapping  with  the 
fingers  of  the  right  hand  upon  the  back  of  the  fingers  of 
the  left  hand  laid  flat  upon  the  part.  There  are  certain 
limitatioins  to  percussion  when  performed  in  this  manner 
that  do  not  obtain  when  some  substance  other  than  the 
fingers  is  brought  between  the  wall  of  the  cavity  to  be 
percussed.  The  fingers  may  not  fit  the  part  accurately. 
They  inevitably  cover  a  considerable  surface,  and,  conse- 
quently, the  vibrations  are  conducted  over  a  considerable 
area.  Various  substitutes  for  the  finger,  made  of  rubber 
and  celluloid,  have  been  devised,  which  have  for  their  gen- 
eral purpose  the  limitation  of  the  area  which  is  to  be  per- 
cussed. The  disadvantage  of  these,  as  compared  with  the 
finger,  is  that  the  sense  of  resistance,  which  is  of  such 
value  in  diagnosis,  is  left  out. 

A  method  devised  by  J.  Plesch,  of  Budapest,  combines 
both  methods  to  advantage.  He  uses  the  middle  finger  of 
the  left  hand,  but  instead  of  laying  it  flat  upon  the  chest, 
only  the  tips  of  the  fingers  are  brought  in  contact  with 
the  part  to  be  percussed.  The  finger  is  bent  at  a  right 
angle  at  the  second  joint  and  the  percussion  is  made  over 
the  first  phalanx.  In  this  way  the  vibrations  are  limited 
to  a  small  area,  and  are  accurately  brought  out;  at  the 
same  time  the  vibrations  are  conducted  to  a  considerable 


SURGERY.  509 

depth  into  the  tissues  because  of  the  limitation  of  the  sur- 
face application.  More  precise  data  are  furnished  by  this 
method  of  percussion  than  by  the  usual  means.  The  value 
of  the  method  has  been  proven  by  Plesch,  who  has  confirm- 
ed the  results  by  radioscopic  examination. — Medicine. 


In  stab  wounds  of  the  abdomen  in  which  intestines 
escape,  they  should  be  immediately  reduced  after  careful 
cleansing  with  saline  solution.  If  there  is  any  difficulty 
owing  to  tightening  of  the  abdominal  wall  around  the 
gut,  the  parietal  wound  should  be  enlarged.  In  some  cases 
it  is  proper  to  let  out  the  gas  with  an  aspirating  needle, 
after  which  a  stitch  should  be  taken  at  the  site  of  puncture. 
— International  Journal  of  Surgery. 


SURQKRY. 

IN  CHARGE   OF 

ROLLO  CAMPBELL,  M.D., 

Lecturer  on  Surgery,  University  of  Bishop's  College  ;  Assistant  Surgeon,  W;stern  Hospital  ; 

AND 

GEORGE  FISK,  M.D. 
Insliuctor  in  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeon,  Western  Hospital 


WHEN  IS   ACUTE   NEPHRITIS,   EXCEPTING  THE  TUBER- 
CULOUS   FORM,   PROPERLY   THE   SUBJECT    OF 
SURGICAL  TREATMENT  ? 

The  most  important  of  the  diseases  here  considered  is 
acute  nephritis  with  miliary  abscesses.  The  danger  of 
urogenic  infection  of  the  kidney  commences  as  soom  as  the 
outflow  is  in  the  least  obstructed,  and  after  the  abscesses 
have  formed  in  one  kidney  it  is  altogether  possible  that 
the  same  may  occur  in  the  healthy  organ  as  a  consequence 
of  embolism.  Thus  it  may  come  about,  and  probably  does 
in  most  cases,  that  the  two  methods  of  infection  combine 
to  account  for  the  condition.  Where  the  transmission  is 
through  blood  current,  it  is  by  far  the  greater  number  of 
cases  which  originate  from  the  intestinal  tract.  However, 
the  greater  number  of  slight  infections  of  this  nature 
never  lead  to  abcess  formation,  and  are  easily  cured  by 
internal  treatment,  which  consists  in  great  part  in  the 
drinking  of  immense  quantities  of  water.     The  first  and 


5IO  SUKGEEY. 

principal  symptom  of  suppurative  nephritis  is  pain  in  the 
vicinity  of  the  affected  organ.  The  disease  is  most  fre- 
quent in  men,  because  they  are  more  subject  to  obstruc- 
tion than  are  women,  and  is,  in  consequence,  almost  always 
bilateral.  In  the  lighter  forms  of  the  disease  the  best 
preventive  treatment  is  free  and  careful  drainage  of  the 
bladder.  It  must  be  kept  constantly  empty.  Where 
suppuration  has  once  occurred  within  the  kidney,  it  is  very 
likely  also  to  affect  the  tissues  immediately  surrounding 
the  organ,  either  by  lymphatic  transmission  or  by  break- 
ing down  of  the  kidney  capsule  under  influence  of  the  pus. 
On  account  of  the  many  blood  vessels  in  the  kidney  and 
the  tension  which  this  capsule  causes,  these  rapidly  lead 
to  general  sepsis.  The  chief  danger  at  first  is  for  the 
second  or  healthy  kidney.  Hence  the  first  indication  is 
to  thoroughly  drain  the  diseased  organ;  but,  however,  it 
has  been  demonstrated  that  if  the  kidney  is  already  slight- 
ly affected,  still  the  patient  may  regain  perfect  health 
after  an  operation  on  the  organ  which  is  primarily  most 
diseased.  Of  course,  the  exact  diagnosis  is  highly  difficult; 
hence  every  operation  for  this  infection  is  primarily  in 
the  nature  of  an  exploration.  If  the  diagnosis  has  been 
correct,  one  finds  edema  of  the  fatty  capsule;  the  kidney 
very  dark  in  colour  and  hard;  then  the  little  abscesses  shin- 
ing through  the  capsule  or  else  felt  as  circumscribed  nodes 
covered  with  fibrin;  then  the  organ  is  split  either  in  the 
ordinary  post-mortem  plane  or  else  through  the  most  dis- 
eased portion,  after  which  it  is  good  practice  to  exercise 
everything  which  seems  bound  to  undergo  softening.  A 
rubber  drain  is  now  placed  in  the  pelvis  of  the  organ  and 
the  incision  stuffed  with  gauze,  the  same  material  being 
packed  around  the  kidney.  By  this  means  the  tension  is 
relieved,  the  circulation  resumes  its  normal  course  and 
free  exit  of  pus  and  urine  is  allowed.  It  is,  further,  good 
practice  to  completely  remove  the  fibrous  capsule  of  the 
organ.  If  it  is  found  that  the  greater  part  of  the  kidney 
has  undergone  pus  formation,  it  is  well  to  completely  re- 
move the  organ.  If  then  there  be  obstruction  of  the  blad- 
der by  clot  formation,  it  is  well  to  make  suprapubic  section 
at  once.  The  principal  symptoms  for  which  operation  is 
necessary  are  local  pain  and  sensitiveness  to  pressure, 
these,  of  course,  being  reinforced  by  the  usual  chemical  and 
microscopical  examination.  Such  an  operation  as  describ- 
ed is  especially  to  be  undertaken  where  a  sudden  oliguria 
or  anuria  occurs  in  a  patient  whose  general  condition  Is 
good  and  who  manifests  symptoms  just  detailed  above. 
The  author  gives  histories  of  several  cases  upon  which 


SURGERY.  511 

he  has  operated  with  results  which  must  be  characterized 
as  brilliant. — Lennander  {Mitteiliingen  atts  den  Granzge- 
bieten  der  Medizin  mid  Chirurgie,  Band  x,  Hft.  1  und  2). — 
Interstate  Medical  Journal. 

THE   SURGICAIi  TREATMENT   OF  TUBERCULOUS 
CERVICAL  ADENITIS. 

J.  F.   Mitchell  (Bulletin  'Johtis  Hcpkins  Hospital)  sa.ys  • 

1.  Tuberculous  cervical  adenitis  is  primarily  a  local 
disease  of  very  frequent  occurrence,  more  often  in  young 
persons  ;  in  itself  not  extremely  serious,  and  rarely,  if  ever, 
proving  fatal. 

2.  It  bears,  however,  a  certain  definite  relation  to  tub- 
erculosis of  the  lungs,  and  serves  as  the  starting-point  from 
which  tuberculosis  may  spread. 

3.  The  tuberculin  test,  as  an  aid  to  diagnosis,  is  positive 
and  harmless. 

4.  While  recovery  may  often  take  place  under  good 
hygienic  conditions,  surgical  interference  is  clearly  demand- 
ed in  most  cases, 

5.  When  surgical  treatment  is  resorted  to,  the  operation 
should  be  radical  in  all  cases. 

6.  Recovery  may  be  predicted  in  70  or  80  per  cent, 
of  cases  so  treated.  Tuberculosis  of  the  lungs,  after  com- 
plete removal  of  the  glands,  is  comparatively  rare, 

7.  Tuberculosis  of  the  lungs,  unless  far  advanced,  is  not 
a  contraindication  to  operation,  the  removal  of  the  glands 
apparently  exerting  a  beneficial  influence  on  condition  of 
the  lungs. 

EXAMINATION  OF  THE  BLOOD  IN  SUPPURATIVE  CASES 
TREATED  SURGICALLY. 

Curschmann  has  pointed  out  that  leucocyte  counts  af- 
ford definite  information  as  to  the  proper  time  to  interfere 
in  cases  of  appendicitis.  Kuttner  and  Brunn  have  verified 
this  statement  in  161  cases,  and  have  at  the  same  time 
tested  the  value  of  Ehrlich's  reaction,  which  depends  on 
the  presence  of  glycogen  in  the  white  corpuscles.  It  is 
necessary  in  these  investigations  to  guard  against  various 
errors,  to  make  two  counts  a  day,  to  remember  the  normal 
variations  in  children,  in  adults,  during  digestion,  etc. 

Leucocytosis  and  Ehrlich's  reaction  have  been  of 
value  in  acute  infections,  but  not  in  tumours  or  in  inflam- 
mation, fhronic  or  specific. 

Even    in    acute    infections    the    results    obtained    are 


512  SURGERY. 

demonstrable  only  where  the  condition  develops  rapidly. 
When  the  process  becomes  localized  and  an  abcess  ia 
formed  the  leucocytosis  diminishes  or  disappears;  the 
iodine  reaction  is  less  definite. 

Thus  the  leucocyte  count  can  only  serve  to  differen- 
tiate between  an  abscess  or  a  tumour  if  with  a  normal- 
temperature  one  finds  at  different  times  an  increase  in  the 
white  cells. 

Abscesses  uncomplicated  by  mixed  infection  never 
show  a  leucocytosis. 

(1)  In  appendicitis  the  results  obtained  by  Ktittner 
accord  closely  with  those  obtained  by  Curschmann  and 
Cabot.  When,  at  the  onset  of  appendicitis,  uncomplicated 
by  pueumonia,  the  number  of  leucocytes  increases  rapidly 
and  remains  high,  after  the  first  few  days  one  can  state 
definitely  the  existence  of  pus,  and  one  should  operate  at 
once  ;  the  temperature  matters  little.  In  the  same  way 
one  meets  with  a  high  leucocyte  count  in  those  cases 
which  clinically  give  the  impression  of  a  general  peritonitis, 
but  in  which  some  parts  of  the  peritoneum  will  be  found 
healthy.  In  cases  of  this  kind  Ehrlich's  reaction  is, 
perhaps,  of  more  value  than  leucocyte  count,  because  it 
disappears  more  quickly  than  the  leucocytosis  if,  after 
interference,  the  patient  goes  on  to  recovery. 

(2)  What  is  true  in  appendicitis  is  true  also  in  rapidly 
spreading  phlegmonous  suppuration.  Here  a  leucocytosis 
indicates  a  rapidly-extending  process.  On  the  other  hand, 
a  rapid  diminution  in  number  of  the  white  corpuscles 
justifies  one  in  making  a  favourable  prognosis,  even  when 
clinically  the  condition  appears  very  grave.  But  in  cases 
of  rapidly  fatal  general  septicemia,  as  in  general  suppura- 
tive peritonitis,  leucocyte  count  fails. 

(3)  The  examination  of  the  blood  is  also  important 
after  operations  in  aiding  prognosis.  If  all  goes  well  and 
there  is  no  infection,  the  leucocytes  progressively  diminish. 
Occasionally  it  is  best  after  an  operation  to  make  the  first 
dressing  as  late  as  possible,  for  example,  after  a  resection- 
of  the  knee.  In  cases  of  this  kind,  even  though  the  tempera- 
ture may  remain  at  40°  C.  for  the  first  few  days,  the  leuco-» 
cytes  may  drop  to  normal  and  healing  take  place  by  first 
intention. — Ktittner.  Abstract  from  Revue  de  Chirurgie}. 
Maryland  Med.  Jour. 


SURGERY.  513 

DULNESS  IN  APPENDICITIS. 

H.  T.  Miller,  Springfield,  O.,  believes  that  in  the 
symptom  dulness,  we  have  an  infallible  means  of  differ- 
entiating in  appendicitis  between  oases  that  are  opera- 
tive and  non-operative.  When  we  have  a  ease  of 
appendicitis  without  the  formation  of  an  inflam- 
matory exudate  we  can  afford  to  wait,  but  with  the 
occurence  of  dulness  it  is  jeopardizing  the  life  of  the  pa- 
tient to  defer  operative  interference.  In  an  acute  attack 
of  appendicitis  with  dulness,  persisting  from  twenty-four 
to  forty-eight  hours,  and  after  the  bowels  have  moved^ 
one  should  operate,  and  the  chances  are  that  pus  will  be 
found.  In  a  recurrent  attack  with  dulness,  even  if  the 
temperature  and  pulse  are  normal  and  the  patient  is  able 
to  be  up  and  around,  one  should  operate,  and  one  will 
most  likely  find  an  indurated  appendix  with  adhesions 
around  the  appendix  and  caecum.  In  the  former  case 
an  immediate  operation  is  the  only  recourse,  in  the  latter 
the  surgeon  will  by  operating  anticipate  an  outbreak  with 
pus  formation.  In  acute  attacks  of  appendicitis  without 
dulness,  the  case  should  be  treated  conservatively;  should 
dulness  make  its  appearance  and  remain,  surgical  inter- 
vention should  be  at  once  advised.  Pain  in  the  region  of  the 
appendix  does  not  always  mean  appendicitis,  but  localized 
dulness  with  the  associated  symptoms  of  appendicitis  al- 
ways does.  While  it  is  true  that  in  every  case  of  appen- 
dicitis with  dulness  we  do  not  find  pus,  in  all  of  these 
cases  the  conditions  are  such  that  no  naistake  is  made  by 
surgical  interference. — N.  T.  Med.  Record. 

UNDER    WHAT    CIRCUMSTANCES    IS   IT   ADVISABLE    TO 
REMOVE    THE    VERMIFORM    APPENDIX    WHEN 
OPENED    FOR    OTHER    REASONS. 

Howard  A.  Kelly,  Baltimore,  having  written  to  eighty 
well-known  American  surgeons  upon  this  subject  received 
replies  from  seventy-four.     His  questions  were  as  follows  : 

1.  When  the  abdomen  is  opened  for  other  causes,  and 
the  perfectly  normal  appendix  is  easily  accessible,  is  it 
your  rule  to  remove  it  ? 

2.  When  the  appendix  is  slightly  adherent  to  neigh- 
bouring structures,  as  peritoneum,  ovarian  or  fibroid  tu- 
mours, do  you  then  remove  it  ? 

His  conclusions  are  embodied  in  the  following  : 

1.  The  appendix  should  always  be  examined  and  its 


514  SURGEBY. 

condition  noted  whenever  the  abdominal  cavity  is  opened 
for  any  reason,  provided  no  additional  risk  is  involved. 

2.  The  opinion  of  the  majority  of  surgeons  in  this 
country  is  against  the  removal  of  a  perfectly  healthy 
appendix,  forty-four  to  twenty-six  being  the  proportion 
shown  in  my  investigation. 

3.  The  opinion  of  a  large  majority  of  surgeons  is  in 
favour  of  removing  an  appendix  which  is  even  slightly 
adherent  to  other  structures,  sixty  to  seven  being  the 
proportion  shown  in  my  investigation. 

4.  The  fact  that  the  appendix  is  normal  in  appear- 
ance does  not  prove  that  it  contains  no  fecal  concretions, 
for  I  have  found  them  in  a  number  of  instances.  Their 
presence  is  sufficient  reason  for  the  removal  of  an  ap- 
parently healthy  appendix.  '. 

5.  After  removal  of  the  right  ovary  the  stump 
should  always  be  covered  with  peritoneum  in  order  to 
prevent  the  risk  of  adhesion  to  the  appendix.  A  long  and 
free  appendix  should  invariably  be  removed. — Jour.  A.  M. 
A.,  St.  Louis  Med.  Rev. 

APPENDICITIS   FROM   A   PHYSICIAN'S   STANDPOINT. 

James  Tyson,  Philadelphia,  after  relating  a  number  of 
cases   in  which   operation   did  not   seem   indicated,   says  : 

It  is  such  experiences  as  these  which  have  brought  me 
to  the  conclusion  that  every  case  of  appendicitis  whose 
diagnosis  is  thoroughly  established  should  be  operated  on, 
always,  if  possible,  in  the  interval  between  attacks.  Of 
the  diagnosis,  however,  we  should  be  reasonably  certain. 
In  view  of  the  occasional  difficulties  of  diagnosis,  it  may 
happen  now  and  then  that  a  normal  appendix  is  removed  ; 
but  I  have  come  to  the  conclusion,  too,  that  it  is  better  to 
have  a  few  normal  appendices  removed  than  that  one 
which  ought  to  have  come  out  should  remain  and  cause 
death  of  its  owner.  The  appendix  is  not  an  organ  of  which 
we  need  be  especially  proud.  It  is  useless  and  exceeding- 
ly vulnerable  and  without  powers  of  resistance  when 
attacked. — Jour.  A.  M.  A. 

THE  PRIMARY  TREATMENT   OF  RAILWAY  INJURIES. 

J.  N.  Baker,  Montgomery,  Ala.,  lays  especial  stress 
on  the  importance  of  recognizing  shock,  which  he  states 
may  be  defined  as  a  state  of  general  depression,    reflexly 


SURGERY.  515 

produced  by  damage  done  the  peripheral  nerves  and  with 
symptoms  referable,  in  the  main,  .to  vasomoter  paralysis. 
A.  Qistinction  snoula  be  made  between  surgical  snock  and 
collapse,  restricting  the  latter  to  cases  in  wliich  serious 
loss  of  plood  is  the  causative  factor  ;  for  it  is  the  exception 
rather  than  the  rule  in  railway  accidents  to  have  serious 
primary  hemorrhage.  The  symptoms  of  shock  are  given 
as  a  depressed  and  enfeebled  circulation,  a  lowering  of 
body  temperature,  a  pinched  and  expressionless  coun- 
tenance, pupils  varying,  though  usually  dilated  ;  mental 
apathy,  a  cold  and  sweaty  skin,  and  in  the  graver  forms  a 
relaxation  of  the  anal-sphincter.  Should  the  head  be 
involved,  instead  of  mental  apathy  we  may  have  profound 
unconsciousness  or  mental  excitability.  Treatment  should 
be  directed  toward  arousing  the  nervous  system,  both 
centrally  and  peripherally.  Centrally  this  may  be  done 
by  the  administration  of  the  usual  agents,  strychnine, 
nitroglycerin,  whisky,  morphine  or  atrophine,  etc.,  all  of 
which  should  be  given  hypodermically.  Morphine,  com- 
bined with  atrophine,  is  usually  the  drug  of  most  service. 
Peripherally,  stimulation  is  induced  by  heat,  the  free  use 
of  blankets  and  hot  water  bags  and  by  having  the  tempera- 
ture of  the  room  more  than  comfortably  warm.  In 
addition  to  these  measures,  saline  infusion  is  of  the  great- 
est service.  After  a  brief  report  of  a  few  cases,  to 
illustrate  the  measures  to  be  adopted  in  various  forms  of 
injury,  the  following  points  are  especially  emphasized: 
The  importance  of  an  understanding  and  an  appreciation 
of  the  nervous  phenomena  of  shock.  The  value  of  the 
saline  infusion,  intravenously  administered,  for  the  relief 
of  this  condition  in  its  graver  forms.  The  importance  of 
prompt  surgical  interference  immediately  upon  the  estab- 
lishment of  reaction.  The  importance  of  a  plantar  flap 
where  the  foot  is  involved,  or  of  a  palmar  flap  where  the 
hand  is  involved.  Never  uselessly  sacrifice  tissue  ;  never 
sacrifice  a  joint;  and  always  strive  to  leave  the  patient 
with  a  smooth,  painless,  "non-contracted,  non-cicatrized 
stump.— 2V.  r.  Med.  Rev.,  St.  Louis  Med.  Rev. 

A  NEIV  PROTECTIVE  DRESSING. 

Karl  Springer  describes  a  new  protective  dressing, 
which  is  intended  especially  for  use  in  plastic  operations, 
skin-grafting,  etc.,  where  it  is  important  to  keep  the  dress- 
mg  from  adhering  to  the  surface  of  the  wound.  The 
various  materials,  such  as  rubber  tissue,  oiled  silk,  oiled 
gauze,  etc.,  which  are  in  general   use  for  this  purpose  are 


5  l6  JOTTINGS. 

open  to  the  objection  that  they  stand  sterilization  by  heat 
but  once,  after  which,  they  must  be  preserved  in  some 
antiseptic  solution,  which  often  impairs  their  strength 
or  pliability,  and  always  requires  washing  off  in  sterile 
water  to  remove  before  use.  Tlie  substance  which  the 
author  employs  as  a  substitute  is  paraffin  of  a  melting 
point  of  45°  to  47°  C.  If  a  small  piece  of  this  is  thrown 
on  the  surface  of  boiling  water  it  is  first  melted,  and  then, 
on  cooling,  forms  a  thin,'  floating  pellicle,  which  may  be 
handled  with  forceps  and  cut  to  the  proper  shape  with 
scissors.  The  technique  of  its  practical  application  is  sim- 
ple. A  flat  vessel  provided  with  a  cover  is  partially  filled 
with  water  and  brought  to  a  boiling  point.  A  piece  of 
paraffin  is  then  thrown  in  and  the  boiling  continued  for  ten 
minutes.  The  vessel  is  then  placed  in  another  dish  of 
cold  water,  causing  the  paraffin  to  harden  as  a  thin  pellicle 
on  the  surface.  As  soon  as  this  occurs  the  vessel  is  placed 
in  water  at  a  little  above  body  temperature,  which  keeps 
pellicle  soft  and  pliable.  Holes  for  drainage  may  then  be 
punctured  through  it  with  a  sterile  needle,  and  after  cut- 
ting to  shape  it  is  lifted  with  forceps  and  applied  to  the 
wound  with  the  water  side  down.  The  thickness  may 
easily  be  controlled  as  experience  dictates  by  the  size  of  the 
lump  of  paraffin  used. — Gentralhlatt  f.  GMr.  St.  Louis.  Mod. 
Rev. 


Jottings, 


Dr.  Bartholow  states  that  the  loss  of  voice  from  fatigue 
or  simple  laryngitis  is  relieved  by  small  doses  of  nitric  acid 
well  diluted  and  given  every  two  hours. 

A  blister  applied  to  a  felon  in  its  early  stages  will  often 
prevent  its  further  progress.  The  blister  need  not  be  more 
than  one  and  a  quarter  inches  square,  but  should  be  kept  on 
perhaps  eighteen  hours,  when  dark  serous  accumulation  can 
be  let  out.  Paint  the  locality  with  comp.  tinct.  of  iodine 
every  hour  or  two  until  the  pain  ceases  or  inflammation  is 
removed.  The  application  of  fresh  grated  Indian  turnip 
moistened  with  turpentine  is  most  highly  extolled. — Med. 
Stimmary. 

Abram  Meyer  {Med,  Record,  March  8,  1902),  reports  a 


JOTTINGS.  5  I  7 

recovery  from  diabetic  coma  following  the  administration  of 
several  twenty-grain  doses  of  urotropin.  He  explains  its 
beneficial  effect  on  the  theory,  that  being  a  chemical  combina- 
tion of  ammonia  and  formaldehyde,  in  the  presence  of  acid 
in  the  blood  it  is  split  into  its  component  parts,  the  ammonia 
serving  to  neutralize  the  acid  in  the  blood. 

The  best  remedy  for  bleeding  at  the  nose  is  in  the  vigor- 
ous motion  of  the  jaws,  as  if  in  the  act  of  chewing.  In  the 
case  of  a  child,  a  wad  of  paper  should  be  inserted,  to  chew  it 
hard.  It  is  the  motion  of  the  jaws  that  stops  the  flow  of 
blood.  The  remedy  is  so  very  simple  that  many  will  feel 
inclined  to  laugh  at  it,  but  it  has  never  been  known  to  fail  in 
a  single  instance,  even  in  the   severest  cases. 

Brieger  has  reported  excellent  results  from  the  treat 
ment  of  sciatica  by  means  of  hot  water  baths  or  packs  and 
massage. 

Dumesnil  says  that  the  most  unsightly  scars  can  be  re- 
moved or  greatly  lessened  by  means  of  electrolysis. 

Derby  obtains  better  results  in  the  treatment  of  pro- 
gressive atrophy  of  the  optic  nerve  from  the  use  of  subcu- 
taneous injections  of  strychnin  in  the  temples,  in  increasing 
doses.  He  begins  with  grain  1-25,  and  increases  this  dose 
daily  by  i-ioo  of  a  grain,  until  constitutional  effects  are 
noticed,  usually  about  the  tenth  day.  The  drug  is  then 
discontinued  for  about  ten  days  and  then  repeated. 

For  the  removal  of  vegetations  from  the  external  geni- 
tals salicylic  acid  is  an  excellent  remedy.  Half  a  drachm 
should  be  dissolved  in  an  ounce  of  acetic  acid  and  applied 
to  parts  with  a  camel's  hair  brush. 

Hare  says  that  the  atonic  stomach  of  drunkards  is  much 
improved  by  a  pill  made  up  as  follows  : 

Oleoresinae  capsici m  x. 

Olei  caryophylli -  m  x. 

Hydrargyri  chloridi  mitis gr.  xx. 

Aloes  socotrinae gr.  xl. 

Ft.  pil,  XX.     S. :  One  t.  i.  d. 

In  ingrowing  toenail,  with  granulations,  a  piece  of  twist- 
ed absorbent  cotton  soaked  in  a  strong  alum  solution  and 
inserted  under  the  edge  of  the  nail  is  a  valuable  remedy. 


the; 


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A  liESSON  TO  THE  AVORLD. 

To  us  it  seems  an  extraordinary  matter  that  to-day  we 
find  even  a  few,  who,  being  possessed  of  average  intelligence 
and  fair  reasoning  powers,  yet  enroll  themselves  among  those 
who  delight  to  style  themselves  "  Anti- Vaccinationists-"  In 
our  opinion,  if  there  is  a  fact  which  is  beyond  the  pale  of 
doubt,  it  is  that  vaccination  and  revaccination  has  saved 
countless  lives  from  smallpox.  Twenty  years  ago  vaccina- 
tion was  almost  totally  neglected  in  the  parishes  of  the 
Province  of  Quebec  and  very  largely  neglected  and  imper- 
fectly performed  in  its  cities.  Of  the  latter  fact  the  writer 
is  perfectly  cognizant,  for  he  was  then,  and  for  many  years 
before,  a  public  vaccinator  in  the  City  of  Montreal.  At  a 
meeting  of  the  Health  Committee  about  that  time,  he  ex- 
pressed the  opinion  after  having  examined  the  arms  of  many 
thousands  among  the  French  Canadian  population,  that  90 
per  cent,  of  that  nationality  were  not  protected,  the  marks 
found  not  being  "  good  vaccine  marks."  That  he  was 
correct  is  proved  by  the  terrible  visitation  which  Montreal 
received  from  smallpox  in  1885,  when  the  epidemic  was 
very  largely  among  French  Canadians.     We,  frequently,  at 


EDITORIAL.  519 

our  clinic  in  the  Montreal  General  Hospital,  with  a  view  of 
enforcing  on  students  our  strong  views  on  the  benefits  of 
vaccination,  relate  what  we  have  written  above  ;  at  the  same 
time,  to  prove  our  assertion,  have  kept  a  record  of  the 
nationality  of  those  who  are  badly  marked  from  the  disease. 
We  have  repeatedly  recorded  one  hundred  French  Canadians 
under  this  head,  without  a  single  English  speaking  person. 
Occasionally,  of  course,  they  are  found,  but  they  are  rare,  and 
their  safety  has  been  due  to  proper  vaccination.  Thanks, 
however,  to  the  intelligence  and  the  zeal  of  our  French 
Canadian  physicians  during  the  past  two  decades,  their 
leading  spirits  being  Dr.  Laberge,  Montreal  Health  Officer, 
Dr.  E.  P.  Lachapelle,  president,  and  Dr.  Pelletier,  secretary 
of  the  Provincial  Board  of  Health.  All  this  is  changed. 
Vaccination  is  to-day  perhaps  as  well  performed  among 
French  Canadians  as  it  is  among  the  English  speaking 
portion  of  our  population.  Since  1885  there  have  been,  on 
a  large  scale,  many  instances  where  smallpox  has  been 
vaccinated  out  of  existence.  An  illustration  of  this  has 
occurred  within  the  last  three  or  four  years  in  Porto  Rico. 
Major  Ames,  brigade  surgeon  United  States  Army,  has 
published  in  \}a^  Pacific  Medical  Journal,  for  September  last, 
a  most  valuable  report  on  vaccination  in  Porto  Rico,  of 
which  he  was  director.  He  summarizes  the  work  and  its 
results  in  the  following  words  :  "  In  October,  1898,  smallpox 
was  endemic  in  Porto  Rico  ;  in  December  it  was  epidemic  ; 
in  January,  1899,  it  had  "honey-combed"  the  Island  ;  by 
February  there  were  over  3,000  recent  cases  and  the  disease 
was  spreading  at  a  gallop. 

"In  February,  systematic  compulsory  vaccination,  carefully 
and  scientifically  conducted  and  recorded,  was  begun  simul- 
taneously and  with  pretty  equal  efficiency  in  all  parts  of  the 
Island,  It  was  vigorously  prosecuted  for  four  months  only^ 
till  1st  July,  when  860,000  vaccinations  had  been  made  in  a 
population  of  about  960,000.  Of  these  87^  per  cent,  were 
successful.  The  work  then  ceased,  because  completed  ;  the 
disease  had,  practically,  disappeared  ;  the  fuel  for  it  to  feed 


520  EDITORIAL. 

upon  had  been  consumed  by  the  "head-fire"  of  vaccination. 
In  the  two  and  a  half  years  that  have  since  passed,  instead 
of  the  former  annual  average  death-rate  of  621,  the  mortality 
from  smallpox  has  been  but  two  per  annum  in  a  population 
of  nearly  a  million.  Can  diV\y  ho7iest,  intelligent  person  doubt 
in  face  of  these  indisputable  and  easily  verified  facts,  what 
it  was  that  in  four  short  months  drove  smallpox  from  its 
wide  and  long-time  reign  on  the  Island,  and  has  since  kept 
it  out?  Vaccination  alone  did  it,  and  will  do  it  effectively 
wherever  compulsory  legislation,  properly  enforced,  secures  its 
benefits  to  all  /" 


URETER CATHETERISM  :      ITS  PURPOSE  AND 

PRACTICABILITY. 

At  the  meeting  of  the  Mississippi  Valley  Medical 
Association,  at  Kansas  city,  October  15,  1902,  Dr.  Brans- 
ford  Lewis,  of  St.  Louis,  read  a  pnper  under  tlie  above  title, 
and  presented  his  perfected  model  of  catheterising  cysto- 
scope  for  male  and  female,  which  permits  of  catheteriza- 
tion of  both  ureters  at  the  same  sitting  because  of  the  new 
double-barrel  arrangement  of  the  ureter  tubes.  After  the 
reading  of  the  paper,  a  demonstration  of  double  ureter — 
catheterism  was  made  by  Dr.  Lewis  before  a  number  of 
members  of  the  Association,  the  time  required  for  getting 
both  catheters  into  the  ureters,  after  the  introduction  of 
the  cystoscope  into  the  bladder,  being  three  or  four  seconds 
for  each  ureter,  local  (cocaine)  anesthesia  was  used;  and 
very  little  discomfort  was  complained  of  by  the  patient 
during  the  procedure. 

The  essayist  claimed  for  ureter-catheterism  great  ad- 
vantages in  respect  to  both  diagnosis  and  treatment,  and 
under  these  two  divisions  presented  a  schedule  of  the  pur- 
pose of  the  procedure. 

A  number  of  cases  were  reported,  in  which  the  clinical 
aspects  of  the  subject  appeared.  Case  I.  referred  to  a 
patient  who  had  been  advised  to  undergo  an  operation  for 


EDITORIAL.  521 

removal  of  three  stones  that  were  supposed  to  be  lodged 
in  the  ureter,  the  diagnosis  being  based  on  an  X-ray  photo- 
graph.' Ureter  catheterism  showed  the  ureter  to  be  ab- 
solutely void  of  any  foreign  material,  and  drainage  gave 
perfectly  clear  and  healthy  urine  from  that  side.  Case  II. 
was  one  of  persistent  cystisis  and  infection  of  the  urinary 
tract  that  was  rebellious  to  various  treatments  applied 
for  several  months,  and  only  responded  satisfactorily 
after  regular  periodic  irrigations  of  the  infected  left 
kidney-pelvis  had  been  carried  out.  These  removed  all 
foci  of  infection  and  restored  the  tract  to  health.  It 
was  mentioned  that  two  other  cases  of  urinary  infections 
with  prolonged  history  had  behaved  similarly  and  had 
proved  equally  as  amenable  to  the  boric  acid  irrigations 
of  the  kidney-pelvis.  Cases  of  unilateral  and  of  bilateral 
renal  tuberculosis,  in  both  male  and  female  subjects,  were 
mentioned,  the  definite  diagnosis  being  made  in  each  case 
without  serious  disturbance  to  the  patients  and  without 
subsequent  increase  of  irrigation,  etc.  On  the  contrary, 
there  was  improvement  in  each  case,  following  the  wash- 
ings with  antiseptics  that  were  also  given.  The  question 
as  to  whether  the  air  used  for  distending  the  bladder  had 
any  beneficial  effects  had  come  to  Dr.  Lewis'  mind.  Sev- 
eral cases  were  mentioned  in  which  there  had  been  so 
much  bleeding  from  the  urinary  tract  that  successful 
cystoscopy  or  ureter  catheterism  with  the  older,  lens,  in- 
struments by  which  the  manipulations  would  have  to  be 
made  through  clear  fluid  in  the  bladder,  would  manifestly 
have  been  impossible;  the  fluid  would  have  become  clouded 
with  blood  so  quickly  that  no  view  of  the  bladder  or  of  the 
ureter  openings  could  have  been  obtained.  But  this  did 
not  deter  the  writer  from  accomplishing  both  objects,  as 
the  blood  flowed  along  the  walls  of  the  bladder,  collecting 
in  small  pool  at  the  fundus,  out  of  the  way  of  the  manipu- 
lations, the  patient  being  in  the  elevated  pelvic  posture 
on  his  back.  Catheterism  of  both  ureters  had  been  ac- 
complished in  each  case  of  this  kind  in  which  it  had  been 
undertaken;  and  a  means  of  appropriate  medication,  with- 


522  EDITORIAL. 

out  operation,  had  been  supplied,  also.  The  bearing  of 
this  method  on  pyo-nephrosis  and  peri-renal  abscess,  with 
respect  to  both  diagnosis  and  treatment,  was  shown  by 
illustrative  cases.  A  description  of  the  instrument  and 
the  technique  of  its  use  was  given.  General  anesthesia 
had  been  abandoned  and  had  been  satisfactorily  replaced 
by  cocaine  anesthesia,  best  secured  by  means  of  the  writ- 
er's urethral  tablet  depositor  and  cocaine  tablets  made  by 
Searle  and  Hereth  Co.  The  ureter-cystoscope  was  being 
made  by  the  Surgical  Appliance  Mfg.  Co.,  Rochester,  N.  Y. 
It  was  mentioned  that  a  table  for  the  purpose  of  expedit- 
ing and  facilitating  the  procedure  was  being  developed 
under  the  author's  supervision  by  the  Willbrant  Surgical 
Mfg.  Co.,  of  St.  Louis.  This  table  was  intended  to  be 
adapted  to  other  genitourinary  operative  and  oflflce  work 
also. 


UNIVERSITY  OF  BISHOP'S  COLLEGE 
FACULTY    OF    MEDICINE. 

The  session  of  this  Faculty  opened  early  last  month,  and 
we  are  glad  to  learn  that  it  promises  to  be  the  most  success- 
ful in  its  history — nearly,  if  not  quite,  thirty  Freshmen  having 
so  far  registered.  An  unusually  large  number  of  Second, 
Third  and  Fourth  Year  men  have  also  registered,  many  being 
new  men  who  have  come  from  distant  schools  on  account  of 
the  reputation  of  the  Faculty  for  its  practical  teaching.  This 
session  will  be  one  of  nine  months,  the  first  in  its  history. 
We  are  informed  that  in  view  of  concluding  work  before  the 
"  dog  days  "  arrive,  the  courses  will  open  next  fall,  early  in 
September. 

The  Annual  Dinner  of  the  graduates  and  un'dergraduates 
in  medicine  and  dentistry  of  Bishop's  took  place  at  the  Place 
Viger  Hotel,  on  the  6th  November;  one  hundred  and 
eleven  sat  down,  among  the  guests  being  the  Hon.  J.  Israel 
Tarte.  The  speeches  were  much  above  the  average  of  such 
occasions.  We  hope  in  our  next  issue  to  give  a  more 
extended  report. 


Book   Reviews, 


A  Text-Book  of  Pathology  and  Pathological  Ana- 
tomy.— By  Dr.  Hans  Schmaus,  Professor  in  the  Patho- 
logical Institute  at  Munich.  Translated  from  the  sixth  German 
edition  by  A.  E.  Thayer,  M.D.,  Instructor  in  Pathology,  and 
edited,  with  additions,  by  James  Ewing,  M.D.,  Professor  of 
Pathology  in  Cornell  University  Medical  College,  New  York. 
In  one  octavo  volume  of  597  pages,  with  351  illustrations, 
including  35  coloured  inset  plates.  Cloth,  $4.00,  net.  Lea 
Brothers  &  Co.,  Publishers,  Philadelphia  and  New  York. 

Professor  Schmaus  is  a  Pathologist  of  high  authority  in  his 
own  country.  Dr.  Ewing  has  won  reputation  in  this,  by  his  work  on 
the  blood  and  his  studies  on  inflammation.  Messrs.  Lea  are  known 
everywhere  for  the  excellence  of  their  publications.  When  these 
three  forces  were  known  to  be  working  together  in  one  direction, 
toward  the  production  of  a  text-book  on  Pathology,  an  unsually 
good  result  was  to  have  been  expected.  The  book  has  appeared  ; 
and  on  account  of  this  high  hope  it  demands  careful  examination 
and  particular  notice. 

The  publishers  have  left  nothing  to  be  desired.  The  book  as 
it  leaves  their  hands  is  substantial,  handsome  and  even  dainty  ;  the 
illustrations  are  fresh,  clear  and  artistic.  In  a  word,  the  make-up  of 
the  work  is  admirable,  pleasing  to  the  hand  and  eye. 

The  best  text-book  is  one  that  is  most  useful,  a  statement  not 
so  obvious  as  it  would  appear.  This  usefulness  depends  on  a 
large  number  of  qualities.  It  must  contain  the  common  informa- 
tion upon  a  subject,  brought  together  for  common  use  ;  it  must  be 
full  and  accurate.  The  present  book  is  full  to  repletion,  it  is 
accurate  in  its  statement  of  fact.  But  there  is  something  more. 
The  information  must  be  well  classified,  and  easily  accessible.  In 
the  present  case  it  is  not  well  classified,  it  is  not  easily  accessible, 
and  English-speaking  students  have  not  the  industry  of  their 
German  confreres  to  dig  into  the  text  for  isolated  facts  and 
correlate  them  in  their  own  minds.  One  example  will  serve.  The 
introduction  is  burdened  with  an  account  of  the  signs  of  death, 
full  and  excellent,  but  no  one  would  think  of  looking  for  it  there. 
It  is  quite  true  this  foreign  material  is  found  in  the  German,  but 
there  is  nothing  profane  in  a  free  handling  of  the  original,  for  the 
comfort  of  the  student  is  the  supreme  law  in  the  making  of  text- 
books.    That  is  the  editor's  business. 

There  is  still  something  more.  A  text-book  does  not  imply 
originality  on  the  part  of  the  maker,  editor  or  translator  ;  it  does 
imply  good  sense  in  selection,  in  leaving  out  as  well  as  putting  in. 
There  must  be  a  correct  and  nice  use  of  words,  a  logical  sequence 
of  sentences,  in  short,  it  must  have  style.  The  text-books  that 
endure  are  those  that  have  this  quality,  in  addition  to  those  already 


524  BOOK  REVIEWS. 

named.  They  are  the  great  books — Erichson's  Surgery,  Quain's 
Anatomy,  Osier's  Medicine.  No  German  professional  book  ever 
has  style  ;  at  least,  it  is  not  apparent  to  the  Gentile  mind.  It  is  the 
business  of  the  translator  and  editor  to  supply  it,  unless  the  book  is 
to  remain  merely  a  translation,  and  so  stated  in  the  outset. 

Dr.  Thayer,  the  translator,  writes  English  excellently  well, — 
for  a  German  ;  but,  apparently,  he  had  not  much  assistance  from  the 
editor,  for  Dr.  Ewing,  in  his  preface,  considers  the  text  has  been 
rendered  into  "  clear  English."  The  rendering  is  neither  clear 
nor  correct.  It  is  doubtful  if  there  is  a  page  which  will  not  yield 
proof  of  this,  and  there  are  nearly  six  hundred  pages  in  the  book. 
The  meaning  of  such  a  sentence  as  the  following,  on  page  i8  : 
"  these  cellular  elements,  the  very  bricks  of  the  edifice,  are  the 
actual  carriers  of  life  functions,"  is  not  clear,  unless  the  cellular 
elements  of  the  blood  be  thought  of  as  bricks  and  the  life  functions 
carried  by  them  as  a  roof  to  the  edifice.  In  the  same  paragraph 
three  subjects  are  named,  and  the  last  is  referred  to  as  "  which 
latter."  Upon  the  same  page  a  "purpose  "  is  referred  to  first 
as  a  "  pathway  "  and  again  as  a  "  foundation." 

There  is  a  straining  after  scientific  exactness  of  definition  com- 
mon also  in  American  books  not  confessedly  translations,  which 
destroys  all  fluidity  and  freedom  of  expression.  The  terms,  "mar- 
antic edema  "  "universal  and  inclusive  view,"  "expression  of 
life,"  "concepts,"  "spontaneous  injury,"  "  signification  of  tuber- 
culosis," "  suggillation "  are  not  essentially  more  correct  than 
simpler  expressions,  and  they  give  to  the  text  a  foreign  sound,  look 
and  feeling. 

Again,  whole  sentences,  excellent  in  themselves,  are  inter- 
jected into  passages  where  they  only  serve  as  obstructions.  There 
is  a  good  example  of  this  on  page  212  where  the  following  occurs  : 
"  Baumgarten  and  Walz  do  not  admit  the  existence  of  such  alexins. 
JSiatural  immunity  means  that  an  animal  is  not  a  favourable  med- 
ium for  the  bacteria  invading  it.  They  rest  their  argument  on. 
the  fact,"  etc. 

The  free  use  of  "  latter"  and  "  former,"  "  first "  and  "  last" 
"  the  same,"  "  the  previous  "  is  obstructive  to  the  flow  of  thought, 
Adjectives  are  continually  used  in  a  substantival  sense  as  "  col- 
loid," "  amyloid."  The  sentence  ;  "  the  arterio-sclerotic  kidney  is 
distinguished  from  atrophy  with  stasis  by  the  over  filled  veins  of 
the  latter,  even  when  very  much  decreased  in  size,"  is  not  "  clear" 
in  its  meaning  nor  aggealable  in  its  form.  When  one  comes  upon 
such  terms  as  "  regressive,"  and  finds  upon  reflection  that  they 
are  strictly  justifiable,  he  is  inclined  to  think  that  terms  like 
**  arrosion,"  on  page  485,  are  also  so,  but  that  is  an  unwarrantable 
inference. 

If  it  be  considered  that  these  are  mere  subtleties,  one  may 
mention  more  obvious  departures  from  normal  writing,  in  sentences 
without  subjects,  in  a  lack  of  agreement  between  nouns  and  their 
verbs,  in  a  wrong  use  of  adverbial  expressions  and  prepositions. 
One  or  two  random  examples  of  each  will  serve;  "  Occurs   in  the 


BOOK   REVIEWS.  525 

blood  in  septic  diseases,"  page  217  ;  "  inflammation  is  but  a 
pathological  exaltation  of  processes  which  serve;"  page  105: 
"  there  appear  to  be  grains,"  page  66  ;  "there  are  found  a  number," 
page  239  ;  "  islands  of  tissue  which  is  little  affected  or  in  fatty  de- 
generation," page  425;  "the  cause  of  the  cyanotic  induration  is 
the  distention  of  the  veins  and  the  hyperplasia  of  the  stroma  which 
leads  to"  page  423  ;  "  similar  as,"  page  216.  These  are  little  matters 
compared  with  the  use  of  "  and  which.''  There  is  a  trace  of 
humour  in  the  expression  "  the  majority  of  the  protozoa  found 
(in  carcinomata)  are  degenerative  products  of  cells." 

The  merits  as  well  as  the  defects  of  the  original  have  been 
faithfully  reproduced.  There  is  often  a  variation  in  definition 
which  is  sure  to  confuse,  as  in  the  case  of  fatty  infiltration  and 
fatty  degeneration,  or  rather  a  definition  is  made  absolutely  and 
later  is  qualified  to  the  point  of  destruction.  Very  little  attempt 
is  made  even  in  matters  of  controversy  to  state  to  compare  and 
decide  between  opposing  views.  In  the  consideration  of  tumours 
the  statement  is  made:  '*  We  know  now  that  true  epithelium,  and 
hence  its  tumours  may  develop  from  the  middle  layer  "  ;  it  may  be 
so,  but  one  would  like  to  have  some  evidence  of  it.  The  handling 
of  what  is  called  inflammation,  the  real  test  of  a  writer  on  patho- 
logy, is  not  clever,  and  the  result  is   disorderly  and  uninteresting. 

Most  of  these  things  concern  the  work  of  the  editor  and 
translator ;  the  fact  still  remains  that  the  original  is  of  great  value 
to  German  students,  and  that  a  translation  would  be  of  great  value 
to  American  students — if  it  were  done  by  other  hands. 

Professor  Schmaus'  work  is  of  so  high  an  authority,  the 
labour  of  rendering  it  more  accessible  to  the  American  student 
has  been  so  great,  the  enterprise  of  the  publisher  has  been  so 
marked,  that  the  result  challenges  criticism,  and  it  is  permissible 
to  speak  thus  freely  of  it  here. 

A.  M. 

Butler's  Materia  Medica.  A  Text-Book  of  Materia  Medica, 
Therapeutics,  and  Pharmacology.  By  George  h\  Butler,  Ph. 
G.,  M.D..,  Professor  of  Materia  Medica  and  of  Clinical 
Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
Fourth  Edition,  revised  and  enlarged.  Octavo.  896  pages, 
illustrated.  W.  B.  Saunders  &  Co.,  Philadelphia  and  London, 
19O2.     Cloth,  $4,00  net. 

This  is  essentially  a  student's  book.  The  fourth  and  revised 
edition  now  before  me  is  a  marked  advance  on  the  first  three 
editions.  It  has,  practically,  been  rewritten,  with  a  resulting 
improvement  in  the  method  of  presentation  of  its  subject  matter. 
The  portion  dealing  with  Materia  Medica  as  ordinarily  understood 
is  full  and  concise.  The  section  on  serum  therapy  (which  by  the 
way  is  placed  under  the  "  Alteratives,"  instead  of  the  **  Specific 
Medications,"  as  one  would  expect)  is  somewhat  sketchy.  Under 
Organotherapy,  seven   pages   suffice  to  dismiss  a  most   important 


526  BOOK  REVIEWS. 

subject,  and  personally  I  should  prefer  the  word  "  secretions  "  in 
the  opening  sentence  :  "  The  striking  fact  that  various  excretions 
"  and  tissues  of  the  organism,  when  administered  under  certain 
"  conditions,  possess  a  peculiar  therapeutic  value  is  now  well 
"  ascertained." 

The  chapter  on  prescriptions  embrace  a  sort  of  condensed 
Latin  grammar.  This  part  of  it  is  (perhaps  unconsciously)  a 
caustic  commentary  on  the  standing  of  American  medical  students 
or  standard  of  the  matriculation  of  American  Medical  Colleges. 
This  "how-tolearn-Latin-ctt-a-glance"  method  seems  strangely 
out  of  place  in  a  volume  intended  for  medical  students  and  for 
whom  the  standard  of  preliminary  requirements  should  be  so 
sufficiently  high  to  obviate  the  necessity  for  such  elementary  notes, 
with  its  corrollary  confession  of  insufficient  educational  foundation. 
The  best  chapter  in  the  book  is  written  by  Martin  H.  Fisher,  M.D., 
Associate  in  Physiology  in  the  University  of  Chicago,  on  "  The 
Relation  of  Physical  Chemistry  to  Pharmacology  and  Therapeutics," 
although  but  eight  pages  are  devoted  to  it,  and  that  it  would  be 
more  at  home  in  a  "quiz-compend"  than  a  text-book — altogether 
the  volume  lacks  the  extended  physiological  experimental  work"  of 
words — the  bio-chemical  work  of  a  Gushing,  the  practical  thera- 
peutical applications  of  a  Shoemaker,  and  has  been  written  for  the 
United  States,  and  its  pharmacopaea.  The  paper  is  excellent  and 
of  dull  finish,  the  type  clear,  and  the  binding  above  reproach. 

R.  W. 

Lindsay  and  Blakiston's  Visiting  List  for  1893.— P. 

Blakiston's  Son  &  Co.,  1012  Walnut  Street,  Philadelphia. 

This  is  the  fifty-second  year  of  this  annual,  and  no  better 
visiting  list  is  published  ;  we  have  used  it  for  over  forty  years,  and 
have  found  that  it  answers  perfectly  every  need.  In  addition  to 
the  numerous  other  valuable  features  for  which  this  little  work  is 
noted  we  specially  wish  to  draw  our  readers'  attention  to  two  new 
features — namely,  the  pages  on  incompatibility,  chemic,  phar- 
maceutic and  therapeutic ;  also  the  page  on  the  immediate  treat- 
ment of  poisoning.  We  believe  these  additions  will  enhance  con. 
siderably  the  value  of  this  Physicians' Visiting  List,  as  an  ever-handy 
reference  guide  for  the  medical  practitioner. 

F.  W.  C. 

A  Text-Book  on  Diseases  of  Infancy  and  Childhood*— 

For  the  use  of  Students  and  Practitioners.  By  Henry  Koplik, 
M.D.,  Attending  Pediatrist  to  Mt.  Sinai  Hospital,  New 
York  ;  ex-President  of  American  Pediatric  Society,  etc. 
Octavo,  675  pages,  169  engravings  and  30  plates  in  colours 
and  monochrome.  Cloth,  $5.00,  net ;  leather,  $6.00,  net.  Lea 
Brothers  &  Co.,  Philadelphia,  1902. 

This  is  a  new  work  on  pediatrics.  The  author  aims  at  giving, 
as  well  as  his  own  views,  those  of  the  best  writers  on  this  subject 


BOOK  REVIEWS.  52/ 

both  in  Europe  and  America.  In  this  he  has  succeeded  well,  and 
the  arrangement  of  the  work  is  excellent,  giving  the  author's 
name  in  brackets  when  quoted,  and  at  tne  end  of  each  chapter  a 
list  is  given  of  the  leading  authorities  referred  to  in  the  chapter. 
There  is  also  an  authoi's  index.  By  this  arrangement  the  views 
of  an  author  on  any  particular  subject  may  be  easily  referred  to. 
The  work,  as  a  whole,  deals  with  about  all  the  diseases  of  infancy 
and  childhood,  but  not  minutely.  The  main  features  of  the 
disease  are  given,  and  the  author  keeps  the  clinical  aspects  well  to 
the  front.  Thus  the  work  is  not  voluminous,  which  makes  it  better 
adapted  for  the  use  of  general  practitioners  and  students.  Special 
attention  is  given  to  methods  of  examination  and  physical  di- 
agnosis. The  work  is  well  illustrated  and  the  publishers  have 
shown  their  usual  skill  and  good  workmanship  in  the  general  make- 
up of  the  book.  I.  C.  S. 

Bacteriologic  Technique.  A  Laboratory  Guide  for  the 
Medical  and  Dental  Student,  by  Dr.  J.  VV.  H.  Eyre,  Lecturer 
on  Bacteriology,  Charing  Cross  Hospital  Medical  School, 
London.  W.  B.  Saunders  &  Co.,  Canadian  agents  :  J.  A.  Car- 
veth  &  Co.,  Toronto.     Price,  $2.50. 

No  guide  could  be  more  useful  than  this  one.  It  is  complete, 
systematic  and  reliable.  It  is  the  outcome  of  the  experience  of  a 
man  who  has  wrought  with  his  own  hands  and  knows  the  difficult 
places  in  the  course.  Every  method  and  operation  employed  in 
the  laboratory  is  clearly  described  and  could  be  performed  by  a 
student  of  average  skill  without  any  further  instruction.  The  work 
is  what  it  purports  to  be — a  guide  through  the  laboratory,  not  a 
text-book,  not  even  a  manual  of  bacteriology.  It  is  intended  for 
workers,  not  for  readers. 

The  illustrations  really  do  illustrate  ;  the  descriptions  are  clear 
and  adequate,  and  given  in  good  style.  The  range  of  work  covered 
is  very  large  and  includes  almost  everything  that  can  be  done  in  a 
laboratory  of  bacteriology.  A.  M. 

The  Medical  News  Visiting   List  for  1903.— Weekly 

(dated,  for  30  patients);  Monthly  (undated,  for  120  patients 
per  month)  ;  Perpetual  (undated,  for  30  patients  weekly  per 
year);  and  Perpetual  (undated,  for  60  patients  weekly  per 
year).  The  first  three  styles  contain  32  pages  of  data  and 
160  pages  of  blanks.  The  60  patient  Perpetual  consists  of 
256  pages  of  blanks.  Each  style  in  one  wallet-shaped  book, 
with  pocket;  pencil  and  rubber.  Seal  Grain  Leather,  $1.25, 
Thumb-letter  Index,  25  cents  extra.  Lea  Brothers  &  Co., 
Publishers,  Philadelphia  and  New  York. 

A  visiting  list  is  an  indispensable  convenience  for  the  active 
practitioner.  Its  carefully  adapted  blanks  enable  him  at  once  to 
note  clinical  details  of  every  day  work,  as  well  as  charges  and 
receipts,  and  to  unburden  his  memory  of  that  which  can  better  be 


5^8  BOOK  REVIEWS. 

carried  on  paper.  It  also  furnishes  him  with  a  legal  record  neces- 
sary for  the  collection  of  delinquent  bills.  Among  the  most  con- 
venient of  the  many  publications  of  this  nature  is  the  Medical 
News  Visiting  List.  Its  blank  pages  are  arranged  to  classify  and 
record  memoranda  and  engagements  of  every  description  occurring 
in  the  practice  of  the  physician,  surgeon  or  obstetrician.  The 
work  opens  with  printed  data  of  the  most  useful  sort,  including  an 
alphabetical  Table  of  Diseases  with  Approved  Remedies,  a  'J'able 
of  Doses,  Sections  on  Examinations  of  Urine,  Artificial  Respiration, 
Incompatibles,  Poisons  and  Antidotes,  a  Diagnostic  Table  of 
Eruptic  Fevers,  and  a  full  page  plate  showing  at  a  glance  the 
incisions  for  ligation  of  the  various  arteries,  an  invaluable  guide  in 
such  emergencies. 

It  is  printed  on  fine,  tough  paper,  suitable  for  pen  or  pencil, 
and  durably  and  handsomely  bound  in  the  size  of  a  wallet  for  the 
pocket.  When  desired  a  Thumb-letter  Index  is  furnished,  which 
is  an  economizer  of  time.  We  have  used  this  little  book  in  the 
past,  and  can  honestly  testify  to  having  had  perfect  satisfaction,  it 
being  quite  a  Multum  in  Parvo. 

R.  C. 

Physical  Diagnosis. — Diseases  of  the  Thoracic  and  Abdo- 
minal Organs.  By  Egb3rt  Lefevre,  M.D.  Lea  Brothers  & 
Co.,  publishers,  Philadelphia,  1902. 

This  is  one  of  the  most  up-to-date  and  concise  works  on  this 
important  subject. 

It  is  useful  alike  to  student  and  practitioner.  The  work 
reflects  credit  on  the  author  and  the  publishers.  The  subject  matter 
of  the  book  is  excellent,  and  the  printing,  paper  and  engravings 
could  not  be  improved  upon. 

The  work  is  divided  into  five  parts. 

Part  I.  takes  up  the  important  subject  of  Regional  Anatomy 
in  a  very  thorough  and  clear  manner. 

Part  II.  deals  with  the  methods  of  diagnosis  of  diseases  of  the 
Respiratory  System.  The  principal  diseases  of  the  chest  are 
discussed,  and  the  important  points  in  the  diagnosis. 

Part  III.  goes  fully  into  the  methods  of  diagnosing  cardiac 
diseases. 

Part  IV. — In  this  section  the  principal  elements  in  the  detec- 
tion of  disease  in  the  abdominal  organs  are  dwelt  upon.  The 
principal  diseases  are  mentioned  with  their  special  diagnostic 
points. 

The  book  ends  with  Part  V.,  in  which  there  is  an  excellent 
dessertation  on  X-Ray  work.  Its  technique  and  the  uses  to  which 
it  is  applied  in  medicine  from  a  diagnostic  point  of  view.  The 
plates  in  this  section  are  particularly  good. 

We  commend  the  book  to  all  those  interested  in  this  depart- 
ment of  medicine. 

W.  G.  S. 


CANADA 


MEDICAL  RECORD 


DECEMBER.     1902. 


Original    Communications. 


vRETROSPECT   OF   LARYNGOLOGY 

Under  charge  of  George  T.  Ross,  M.D.,D.U.L..  Lecturer  on  Laryngology  and 
Kbiuology,  Medical  Faculty  University  of  Bishops  College. 

SURGICAL    TREATMENT    OF    PURULENT    ETHMOIDITIS. 

One  of  the  most  complete  and  most  exhaustive  studies 
ever  published  on  this  subject  is  given  by  Guisez,  in  the 
August  number  of  '^Annales  de  I'Oreille,  de  Larynx  and 
du  Nez "  (Paris).  He  carefully  defines  all  the  relations 
which  the  cells  bear  to  neighbouring  sinuses,  and  vascular 
connections.  He  shows  the  advantages  and  disadvantages 
of  different  methods  of  treatment,  quoting  many  European 
as  well  as  American  authors  for  illustration,  and  finishes 
by  giving  the  technique  of  cases  operated  on  with  results 
of  treatment. 

LOCAL    APPLICATION    OP    HEROIN    HYDROCHLORIDE. 

Eosenberg  (Berlin)  discusses  the  local  application  of 
heroin  hydrochloride  in  the  larynx  and  the  objections  to 
its  topical  use  which  some  writers  have  made.  He  says, 
if  the  quantity  used  in  this  way  is  not  greater  than  the 
dose  usually  prescribed  internally,  no  harm  can  follow, 
and  this  quantity  is  generally  more  than  is  required  in 
the  larynx  for  beneficial  effect  to  follow.  The  author  uses 
a  1  to  40  watery  solution,  0.2  cm  containing  0.005  heroin, 
corresponding  to  the  customary  dose.  Being  absorbed 
as  readily  by  the  larynx  and  trachea  as  by  the  stomach, 
the  effect  is  twofold,  viz:  cough  allaying  and  analgesic, 
by  reducing  both  central  and  peripheral  irritability. 
If  this  solution  be  sprayed  on  the  posterior  laryngeal 
wall,  the  most  sensitive  cough  locality  in  the  larynx, 
in  a  case  of  tuberculosis  of  this  organ,  the  relief  is  often 


530  ROSS:    RETROSPECT   OF    LARYNGOLOGY. 

good  for  the  entire  night,  being  in  this  way  of  great  service 
to  cases  where  the  exhausting  night  cough  is  very  weak- 
ening to  the  patient.  In  the  dysphagia  of  these  patients 
heroin  is  useful.  It  should  be  continued  for  some  time,  as 
the  effect  seems  cumulative,  the  pains  being  only  relieved 
for  a  few  hours  at  first,  but  later  remaining  absent  the 
entire  day.  Altogether,  it  is  regarded  as  one  more  efficient 
remedy  in  cases  of  tubercular  laryngitis  as  well  as  those 
of  irritable  larynx  from  other  causes. 

CONSTITUTIONAL     MANIFESTATIONS     DUE     TO     INFECTIOUS     TRO- 
CESSBS   IN   THE   ADENOID   TISSUE   OF   CHILDREN. 

Kyle  (Phala.)  shows  that  this  source  of  disease  in  child- 
ren is  often  overlooked.  Modern  thought  inclines  to  the 
belief  that  many  constitutional  diseases  owe  their  origin 
to  microbic  development  in  the  lymphoid  tissues  of  the 
upper  respiratory  tract.  Many  physicians  heretofore  op- 
posed removal  of  adenoids  unless  they  occluded  the  tube 
or  interfered  with  nasal  respiration,  but  experience  has 
shown  that  even  a  small  mass  of  lymphoid  tissue  may  act 
as  an  infective  centre  setting  up  recurrent  attacks  of  fever 
until  removed.  Otitis  media  is  well  known  to  be  due  some- 
times to  this  cause. 

AURAL    BOUGIES. 

Eichards  calls  attention  to  the  usefulness  of  these,  es- 
pecially in  children  who  are  attacked  with  earache.  They 
are  made  the  size  of  a  quill,  and  half  an  inch  long.  Any 
medication  can  be  incorporated,  but  particularly  carbolic 
acid,  opium,  cocaine,  atropine,  etc.,  in  suitable  doses. 

DISTURBANCE    OF    MUSCULAR   ACTION    OP    NOSE    BY    PARAFFIN 
INJECTION. 

Alter  calls  attention  to  this  accident  in  a  case  of  his, 
where  a  natural  nasal  breather  was  changed  into  a  mouth 
breather  by  the  paraflBn  operation,  to  correct  saddle  nose, 
It  was  found  the  injected  paraffin  obstructed  free  muscular 
contraction  and  relaxation  so  that  the  alae  nasi  were  col- 
lapsed during  inspiration.  To  obviate  this  accident  it  is 
suggested  that  an  assistant  should  place  a  thumb  in  each 
nostril,  making  counter  pressure  on  the  outside  with  the 
index  fingers  until  the  nose  had  been  moulded  into  the 
desired  shape,  when  the  muscles  affected  would  not  be 
encroached  upon. 


foktin:  malaria  on  the  west  coast  of  AFRICA.    531 

THE    USE    OF    SUPRARENAL    GLAND    IN    DISEASES    OF    THE    NOSE 

AND    THROAT. 

Kyle  notes  that  occasionally  disastrous  results  were 
obtained  from  a  comparatively  diluted  solution  of  adrena- 
lin chloride,  possibly  attributable  to  changes  in  the  drug 
brought  about  by  acid  secretions.  For  operative  w^ork  he 
employs  solutions  of  one  to  a  thousand  or  two  thousand; 
for  the  relief  of  local  congestion  one  to  ten  thousand.  In 
the  latter  case  a  pleget  of  cotton  is  soaked  and  left  in  the 
nostril  for  ten  minutes.  He  has  also  noticed  a  marked  sec- 
ondary congestion  after  its  use.  Congestion  has  even  been 
made  worse  after  the  application  of  this  drug.  He  regards 
it  as  a  more  powerful  vasoconstrictor  than  cocaine,  and  does 
not  recommend  its  use  in  operations,  as  it  is  likely  to  be 
followed  by  severe  hemorrhage.  He  has  also  seen  slough- 
ing follow  its  use,  and  has  had  an  unfavorable  experience 
with  it  in  hay  fever. 

SIMPLE    METHOD    OF    CULTIVATING    DIPHTHERIA 
BACILLI     (bAYNE). 

Take  an  egg  and  boil  until  hard.  With  sterilized  for- 
ceps break  gently  into  the  air  sack  and  peel  off  the  shell 
and  membrane  immediately  beneath  it,  leaving  enough 
of  the  same  to  protect  the  culture.  Now  make  a  swab 
from  the  throat  and  gently  smear  on  the  surface  of  the 
egg  under  that  part  of  the  shell  which  is  left.  Then  take 
an  ordinary  cup  and  pass  through  a  flame  very  rapidly 
several  times  to  sterilize.  Place  the  egg  in  the  cup  with 
the  broken  end  down  and  leave  by  a  stove  twelve  hours. 
By  this  method  is  gotten  an  almost  pure  culture  of  diph- 
theria bacillus  in  from  eight  to  twelve  hours,  this  organ- 
ism growing  more  rapidly  than  others  usually  present. 


MALARIA  ON  THE   WEST   COAST  OF   AFBilCA. 

By  C.  A.  FoRTiN,  M.D.C.M.   (Bishop's  1897),  Surgeon  R. 
M.S.  Orissa,  H.  M.  Transport  No.  18. 

It  has  been  my  privilege,  during  the  last  year,  to  make 
several  voyages  to  the  west  coast  of  Africa,  and  as  little  is 
known  of  this  rapidly  growing  part  of  Africa,  perhaps  a  few 
personal  observations  as  to  the  health  question   may  prove 


532  fortin:  malaria  on  the  west  coast  of  Africa. 

interesting.  Of  late  years,  quite  a  "gold  boom"  has  been 
in  operation.  Naturally,  as  in  all  other  "  gold  booms," 
there  has  been  a  great  rush  to  these  parts  of  men  of  all  sta- 
tions of  life,  and  many  have  left  their  bones  there,  as  a  monu- 
ment to  the  unhealthy  state  of  the  country.  For  years  the 
west  coast  has  been  called  the  "  white  man's  grave,"  and 
to  some  extent  the  cognomen  is  a  correct  one,  but,  on  care- 
ful investigation,  one  finds  that  the  climate  is  not  so  bad  as 
it  is  made  out  to  be. 

As  the  country  is  being  developed,  an  increasing  band 
of  traders,  miners,  planters,  etc.,  are  populating  the  various 
settlements.  This  noticeable  increase  in  the  European  popu- 
lation has  called  the  attention  of  the  scientific  medical 
world  to  the  great  mortality  due  to  the  ravages  of  the  ma- 
larial bacillus. 

Recent  investigations  have  led  to  a  great  following  of 
the  "  mosquito  theory,"  and  every  possible  effort  is  being 
made  to  exterminate  the  pest. 

All  possible  praise  is  due  to  those  scientific  men  who 
have  worked  so  patiently  and  endured  so  many  hardships  to 
prove  that  the  mosquito  is  an  important  factor  in  the  causa- 
tion of  malaria. 

There  can  be  no  possible  doubt  as  to  the  correctness  of 
the  "  mosquito  theory,"  but  in  this,  as  in  many  other  im- 
portant theories,  too  much  stress  is  laid  upon  one  point. 
The  mosquito  may  be,  and  undoubtedly  is,  an  important 
factor,  but  it  is  not  the  only  factor  in  the  etiology  of  malaria. 
The  climate  itself,  the  diet,  the  isolation  and  associa- 
tions of  the  resident  on  the  west  coast,  are  in  my  humble 
opinion  the  predominant  factors. 

To  better  understand  the  effect  of  these  factors,  let  me 
briefly  explain  what  they  are  : 

I.  T^e  climate  is  very  peculiar.  The  day  during  the 
dry  season  can  be  roughly  divided  into  four  stages : 

(a),  6  a.m.  to  ii  a.m. — Here  you  have  a  clear  healthy 
atmosphere  with  the  temperature  gradually  increasing  from 
60°  F.  to  90"  F. 


FORTIN:  malaria   on  the   west   coast  of  AFRICA.      533 

(b).  1 1  a.ni  to  4  /.w.— This  is  the  time  of  the  day  when 
the  sun's  rays  beat  down  most  heavily.  The  temperature 
gradually  increases  to  about  i  \o°  F.,  reaching  its  height  at 
about  I  p.m.  The  atmosphere  is  stifling  ;  there  is  not  a 
breath  of  air,  and  even  in  the  shade  one  experiences  a  hor- 
rible sense  of  a  heavy  weight  pressing  upon  the  chest. 

Gradually  the  temperature  begins  to  fall,  and  at  4  p.m. 
we  find  the  thermometer  registering  about  85*^  F. 

(c)  ^p.m.  to  12  p.m. — The  air  gradually  becomes  cooler, 
gentleb  reezes  spring  up,  and  by  degrees, a  sense  of  well-being 
begins  to  steal  over  the  body.  As  darkness  comes  on,  how- 
ever, a  peculiar,  moist  swampy  kind  of  a  scent  seems  to 
pervade  the  atmosphere. 

Then  comes  the  mosquito,  sand-fly  and  other  irritating 
insects  that  the  flesh  is  heir  to,  and,  unless  carefully  sur- 
rounded with  nettings,  one's  life  becomes  a  burden. 

(d)  \2 p.m.  to  6 a.m. — Here  we  find  the  state  of  the 
weather  most  undecided.  Generally  at  about  2  to  3  a.m., 
a  cold  breeze  springs  up  and  the  temperature  may  fall  as  low 
as  40^  F.  This  cold  spell  is  often  the  cause  of  very  serious 
results  for  the  following  reason  :  When  a  man  retires,  say 
at  1 1  or  12  p.m.,  he  requires  a  minimum  of  clothing.  This 
generally  consists  of  a  pajama  suit  and  a  sheet.  With  the 
loss  of  consciousness,  the  sheet  is  often  cast  off,  and  when 
the  cold  breeze  comes  it  has  full  play  upon  an  unprotected 
body  with  open  pores,  and  hence  causes  a  chill. 

In  a  large  majority  of  cases  the  exposed  part  is  either 
the  abdomen  or  chest,  and  I  have  seen  several  cases  of  pneu- 
monia and   dysentry  all  attributable  to  this  cause. 

At  sunrise  a  thick  fog  or  mist  arises  from  the  numerous 
swamps  and  lagoons  and  hangs  over  the  land  until  the  more 
powerful  rays  of  the  rising  sun  dissipate  it. 

These  are,  roughly  speaking,  the  four  different  stages 
of  the  climatic  changes  during  the  24  hours. 

The  country  as  a  whole,  along  the  coast  is  mostly 
swampy  and  low-lying. 

Long   lagoons    or  inland  seas    traverse   the    coast    for 


534        fortin:  malaria  on  the  west  coast  of  Africa. 

miles,  opening  occasionally  into  the  sea.  These  to  a  slight 
extent  feel  the  effect  of  the  tides,  but  in  a  large  number  of 
cases,  the  water  in  them  is  stagnant,  the  bed  muddy  and 
lined  on  either  side  with  thick  jungle  and  assume  the  general 
characteristics  of  swamps. 

This  stagnant  water  has  the  effect  of  rendering  the  atmos- 
phere very  humid,  and  when  the  hot  rays  of  the  sun  beat 
down  upon  it,  the  vapour  given  off  can  be  likened  to  that 
experienced  whilst  taking  a  steam  bath. 

This  leads  on  to  the  question  of  Z?/^/.  Necessarily,  fresh 
meat  will  not  keep  in  this  kind  of  temperature. 

I  have  seen  the  meat  of  a  freshly  killed  bullock  become 
tainted  and  covered  with  a  greenish  mould  within  four  hours 
after  dressing  ! 

This  being  the  case,  canned  meats  have  to  be  resorted 
to.  With  all  due  respect  to  the  various  canning  manufactories, 
it  is  a  well-known  fact  that  canned  meats  lose  a  great  deal 
of  their  virtue  in  the  process  of  canning. 

Resource  is  made,  therefore,  to  the  native  chicken  and 
duck,  both  very  diminutive  affairs.  A  well-known  coast 
saying  is — that  a  man  gets  such  a  surfeit  of  chicken  on  the 
west  coast  that  he  is  unable  to  look  a  hen  in  the  face  on 
his  return  to  England.  Fish,  of  course,  can  be  obtained  in 
abundance,  and  forms  a  staple  dish. 

Not  only  is  there  a  scarcity  of  meat  foods,  but  there  is 
also  a  scarcity  of  vegetables.  Strange  as  it  may  seem,  no 
vegetable  will  grow  on  this  coast,  except  in  a  very  few  places. 
Hence,  such  commodities  as  potatoes,  onions,  etc.,  have  to 
be  imported. 

The  substitute  used  is  rice,  the  food  of  the  native. 

To  simplify  matters,  I  will  give  a  brief  resume  oi  the 
bill  of  fare  of  an  ordinary  coaster,  not,  of  course,  takinc; 
into  consideration  the  fare  of  those  who  have  the  good 
fortune  to  be  stationed  in  seaport  towns  :  — 

Native  fowl,  goat,  bullock  or  sheep,  canned  meats  and 
fresh  fish. 

Rice,  yams  and  Indian  corn. 

Fruits  in  iair  abundance,  i.e.,  bananas,  pines,  cocoanuts. 


FORTIN:  malaria  on  the   west  coast  of  AFRICA.    535 

limes,   oranges,  etc.     As  can  be  seen,  the   coaster  has    not 
very  much  of  a  variety  to  choose  from. 

The  excessive  heat  has  the  effect  of  causing  loss  of 
appetite  and  taste,  and  the  surrounding  unsanitary  state  of 
the  native  villages  and  the  peculiar  smell  of  the  natives  them- 
selves, all  assist  the  heat  in  its  deleterious  effects. 

This  loss  of  appetite,  etc.,  leads  on  naturally  to  one  of 
the  most  important  questions  to  be  debated,  i.e.,  the  resort 
to  the  taking  of  stimulants. 

The  drink  question  has  been  mentioned  by  a  good  many 
writers,  who  have  reported  upon  the  health  question  of  the 
west  coast.  Not  many  months  ago  a  well-known  investi- 
gator raised  a  furore  of  condemnation  amongst  past  and 
present  coasters,  by  saying  that  "  a  majority  of  the  deaths 
were  due  to  whiskey  fever."  Whilst  this  was  rather  a 
sweeping  statement  to  make,  still  it  contained  more  truth 
than  the  coasters  would  like  to  admit.  The  favourite  ap- 
petizer is  the  "  Gin  Cocktail,"  This  is  a  decoction  made  from 
gin,  bitters,  egg,  sugar  and  lime  juice,  well  beaten  up  with  a 
swizzle  stick.  It  is  a  very  good  and  harmless  drink  when 
taken  in  moderation,  but  how  many  are  moderate  .-' 

III.  The  Isolation  Question  should  now  be  considered. 
The  coaster  is  generally  situated  in  a  district,  with  only  the 
companionship  of  the  native.  In  some  cases  there  are  one 
or  two  other  factories  in  the  place,  and  the  white  popu- 
lation may  reach  the  number  of  three  or  four.  There  is* 
therefore,  no  amusement,  and,  after  the  strangeness  of  the 
situation  wears  away,  a  sense  of  complete  isolation  from  the 
outside  world  begins  to  steal  over  the  white  coaster.  The 
climate  is  very  depressing  ;  he  begins  to  brood  after  the  busi- 
ness cares  of  the  day  are  over.  His  mind  naturally  reverts 
to  the  unhealthy  state  of  the  country,  and  he  wonders  if 
he  will  survive  to  reach  home  again. 

Finally,  to  buoy  up  his  spirits  he  will  take  a  cocktail  and 
perchance  repeat  the  dose  several  times  before  the  meal. 
Should  friends  visit  him,  it  is  worse,  for  then  the  usual  allow- 
ance is  bound  to  be  increased. 


536      fortin:  malaria  on  the  west  coast  of  Africa. 

This  goes  on  from  day  to  day  ;  therefore,  can  anybody 
gainsay  the  fact  that  this  habit  alone  will  not  tend  in  time  to 
undermine  the  system  ?  Not  that  I  advocate  total  abstinence, 
far  from  it,  for  in  that  part  of  the  world  a  certain  amount  of 
stimulation  is  required  for  the  debilitated  system.  If  greater 
attempts  were  made  to  moderate  the  amount  of  alcholic  stimu- 
lants taken,  I  feel  confident  that  the  death-rate  would  rapidly 
decrease. 

Thus  we  have,  then,  very  briefly  considered  three  im- 
portant factors  which  play  a  most  important  part  in  the 
etiology  of  malaria. 

From  personal  observations,  I  would  advise  the  follow- 
ing preventatives  for  malaria  : 

I.  Better  sanitation  in  the  towns  and  villages, 

II.  Traders  to  supply  their  clerks  with  better  food  and 
ice  machines  (of  which  there  are  very  many  good  ones  on 
the  market). 

III.  A  shorter  service  on  the  coast.  The  Government 
only  demand  a  12  months'  stay  on  the  coastj  which  is  quite 
sufficient. 

IV.  More  medical  men  to  be  sent  out,  and  when  a 
clerk  by  force  of  circumstances  is  situated  at  some  distance 
from  medical  advice,  he  should  be  supplied  with  a  specially 
prepared  medicine  chest  and  explained  the  use  of  the  various 
drugs. 

V.  Each  resident  to  take  at  least  three  grains- of  quinine 
twice  a  week,  and  no  more. 

These  suggestions  are  only  a  few  of  many  that  could 
be  given,  but  these  are  essential. 

With  care  and  attention  to  the  ordinary  rules  of  general 
health,  I  do  not  see  why  life  at  the  west  coast  of  Africa  should 
not  be  as  healthy  as  life  in  England  itself.  The  high  death- 
rate  on  the  coast  is  more  noticeable,  naturally,  on  account 
of  the  smallness  of  the  population.  If  the  mortality  rate  were 
considered  pro  rata  to  population,  I  fancy  that  of  England 
would  take  the  lead. 

Another  great  and    very  important  evil    which    affects 


ANNUAL    DINNER    OF  BISHOPS  COLLEGE.  537 

the  coaster    is  the  prevalence  of  syphilis,  gonorrhoea    and 
other  genital  troubles,  too  numerous  to  mention. 

Veneral  disease  is  as  often  the  cause  of  the  breakdown 
of  the  coaster  as  malaria,  and  taken  together  are,  of  course, 
often  attended  by  fatal  results. 

But  this  complaint  cannot  be  laid  down  to  the  effects 
of  the  climate,  but  must  be  considered  as  a  legacy  left  to 
the  coast  by  the  early  white  settlers. 

The  great  idea  of  the  coaster  is  to  get  acclimatized.  I 
hardly  think  this  is  possible,  for  the  natives  themselves 
suffer  from  malaria.  Strange  as  it  may  seem,  those  who  suffer 
more  severely  are  those  who  belong  to  the  civilized  and 
educated  class.  Those  men  and  women  assume  European 
habits  and  vices,  and  hence  the  climate  seems  to  have  more 
effect  on  them  than  upon  the  crude  article.  These  few  brief 
remarks  on  west  coast  life  may  be  of  interest  to  a  few  of 
your  readers  and  may  cause  some  interest  to  be  raised  in 
this  long  forgotten  part  of  our  British  domain.  In  conclu- 
sion I  may  say  that,  during  the  last  few  years,  many  of  our 
young  Canadian  doctors  have  made  voyages  down  tj  this 
coast,  and  from  all  sides  I  have  heard  nothing  but  praise  for 
their  skill  and  particular  knowledge  of  the  various  cases  they 
have  had  under  their  care.  By  small  successes  like  these, 
people  in  various  parts  of  the  world  will  soon  begin  to  realize 
that  even  from  frozen  Canada  can  knowledge  be  dissemi- 
nated. 

C.   A.   FORTIN,  M.D.,  CM.,  Bishop's,  L.R.C.P. 
and  S.  Ed.,L.F.P.  and  S.,    Glasgow,  Surgeon 
H.M.  Transport  "  Orissa."  No.  18, 
Bermuda,  W.  I..   December  6,  1902. 


ANNUAIi    DINNER    OF    THE    GRADUATES    AND    UNDER- 
GRADUATES   OF   THE    FACULTIES    OF    MEDICINE 
AND  DENTISTRY,  UNIVERSITY  OF 
BISHOP'S  COLLEGE. 

Bishop's  College  Medical  graduates  and  Medical  stu- 
dents were  the  first  in  Montreal  to  break  away  from  the 
beer  and  cheese  stage,  when  the  Freshman  treated  their 
Seniors,  and  thus  ingratiated  themselves  into  their  favour. 


53^  ANNUAL    DINNER    OF    THE    GRADUATES 

At  the  Windsor  Hotel,  many  years  ago,  they  asserted 
their  right  to  sit  down  and  enjoy  a  good  dinner  with  a  feast 
of  reason  and  a  flow  of  soul  thrown  in.  Year  after  year 
it  has  been  continued,  and  other  Medical  Schools,  Bishop's 
senior  in  age,  have  taken  their  place  in  the  line.  Nearly 
all  have  been  successful  functions — a  few  may  not  have 
been  so  successful  as  was  wished,  but  this  was  the  excep- 
tion. But  of  all  the  dinners  bearing  Bishop's  name,  the 
one  which  took  place  on  the  6th  November  last,  at  the 
Place  Viger  Hotel,  at  which  Medical  and  Dental  Students 
attended,  bears  the  palm.  One  hundred  and  eleven  guests 
sat  down,  and  some  eminent  men  were  there,  among  them 
the  Hon.  J.  Israel  Tarte,  whose  bright  and  witty  speech 
show^ed  that  loss  of  office  had  not  dampened  him  in  the 
least.  Mr.  James  Francum,  1903,  occupied  the  chair,  ihav- 
ing  the  Dean,  Dr.  F.  W.  Campbell  on  his  right  and  Mr. 
Tarte  on  his  left.  After  dinner  the  usual  toast  list  was 
gone  through  with. 

Since  the  affiliation  of  the  Dental  College,  of  the 
Province  of  Quebec,  with  Bishop's,  the  Medicals  have  had 
the  assistance  of  5ts  Dental  Graduates  and  Students  at  these 
annual  functions.  The  number  thus  present  at  this  func- 
tion was  large,  and  the  flags  of  the  two  departments  de- 
corated the  Dining  Hall. 

To  the  toast  of  the  Dean  and  Professors,  Dr.  W.  H. 
Drummond,  Professor  of  Medical  Jurisprudence,  respond- 
ed as  follows: — 

Since  the  inception  of  this  Faculty,  the  relations  be- 
tween teachers  and  students  have  always  been  of  the  most 
cordial  and  friendly  character,  and  to-day  sees  us  more 
loyal  each  to  the  other  than  ever  before  in  the  history  of 
the  University. 

It  is  true  that  among  Medical  Faculties,  our  children, 
comparatively  speaking,  have  not  been  very  numerous,  but 
those  who  have  been  born  to  us  are  good  children  and 
have  never  yet  brought  the  blush  of  shame  to  the  face 
of  the  old  mother,  and,  though  far  scattered,  many  of  them 
may  be,  yet  we  feel  that  to-night  they  are  with  us  in  heart 
and  spirit,  rejoicing  that  the  traditions  of  Bishop's  are 
still  as  they  have  ever  been,  spotless  and  unsullied. 

We  welcome  to  our  halls  of  learning  all  who  come  to 
us  in  the  right  spirit,  and  we  are  glad  to  train  in  our 
Universities,  and  return  well  equipped  to  their  own  coun- 
tries, those  who  hail  from  other  lands  beyond  the  Can- 


AND    UNDERGRADUATES    OF    BISHOP's    COLLEGE.  539 

adian  borders;  we  greet  them  as  brothers  and  children 
of  one  common  mother,  for  that  is  the  true  University 
spirit.  Often  when  reading  the  calendars  of  our  Can- 
adian Colleges,  have  I  been  deeply  pained  by  noticing  the 
large  numbers  of  Canadian  born  young  men  who  have 
been  obliged  to  forsake,  in  most  cases,  forever,  the  land 
of  their  birth  and  affinity  to  acquire  abroad  the  com- 
petence denied  them  at  home.  It  is  very  mete  to  recite 
proudly,  as  we  often  do,  the  magnificent  successes  of  an 
Osier  or  a  Casey  Wood,  but  why  have  we  not  been  able 
to  keep  these  men  at  home  in  their  own  country?  Have 
we  such  abundance  of  the  great  in  medicine  that  we  can 
spare  such  giants?  This  continual  sacrifice  of  our  best 
and  brightest  to  help  in  building  up  the  institutions  of 
a  rival  people  has  always  rankled  in  my  Canadian  breast. 
Only  a  few  months  ago  you  probably  read  in  the  Press, 
that  of  some  thirty  graduates  in  science  of  a  well-known 
Canadian  School,  all  with  the  exception  of  one  or  two 
passed  over  to  the  United  States,  and,  when  attending 
last-  spring  the  convocation  of  an  Ontario  University,  1 
learned  that  the  chief  prize  winners  had  already  received 
appointments  among  our  cousins  of  the  Great  Eepublic  ; 
in  fact,  the  American  College  representative  who  selected 
the  flower  of  the  graduating  class  was  actually  there  on 
the  spot  to  personally  escort  his  captives  to  their  future 
homes  on  the  other  side  of  the  line,  much  after  the  manner 
of  days  gone  by,  when  the  New  England  horse  trader 
used  to  pick  and  choose  our  Canadian  ponies,  till  to-day 
there  is  hardly  a  specimen  of  the  breed  left  in  the  Pro- 
vince of  Quebec. 

I  do  not  for  a  moment  blame  our  ambitious  young 
countrymen  for  wishing  to  better  themselves  in' the  world, 
for  self-preservation  is  a  law  in  itself,  but  it  is  gall- 
ing to  think  that  the  bright  Canadian  College-bred  lad, 
who  to-night  sings  ''The  Maple  Leaf  Forever,''  may  in  a 
week  or  two  expand  his  lungs  with  ''The  Star  Spangled 
Banner."  However,  I  believe  a  better  day  has  dawned  for 
us  in  Canada.  Students  of  the  times,  as  Medical  students 
ought  to  be,  must  realize  that  we  are  now  in  an  era  of 
extraordinary  prosperity,  and  that  the  country  which  to- 
day possesses  a  population  of  six  millions  will  in  ten 
years  number  over  ten  millions.  The  opening  up  of  out 
immense  waterways,  the  multiplying  of  railway  lines,  the 
manufacturing   of   the  natural   products   with   which  the 


540  ANNUAL    DINNER    OF    THE    GRADUATES    ; 

Almighty  has  so  amply  endowed  us,  the  stimulation  under 
proper  laws  of  our  native  industries,  will  have  the  effect 
of  creating  employment  for  every  graduate  of  our  Cana- 
dian Universities,  and  I  am  sanguine  enough  to  believe 
that  the  time  is  not  far  distant  when  the  condition  of  the 
past  will  be  reversed,  and  American  physicians  will 
gravitate  towards  this  country  as  naturally  as  many 
Canadians  at  the  present  day  gravitate  towards  the  United 
States. 

When  I  consider  the  practically  limitless  possibilities 
of  Canada,  surely  it  is  reasonable  for  me  to  predict  that 
very  soon  this  country  will  be  able  to  levy  an  export  duty 
on  our  boys  and  girls,  and  the  measure  of  that  duty  will 
be  the  ability  of  Canada  to  provide  for  her  children  em- 
ployment and  remuneration  sufficient  to  enable  those  sons 
and  daughters  to  live  out  their  natural  lives  on  their  own 
soil. 

Sink  provincialism,  the  warring  and  clashing  of 
creeds,  avoid  secret  societies,  which  are  the  bane  of 
modern  college  life,  do  everything  to  develop  our  national 
resources,  learn  how  the  strength  of  our  neighbours  has 
been  acquired,  and  profit  by  that  knowledge.  Remember, 
Resemble,  Persevere,  and  under  God  you  need  have  no 
fear  for  the  future. 

To  the  toast  of  "Our  Guests,''  Dr.  W.  Grant  Stewart 
responded,  as  follows: — 

Mr.  Chairman  and  Gentlemen: 

The  onerous  but  pleasant  duty  of  proposing  the  toast 
to  our  guests  devolves  upon  me.  I  would  the  task  had 
fallen  on  more  worthy  shoulders.  After-dinner  speakers 
like  poets  are  born,  not  made,  but  I  am  sure  thej^  will 
accept  the  will  for  the  deed.  In  the  far  west,  better 
known  as  the  wild  and  woolly  west,  stands  a  little  church, 
unpretentious  in  appearance,  claiming  no  architectural 
charms,  plain  without,  and  if  possible  more  plain  within. 
The  seats  few  and  far  between,  because  the  worshippers 
are  like  the  seats,  few  in  number.  The  aesthetic  part  of 
the  service  has  not  been  neglected,  for  away  in  one  corner 
stands  an  ancient  organ,  in  keeping  with  the  surround- 
angs  of  the  church.  Above,  hung  upon  the  bare  wall,  is 
a  placard,  on  which  is  printed  in  large  bold  letters,  the 
following  polite  request: 

"Please  don't  shoot  the  organist;  he  is  doing  his 
best."   The  moral  of  the  story  I  leave  to  my  hearers. 


AND    UNDERGRADUATES    OF    BISHOP'S    COLLEGE.  54 1 

During  the  past  summer,  as  you  all  know,  London 
was  a  mecca  for  all  tourists,  and  every  one  who  could,  bent 
his  steps  thitherward,  I  among  the  number. 

I  reached  London  the  evening  before  the  operation  on 
the  King. 

AA'^hat  a  wonderful  sight  it  presented  with  its  teeming 
crowds!  Here  were  to  be  seen  all  sorts  and  conditions  of 
men.  The  ubiquitous  American,  the  sturdy  colonial,  the 
canny  Scot,  the  true-hearted  Irishman,  the  bareheaded, 
bowlegged,  barefooted  Figi  Islander,  the  pigtailed  China- 
men, princes  from  far  off  India  with  wealth  beyond  the 
dreams  of  avarice,  civilians  and  soldiers,  princes  and  pau- 
pers, a  motley  crowd  indeed  full  of  eager  expectation. 
For  were  they  not  here  to  witness  one  of  the  greatest 
pageants  of  ancient  and  modern  times? 

When  the  news  came  out  that  there  was  to  be  no 
coronation,  that  the  King  had  been  operated  on,  and  that 
instead  of  witnessing  the  Coronation  it  might  be  a  fune- 
ral, the  gloom  and  sorrow  and  disappointment  was  great 
indeed.  The  old  adage  was  never  more  forcibly  demon- 
strated, that  "man  proposes,  God  disposes." 

But,  as  the  reports  became  more  reassuring  day  by 
day,  the  tension  gave  way,  and  joy  followed  sorrow,  and 
laughter  followed  tears. 

London  witnessed  at  this  time  many  stirring  events; 
one  of  the  most  interesting  to  us  from  Canada  was  the 
Review  of  the  Colonial  troops. 

As  I  stood  on  Constitution  Hill  and  witnessed  the 
march  past  of  2,000  troops  from  all  the  colonies,  a  thrill 
of  patriotism  and  pride  welled  through  me  ;  a  feeling 
which  only  those  who  have  experienced  can  appreciate.  An 
object  lesson  of  the  unity  and  strength  of  a  great  empire, 
an  empire  on  which  the  sun  never  sets. 

And  as  I  on  the  succeeding  day  stood  on  the  Mall  and 
witnessed  the  Queen,  beautiful,  majestic,  every  inch  a 
queen  as  she  drove  past,  accompanied  by  the  Royal  family, 
and  followed  by  Lord  Roberts  and  2,000  Indian  troops  in 
their  gorgeous  and  picturesque  uniforms,  their  stately 
military  bearing,  my  enthusiasm  again  reached  the  burst- 
ing point,  and  I  was  proud  that  I  was  the  son  of  an  Em- 
pire that  was  able  to  rule  by  love  such  a  great  country 
as  India,  and  that  these  same  soldiers  were  happy  to  do 
honour  to  their  King,  and  if  need  be  to  lay  down  their 
lives  in  the  service  of  the  Empire  and  be  reckoned  amongst 
the  soldiers  of  the  King. 


54  2  ANNUAL    DINNER    OF    THE    GRADUATES 

But  of  all  the  stirring  events  I  saw,  none  perhaps  im- 
pressed nie  like  the  great  banquet  held  in  the  Hotel  Cecil 
on  UominionDay,  to  drink  health  and  continued  prosperity 
to  Canada,  the  gem  of  the  colonies. 

Never  in  my  life  has  it  been  my  good  fortune  to  sit 
down  amongst  such  a  distinguished  company.  Dukes, 
Lords,  Earls,  Generals,  Admirals,  Captains,  Politicians, 
Authors,  Artists,  Lawyers,  Doctors,  Bishops,  men  great 
in  position,  great  in  wealth,  great  in  science  and  intellect. 

Lord  i^trachona  full  of  years  and  honour  presided. 

There  were  many  great  speeches,  but  without  excep- 
tion the  grandest  after-dinner  speech  I  ever  listened  to  was 
delivered  by  one  of  the  guests  of  the  evening,  Sir  Wilfrid 
Laurier,  the  premier  of  Canada,  the  silver-tongued  orator. 
In  an  address  full  of  flowing  sentences,  rounded  periods, 
elegant  diction  and  beauty  of  thought,  he  held  his  audience 
spellbound. 

He  described  this  Canada  of  ours  in  flowing  terms, 
and  like  Nicodemus  of  old  he  invited  our  English  guests 
to  come  and  see. 

Come  in  the  leafy  month  of  June,  when  the  country 
is  in  beautiful  verdure  clad;  stay  and  see  the  fields  of 
golden  grain  in  the  far  west.  Stay  a  little  longer  and 
view  the  glorious  tints  of  autumn. 

Stay  on  and  see  Canada  in  winter,  the  ground  clad 
in  snow-white  garb,  the  rivers  and  lakes  bound  in  ice,  the 
keen  frosty  air  reverberating  with  the  merry  jingle  of 
the  sleigh-bells,  and  the  shouts  of  the  merry  skater  and 
snowshoer,  and  when  the  day  has  waned  see  the  night, 
the  blue  vault  of  heaven  lit  up  with  myriads  of  stars  and 
the  moon  shedding  a  pale  light  over  the  scene;  turning  the 
darkness  of  night  into  the  brightness  almost  of  noonday. 

And,  as  Agrippa  exclaimed  as  he  listened  to  the 
eloquence  of  Paul,  '^almost  thou  persuadest  me  to  be  a 
Christain,''  so  every  Englishman  said  in  his  inmost  soul, 
"almost  thou  persuadest  me  to  be  a  Canadian." 

Then  followed  such  a  burst  of  cheering  and  enthu- 
siasm   as  I  had  never  before  heard. 

Such,  indeed,  was  the  speech  of  a  man,  born  an  after- 
dinner  speaker,  and  what  would  I  not  give  to  have  such  a 
gift,  but  this  is  a  digression. 

I  am  not  here  as  an  emissary  of  Sir  Wilfrid's,  nor  has 
the  Government  subsidized  me  to  gain  votes  for  the  next 


AND    UNDERGRADUATES    OF    BISHOP'S    COLLEGE.  543 

election.  Neither  do  I  ask  you  to  follow  the  proverbial 
man  from  Cook's. 

I  am  sure  I  voice  the  sentiments  of  the  Faculty,  and 
give  expression  to  the  feelings  of  the  students  of  Bishop"  s 
College  when  I  bid  our  guests  welcome. 

Cod  millc  faitlie,  a  hundred  thousand  times  welcome. 

If  there  is  one  thing  more  than  another  for  which 
Bishop's  is  noted,  it  is  her  hospitality. 

Our  guests  are  our  friends,  and  as  Sir  John  Lubbock 
beautifully  puts  it  in  his  "Pleasures  of  Life,"  "if  we  choose 
our  friends  for  what  they  are,  and  not  for  what  they  have, 
and  if  we  deserve  so  great  a  blessing,  then  are  they  al- 
ways with  us,  preserved  in  absence  and  even  after  death 
in  the  amber  of  memory." 

We  are  glad  to  have  our  guests  with  us;  we  want 
them  10  near  oi  our  success,  lo  Know  of  our  aspirations; 
we  want  them  to  see  the  Faculty,  to  meet  our  genial 
Dean,  whom  we  all  love  and  admire  for  his  kindness  of 
heart  and  his  sound  judgment  and  wise  counsels. 

"And  still  we  gaze  and  still  our  wonder  grows  ; 
That  one  small  head  should  carry  all  he  knows." 

Our  wish  is  that  he  may  be  long  spared  to  occupy  his 
preseht  position. 

We  want  our  guests  to  meet  our  students,  of  whom 
we  are  proud  and  before  whom  we  are  striving  to  lay  down 
high  ideals  of  practice. 

I  think  we  can  say  we  are  rivals  of  no  Institution. 
We  are  co-workers  in  the  earnest  held  of  practical  and 
scientific  medicine. 

Not  all  of  us  can  claim  Bishop's  as  our  Alma  Mater. 
Many  of  us  are  proud  to  claim  old  McGill  as  our  kind 
good  mother.  And,  although  we  teach  in  Bishop's,  we 
have  not  forgotten  the  old  love;  we  could  not  if  we  would, 
and  we  would  not  if  we  could. 

We,  all  of  us,  are  delighted  at  her  ever-growing  suc- 
cess. And  I  am  quite  sure  she  in  her  turn  is  glad  to  see 
her  sons  carrying  on  the  good  work  she  so  ably  began. 

To  our  confreres  in  the  profession,  we  extend  a  hearty 
welcome;  a  fellow  feeling  makes  us  wondrous  kind;  we  all 
belong  to  a  profession  whose  creed  is  wide  as  humanity 
itself.  The  portals  of  the  temple  of  Esculapius  are  shut 
to  no  creed,  to  no  nationality;  of. all  the  professions  there 
is  none  more  liberal,  and  perhaps  there  is  no  more  beau- 
tiful type  of  man  than  the  general  practitioner  of  high  pur- 
pose and  lofty  ideals.    No  more  beautiful  compendium  of 


544  ANNUAL    DINNER    OP    THE    GRADUATES 

what  the  profession  has  done,  what  it  is  doing,  and  what 
it  aims  to  do  is  there  than  that  scholarly  address  of 
Osier's — Chauvinism  in  Medicine— the  most  practical  ser- 
mon I  have  ever  heard.  It  converted  me  so  to  speak,  for  my 
sympathies  are  much  widened  ever  since  I  heard  it.  This  ad- 
dress I  would  like  to  see  put  into  the  hands  of  every  one  of 
the  men  graduating  from  our  school. 

There  is  one  of  our  guests  whom  I  have  always  looked 
upon  as  an  example  of  the  courtly  physician.  We,  to-day, 
lack  much  of  the  grace  and  true  culture  of  the  older 
generation  of  physicians.  This  is  an  age  of  rush  in  every 
thing,  and  we  do  not  take  time  to  cultivate  the  aesthetic 
side  of  our  nature.  There  is  one  who  exhibits  the  stiaviter  in 
modo  and  fortiter  in  re  in  a  marked  degree.  He  is  an  old 
friend  of  Bishops,  a  tried  friend,  and  after  all  there  is  no- 
thing better  than  the  old  friend:?.  I  think  it  is  Shakespeare 
who  says: — 

"Old  books,  old  wines, 

"Old  friends,  old  times." 

I  refer  to  my — to  our  distinguished  friend,  Sir  Wm. 
Hingston,  and  I  am  sure  we  feel  honoured  at  having  him 
with  us  to-night. 

And  now,  I  turn  to  our  clerical  friends.  I  have  al- 
ways had  a  warm  spot  for  the  clergy.  A  son  of  the  manse 
myself,  it  has  been  as  it  were  bred  in  the  bone. 

Religion  and  medicine  should  ever  go  hand  in  hand, 
and  it  is  mete  that  we  and  the  clergy  should  be  good 
friends;  whether  it  be  the  pious  cur6  who  faces  the  dan- 
gers of  a  stormy  winter's  night  to  give  consolation  to  the 
dying  and  a  word  of  friendly  solace  to  the  living,  or  the 
earnest  minister,  who,  though  poor  in  filthy  lucre,  is  rich  in 
grace  and  truth,  we  respect  them  all;  they  deserve  our 
co-operation  and  esteem. 

I  do  not  know  the  learned  principal  of  Bishop's  Col- 
lege well  enough  to  know  whether  he  practices,  but  I  do 
know  he  can  preach,  for  we  heard  him  deliver  one  of  the 
finest  after-dinner  speeches  that  we  have  ever  heard  at 
the  Faculty  dinners.  If  he  practices  as  well  as  he  preaches, 
which  I  am  sure  he. does,  then  he  is  a  good  man  indeed. 
We  are  pleased  to  see  him  amongst  us  to-night,  and  I  am 
quite  sure  he  will  be  much  pleased  with  what  he  sees  and 
hears  to-night,  as  no  one  at  this  board  has  more  the  wel- 
fare of  the  Faculty  at  heart  than  he  ;  we  feel  he  is  the 
right  man  in  the  right  place. 


AND    UNDERGRADUATES    OF    BISHOP'S    COLLEGE.  545 

At  the  Annual  Dinner  of  the  British  Medical  Associa- 
tion in  Manchester,  there  was  a  toast  to  the  Clergy.  The 
proposer  told  an  amusing  story  about  a  man  who  fre- 
quently inbibed,  and  one  day,  when  partly  under  the 
influence,  he  met  the  parish  priest,  and  he  unburdened  his 
mind.  He  said  that  he  had  lived  in  the  world  for  65  years 
and  he  was  still  unable  to  make  up  his  mind  as  to  which 
was  right — a  good  Catholic  or  a  good  Protestant.  The  old 
priest  immediately  replied:  "Faith  and  sure  you  won't  be 
in  the  nixt  world  sixty-foive  minutes  before  you  will 
know  which  is  roight." 

We  are  all  much  pleased  to  have  our  worthy  Mayor 
with  us  to-night;  we  congratulate  him  on  the  able  way  in 
which  he  is  conducting  the  civic  chair.  He  is  with  us  to- 
night, not  only  as  representative  of  the  city,  but  as  an 
enthusiastic  worker  of  the  Western  Hospital,  and  we 
know  he  is  deeply  interested  in  the  welfare  and  success  of 
Bishop's  College. 

While  he  is  here,  we  would  take  the  opportunity  of 
bringing  to  his  attention  the  question  of  the  Civic  Hospital, 
one  of  the  most  crying  needs  of  our  great  city.  If  the  mem- 
bers of  the  Council  were  all  likeminded  with  him  this 
question  would  soon  be  settled. 

It  is  a  great  pity  that  all  social  and  religious  dif- 
ferences could  not  be  set  aside  in  a  matter  like  this,  which 
appeals  to  the  common  good  of  all. 

Now,  gentlemen,  drink  with  me  to  the  health  of  our 
guests.  Let  us  "welcome  the  coming,  speed  the  parting 
guest." 

Mr.  W.  W.  Kelly,  from  Jamaica,  a  fourth  year  student 
of  Bishop's   Faculty   of  Medicine,   proposed   the  toast   of 
"Sister  Universities,"  by  the  following  sx)eech: — 
Mr.  President  and  Gentlemen: — 

When  tbe  Committee  selected  me  for  the  task  of  pro- 
posing this  most  important  toast  of  "Sister  Universities," 
I  assure  you  I  felt  deeply  honoured.  On  thinking  over 
a  possible  reason  for  their  selection,  I  came  to  the  conclu- 
sion that  it  was  because  I  am  an  Irishman,  and  as  such 
supposed  to  be  endowed  with  the  gift  of  the  gab.  But, 
gentlemen,  there  are  exceptions  to  every  rule,  and  I  have 
the  misfortune  to  be  one  of  those  exceptions. 

However,  like  every  one  who  has  a  speech  to  make 
and  who  has  had  lots  of  notice  thereof,  I  immediately  set 
about  hunting  for  ideas,  for  something  to  say,  but  my  search 
was  fruitless,  and  I  vainly  sought  for  inspiration. 


546  ANNUAL    DINNER    OP    THE    GRADUATES 

I  was  at  a  loss  to  understand  this  for  some  time  until 
i  made  a  startling  discovery,  which  fully  explained  the 
futility  of  my  efforts. 

It  was  this,  that  such  a  toast  at  such  a  dinner  needed 
no  talking  on  my  part,  for  it  spoke  for  itself  I 

And  is  this  not  so  gentlemen?  I  firmly  believe  yes, 
for  such  a  toast,  without  any  additionally  flowery  eloquence, 
to  my  mind  speaks  in  no  uncertain  voice  of  all  that  stands 
for  friendship,  good  fellowship  and  unity.  Yes,  unity,  that 
magic  word  which  is  to  play  such  an  important  part,  not 
so  much  in  these  rolling,  rolicking,  students  days,  but  in 
the  great  future  to  which  we  all  look  forward. 

We  students,  like  the  general  run  of  the  Medical 
profession,  are,  I  think,  too  much  inclined  to  develop  into 
a  lamentable  spirit  of  Chauvinism,  against  which  Dr.  Wm. 
Osier  (whom  Dr.  Grant  Stewart  has  so  eloquently  quoted 
to-night),  in  his  annual  address  at  the  recent  meeting  of 
the  Canadian  Medical  Association,  so  strongly  warned 
the  profession. 

With  us,  this  Chauvinism  takes  the  form  of  imagining 
that  our  University  is  the  only  one  which  ought  to  exist, 
and  that  though,  by  some  unfortunate  mistake,  other 
institutions  similar  to  our  own  are  to  be  found,  yet  ours 
is  the  only  one  competent  to  turn  out  good  men. 

Gentlemen,  pride  in  one's  own  University,  pride  in 
ats  professors,  pride  in  the  graduates  which  our  College 
turns  out,  is  only  right  and  just,  and  we  should  be  less 
than  human,  nay,  wanting  in  a  just  and  proper  esprit  de 
corps,  if  we  failed  to  cultivate  and  cherish  such  senti- 
ments as  these;  but  surely  there  is  a  wider  sentiment,  aye, 
and  a  w^der  yet  which  should  animate  us!  I  should  like  to 
divide  this  relationship  into  three  circles. 

In  the  first  I  would  place  the  spirit  of  which  I  have 
already  spoken,  viz.,  that  personal  pride  in  our  Alma  Mater, 
that  anxiety  for  her  success,  pride  in  the  advantages 
which  she  offers,  and  in  the  successes  of  our  fellow  gra- 
duates. The  next  is  a  wider  one,  and  one  into  which  all 
of  us  here  to-night  may  enter — it  is  the  pride  we  should 
feel  as  Canadians  and  Canadian  graduates  in  the  med- 
ical schools  of  this  broad  Dominion,  pride  in  the  men 
which  these  schools  turn  out;  and  the  history  of  this  Con- 
tinent, at  least,  shews  us  that  we  have  just  cause  for 
pride.  ^ 


AND   UNDERGRADUATES  OF   BISHOP'S   COLLEGE.  547 

But,  gentlemen,  there  is  a  wider  circle  yet,  and  one 
that  absolutely  puts  all  Chauvinism  and  provincialism  in 
the  background  ;  I  refer  to  the  common  heritage  we  all 
possess,  irrespective  of  school  or  country,  of  language,  of 
customs,  the  great  heritage  of  a  common  cult,  a  common 
profession,  whose  history  is  universal,  whose  literature 
is  common  to  us  all,  whose  members  are  governed  by  one 
common  Code  of  ethics,  which  knows  no  special  religion 
and  no  politics  in  the  performance  of  its  duty. 

The  time  will  soon  come  when  we  shall  all  have  to 
take  our  places  in  the  firing  line  and  fill  the  gaps  which 
the  ravages  of  death  have  left  in  the  ranks  of  those  physi- 
cians whose  lives  stand  for  integrity  and  loyalty  to  the 
cause.  It  is  then  that  we  shall  realize  the  full  meaning  of 
the  term  unity,  when  all  distinction  as  to  school  and 
country  shall  be  placed  aside,  not  so  much  in  these  great 
University  centres,  but  in  the  '^far-off"  to  which  90  per 
cent,  of  us  must  go. 

Then  we  shall  have  no  University  to  guide  and  pro- 
tect us,  no  professor  to  whom  we  can  go  in  a  case  of  ques- 
tionable diagnosis,  but  when  we  must  stand  shoulder  to 
shoulder,  the  one  helping  the  other,  guided  and  animated 
by  what,  gentlemen? — by  the  membership  of  a  common 
cult,  a  cult,  the  result  of  whose  teachings  the  evidences  of 
whose  example  and  the  spirit  of  whose  laws  have  made 
the  music  of  the  world. 

We  have  with  us  to-night  representatives  from  the 
Universities  of  Laval,  Trinity,  McGill,  Queen's  and  To- 
ronto, in  verity  are  We  in  good  company.  It  would  have 
been  a  pleasure  to  me  to  have  spent  some  time  in  par- 
ticularizing the  many  almost  personal  ties  which  compel 
us  to  delight  in  honouring  them  to-night,  but  the  hour  is 
late  and  you  are  all  anxious  to  get  to  bed.  I  should  have 
liked,  for  instance,  to  have  spoken  of  Queen's,  enlarging 
upon  the  tie  that  unites  us  in  the  person  of  Dr.  J.  V. 
Anglin.  one  of  her  distinguished  sons. 

Then  of  Laval,  that  great  French  Canadian  University 
with  whom  our  relations  have  always  been  so  felicitous  ; 
of  Trinity,  in  truth  our  sister  University  representing  in  the 
Province  of  Ontario,  as  we  do  in  the  Province  of  Quebec, 
the  interests  of  the  Church  of  England  in  Canada,  but 
like  ourselves  open  to  all  irrespective  of  creed  or  colour, — 
to  Jew  and  Gentile,  Chinamen  and  even  Irishmen,  if  they 


548  ANNUAL    DINNER    OF    BISHOP'S    COLLEGE. 

will  confrom  to  their  stand,  and,  of  course,  pay  their  fees. 
And  then  we  have  McGill;  why,  gentlemen,  I  could  speak 
all  night  of  McGill,  flesh  of  whose  womb  we  are  and  bone 
of  whose  bone.  Yes,  flesh  of  whose  womb,  and  our  worthy 
Dean  and  Sir  Wm.  Kingston .  and  Dr.  Perrigo,  and  one  or 
two  others  who  were  present  at  that  accouchement  are 
with  us  to-night.  Judging,  from  the  writings  of  Dr.  Camp- 
bell, the  delivery  was  not  an  entirely  normal  one,  no 
simple  left  occdpito  auterior,  but  a  case  of  anesthesia  and 
the  forceps.  But,  thanks  to  such  able  obstetricians,  we 
were  not  still-bom!! 

And,  Anally,  we  have  Toronto.  When  I  speak  of  To^ 
Fonto  University  I  am  reminded  of  the  man  who,  when 
asked  if  he  «ould  speak  German,  said  no,  but  that  he  had 
slept  in  the  room  with  one.  Well,  we  don't  belong  to  'Var- 
sity, but  we  take  dinner  with  her  representative  every 
year,  and  that  is  the  next  best  thing. 

As  I  said  before,  I  should  have  been  happy  to  have 
dilated  upon  these  pleasant  themes,  but  the  time  will  not 
permit  it. 

It,  therefore,  only  remain*  for  me  to  extend  to  you  on 
behalf  of  my  fellow  students  and  the  Faculty  a  hearty 
welcome,  to  express  our  pleasure  at  this  meeting,  and  our 
regret  that  such  gatherings  are  not  more  frequent. 

Unfortunately,  owing  to  the  paucity  of  our  numbers 
and  to  the  fact  of  being  isolated  from  our  sister  Faculties, 
we  are  unable  to  meet  you  all  in  that  friendly  strife  of 
sport  which  does  so  much  towards  cementing  the  friend- 
ship of  sister  Colleges,  but  the  large  Freshmen  class  of  this 
year  leads  us  to  believe  that  the  time  is  not  far  distant 
when  we  will,  as  a  Faculty,  be  able  to  carry  the  purple  and 
white  into  your  intercollegiate  contests. 

In  the  meantime,  we  would  ask  you  to  believe  the 
sincerity  of  our  welcome,  and  charge  you  each  to  carry 
back  to  your  respective  Universities  the  right  good  hand 
of  fellowship  which  we  extend  to  you  to-night,  and  we 
^ould  ask  you  to  express  to  them  our  sincerest  wishes 
for  their  future  success,  and  the  pleasure  we  feel  in  the 
anticipation  of  another  jovial  meeting  next  year. 

Gentlemen,  I  give  you  "The  Sister  Universities.'' 


Selected  Articles. 


CAN   VTE   BY  MODERN  METHODS  ANTICrPATE  IMPEND- 
ING ATTACKS    OF   PUERPERAIi   ECLAMPSIA?* 

By  J.  L.  KoTHRocK,  M.  D.,  St.  Paul. 

There  is  perhaps  no  complication  in  obstetrical  prac- 
tice which  is  the  occasion  of  so  much  anxiety  as  puer- 
peral eclampsia. 

Insidious  in  its  onset,  presenting  no  marked  nor  char- 
acteristic premonitory  symptoms,  too  often  the  busy  prac- 
titioner, who,  it  must  be  confessed,  seldom  pays  much  at- 
tention to  his  expectant  patient  until  called  to  her  in 
labour,  is  taken  by  surprise,  and  finds  himself  wholly  un- 
prepared to  meet  such  a  grave  emergency. 

Eclampsia  is  variously  estimated  to  occur  in  1  in  150 
to  1  in  400  cases  of  labour.  It  is  more  common  in  large 
cities  than  in  small  towns  and  rural  districts.  According 
to  statistics  it  is  more  common  in  Kussia  than  other  por- 
tions of  Europe. 

Eace  too  seems  to  have  some  influence.  My  own  ob- 
servation among  Russian  Jews  in  American  cities  leads 
me  to  belieA  e  that  it  is  of  less  common  occurence  among 
them  than  Americans. 

Eclampsia  is  said  to  be  unknown  among  American 
Indians,  as  also  may  be  said  of  other  savage  tribes,  it 
being  a  disease  exclusively  confined  to  civilized  peoples. 

In  the  entire  field  of  medicine  there  is  probably  no 
disease  which  has  been  the  subject  of  so  much  investiga- 
tion in  recent  years  as  puerperal  eclampsia,  and  as  yet 
we  are  in  absolute  ignorance  of  its  cause. 

We  shall  pass  over  the  various  theories  which  have 
been  proposed  from  time  to  time  and  which  are  no  longer 
regarded  as  tenable. 

At  present  two  theories  demand  special  considera- 
tion. One  that  eclamptic  attacks  are  uremic  and  occur 
in  patents  with  pre-existing  nephritis.  Those  who  contest 
this  theory  assert  that  eclampsia  may  occur  in  patients 
whose  kidneys  show  no  evidence  of  pre-existing  nephritis. 
On  the  other  hand  it  is  a  common  clinical  observation, 
that  patients  with  marked  nephritis  if  they  become  preg- 
nant rarely  are  the  subject  of  eclampsia.  In  further 
proof  that  eclampsia  is  not  a  pure  uremia,  certain  char- 

*Read  before  the    34tli  annual  meeting  of    the  Minnesota  State 
Medical  Society,  Minneapolis,  June  18,  1902. 


550       fiOTHROCK:  CAN  WE    BY  MODERN  METHODS  ANTICIPATE 

acteristic  changes  in  tlie  liver  and  blood,  whicli,  as  we  shall 
see  later,  are  almost  constantly  present  in  eclampsia,  are 
wanting  in  ordinary  cases  of  uremia.  The  theory  of 
uremia  presupposes  a  pre-existing  nephritis  as  the  pri- 
mary condition  while  the  pathologic-anatomic  findings  in 
cases  of  eclampsia  make  it  reasonably  certain  that  the 
kidney  lesions  are  in  general  secondary. 

The  theory  of  uremia  has  at  present  but  few  support- 
ers especially  when  generally  applied  to  cases  of  eclamp- 
sia, but  there  are  some  who  still  believe  it  applicable  to 
certain  cases. 

The  other  theory  and  the  one  which  to-day  finds  most 
adherents  is  that  of  auto-intoxication,  which  signifies  that 
during  pregnancy  under  certain  conditions  poisons  are 
elaborated  and  may  by  accumulation,  circulating  in  the 
blood,  reach  such  a  degree  of  concentration  as  to  produce 
the  characteristic  eclamptic  seizures  by  their  action  on  the 
nerve  centres. 

The  recent  experiments  of  Blumbreich  and  Zuntz  (1) 
have  shown  that  during  pregnancy  a  considerable  increase 
in  the  excitability  of  the  nerve  centres  takes  place,  render- 
ing them  peculiarly  responsive  to  any  form  of  stimulus, 
which  may  in  part  explain  the  unusual  tendency  to  eclamp- 
tic attacks  at  this  time. 

The  theory  of  auto-intoxication  had  its  inception  in 
the  teachings  of  Bouchard  some  years  ago. 

Bouchard  had  determined  that  the  urine  in  health  was 
extremely  poisonous  to  lower  animals  when  injected  into 
the  circulation. 

Laulanie  and  Chambrelent  (2)  conducted  a  series  of 
experiments  in  eclamptic  patients  and  found  that  the 
urine  was  much  less  poisonous  than  of  normal  pregnant 
women. 

They  also  conducted  experiments  to  determine  the  re- 
lative toxicity  of  the  blood  serum  of  eclamptic  women  and 
found  that  the  blood  serum  of  such  women  was  far  more 
toxic  than  in  health.  They  further  determined  by  their 
experiments  that  the  degree  of  toxicity  of  the  blood  serum 
of  eclamptics  was  in  direct  proportion  to  the  diminished 
toxicity  of  the  urine.  They,  therefore,  interpreted  these 
findings  as  proof  of  the  accumulation  of  poisons  in  the 
blood  of  eclamptics,  and  a  corresponding  diminution  of 
elimination  of  the  poisons  by  the  kidneys.  These  experi- 
ments have  in  the  main  been  confirmed  by  Ludwig  and 
Savor  (3),  while  Volhard's  (4)  experiments  gave  results 
directly  antagonistic. 

Recently  Schumacher's  (5)  has  thoroughly  gone  over 
the  ground  in  an  exhaustive  series  of  experiments,  and 


IMPENDING  ATTACKS  OF  PUERPERAL  ECLAMPSIA?   551 

concludes  that  both  the  blood  serum  and  the  urine  of  the 
normal  as  well  as  the  eclamptic  patient  while  poisonous 
are  constantly  changing,  being  subject  to  wide  variations 
in  the  degree  of  their  toxicity,  and  that  it  is  by  no  means 
certain  that  the  toxic  agent,  which  produces  results  on 
experimental  animals,  is  the  same  which  causes  eclampsia. 
The  nature  of  the  poison  has  given  rise  to  much  specula- 
tion. Early  investigators  believed  it  to  be  ammonium 
carbonate,  the  result  of  a  splitting  up  of  urea  in  the  blood. 
Others  have  advanced  the  theory  that  the  poison  was  a 
retained  constituent  of  the  urine,  kreatin  or  kreatinin. 
Masin  (6),  by  an  elaborate  series  of  experiments,  attempt- 
ed to  show  that  it  was  carbonic  acid,  a  product  of  inter- 
mediary metabolism,  while  Poehl  attributed  the  eclamp- 
tic seizures  to  leucomain  poisoning,  basing  his  conclusions 
on  the  increase  of  leucomains  in  the  urine  of  eclamptics. 

Recently,  Albert  (7)  has  advanced  the  theory  that 
the  poison  has  a  bacterial  origin,  from  a  latent  infectious 
endometritis  existing  during  pregnancy.  Most  of  the  sup- 
porters of  the  auto-intoxication  theory  regard  the  poison 
as  the  product  of  intermediary  metabolism  of  the  liver, 
while  others  (Fehling)  look  upon  the  fetus  as  being  the 
source  of  the  poison.  While  each  of  these  theories  has 
arguments  in  its  favour,  neither  the  nature  of  the  poison 
nor  its  source  are  known.  The  pathologic  anatomic  find- 
ings in  patients  dead  of  eclampsia  furnish  perhaps  the 
strongest  proof  of  the  chemotoxic  theory.  Schmorl  (8), 
who  has  made  an  exhaustive  examination  of  the  bodies  in 
73  patients  dead  of  eclampsia  found  changes  in  the  kidneys 
in  all  but  one,  consisting  of  cloudy  swelling,  fatty  de- 
generation and  desquamation  of  the  renal  epithelium, 
with  frequently  but  not  constantly  epithelial  necrosis.  In 
addition,  thrombi  were  found  in  the  glomeruli  and  in  the 
small  veins  and  arteries.  The  li^-er  also  was  quite  con- 
stantly involved,  presenting  in  71  of  73  cases  examined 
hemorrhagic  and  anemic  necrosis  and  in  the  two  cases  in 
which  these  changes  were  not  found,  there  were  present 
fresh  thrombi  in  the  portal  vein.  Similar  changes  were 
found  in  the  brain  and  lungs,  and  in  the  heart  fatty  and 
parenchymatous  degeneration  was  common.  Schmorl  in- 
terprets these  changes  in  the  different  organs  as  com- 
plicated necrotic  processes  secondary  to  the  thromboses. 

The  recent  experiments  of  Kohlman  (9),  and  Dienst 
(id),  have  shown  that  there  is  an  increase  of  fizrin  in  the 
blood  of  an  eclamptic. 

Volhard,  who  has  confirmed  these  experiments,  at- 
tributes this  rather  to  an  increase  in  the  fibrin  ferment 


t;32     rothrock:can  we  by  modern  methods  anticipate 

than  an  actual  increase  of  the  fibrin  in  the  blood,  and  that 
this  explains  the  multiple  thromboses  which  are  so  con- 
stantly present  in  the  organs  of  those  dead  of  eclampsia. 
Having  thus  briefly  stated  the  more  recent  views  on  the 
nature  and  etiology  of  eclampsia,  let  us  consider  what 
means  we  have  at  our  disposal  to  determine  that  an  attack 
of  eclampsia  is  approaching. 

The  discovery  of  albuminura  in  a  large  proportion  of 
€ases  of  eclampsia  early  called  attention  to  the  import- 
ance of  urinalysis  in  pregnant  women.  Albuminuria  is 
almost  constant  in  eclampsia,  if  not  before,  certainly  dur- 
ing the  attack.  Olshausen,  from  a  series  of  200  cases  of 
eclampsia  occurring  in  his  own  clinic  and  a  like  number 
from  the  clinic  of  (lusserow,  found  albuminuria  present 
in  98  per  cent,  of  the  cases.  Zweifel  in  a  series  of  129 
cases  never  failed  to  find  albumin  in  the  urine.  Its  almost 
constant  presence  renders  it  a  sign  of  considerable  im- 
portance, a  danger  signal  which  should  not  be  passed  un- 
heeded. In  recent  years  there  has  been  a  tendency  to 
attach  less  importance  to  the  presence  of  albumin  in  the 
urine  of  pregnant  women,  from  the  clinical  observation 
that  many  patients  with  albuminuria  go  through  labour 
with  no  eclamptic  manifestations.  The  significance 
of  albuminuria  in  the  light  of  the  recent  investigations 
of  Schmorl  is  of  vast  importance  as  indicating  either 
vcrj'  serious  renal  changes  of  a  character  which  nre  con- 
stantly present  in  eclampsia  or  chronic  nephritis.  On  the 
other  hand,  from  our  present  knowledge  it  is  evident  that 
while  the  search  for  albumin  in  the  urine  is  a  very  im- 
portant procedure  in  all  cases,  it  does  not  give  us  sufficient 
information  of  the  patient's  condition.  For  example,  we 
may  have  very  marked  renal  insufficiency  before  the  ap- 
pearance of  albumin,  while  in  the  presence  of  the  most 
pronounced  albuminuria  the  eliminative  power  of  the  kid- 
ney may  be  perfectly  maintained.  It  is  to  the  urine  that 
we  must  still  look  for  signs  of  threatening  eclampsia,  since 
it  has  been  pretty  definitely  determined  that  the  elimi- 
native power  of  the  kidney  bears  some  relation  to  the  prob- 
ability of  eclamptic  seizures. 

Kecentlv.  we  have  added  to  our  hitherto  known  me- 
thods of  determining  the  eliminate  activity  of  the  kidney, 
a  new  one  based  on  the  molecular  concentration  of  the 
urine  as  ascertained  by  determining  its  freezing  point. 
This  method,  which  was  first  applied  to  the  blood  by 
Richter  and  Roth  (11),  and  later  to  the  urine  by  Koranyi 
(12),  and  Lindemann  (13),  has  been  found  a  valuable  aid 
in  determining  the  functionating  power  of  the  kidneys. 
Schroeder    (14)     has    recently    made    application   of    this 


IMPENDING  ATTACKS  OF  PUERPERAL  ECLAMPSIA?   553 

method  for  the  determination  of  renal  activity  in  pregnant 
women  and  from  a  series  of  111  cases  examined,  he  arrives 
at  the  following  conclusion: 

In  chronic  interstitial  nephritis  during  pregnancy  the 
molecular  concentration  of  the  urine  is  very  low,  in  labour 
it  falls  enormously,  and  in  the  puerperium  it  again  ascends. 

In  man.y  cases  of  nephritis  of  pregnancy  before  labour 
the  urine  maintains  a  fairh'  good  degree  of  concentration 
and  only  shortly  before  or  during  labour  does  it  fall  and 
again  rise  in  the  puerperium.  According  to  Koranyi  a 
beginning  rise  in  the  molecular  concentration  is  a  favour- 
able prognostic  sign.  Should  an  eclamptic  attack  occur, 
the  molecular  concentration  of  the  urine  at  once  sinks 
very  low.  Schroeder  concludes  from  these  experiments 
that  the  lowering  of  the  molecular  concentration  of  the 
urine  may  be  accepted  as  indicating  renal  insufficiency 
which  ma}-  be  followed  by  eclampsia  during  labour  or  in 
the  puerperium. 

In  these  experiments  Schroeder  found  that  the 
amount  of  albumin  present  bears  no  relation  to  the  mole- 
cular concentration  of  the  urine,  and  that  frequently  in 
the  absence  of  albuminuria  the  determination  of  the  freez- 
ing point  showed  almost  absolute  renal  insufficiency. 

Schroeder  also  conducted  experiments  for  the  deter- 
mination of  the  freezing  point  of  the  blood,  and  in  two 
cases  of  eclampsia  with  low  molecular  concentration  of 
the  urine,  there  was  an  enormously  high  pathological  con- 
centration of  the  blood. 

He  also  conducted  a  series  of  experiments  for  the 
determination  of  the  degree  of  blood  pressure  in  pregnant 
women,  and  found,  that  while  it  is  slightly  increased  just 
before  and  during  labour,  its  only  value  is  in  diiferentiat- 
ing  cases  of  chronic  interstitial  nephritis,  in  which  the 
blood  pressure  is  invariably  greatly  increased. 

Very  closely  related  to  the  determination  of  the  freez- 
ing point  is  the  specific  gravity  of  the  urine,  which  Schu- 
macher regards  as  one  of  the  most  important  indices  of 
renal  sufficiency.  A  careful  examination  of  Schroeder's 
tables,  however,  shows  in  certain  cases  a  wide  variation 
between  the  molecular  concentration  as  estimated  by  deter- 
mination of  the  freezing  point  and  the  specific  gravity, 
though  in  many  cases  there  does  seem  to  be  a  close 
relation. 

For  several  years  I  have  insisted  upon  the  importance 
of  the  quantitive  estimation  of  the  urea  in  the  urine  of 
the  pregnant  women,  as  forming  an  index  to  the  degree 
of  renal  sufficiency  and  during  that  time  I  have  repeatedly 


554  eothkock:   puerperal  eclampsia. 

made  the  observation  that  the  quantity  of  urea  eliminated 
bears  absolutely  no  relation  to  the  degree  of  albuminuria. 
Frequently,  in  very  highly  albuminous  urine^  the  quantity 
of  urea  will  be  quite  up  to  normal,  while  urine  entirely 
free  from  albumin  may  show  the  presence  of  very  little 
urea. 

In  all  cases  in  which  the  urea  was  diminished  the 
specific  gravity  was  reduced,  but  the  relative  proportions 
were  not  maintained.  In  eases  of  renal  insufficiency  the 
quantity  of  urea  eliminated  at  different  times  varies  great- 
ly, so  that  it  is  absolutely  necessary  to  estimate  from  a 
specimen  taken  from  a  twenty-four  hours'  collection. 

Very  frequently  it  has  been  possible  to  predict  im- 
pending trouble,  which  sooner  or  later  was  confirmed  by 
the  appearance  of  albumin  in  the  urine  and  in  one  case 
under  my   observation  an   attack   of  eclampsia  followed. 
It  is  true,  as  has  been  argued  of  the  value  of  this  method, 
that  many  patients  in  whom  in  the  latter  weeks   of   preg- 
nancy   a  marked    diminution    of   the   elimination    of   urea 
takes  place,  pass  through  labour  without  eclampsia,   with- 
out  even   so   much   as   dietetic  treatment,    but   we  never 
know  how  narrowly  such  patients  escape.     Among  other 
methods  of  determining  the  renal  sufficiency  which  have 
been    proposed     may    be   mentioned    the    phloridzin    test, 
which,  so  far  as  I   am  aware,  has  never  been   applied  to 
pregnant  women.   Recently,  Olivier  (15)    conducted  a  series 
of  experimeuts  for  the  determination  of  renal  sufficiency 
by  the  administration   of  methylene  blue.     In   five   cases 
of  eclampsia  the  elimination  was  defective  in  all  but  one. 
In  this  patient  the  elimination  was  perfectly  regular,  but 
the  symptoms  were  far  more  severe  and  it  terminated  fatal- 
ly.    Olivier  concludes  that  renal  or    hepatic    insufficiency 
is  not  inevitably  necessary  to  the  production  of  auto-in- 
toxication, but  that  with  an  over-production  of  toxines,  in 
spite  of  a  normal  elimination,  the  accumulation  necessary 
for  the  production  of  eclampsia  may  take  place. 

In  order  that  any  of  these  tests  may  have  clinical 
value,  they  must  form  a  part  of  routine  practice.  It  is 
highly  essential  that  the  urine  of  pregnant  w^omen  be  ex- 
amined frequently  during  the  latter  months  of  preg- 
nancy. During  the  latter  weeks  of  pregnancy  weekly 
examinations  should  be  made,  or  even  more  frequently 
should  a  suspicious  specimen  be  received.  I  am  satis^ 
fied  that  if  such  examinations  were  made  in  all  cases 
as  suggested,  only  in  the  most  exceptional  instances 
would  we  fail  to  anticipate  threatened  eclampsia.  The 
more  weighty  argument  in  favour  of  routine  examinations 
of  the  urine  in  all  cases    is  that  with  the  early  recogni- 


shbllenberg:  how  to  make  confinement  easy..      555 

tion  of  the  first  sign  of  renal  insufficiency,  the  patient  may 
be  placed  on  prophylactic  treatment,  and  the  attack,  if  not 
absolutely  averted,  may  be  so  modified  that  the  patient 
may  be  safely  carried  through  it.  Furthermore,  being  in 
anticipation  of  an  attack,  prompt  and  active  treatment 
could  at  once  be  instituted  and  the  convulsions  be  brought 
under  control,  for  all  authorities  agree  that  with  each  suc- 
ceeding convulsion  the  prognosis  becomes  more  grave. 

BIBLIOGRAPHY. 

1.  Archiv.  f.  Gyn.  Bd.  65  H.  3. 

2.  Aonales  de  Gynecol.  1890  P  253. 

3.  Mouatsschrift  f.  Geb.  u.  Gyn.  Bd.  1. 

4.  Monatsschrift  f.  Geb.  n.  Gyn.  Bd.  5. 

5.  Beitrage  Zur  Geb.  u.  Gyn.  Bd.  5.  H.  2 

6.  Centralbktt.  f.  Gyn.  1895,  No.  42. 

7.  Archiv.  F.  Gyn.  Bd.  66.  H.  2. 

8.  Archiv.  f.  Gyn.  Bd.  65.  H.  2. 

9.  Centralblatt  1.  Gyn.  1897.  S.  341. 

10.  Archiv,  P.  Gyn.  Bd.  65.  H.  2. 

11.  Berliner  Klin.  Woch.  July  24,  1899. 

12.  Berliner  Klin.  Woch.  Sept.  4,  1899. 

13.  Deutsch  Archiv.  f.  Klin,  Med.  Sept.  1899. 

14.  Beitrage  Zur.  Geb.  u.  Gyn.  (bVitsch  Fej<t?'chrift)  1902. 

15.  Relerence,  Jour.  Amer.  Ass.  June  21,  1902,  P.  1628. 

— St.  Paul  s  Med.  Journal-, 


HOW  TO  MAKE  CONFINEMENT  EASY. 

,    By  M.  Shellenberg,  M.  D.,  Philadelphia. 

The  medical  practitioner  should  look  into  the  future 
in  treating  the  girls  who  are  growing  up,  and  correct 
errors  in  the  method  of  living,  dress  and  exercise.  He 
must  warn  the  mother  against  allowing  her  daughter  to 
indulge  in  habits  which  injure  the  health  and  especially 
anything  likely  to  cause  weakness  or  disease  in  the  pelvis. 
The  prevention  of  pelvic  congestion  by  the  use  of  warm 
undergarments,  especially  during  menstruation,  the  for- 
biddance  of  heavy  lifting  or  long  standing,  which  tend  to 
cause  uterine  displacements  ;  the  avoidance  of  constipa- 
tion, a  fruitful  source  of  trouble  in  producing  congestion, 
stagnation  and  debilitation  in  the  venous  supply  of  the 
pelvic  organs  ;  pre^-ention  of  the  habitual  retention  of 
urine,  which  weakens  the  bladder  and  presses  the  uterus 
backwards  ;  avoidance  of  climbing  stairs  of  high  city 
buildings,  both  at  home  and  at  school  ;  excess  of  sedentary 
habits,  with  lack  of  good  muscular  exercise  ;  the  use  of 
ill-applied  or  tightly  laced  dresses,  all  fall  to  doctor's 
practice.  A  good,  well  fitting,  easy  corset  is  far  superior 
to  the  custom  of  tying  heavy  skirts  tightly  about  the  waist, 


5516       shellenberg:  how  to  make  confinement  easy. 

to  drag  down  the  abdomen,  displacing  all  organs  beneath 
it. 

The  bearing  of  these  points  upon  future  parturition 
are  rarely  considered  by  the  woman  or  her  parents,  and 
frequently  neglected  by  the  family  physician.  Diet  in 
pregnancy  is  important  to  consider.  The  prospective 
mother  is  now  eating  for  two  persons  instead  of  one.  The 
child  must  be  made  from  the  constituents  of  the  mother's 
food,  and  by  controlling  this  we  control  the  condition  of  the 
child's  body  at  birth.  The  head  and  bones  of  a  child  shape 
themselves  to  the  parturient  passage,  if  they  be  soft  and 
cartilaginous,  while  delay  and  distress  to  the  mother  oc- 
curs where  the  bones  of  the  child  have  become  so  far 
ossified  as  to  make  them  but  slightly  yielding. 

The  idea  of  keeping  the  fetus  small  by  starving  the 
mother  during  pregnancy  has  been  tried  from  time  to  time, 
but  it  must  be  remembered  that  the  fetus  acts  as  a  true 
parasite  and  takes  good  care  of  itself  and  its  own  nutrition 
without  any  regard  to  the  results  to  the  mother.  It  is  well 
known  that  well  nourished  children  are  frequently  born  of 
women  sutfering  from  advanced  disease  and  much  ema- 
ciated. Bedone  reports  on  the  difference  between  the  fetal 
and  maternal  blood  in  cases  of  anemia  during  pregnancy. 
He  reports  nine  cases,  in  one  of  which  the  red  corpuscles 
in  the  fetal  blood  were  over  4,000,00t),000  as  compared  with 
928,000  in  the  maternal  blood.  In  another  case  there  were 
5,800,000  fetal  blood  as  compared  with  000,000  in  the 
maternal  blood.  From  this  data  this  authority  concludes 
that  extremely  anemic  women  may  bear  healthy  children. 

The  food  eaten  by  the  mother  during  gestation  can  be 
regulated  as  easily  as  a  person  can  be  fattened  or  reduced 
in  adipose  tissue.  Those  foods  which  contain  large  quan- 
tities of  earthy  phosphates  should  not  be  permitted.  The 
patient  should  use  starchy  foods,  as  white  bread,  potatoes, 
with  vegetables,  and  especially  fruits.  The  latter  acting 
in  a  twofold  manner,  the  bowels  free,  causing  a  solution 
of  the  earthy  salts  of  other  articles  of  diet  carrying  them 
off  by  the  kidneys.  A  softer,  more  cartilaginous  condition 
of  the  bones  of  the  new-born  infant  will  result  when  the 
mother  eats  largely  of  acid  fruits  during  pregnancy. 
Prochownik  has  prepared  a  diet  for  women  with  narrow 
pelvis  or  with  whom  dystosia  has  been  due  to  the  size  of 
the  fetus.  It  consists  in  giving,  during  the  last  three 
months  of  pregnancy,  roast  and  boiled  meats  without 
sauces,  fresh  green  vegetables,  salads,  cheese,  butter  in 
small  quantity.  With  the  prejudice  against  water,  shared 
by  all  Continental  writers,  he  forbids  its  use  and  gives 
light    wine   instead.     No    sugar,    but    saccharin    is    given, 


SHBLLENBEB.G :  HOW  TO  MAKE  CONFINEMENfT  EASY.  557 

while  potatoes,  soups,  farinaceous  foods  and  beer  are 
prohibited.  A  German  physician  has,  according  to  the 
Medical  Age,  tried  this  method  during  the  last  two  years, 
and  asserts  "that  the  children  come  into  the  world  small 
and  thin,  and  depleted  of  fatty  tissue.  The  passage  of  the 
pelvic  strait  is  easily  accomplished,  always  more  easily 
than  in  ordinary  conditions.  The  method  is  applicable  in 
three  classes  of  cases  :  First,  in  those  of  narrow  pelvis, 
in  which  this  effect  is  not  inordinately  accentuated,  if  this 
be  so,  premature  delivery  is  the  only  resource.  Secondly, 
in  cases  in  which  the  dystosia  has  previously  been  due  to 
the  excessive  dimensions  of  the  fetus.  Thirdly,  in  cases  of 
primiparae  of  over  thirty  years  of  age. 

"The  regimen  is  one  which  it  is  claimed  can  be  tried 
without  danger  to  the  mother,  and  the  ulterior  develop- 
ment of  the  child  goes  on  normally  and  without  prejudice." 

After  birth  change  the  diet  of  the  mother  to  the  varie- 
ties of  food  pi'eviously  prohibited,  which  will  supply  bone- 
making  material  through  her  milk  to  the  nursing  infant. 
Pelvic  trouble  of  all  kinds  must  be  carefully  looked  after 
and  corrected,  especially  inflammatory  conditions.  Occa- 
sionally, pelvic  inflammation  producing  pain  upon  digital 
examination  will  exist  for  several  months  during  gestation 
and  continuing  even  after  labour  is  over. 

Give  local  treatment  to  a  pregnant  woman,  and  im- 
mense relief  follows  thereby.  These  applications  may  be 
used  from  the  beginning  of  pregnancy  to  the  day  for 
parturition  without  injury  if  carefully  and  judiciously  ad- 
ministered. The  occurrence  of  varicose  veins  in  the  lower 
limbs  or  vulva  is  a  sign  of  pressure  by  the  gravid  uterus 
upon  the  veins  of  the  pelvis,  demanding  correction. 

An  antiseptic  wool  tampon  in  the  vagina,  renewed  every 
three  to  ^ve  days,  is  excellent  here,  acting  as  an  elastic 
cushion  for  the  heavy  uterus  to  rest  upon,  taking  the 
pressure  from  the  veins.  The  dorsal  position  is  also  of 
assistance  to  relieve  this  condition.  Baths  and  vaginal 
injections  at  all  times  are  excellent.  Occasional  vaginal 
douches,  particularly  if  made  antiseptic  by  some  of  the 
weaker  germicides,  tend  to  keep  the  genitals  in  a  healthy 
state  of  tonicity  and  to  prevent  the  entrance  of  germs. 

In  the -last  week  of  pregnancy,  hot  hip  baths,  enemata, 
vaginal  douches,  and  hot  wet  cloths,  and  in  the  earliest 
stage  of  labour,  relax  the  perineal  and  sphincter  muscles, 
allowing  an  easy  passage  of  the  fetus.  Nothing  will  make 
flaccid  the  perineal  tissues  and  relax  the  sphincters  of 
uterus,  anus  and  vagina  so  satisfactorily  as  heat  and 
moisture.  But  the  water  must  be  hot  for  use  in  the  hip 
bath,  injection,   or  by  means    of  saturated   cloths  to  peri- 


558      shellenberg:  how  to  make  goneinembnt  easy. 

neum.  A  temperature  of  118°  F.  must  be  continued  for  a 
long  time.  In  cases  of  uterine  inertia  the  hot  douche 
stimulates  muscular  contractions  of  the  uterus  as  well  as 
■  to  relax  the  tissues  below.    . 

Contractions  of  the  uterus  are  stimulated  by  the 
presence  of  the  examining  fingers  in  the  vagina,  but  as 
frequent  examinations  are  both  dangerous  and  unpleasant, 
the  hand  should  be  placed  in  position  only  after  a  thorough 
antiseptic  cleansing. 

The  physician  should  learn  the  position  of  the  child 
before  labour  begins,  if  possible,  and  if  a  breech  or  lateral 
presentation  occur  it  should  be  changed  to  a  head  presenta- 
tion. Perform  cephalic  version,  if  possible,  two  weeks 
before  expected  labour.  It  is  done  by  the  patient  lying  on 
her  back  with  her  knees  and  thighs  flexed,  while  rotary 
passages  are  made  by  the  hands  of  the  physician  en  the 
abdomen  in  such  a  manner  as  to  press  the  child's  head  into 
the  pelvis  and  bring  the  limbs  uppermost.  The  genu- 
pectoral  position  during  this  manoeuvre  will  materially 
assist  in  its  success. 

The  clothing  of  both  bed  and  patient  should  receive 
the  doctor's  attention.  It  is  unnecessary  to  say  they  should 
be  clean.  Any  old  cloths,  possibly  loaded  with  germs,  will 
not  do.  Under  the  bed  sheet  should  be  spread  a  sheet  of 
rubber  or  common  table  oilcloth,  to  protect  the  bedding 
beneath.  The  patient  should  wear  a  warm  undervest  and 
clean  nightdress,  neatly  and  smoothly  folded  or  rolled  up 
almost  to  the  armpits  ;  a  roll  of  cloths  or  towels  placed  in 
the  hollow  of  the  back  to  prevent  the  clothing  working 
downward,  and  also  to  prevent  blood  or  other  discharges 
working  upward.  Have  her  put  on  a  clean  wrapper,  to  be 
taken  off  after  the  labour  is  over.  Such  preparation  will 
save  much  discomfort  during  and  after  parturition. 

Lister  was  the  pioneer  in  demonstrating  the  arrest  of 
pus  formation  building  on  the  work  of  Pasteur,  while  Sur- 
gery has  taught  obstetrics  the  sterilization  of  instruments 
as  well  as  the  ways  of  preventing  sepsis.  No  greater 
advance  was  ever  made  than  the  introduction  of  asepsis, 
and  antiseptics  applied  to  obstetric  work  has  proven  the 
physical  redemption  of  thousands  of  parturient  women. 
Even  if  the  accoucheur  has  large  experience'  and  great 
skill,  and  yet  does  not  render  himself,  the  nurse,  .and  his 
patient  aseptic,  he  fails  in  the  most  vulnerable  point.  The 
high  degree  of  antisepsis  of  the  surgery  of  the. abdomen 
should  be  the  type  of  cleanliness  for  the.  obstetrician. 

All  prolonged  or  diflScult  and  especially  operative 
labours  should  be  treated  with  the  greatest  care,  for  fresh 
abrasions  and  deep  lacerations  seem  to  reach  septic  germs. 


shellenberg:  how  to  make  confinement  easy.  559 

TEe  hand  of  the  physician  and  of  the  nurse  should  not 
e\^r  touch  the  genitalia  without  having  been  carefully 
washed  at  the  moment.  The  unsterilized  hand  is  unfit 
for  obstetrics. 

In  Europe  there  has  been  recently  inaugurated  train- 
ing schools  for  midwives,  but  the  sacredness  and  respon- 
sibility of  obstetric  workmakes  the  idea  of  giving  it  to 
midwives  most  repellant  to  an  American.  In  these  days 
when  such  noble  and  inspiring  effort  is  being  made  to  ele- 
vate the  standard  of  qualification  in  medicine,  why  should 
this  branch  be  degraded  ?  This  midwife  debris  should  be 
suppressed.  Even  in  such  a  city  as  Baltimore,  with  more 
than  600  doctors,  there  are  75  midwives  who  attend  re- 
latively a  very  large  proportion  of  the  labour  cases.  With 
the  raising  of  the  standard  of  medical  education  in  this 
country  in  the  interest  of  the  people,  why  should  the  poor 
and  ignorant  be  left  to  the  mercy  of  the  untutored  mid- 
wives?  Especially  when  now  the  young  doctors,  infinitely 
better  qualified,  are  longing  for  practical  opportunities  in 
obstetric  work. 

If  the  amniotic  fluid  be  lost  before  labour  begins,  or 
should  the  pains  stop  after  the  fluid  is  discharged,  restora- 
tion of  parturient  contractions  is  in  order.  Dry  births, 
with  their"  attendant  misery  and  suspense  to  the  mother 
and  danger  to  the  child,  might  be  obviated  if 'the  physi- 
cian be  enterprising  enough  to  assist  nature  to  throw  off 
the  child,  owing  to  a  lack  of  tonicity  in  the  muscular  struc- 
tures of  the  mother.  This  is  done  by  gently  kneading 
the  abdomen  to  incite  uterine  contractions  with  one  hand, 
at  the  same  time  dilating  the  os  by  the  fingers  of  the  other 
hand  to  secure  both  contractions  and  an  open  passage- 
way for  the  child. 

Nature  often  produces  by  reflex  action  by  more  or  less 
severe  vomiting,  having  the  effect  of  relaxing  the  parturient 
canal  and  materially  assisting  in  delivery.  Janvier 
suggests  that  emesis  can  be  induced  by  having  the  patient 
drink  large  quantities  of  luke  warm  water,  which  is  easily 
thrown  off  by  the  stomach  producing  general  muscular 
relaxation. 

Chloroform  as  a  relaxant  is  used  largely  abroad,  but 
not  so  extensively  in  this  country-,  to  secure  a  partial 
immunity  from  the  agony  of  uterine  contractions.  In 
small  doses  it  has  seldom  proved  harmful  ;  given  with  a 
free  hand  it  causes  a  lessening  or  even  a  cessation  of  pains 
and  thus  prolongs  the  labour  beyond  a  normal  duration. 
Given  in  short  inhalations  at  the  time  of  severest  pains  it 
is  one   of  the  most  valuable   agents  we  have  in  securing 


560       SHELLENBERG :  HOW  TO  MAKE  CONFINEMENT  EASY. 

easy  papturition,  and  will  not  tend  to  produce  post  partum 
hemorrhage  unless  used  after  the  uterus  is  emptied  of  the 
greater  part  of  its  contents. 

Occasionally  in  prolonged  labour,  where  the  strength 
of  the  patient  has  given  out  and  the  pains  have  ceased 
altogether,  a  large  hypodermic  injection  of  morphine 
temporarily  checks  the  labour  and  gives  the  patient  rest 
and  sleep,  lasting  from  one  to  several  hours.  On  awaken- 
ing the  pains  start  with  renewed  vigour  and  the  patient  is 
in  a  much  better  condition. 

Cocaine  has  been  recommended  for  lessening  the  pain 
from  the  intense  pressure  and  stretching  exerted  upon  the 
vagina,  vulva,  and  perineum.  Introduced  in  cocoa  butter 
suppositories,  or  wrapped  in  a  small  pledget  of  cotton, 
about  the  time  the  head  impinges  upon  the  perineal  tissues 
it  has  received  favourable  reports;  slowly  dissolving  it 
spreads  itself  over  the  mucous  membrane  of  the  pelvic 
outlet,  producing  an  anesthetic  effect  which  lasts  about  an 
hour.  If  there  be  a  lack  of  the  natural  lubricating  dis- 
charges, the  cocoa  butter  suppositories  are  best,  otherwise 
the  cocaine  applied  on  cotton,  or  even  on  the  ends  of  the 
fingers,  answers  every  purpose  and  is  more  convenient. 
I  have  been  told  many  times  that  the  patient  dreaded  most 
the  last,  severe,  expulsive  pains  ;  and  the  immunity  from 
suffering  offered  by  this  simple  procedure  has  been  very 
gratifying  to  both  patient  and  physician.  The  danger  of 
absorption  has  not  been  reported. 

The  umbilical  cord  should  not  be  cut  at  once,  for  after 
expulsion  of  the  child  more  blood  is  pumped  into  the  babe 
than  returns  to  the  mother.  Wait  until  pulsation  has 
nearly  or  entirely  ceased.  This  secures  a  greater  supply  of 
blood  for  the  child  and  reduces  the  size  of  the  placenta. 

Squeezing  of  the  uterus,  as  though  it  were  an  orange, 
through  the  abdominal  walls  is  excellent  to  stimulate  con- 
traction so  that  the  secundines  can  be  expressed  entire, 
without  any  traction  upon  the  cord.  Traction  delays  de- 
livery by  pulling  the  flat  surface  of  the  placenta  to  the 
mouth  of  the  womb  instead  of  the  edge  of  the  rolled  up 
placenta.  This  procedure  of  expression  empties  the  uterus 
of  all  the  clots  and  debris,  and  leaves  it  in  a  condition  for 
the  continuance  of  gentle  tonic  contraction,  less  exposed  to 
spasmodic  after-contractions. 

This  tonic  contraction  of  the  uterus  after  labour  not 
only  rids  many  after  pains,  but  frees  the  organ  from  clots, 
and  danger  of  sepsis  is  obviated,  and  the  uterus  is  in  a 
better  condition  for  involution.  For  a  large  and  flabby 
uterus,  give  small  doses  of  ergot  or  viburnum  four  or  five 
times  daily  for  several  days  or  even  weeks. 


crosson:  insomnia.  561 

Ergot  in  labour  has  become  much  restricted  in  late 
years.  It  often  does  as  much  harm  as  good,  and  produces 
much  suffering  by  its  cramping,  spasmodic  contractions. 
It  tends  to  contract  only  the  middle  or  lower  portion  of 
the  uterus,  hindering  expulsion.  Far  better  in  the  major- 
ity of  cases  is  friction  or  massage  of  the  abdomen  above 
the  uterus.  Future  experiences  will  probably  demonstrate 
that  it  is  superfluous  and  ofttimes  dangerous  in  securing 
easy  parturition.  Quinine  is  a  better  oxytocic,  producing 
a  more  natural,  intermittent  contraction  than  ergot.  But 
remember,  nature  intended  parturition  to  be  a  physiolo- 
gical process;  hence,  interfere  as  little  as  the  case  permits. 
— Medical  Times. 


insomnia. 

By  Dr.  Francis  Crosson,  Albuquerque,  N.  M. 

Along  with  the  heat  and  rush  of  modern  industrial 
development  have  come  new  and  strange  manifestations  of 
disease  not  heretofore  common  in  medical  and  surgical 
practice.  Among  these  there  is  perhaps  none  more  fre- 
quently encountered  to-day  by  the  average  practitioner  than 
insomnia.  It  is  not  always  an  easy  matter  to  get  behind 
the  cause  or  causes  responsible  for  the  production  of  this 
condition  ;  nor  need  its  presence  be  invariably  attributable 
to  pathological  factors  per  se.  A  form  of  insomnia  now 
commonly  met  with  can  be  traced  to  a  purely  psychological 
cause,  and  the  presence  of  a  disease  is  not  necessarily  a  con- 
comitant. I  have  had  many  such  cases, — patients  refusing 
to  sleep  upon  retiring.  Instead  of  immediately  relaxing 
mind  and  body,  the  mental  clock  is  wound  up,  so  to  speak, 
and  free  and  unrestrained  vent  given  to  the  thoughts,  which 
are  permitted  to  run  wild,  traversing  in  mental  introspection 
a  vast  field,  and  reviewing  an  enormous  number  and  variety 
of  subjects,  that  pass  with  marvellous  rapidity  before  the 
mental  inspection  of  the  patient.  In  a  very  short  time  this 
habit  becomes  fixed.  The  sufTerer  makes  an  effort  to  over- 
come the  growing  and  stubborn  condition,  but  the  habit  is 
not  easily  uprooted  when  once  it  has  taken  seed  and  arrived 
at  the  stage  of  fruition.  Try  as  he  will,  the  victim  of  this 
condition  will  find  himself  or  herself  powerless,  after  a  short 
time,  to  make  any  headway  against  this  growing  insomnia 
habit.  The  mind  will  seek  almost  unconsciously  in  the 
stillness  of  the  night  subjects  and  distractions  of  one  kind 
or  another  to  fasten  its  wild  riot  upon.     The  senses  become 


562  crosson:  insomnia. 

more  and  more  active  and  alert,  until  in  a  spirit  of  despair 
the  patient  suffers  himself  to  relapse  into  a  state  of  complete 
wakefulness,  accompanied  by  the  peculiar  nervous  phenomena 
of  this  condition,  when  he  or  she  lies  with  more  or  less 
philosophic  resignation  upon  the  sleepless  couch,  awaiting 
with  anxious  expectation  the  advent  of  a  new-born  day. 
With  the  approach  of  dawn,  in  most  cases,  a  slight  feeling 
of  drowsiness  occurs,  the  result,  perhaps,  of  complete 
physical  and  mental  exhaustion.  But,  unfortunately  for  the 
insomnia  victim,  this  is  a  poor  time  to  secure  the  much- 
needed  sleep, — the  myriad  noises  of  the  day  begin  now,  and 
increase  in  volume  and  variety,  until  the  culmination  is 
reached  in  the  nerve-racking  hubbub  of  our  modern  large 
towns  and  cities. 

In  attempting  to  treat  successfully  such  cases  as  these, 
certain  essentials  are  obviously  required,  among  the  more 
prominent  of  which  may  be  mentioned  isolation  and  seques- 
tration from  noises  of  all  kinds,  complete  mental  and  physical 
relaxation  from  business  cares,  and  last,  but  not  least 
important,  the  employment  of  a  safe  and  reliable  medicine 
to  produce  sleep.  The  number  of  drugs  employed  for  such 
purpose  is  legion,  but  few  of  these  are  devoid  of  harm  and 
influence  upon  the  future  of  the  patient,  and  still  fewer  are 
in  any  sense  either  efficient  or  reliable.  Like  the  average 
medical  man,  I  presume  I  have  run  the  gamut  of  many  of 
the  more  conspicuous  hypnotics  that  have  been  in  use  and 
have  enjoyed  prominence  during  the  last  twelve  or  fifteen 
years.  Few  men  to-day  care  to  tamper  with  the  old  com- 
binations of  chloral,  and  the  bromides,  while  opium  and  its 
alkaloids  prove  of  service  only  in  the  case  of  certain  persons, 
and  then  only  in  the  hands  of  judicious  and  wise  doctors. 
The  later  coal  tar  products,  while  they  doubtless  served  a 
useful  purpose  in  their  earlier  career,  have  been  found 
wanting  in  many  essentials,  have  never  been  entirely  devoid 
of  direct  danger  and  certain  unpleasant  sequelae.  About 
nine  months  ago  I  had  on  my  hands  three  cases  of  a  rather 
severe  type  of  insomnia.  In  looking  about  for  a  prop  to 
help  carry  these  sufferers  along,  I  decided  to  try  hedonal, 
about  which  I  had  read  some  very  excellent  clinical  reports 
recorded  by  men  of  standing  and  note  in  Germany.  I  set 
about  the  use  of  this  preparation  with  all  the  preconceived 
pessimism  which  comes  with  years  of  therapeutical  experi- 
mentation. To  eliminate  any  doubt  as  to  its  value,  the  tests 
made  by  me  were  severe  and  sufficiently  varied  in  character 
to  satisfy  my  mind  in  all  essentials.  Now,  after  nine  months 


crosson:  insomnia.  563 

of  careful  observation  on  the  action  of  hedonal,  I  am  pre- 
pared to  testify  to  its  usefulness  in  the  simpler  forms  of 
insomnia,  especially  those  of  physical  origin.  In  the  in- 
somnia of  advanced  tuberculosis  it  has  likewise  proved  of 
great  value  in  my  hands,  securing  to  the  sufiferer  calm  and 
restful  sleep  night  after  night,  for  weeks  and- months,  without 
harmful  results. 

The  cases  in  which  I  employed  hedonal  embrace  dip- 
somania, mo'-phinomania,  pulmonary  and  laryngeal  tubercu- 
losis, tubercular  empyema,  acute  follicular  tonsillitis,  pleuritis, 
hallucinations  following  ovariotomy,  neurasthenia  following 
excessive  mental  work  and  severe  physical  strain.  The 
variety  of  conditions  in  which  I  have  resorted  to  hedonal 
has  been  sufficient  to  enable  me  to  draw  some  general  conclu- 
sions in  regard  to  this  new  chemical  compound. 

1.  I  have  found  it  safe  to  administer  hedonal  in  all  the 
above  diseases,  night  after  night,  or  in  some  instances 
upon  alternate  nights.  In  my  hands  its  use  has  not  been 
attended  with  unpleasant  consequences,  except  in  one  in- 
stance, a  gastritis  lasting  five  or  six  days;  but  as  this 
patient  had  been  taking  heroic  doses  of  heroin  prior  to  my 
employment  of  hedonal,  I  am  not  entirely  satisfied  that 
the  stomach  disturbance  was  not  as  much  due  to  the  use 
of  heroin  as  it  was  to  hedonal. 

2.  I  have  not  found  any  indications  of  cardiac  de- 
pression following  doses  of  forty  grains  of  hedonal. 

3.  It  seems  to  be  entirely  devoid  of  cumulative  effect, 
and  is  apparently  rapidly  eliminated  from  the  system 

4.  It  produces  sleep  a  few  moments  after  administration, 
and  the  number  of  hours  of  sleep  can  in  most  instances  be 
regulated  by  the  dosage.  I  have  employed  hedonal  in 
fifteen  grain  doses  for  forty  to  fifty  consecutive  nights, 
without  the  slightest  deleterious  effect  upon  any  of  the  vital 
organs  or  functions.  I  have  made,  while  using  this  drug, 
frequent  analyses  of  the  urine,  but  have  failed  to  find  any 
evil  influence  upon  the  function  of  the  kidneys.  Hedonal 
can  be  discontinued  at  any  time.     It  creates  no    habit    nor 

he  necessity  for  any  other  hypnotic  to  take  its  place. — Oc- 
idental  Medical  Times. 


Progress  of  Medical  Science. 


MKDICINK    AND     NKUROLOQY 

IN   CHARGE   OF 

J.  BRADFORD  McCONNELL,  M.D. 

Associate  Professor  of  Medicine  and  Neurology,  and  Professor  of  Clinical  Medicine 
University  of  Bishop's  College ;  Physician  Western  Hospital . 


THE  ETIOLOGY  OF  ACUTE  DYSENTERY  IN  THE 
UNITED  STATES. 

The  problem  of  the  authors  has  been  to  determine  by 
comparative  study  whether  the  organisms  described  by  the 
various  observers  (Shiga  in  Japan,  Flexner  and  Strong  in  the 
Phih'ppines  and  Kruse  in  Germany)  are  not  really  of  the 
same  species,  though  possessed  of  individual  differences  and 
peculiarities,  and  to  discover  the  cause  of  acute  dysentery  in 
this  country,  and,  if  possible,  to  identify  it  with  the  organisms 
of  the  observers  mentioned. 

The  authors  describe  in  detail  the  technique,  which 
consisted  in  examination  of  the  stools  of  persons  supposed 
to  have  dysentery  and  the  intestines  of  several  fatal  cases  of 
the  disease.  Agar  plates  were  made  from  bouillon  suspen- 
sions of  the  dejecta,  and  were  incubated  for  twenty- four  hours. 
The  colonies  after  this  time  resembled  very  closely  those  of 
the  colon  bacillus.  Inasmuch,  however,  as  the  colon  bacillus 
produces  gas  in  glucose  agar,  while  the  dysentery  does  not, 
simple  stabs  from  the  colonies  into  glucose  agar  readily  dif- 
ferentiates the  two. 

Before  the  organism  under  consideration  can  be  consider- 
ed to  be  the  B.  dysenteriae  it  must  fulfill  the  following 
requirements  :  (a)  It  must  give  the  proper  culture  characteris- 
tics as  shown  by  standard  cultures  of  Shiga,  Flexner,  Kruse, 
etc.;  (b)  It  must  possess  the  right  morphology  as  shown  by 
the  same  ;  (c)  It  must  give  a  positive  agglutinative  reaction 
with  some  of  the  known  dysenteric  sera. 

The  authors  report  the  study  of  twenty- two  cases,  five 
of  which  occurred  in  Philadelphia,  three  from  the  Lancaster 
Company  Insane  Asylum;  the  remainder  were  obtained  at 
the  Springside  Home,  New  Haven,  Conn.  From  all  these 
cases  the  B.  dysenteriae  were  isolated. 

With  the  view  of  determining  the  relationship  between 
the  various  bacilli  described  by  Shiga,    Flexner,  Kruse  and 


MEDICINE  AND  NEUROLOGY.  565 

Strong,  and  the  authors,  a  series  of  parallel  cultures  of  all 
these  was  made,  beginning  with  agar  plates,  and  carrying 
them  through  all  the  common  culture  media.  While  a  slight 
difference  was  observed  between  the  varieties,  these  were 
not  constant  enough  or  sufficient  to  distinguish  one  set  of 
cultures  from  the  other  unless  the  name  of  the  organism 
was  known  beforehand.  Therefore,  the  conclusion  was  reached 
that  the  cultural  characteristics  of  the  various  forms  studied 
are  essentially  alike. 

As  to  the  morphology  of  the  organism,  it  is  a  slender 
rod  with  rounded  edges.  It  stains  with  aniline  dyes,  but  not 
by  Gram's  stains.  By  a  special  method  the  authors  were 
enabled  to  demonstrate  numerous  flagella.  The  authors,  as 
Kruse,  could  detect  no  motility,  whereas  Flexner  and  Shiga 
describe  the  organism  as  motile.  Considering,  however,  that 
the  organism  is  flagellated,  it  is  possible  that  under  certain 
conditions  it  does  possess  motility. 

The  study  of  the  agglutinative  reactions  likewise  gave 
interesting  and  positive  results.  The  tests  consisted  (i)  of 
the  reaction  of  the  patient's  blood  with  the  cultures  of  Shiga, 
Flexner,  Strong  and  Kruse  ;  (2)  of  the  reaction  of  the  bacilli 
isolated  by  the  authors  with  the  patient's  blood,  and  (3)  the 
reactions  toward  Shiga's  antidysenteric  serum.  In  conclu- 
sion, the  following  are  the  authors'  opinions  : 

1.  The  several  standard  cultures  used  in  the  study  are 
indistinguishable — a  conclusion  previously  stated  by  Flexner. 

2.  The  acute  dysentery  of  the  United  States  is  due  to 
a  bacillus  indistinguishable  from  that  obtained  from  the 
epidemics  of  dysentery  in  several  parts  of  the  world. 

3.  The  sporadic  and  institutional  outbreaks  of  acute 
dysentery  are  caused  by  the  same  micro-organisms,  and  this 
organism  is  identical  with  that  causing  epidemic  acute 
dysentery.     (See  review  of  Kruse's  article  on  this  point.) 

4.  The  cause  of  acute  dysentery,  whether  sporadic, 
institutional  or  epidemic,  is  B.  dysenteriae  Shiga. — Vedder 
and  Duval,  Journal  of  Experimental  Medicine,  February, 
1902. — Maryland  Medical  Jonrnal. 

PRESENT  STATES  OF  DYSENTERY. 

Kruse  gives  a  systematic  resume  of  the  various  forms  of 
dysentery,  which,  although  resembling  each  other  clinically, 
have  been  shown  in  their  pathological  anatomy  as  well  as 
etiologically.  Without  believing  that  the  last  word  has  been 
said  as  to  the  etiology,  he  divides  dysentery  into  four 
groups : 

I.     The  German  epidemic  dysentery,  due  to  the  bacillus 


566  MEDICINE   AND    NEUROLOGY. 

which  he  himself  has  isolated  (Bac.  dysenterL-E  Germanicae), 

II.  The  dysentery  of  the  Philippines  and  Japan  (Flexner 
and  Shiga). 

III.  The  atypical  dysentery  which  occurs  partly  spora- 
dic, partly  in  small  epidemics,  especially  in  insane  asylums, 
and  are  probably  due  to  several  different  types  of  pseudo- 
dysentery  bacilli. 

IV.  The  amebic  dysentery,  which  differs  from  the 
preceding  forms  not  only  etiologically,  but  also  anatomical- 
ly.—  Kruse,  Deutsche  Aerztezeitung,  1902,  No.  2.  Maryland 
Medical  Journal. 

TREATMENT      OF      SYPHILIS      WITH     INTRAMUSCUIiAK 
INJECTIONS  OF  HERMOPHENYIi. 

'  ,( I.  Nicolle  {La  Revue M edicale de  Normandie,  April  25,  1902) 
believes  that  he  has  obtained  an  ideal  form  in  which  to 
administer  mercury  in  hermophenyl.  Although  many  pre- 
parations of  mercury  have  been  hitherto  described  for  intra- 
muscular or  subcutaneous  injections,  most  of  them  are  not 
free  from  criticism,  for  the  insoluble  preparations  of  mercury 
require  a  long  period  of  time  for  absorption,  and  may  lead  to 
severe  accidents,  while  the  soluble  forms  are  often  of  very 
feeble  strength,  and  the  fact  that  they  have  to  be  repeated 
daily  renders  their  use  extremely  dangerous  in  the  hands  of 
a  large  number  of  practitioners. 

Hermophenyl  is  a  compound  of  mercury,  phenol  and 
sodium  sulphate,  containing  40  per  cent,  of  mercury,  and 
very  soluble  in  water.  Nicolle  has  used  this  drug  in  ninety- 
four  syphilitic  cases  in  his  service  at  Rouen.  Primary, 
secondary  and  tertiary  cases  were  all  met  with  in  this  series. 
Nine  hundred  and  eight  injections  in  all  were  used ;  the 
solution  employed  was  i  to  100,  the  dose  2  c.  cm. — that  is, 
8  mg.  of  metallic  mercury.  The  injections  were  given  twice 
a  week  at  first,  later  once  a  week.  The  injections  were  made 
into  the  gluteal  muscles,  and  were  never  accompanied  by  any 
inconvenience. 

The  results  have  been  more  favourable,  according  to 
Nicolle,  than  with  any  other  preparation  of  mercury.  In 
only  one  case  was  a  stomatitis  observed,  which  was  mild,  and 
followed  the  eleventh  inoculation,  while  a  local  induration 
was  noted  in  two  cases  at  the  point  of  inoculation,  with- 
out, however,  producing  any  inconvenience.  Nicolle, 
therefore,  recommends  heimophenyl  as  a  most  satisfactory 
method  of  administering  mercury  in  specific  cases. — Mary- 
land Medical  Journal. 


SURGKRY. 


IN   CHARGE    OF 

ROLLO  CAMPBELL,  M.D., 

Lecturer  on  Surgery,  U:;i\'ersity  of  Bishop's  College  ;  Assistant  Surgeon,   W  isiern  Hospital  ; 

AND 

GEORGE  FISK,  M.D. 

Insir actor  in  Surgery,  University  of  Bishop's  College  ;   Assistant  Surgeon,  Western  Hospital  ; 


SURGICAL   TREATMENT   OF  EMPYEMA  IN   CHILDREN. 

DowD    summarizes  as  follows: — 

(1)  For  simple  cases  of  empyema  the  following  treat- 
ment is  used:  Excision  of  about  one  and  a  half  inches  of 
the  seventh  or  eighth  rib  in  the  posterior  axillary  line; 
light  ether  anesthesia  is  usually  employed;  the  purulent 
coagula  are  removed;  short  rubber  tubing,  cut  partly 
across,  doubled  and  held  by  large  safety  pins,  is  used  for 
drainage;  abundant  gauze  dressing  is  applied  and  changed 
when  saturated. 

(2)  If  the  patient's  condition  contra-indicates  general 
anesthesia,  an  incision  in  the  chest  may  be  made  between 
two  ribs  under  cocaine  anesthesia. 

(3)  Aspiration  is  only  used  to  give  temporary  relief  in 
patients  who  are  in  great  distress  from  the  pressure  of  the 
fluid,  or  temporarily  to  relieve  the  second  side  of  a  double 
empyema  after  the  first  side  has  been  opened. 

(4)  The  patients  are  allowed  out  of  bed  as  soon  as  is 
practicable,  and  the  expansion  of  the  lung  is  encouraged 
by  forced  expiration. 

(5)  Irrigation  is  only  used  where  there  is  a  foul-smell- 
ing discharge  from  necrotic  lung  tissue. 

(6)  Secondary  operations  are  not  done  until  good  op- 
portunity has  been  given  for  healing;  usually  three  or  four 
months  should  have  elapsed  after  the  primary  operation, 
and  there  should  have  been  no  noticeable  improvement  for 
about  a  month. 

(7)  In  the  secondary  operation  the  expansion  of  the 
lung  should  be  encouraged  by  incising,  stripping  back,  and, 
if  necessary,  removing  portions  of  the  thickened  pulmonary 
pleura. 

(8)  The  examination  of  forty-four  of  the  patients  at 
long  periods  after  operation  indicates  that  recovery  is 
usually  complete  in  the  simple  cases,  and  that  there  is  sur- 
prisingly little  deformity  in  most  of  the  severe  cases. — 
DowD  {Medical  Neics,  September  12,  1902). 


■Xtili; 


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Editorial. 


DINNER   TO   DR.   C.   A.     AVOOD,    OF    CHICAGO. 

On  the  22nd  of  December  a  complimentary  dinner 
was  given  in  the  Club  room  of  the  Windsor  hotel, 
Montreal,  to  Dr.  C.  Albert  Wood,  of  Chicago.  About 
forty  medical  men  sat  down,  and  the  dinner  was  unique  in 
a  way,  those  present  consisting  of  present  and  past  members 
of  the  Medical  Faculty  of  Bishop's  College,  from  which 
University  Dr.  Wood  graduated  in  1877.  This  combination 
brought  not  only  the  members  of  the  Faculty  of  his  Alma 
Mater,  but  several  of  the  leading  members  of  McGill 
University  Faculty  of  Medicine  to  do  honour  to  the  guest 
of  the  evening.  Dr.  F.  W.  Campbell,  Dean  of  Bishop's 
Faculty  of  Medicine,  occupied  the  chair,  and  had  on  his 
right  the  guest  of  the  evening,  and  on  his  left  Dr.  Roddick, 
M.P.,  Dean  of  McGill,  who  was  present  as  the  guest  of  the 
Medical  Faculty  of  Bishop's.  In  reply  to  the  toast  of 
"  Our  Guest,"  Dr.  Wood  made  a  feeling  reply,  alluding  to  his 
long  residence  as  a  practitioner  in  Montreal,  which  he 
looked  upon  even  yet  as  home.  Dr.  Roddick  replying  to 
the  toast  of  the  Faculty  of  Medicine  of  McGill  said  that  if 
some  years  sgo  there  was  friction  between  McGill  and 
Bishop's,  those  days   were  passed,  and   the  two  Schools    of 


EDITORIAL.  569 

Medicine  stood  shoulder  to  shoulder  for  the  advancement  of 
medical  teaching  in  Canada, 

Dr.  Wood,  who  for  several  years  was  a  Professor  in 
Bishop's,  is  now  the  leading  occulist  in  Chicago,  and  his 
reputation  extends  all  over  the  rorthwest  of  the  United 
States.  The  dinner  was  under  the  charge  of  a  committee 
consisting  of  Drs,  G.  T.  Ross  and  Dr.  George  Fisk. 
Bishop's  men  are  exceedingly  proud  of  Dr.  Wood's  record, 
and  by  all  his  old  friends  he  was  warmly  welcomed  to 
Montreal. 

FOUR  HUNDRED  DOLLAR  PRIZE. 

Dr.  J.  B.  Mattison,  Medical  Director,  Brookhn  Home 
for  Narcotic  Inebriates,  offers  a  prize  of  400  dollars  for 
the  best  paper  on  the  subject: 

Does  the  habitual  subdermic  use  of  morphia  cause 
organic  disease? 

If  so,  what? 

Contest  to  be  open  two  years  from  December  1,  1901, 
to  any  ijlnsician,  in  any  language. 

AWard  to  be  determined  by  a  Committee:  Dr.  T.  D. 
Crothers,  Hartford,  Conn.,  Editor  Journal  of  Inebriety, 
Chairman;  Dr.  J.  M.  Van  Cott,  Prof,  of  Pathology,  Long 
Island  College  Hospital,  Brooklyn,  and  Dr.  Wharton  Sink- 
ler,  Neurologist  to  the  State  Asylum  for  the  Chronic 
Insane,  Philadelphia. 

All  papers  to  be  in  the  hands  of  the  Chairman,  by 
or  before  1st  December,  1903,  to  become  the  property  of  the 
American  Association  for  the  Study  and  Cure  of  Inebriety, 
and  to  be  published  in  such  journals  as  the  Committee 
may  select. 


A  STUDY  XJT  BACTERIAL  CELLS. 

The  University  of  Michigan  "News  Letter"  of  November 
21,  says: — "The  report  of  the  Kockefeller  research  in  the 
hygienic  laboratory  of  the  University  of  Michigan,  for  the 
year  1902,  has  recently  appeared  in  pamphlet  form.    It  is 


570  EDITORIAL. 

taken  from  'The  Transactions  of  the  Association  of  Ameri- 
can Physicians,  1902/    The  work,  'A  Study  of  Bacterial 
Cells,'  was  carried  on  under  the  direction  of  Dr.  Victor 
C.   Vaughan,   in   the   laboratories  of  the  University.    By 
means  of  large  incubating  tanks  devised  by  Dr.  Vaughan, 
cellular  substance  of  pathogenic  bacteria  was  obtained  in 
large  amount.   It  was  with  material  thus  obtained  that  all 
the  experiments  were  carried  on.    The  research  work  was 
not  confined  to  toxins  alone,  but  a  broader  study  of  cel- 
lular chemistry  was  attempted.    Incidentally  an  opportun- 
ity offered  itself  for  the  study  of  some  of  the  bacterial 
pigments  which  were  found  in  the  tank  growths  in  large 
quantities.    The  germs  were  scraped  from  the  tanks  with 
glass    rods,    and    repeatedly    extracted    with    alcohol.     In 
many  cases  the  extractions  were  made  with  water.    The 
alcohol  seemed  to  harden  the  cells. 

''The  pamphlet  contains  the  following  papers: — 
"I,  Introduction,  Victor  C.  Vaughan,  M.D.,  LL.D. 
"II.  A  preliminary  Report  on  Certain  Bacterial  Pigments, 

A.  J.  Detweiler,  A.B.,  M.D. 
"III.  The  Toxicity  of  the  Dry,  Sterile  Cells  of  certain  Non- 
Pathogenic  Bacteria,  A.  J.  Detweiler,  A.B.,  M.D. 
"IV.  The  Chemistry  of  Sarcina  Lutea,  May  Wheeler,  A.B. 
"V.  The  Chemistry  of  the  Bacillus  Coli  Communis,  Mary 

F.  Leach,  B.S. 

"VI.  The  Toxicity  of  the  Cellular  Substance  of  the  Colon 
Bacillus,  Charles  E.  Marshall,  Ph.D.,  and  L.  M.  Gels- 
ton,  A.B. 

"VII.  The  Interacellular  Toxins  of  the  Diphtheria  Bacillus, 
L.,M.  Gelston,  A.  B. 

"VIII.  The  Anthrax  Toxin,  J.  Walter  Vaughan,  A.B. 

"IX.  Conclusions,  Victor  C.  Vaughan,  M.D.,  LL.D." 


Personals. 

III  -  r :  ^ 

Dr.  Shi'rres,  of  Montreal,  has  accepted  the  position  of 
Professor  of  Nervous  Diseases,  in  ^the  University  of 
Vermont. 

Dr.  T.  Paiizeau  has  been  appointed  to  sncceed  the  late 
Dr.  Brunelle  as  Professor  of  PatholocTV  and  Surgery  in  the 
Medical  Faculty  (Montreal)  of  Laval  University. 

Dr.  Rorke  M.D.,  McGill,  1893,''  has  been  appointed 
Lecturer  on  Histology  in  the  Medical  Faculty  of  Bishop's 
University,  Montreal. 

Dr.  George  Hall  (M.D.,  Bishop's,  1896),  has  been 
appointed  Lecturer  on  Physiology,  in  succe-sion  to  Dr, 
Bruere,  in  the  Medical  Faculty  of  Bishop's  University, 
Montreal. 

Dr.  C.  A,  Dugas,  who  for  some  years  was  assistant  to 
the  late  Dr.  Wyatt  Johnston,  Montreal,  official  autopist,  has 
succeeded  to  the  chief  position.  He  will  have  for  his 
assistant  Dr.  D.  D.  McTaggart. 

Dr.  Derome  and  Dr.  Brennan,  of  Montreal,  have  re- 
turned from  attending  the  International  Congress  of 
Gynaecology  and  Obstetrics,  which  was  held  in  Rome,  the 
middle  of  September. 

Dr.  C.  H.  Christie,  a  graduate  of  Bishop's,  1901,  has 
been  appointed  surgeon  on  the  steamship  "Wyamaga," 
which  recently  sailed  from  England  for  the  West  Coast  of 
Africa. 

Dr.  Sharkey,  who  has  been  appointed  Professor  of 
Hygiene  in  the  Faculty  of  Medicine  of  McGill  University, 
has  arrived  from  England.  He  made  his  first  speaking 
appearance  before  the  students  at  the  McGill  Medical 
dinner,  held  at  the  Windsor  Hotel,  on  the  8th  December. 

Dr.  Martineau  has  returned  from  Grosse  Isle,  the 
quarantine  being  closed. 

Dr.  Austin,  of  Sheibrooke,  was  in  Montreal  on  the 
i8th  December,  to  visit  his  brother  who  has  been  quite  ill. 
He  called  upon  the  editor. 

Dr.  J.  A.  Hamilton  (M.  D.,  Bishop's,  1900),  has  settled 
in  Tacoma,  Washington  Territory,  and  has  selected  a 
specialty — nose  and  throat.  He  has  written  the  editor 
for  an  assistant. 


572  BOOK   REVIEWS. 

Dr.  C.  A.  Fortin  (M,  D.,  Bishop's,  1897)  has  almost, 
since  his  graduation,  been  at  sea.  At  present  he  is  surgeon 
on  the  R.M.S.  "Ori.ssa,"  His  Majesty's  Transport  No.  18, 
and  writes  us  from  Bermuda,  under  date  of  December  6, 
We  extract  the  following  from  his  letter:  "  I  hope  to  be 
back  in  Canada  soon  and  renew  acquaintances  with  my  old 
friends  after  over  five  years'  absence.  I  am  at  present  on 
the  crack  transport  and  am  seeing  a  bit  of  the  world.  We 
have  been  out  to  the  Cape  twice,  India  once,  and  now  on 
the  West  India  route,  picking  up  the  black  troops,  and 
shipping  them  to  their  various  stations." 


Book    Reviews, 


A  Treatise  on  the  Eye,  Nose,  Throat  and  Ear.— For 

Students  and  Practitioners.  By  Eminent  American  and  Eng- 
lish Authors.  Edited  by  William  Campbell  Posey,  M.D., 
Surgeon  to  Wills  Eye  Hospital,  Philadelphia,  and  Jonathan 
Wright,  M.D.,  Laryngologisl  to  the  Brooklyn  Eye  and  Ear 
Hospital,  etc.  In  one  octavo  volume  of  1,234  pages,  with  650 
engjavirgs  and  35  plates  in  colours  and  monochrome.  Cloth, 
$7.00  net ;  Leather,  $8.00  net.  Lea  Brotheis  &  Co  ,  Pub- 
lishers, Philadelphia  and  New  York. 

This  volume  of  over  twelve  hundred  pages  has  been  arranged 
so  that  the  various  special  departments  may  be  treated  in  a  manner 
at  once  authoritative,  comprehensive  and  practical,  by  men  whose 
namesarewell  known  in  the  medical  world.  Theauthors  have  aimed 
to  adapt  the  book  particularly  to  practitioners  and  students,  but  even 
specialists  will  find  the  recent  views  of  their  co7ifreres  to  be  interest- 
mg  reading.  One  practical  feature  about  it  is  that  each  contributor 
has  treated  his  subject  in  its  entirety,  so  that  repetitions  have  been 
avoided.  Pathology  and  symptomatology  have  been  dealt  with 
liberal  y,  while  anatomy  and  physiology  have  been  omitted  to  a 
marked  degree.  To  the  practitioner  the  chapter  on  the  eye  in  its 
relation  to  general  diseases  will  commend  itself.  The  printing  is  very 
clear,  the  paper  good,  while  the  engravings  and  monochromes  are 
excellent,  the  entire  book  being  one  which  will  prove  helpful  to 
any  medical  man.  , 

G.  T.  R 

A  Nurse's  Guide  for  the  Operating  Room.— By  Nicholas 
;-eward,  M  D.,  Ph.D.,  LL.D.,  CM.,  Professor  of  Surgery, 
Rush  Medical  College  in  affiliation  with  the  University  of 
Chicago,  Attending  Surgeon  to  the  Presbyterian  Hospital, 
Surgeonin-Chief  ol  St.    Joseph's   Hospital,    Professional  Lee- 


574  BOOK   REVIEWS. 

Clinical  Methods,— A  guide  to  the  Practical  Study  of  Medicine. 

1^  By  Robert  Hutchison,  M.D.,  M.R.C.P.,  Assistant  Physician 
to  the  London  Hospital  and  to  the  Hospital  for  Sick  Children, 
Great  Orraond  street,  and  Harry  Rainy,  M.A.,  F.R. C.P.Ed., 
F.R  S.E.,  University  Tutor  in  Clinical  Medicine,  Royal 
Infirmary,  Edinburgh,  with  150  illustrations  and  8  coloured 
plates.  Fifth  Edition.  Ninth  thousand.  Chicago,  W.  T. 
Keener  &  Co.,  1902. 

This  little  volume — little  only  in  the  size  of  its  pages — for  it 
consists  of  six  hundred  of  them,  was  first  published  in  1897,  since 
which  it  has  gone  through  five  editions.  The  last  one  brings  it 
thoroughly  up  to  date,  though  the  author  in  his  preface  says 
"  many  methods  which  have  been  recently  proposed  are  not  in- 
cluded in  the  volume  ;  some  because  they  have  not  yet  been  suf- 
ficiently proved,  others — and  this  holds  true  especially  of  chemi- 
cal analyses — because  they  are  too  complicated  for  clinical  use 
whe'-e  simpler  though  less  accurate  procedures  suffice."  We  have 
examined  the  work  very  thoroughly  and  have  no  hesitation  in 
saying  that  it  should  be  in  the  hands  of  every  medical  student. 
Without  such  a  book  to  fall  back  upon  and  guide  him  in  his  hospi- 
tal work,  he  is  like  a  vessel  without  a  rudder. 

F.  W.  C. 

International  Clinics. — A  quarterly  of  clinical  lectures  and 
especially  prepared  articles  on  all  branches  of  Medicine  and 
Surgery  and  other  topics  of  interest  to  students  and  practi- 
tioners. By  leading  members  of  the  Medical  profession  through- 
out the  world.  Edited  by  Henry  W.  Cattell,  A.M.,  M.D., 
I'hiladelphia,  U.  S.  A.,  with  the  collaboration  of  John  B.  Mur- 
phy, M.D.,  Chicago;  Alex.  D.  Blackader,  M.D.^  Montreal; 
H.  C.  Wood,  M.D.,  Philadelphia;  T.  M.  Rotch,  M.D.,  Bos- 
ton ;  E.  Landolt,  M.D.,  Paris  ;  Thos.  G.  Morton,  M.D., 
of  Philadelphia  ;  James  J.  Walsh,  M.D.,  New  York;  J.  B.  Bal- 
lantyne,  M.D.,  of  Edmbuigh,  and  John  Harold,  M.D.,  of 
London,  with  regular  correspondents  in  Montreal,  London, 
Paris,  Leipsic  and  Vienna ;  volumes  II.  and  III.,  twelfth 
series.  J.  B.  Lippincott  &Co.,  Philadelphia,  1902.  Canadian 
Agent:  Charles  Roberts,  1524  Ontario  Street,  Montreal. 

Volume  II.  contains  twenty-eight  articles  on  as  many  different 
subjects,  by  leading  clinicians  from  America  and  Europe. 

Professor  R.  Lepine,  of  Lyons,  France,  has  an  article  on  the 
Treatment  of  Diabetes.  R.  Romme,  M.D.,  of  Paris,  writes  on  Ger- 
sung's  method  of  Prolhesis,  by  Subcutaneous  and  Submucous  In- 
jections of  Vaseline.  The  method  of  employing  the  vaseline  is 
explamed  and  the  deformities  and  various  other  conditions  in 
which  it  has  been  found  useful  pointed  out ;  Treatment  of  Blad- 
der and  Rectal  Troubles  in  Nervous  Diseases,,  by  L.  R.  Miiller, 
M.D.,  of  Erlangen,  Ge;many;    Treatment  of  Acute  Urethritis,  by 


BOOK  REVIEWS.  573 

turer  on  Military  Surgery,  University,  Chicago;  Chief  of  the 
Operating  Staff  with  the  Army  in  the  Field  during  the  Spanish- 
American  war,  Surgeon  General  of  the  State  of  Illinois.  Pub- 
lished under  the  direction  of  the  Sisters  of  Charity,  St.  Joseph's 
Hospital,  360  Garfield  Av,,  Chicago.  W.  T.  Keener  &  Co., 
90  Wabash  Av.,  Chicago. 

A  useful  little  book  which  is  bound  to  meet  with  appreciation  ; 
the  author's  name  is  a  sufficient  guarantee  for  its  merits.  It  is 
thoroughly  up  to  date,  and  the  operating-room  nurse  who  reads 
and  inwardly  digests  its  contents  will  be  a  great  comfort  to  the 
surgeon  under  whom  she  works.  Full  and  systematic  instruction 
is  given — preparation  of  operating  room  and  the  preparation  of 
the  patient  for  any  and  many  special  operations.  It  is  a  book  of 
details — from  hand  washing  and  the  preparation  of  ligatures  and 
dressings  to  what  to  do  in  emergencies  and  the  various  wound 
complications.  The  chief  operations  are  mentioned,  and  a  list  of 
the  instruments  required  in  each  is  given.  After-treatment  of 
laparotomy  cases  is  indicated  and  the  nurse  is  advised  to  place 
such  medicines  and  articles  as  may  be  required  on  a  little  table 
close  at  hand  where  they  may  be  had  in  a  moment  and  without 
delay.  The  little  book  has  been  well  thought  out  and  will  be 
found  of  real  worth.  It  has  been  well  named  the  "  Nurse's  Guide." 

F.  R.  E. 

Woolsey's  Surgical  Anatomy.  — Applied  Surgical  Ana- 
tomy regionally  presented  for  the  use  of  Students  and  Prac- 
titioners of  Medicine,  by  Geo.  Woolsey,  A.B.,  M.D.,  Professor 
of  Anatomy  and  Clinical  Surgery  in  the  Cornell  University 
Medical  College  ;  Surgeon  to  Bellevue  Hospital,  etc.  Octavo, 
511  pages,  125  illustrations,  including  59  full-page  inset  plates 
in  black  and  colours.  Cloth,  $5.00  net.  Leather,  $6.00,  net. 
Lea  Brothers  &  Co.,  Philadelphia  and  New  York,  1902. 

The  author  has  from  the  beginning  to  the  end  of  his  book 
shown  himself  to  be  a  true  tedcher.  Anatomy  and  even  surgical 
anatomy  as  generally  treated  is  heavy,  dull  and  often  difficult. 
In  this  work  the  various  parts  and  regions  are  presented  in  such 
an  interesting  and  practical  way  that  points,  which  before  seemed 
intricate  and  difficult,  now  stand  out  surgically  clear  and  full  of 
interest.  The  excellent  plates  and  cuts  help  much  to  increase  the 
value  of  the  book.  A  true  teacher  is  able  to  simplify  and  make 
what  is  obscure  and  difficult,  easy  and  attractive.  Dr.  Woolsey 
has  certainly  done  this.  He  has  presented  a  book  on  the  very- 
groundwork  of  surgery,  and  it  is  sure  to  be  appreciated  by  the  men 
who  operate.  It  is  generously  filled  with  practical  surgery  remind- 
ing us  in  many  ways  of  that  old  and  valuable  little  work  on  surgical 
applied  anatomy  by  Frederick  Treves. 

F.  R.  E. 


576  BOOK   REVIEWS. 

Part  II.  of  Barissof's  article  on  the  function  of  the  digestive 
glard  based  on  the  researcl>es  of  Pavlof  and  his  pupils,  which 
appears  here,  concludes  the  subject.  It  represents  the  substance 
of  some  fifty -six  papers  written  by  Pavlof  and  his  collaborators. 
The  last  article  is  an  exhaustive  one  on  the  Critical  Study  of 
the  theory  of  Inflammation,  by  Hans  Schmaus,  M.D.,  Prof,  at 
the  University  of  Munich.  Many  of  the  articles  in  both  these 
volumes  are  illustrated  by  plates  and  figures. 

J.  B.  McC. 

The    Public     and    the   Doctor — By    a    regular    Physician. 

Pubhshed  by  Dr.    B.    E.   Hadra,  Dallas,  Texas,  U.  S. 

We  presume  that  the  writer  and  publisher  of  this  little  book 
of  one  hundred  and  forty-nine  pages  are  the  same.  The  inten- 
tion of  publication  is  a  laudable  desire  that  the  intellectual  and 
thinking  public  should  have  a  good  conception  of  the  claims  which 
a  truly  scientific  physician  has  upon  them.  For  the  public  it  is 
therefore  intended,  and  that  it  should  reach  them  it  is  the  desire 
of  the  author  that  doctors  distribute  it  among  their  clients  at  a 
cost  of  fifty  cents  each  copy.  We  have  read  the  book  carefully, 
and  freely  acknowledge  that  it  is  in  truth  a  missionary  document 
of  very  considerable  value.  We  question,  however,  whether  there 
are  many,  or  indeed  any,  except  where  exceptionally  large  incomes 
exist,  who  would  feel  inclined  to  subscribe  from  one  hundred  dol- 
lars upward,  to  send  this  missionary  book  on  its  mission  of  educat- 
ing the  public  on  the  blessings  of  Scientific  Medicine,  and  the 
cause  ;  f  quackery,  and  the  various  medical  fads,  which  every- 
where abound.  The  intention  of  the  author  is  most  praise- 
worthy— his  work  is  really  excellent  reading —  but  how  many  will 
be  willing  to  place  a  considerable  sum  outside  of  their  pockets  to 
extend  its  circulation.  We  hope  some  at  least  will  do  so,  but  our 
experience  leads  us  to  believe  they  will  be  few.  F.  W.  C.     • 

Schmidt  on  Venereal  Diseases.  Lea's  Series  of  Medi- 
cal Epitomes. — A  Manual  of  Genito-Urinary  and  Venereal 
Diseases  for  the  use  of  Students  and  Practitioners.  By  Louis  E. 
Schmidt,  M.  D.,  of  the  Chicago  Polyclinic.  In  one  handy 
i2mo  volume  of  250  pages,  with  21  illustrations.  Cloth 
$1.00,  net.  Lea  Brothers  &  Co.,  PubHshers,  Philadelphia 
and  New  York,  1902. 

This  work  has  been  designed  by  Dr.  Schmidt  more  espe- 
cially to  meet  the  needs  of  the  medical  students  who  are  taking  up 
this  branch  of  work  for  the  first  time.  As  such  it  is  very  creditable 
and  enables  a  student  to  review  in  a  short  time  the  main  features  of 
the  venereal  diseases.  The  work  is  concise,  yet  clear  and  well 
arranged.  It  is  especially  strong  on  treatment,  and  is  even  m.ore 
explicit  in  this  than  many  larger  works.  We  are  pleased  to  note 
the  arrangement  of  the  host  of  remedies  for  acute  gonorrhoea  and 
the  excellent  remarks  on  their  indications,  A  list  of  questions  is 
given  at  the  end  of  each  chapter  which  may  be  used  ici  reviewing 
the  subject.  G.  F. 


^^ 


BOOK  REVIEWS.  575 

Prof.  Ernest  Finger,  of  the  University  of  Vienna  ;    Passive  Move 
ments  and  Massage  for  the  Treatment  of  Fractures,  by  Prof.  Lucas, 
Championniere,    University  of   Paris  ;  Two   cases  of  Immediate 
Deatli  Caused  by  the  Spinal   Injections  of  Cocaine,  by  F,  Leguen, 
M.D.,  Surgeon  to  the   Paris  Hospitals;    Pachymeningitis   Haemor- 
rhagica,  as    a   Cause    of  Drunkard  s  Death,  by  Prof.  Arnold  Pick, 
University  of  Prague  ;    The  Presence  and  Significance  of  Beta- 
Oxybutyric  Acid  in  the  Urine  of  Diabetics  and  its  Eelation  to  the 
Coma,  by  Carstairs  Douglas,   Ml).,   etc.,  Glasgow  ;  Gastro-Intes 
tinal  Auco-Intoxication,  by  John  C.  Hemmeter,  M.D.,  Baltimore; 
Resection   of  the  Cervical   Sympathetic,    by   Prof.  Thomas  Jon- 
nesco,  Bucharest,  Roumania.  Some  excellent  results  are    recorded 
here  from  the  application  of   this  means    in  epilepsy,  Basedow's 
disease,  etc.  ;  Radical  Cure  of  Inguinal  and  Femoral  Hernia,  Slid- 
ing Hernia,  Hydrocele  of  the  Canal  of  Nuck,  Epithelioma  of  the 
Face,  Sarcoma  of  the  Upper  Jaw,    by  William  B.  Caley,  M.D., 
New  York;    also    articles   by    Charles    Gibbs.   F.R.C.S.,    Eng. ; 
N.  Senn,  M.D.,  LL.D.  ;  H,  A.  Kelly,  A.M.,  M.D. ;  Guy  Hiasdale, 
A.M.,  M.D.,  who  gives  a  biographical  sketch    of  John  B.  Murphy, 
of  Chicago. 

Of  special  interest  also  are  the  articles  on  the  organization 
and  work  of  the  Medical  Department  of  the  United  States  Army, 
by  E.L.  Munson,  A.M-,  M.D.,  and  the  first  part  of  a  paper  on 
the  Function  of  the  Digestive  Glands,  based  on  the  researches  of 
Pavlof  and  his  pupils,  by  Peter  Barissof,  of  St.  Petersburg. 

Volume  III.,  just  iisued,  is  also  replete  with  interesting  and 
instructive  articles,  not  one  of  which  the  reader  of  the  volume 
can  afford  to  miss. 

Among    those  of   special  interest    are  the    articles    on     the 
Treatment  of   Typhoid    Fever,  by  A.  T.   Osborne,   M.A.,  M.D., 
of  Yale  University;  Treatment  of  Intestinal  Perforation  in  Typhoid, 
by  Noel  Manger,  M.D.,  of  Versailles;  The  Treatment  of  Morphin- 
ism, by  T.  D.  Crothers,  Prof.  Nervous  and  Mental  Diseases,   New 
York  School  of  Clinical  Medicine;  The   Diagnosis  and  Treatment 
of  Osteomyelitis,   by   P.   Mauclaire,  M.D.,   surgeon  to   the  Paris 
Hospitals ;    Treatment   of   Deafness    by  Direct    Massage    of    the 
Ossicles  of    the    Ear,  by  Dr.  Charles  J.  Koenig,  Laureate  of  the 
Faculty  of  Medicine,  Paris  ;   Means  of  Telling  Whether  an  Attack 
of  Serofibrinous  Pleurisy  is   Tuberculous  by  G.  Dieulafoy,    M.D., 
Paris  ;  Insect    Pests  of  Human  Beings,  by  James  J.  Walsh,  M.D., 
Pn.D  ,    New   York    Polyclinic;    Treatment    of  Dilatation  of  the 
Stomach,  by  Gastro-Enterostomy,  by  G.  M.  Debove,  Paris  Faculty 
of  Medicine;    Surgical  Intervention  of  Cases  of  Great    Dilatation 
of  the  Stomach,  by  Prof  Antonio  Cardarelli,  University  of  Naples, 
Italy;    Abdominal  Tumour,  by  J.  M.  Baldy,  M.D.,    Philadelphia; 
The    Treatment    of    Cases    of    Face     Presentation,    by    Robert 
Jardine,    M.D.,    F.R.S.E.,    University  of  Glasgow ;    The    Faucial 
Tonsils,  the  Indications  for  Their  Removal,  and  the  Best  Methods 
by  which    to  Acco^nplish  it,  by  Francis  R.  Packard,   M.D.,  Phi- 
ladelphia Polyclinic. 


ItRIAl, 


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GERSTS